Physical restraint of elderly patients in critical care: historical perspectives and new directions

The use of physical restraints in health care settings is being examined carefully at all levels. Experience with the elderly in long-term care settings teaches us that in many instances physical restraints are not only unnecessary, they are also not the best available therapy. There can be little doubt that careful evaluation of the use of restraints in the critical care unit is likely to reveal alternatives to their use in many situations. In the American health care system, nurses primarily determine restraint use. Professional nurses are leading the movement to find alternatives to restraints, and critical care nurses can contribute much to the effort. Nurses must recognize restraint application as a serious treatment decision, and must apply risk-to-benefit analysis to each decision. Continuing nursing education and nursing research on restraint reduction will lead to improved care for our elderly patients.

Discharge planning for the patient with a new tracheostomy

A patient with a new tracheostomy will face threatening changes upon discharge from hospital support. Nurses, particularly in the critical care unit, frequently and closely support a patient and family through new and often difficult situations during hospitalization. The patient leaving the hospital with a new tracheostomy will face problems with secretion management, increased risk of infections, alterations in body image, and impaired vocalization. To ensure a safe transition from the hospital to home, the patient and family must demonstrate competence in all aspects of tracheostomy care, must be able to recognize signs and symptoms that should be reported to the physician, and must have adequate support at home (such as homecare nurses, properly functioning equipment, and access to necessary supplies). These "musts" form the basis of the discharge care plan. Nurses can help a patient successfully manage these problems through comprehensive discharge planning. Although the critical care nurses who initiate the multidisciplinary discharge planning process may not remain involved in that process throughout the patient's hospitalization, their early efforts can provide an orderly, comprehensive discharge plan optimally suited to ensure that the patient and family acquire the necessary skills, confidence, supplies, and support for the eventual transition home. The information, encouragement, skills demonstrations, and referrals to other resources that critical care nurses provide help the patient adjust to a new tracheostomy.

Discharge planning for the patient with a new tracheostomy

A patient with a new tracheostomy will face threatening changes upon discharge from hospital support. Nurses, particularly in the critical care unit, frequently and closely support a patient and family through new and often difficult situations during hospitalization. The patient leaving the hospital with a new tracheostomy will face problems with secretion management, increased risk of infections, alterations in body image, and impaired vocalization. To ensure a safe transition from the hospital to home, the patient and family must demonstrate competence in all aspects of tracheostomy care, must be able to recognize signs and symptoms that should be reported to the physician, and must have adequate support at home (such as homecare nurses, properly functioning equipment, and access to necessary supplies). These "musts" form the basis of the discharge care plan. Nurses can help a patient successfully manage these problems through comprehensive discharge planning. Although the critical care nurses who initiate the multidisciplinary discharge planning process may not remain involved in that process throughout the patient's hospitalization, their early efforts can provide an orderly, comprehensive discharge plan optimally suited to ensure that the patient and family acquire the necessary skills, confidence, supplies, and support for the eventual transition home. The information, encouragement, skills demonstrations, and referrals to other resources that critical care nurses provide help the patient adjust to a new tracheostomy.

Red blood cell survival following admixture with heated saline: evaluation of a new blood warming method for rapid transfusion

We studied the in vivo survival of packed red blood cells (RBC's) which had been warmed using the new technique of admixture with high-temperature saline. Packed RBC's from five normal male subjects were stored in CPDA-1 at 4 degrees C for 14 days. They were then warmed via admixture with an equal amount of saline heated to 70 degrees C. Osmotic fragility, and supernatant hemoglobin and potassium levels of the warmed RBC's were not significantly different from baseline values. Aliquots of the warmed RBC's were labeled with 51Chromium and transfused into autologous donors. Mean radiolabeled RBC survival at 24 hours was 90.2% (S.D. 6.2%), and mean radiolabeled RBC survival time was 25.3 days (S.D. 2.7 days). These results are within the normal range for RBC's stored for 14 days. This study suggests that RBC survival after transfusion is not impaired by admixture blood warming using saline at 70 degrees C.

Red cell tolerance of admixture with heated saline

Red cell stability in the face of thermal stress has been evaluated only in the setting of prolonged incubation. This study was conducted to determine red cell tolerance of rapid mixture with heated saline, which exposes red cells to heat only until thermal equilibration, which is a matter of seconds. Half-units of 35-day-old red cells stored in CPDA-1 were mixed at 6 to 10 degrees C in the blood container with an equal weight of 60, 70, or 80 degrees C saline. This resulted in mean mixture temperatures of 30.9, 37.5, and 42.6 degrees C, respectively. Controls consisted of the same mixture, but with 6 to 10 degrees C saline. The red cells in the mixtures were assessed for osmotic fragility, and the supernatant was examined for plasma hemoglobin and potassium. Neither osmotic fragility curves nor supernatant hemoglobin or potassium changed significantly with saline temperatures of 60 or 70 degrees C. When 80 degrees C saline was used, osmotic fragility, supernatant hemoglobin, and potassium all increased significantly (p less than 0.01) over control values. Red cells tolerate rapid mixture with 70 degrees C saline without hemolysis or change in osmotic fragility.

Admixture bloodwarming: a technique for rapid warming of erythrocytes

Admixture of erythrocytes (packed red blood cells) with heated saline solutions may provide a faster and safer method of bloodwarming and infusion than is currently available. We developed and tested such a system for ease and efficacy. One-day-old aliquots of erythrocytes (6 to 10 C) were combined with equal amounts of saline that had been heated to a temperature of 50 or 60 C. After this rapid admixture, equilibrated temperatures were 29.1 and 34.0 C, respectively. The procedure also was performed using 35-day-old erythrocytes and 60-C saline. Samples were obtained for analysis immediately after admixture. There was no significant plasma hemoglobin elevation, indicating no significant hemolysis, in any sample at either temperature. Rapid admixture bloodwarming appears to be a technique in which erythrocytes and heated saline may be combined rapidly without causing significant hemolysis. However, further studies of red cell function and survival will be needed before this technique should be put into clinical practice.