A professional code of ethics: providing a moral compass for turbulent times

PURPOSES/OBJECTIVES

To describe the importance of a professional code of ethics and values in guiding and supporting the practice of nurses and to present the proposed Oncology Nursing Society (ONS) Statement of Core Values.

DATA SOURCES

Published articles and books on nursing ethics and bioethics, as well as authors' clinical experiences.

DATA SYNTHESIS

Ethical quandaries are commonplace for nurses, and the contemporary context of health care has created new concerns and redefined others. Throughout its history, nursing has been an ethical endeavor, with nurses attempting to sift through complex ethical issues and fulfill their professional responsibilities. A professional code of ethics and values explicates the goals and norms of the profession and provides direction for practice.

CONCLUSION

Together, the profession's code of ethics and the proposed ONS Statement of Core Values serve as a resource to guide oncology nurses as they develop an ethically competent practice and confront contemporary ethical challenges.

IMPLICATIONS FOR NURSING PRACTICE

The goal of developing an ethically competent practice, maintaining professional integrity, and rendering quality patient care is of vital concern to oncology nurses. Familiarity with and commitment to the primary ethical precepts and values of the profession are essential to accomplishing this goal.

Colorectal complications following cardiac surgery. Six-year experience

PURPOSE

This study was undertaken to assess colorectal complications following cardiopulmonary bypass surgery.

METHOD

This is a retrospective review of 5,801 patients who underwent 5,801 cardiopulmonary bypass procedures from 1985 to 1991. Patients were evaluated for type of bypass procedure, postoperative colorectal complications, age, sex, bypass time, aortic cross-clamp time, elective vs. emergency cases, uses of intra-aortic balloon pump, perioperative hypotension, and use of vasopressors. Statistical analysis was performed using chi-squared analysis and Student's t-test.

RESULTS

Nineteen of the 5,801 patients developed 19 colorectal complications, a prevalence of 0.3 percent for the initial hospital stay following bypass surgery. Mortality in those with complications was 37 percent (7/19). Of the 19 complications, 9 (47 percent) followed coronary artery bypass grafting, whereas 10 (53 percent) followed valve replacement or combined coronary artery bypass grafting with other cardiac procedures. Five (26 percent) of the complications followed emergency cases, whereas 14 (74 percent) followed elective cases. Average age of those with complications was 69.8 years, compared with 63.2 years for those without complications. Average aortic cross-clamp time for those with complications was 71 +/- 25 minutes; pump time was 106 +/- 34 minutes. That was significantly higher than in those without complications. Nine (47 percent) patients with complications required vasopressors during the perioperative period, whereas eight (42 percent) suffered prolonged hypotension (systolic blood pressure, < 90 mmHg).

CONCLUSIONS

It appears that increased age, valve replacement, or combined cardiac procedures, emergency procedures, and prolonged aortic cross-clamp and bypass pump times are risk factors for development of colorectal complications. Hypoperfusion, as suggested by prolonged pump times, clamp times, and emergency procedures may be a possible cause for development of colorectal complications.

Supplementation of breastfeeding newborns: a flow chart for decision making

Although research clearly demonstrates that supplementation of healthy infants in the early neonatal period has many potentially negative effects on breastfeeding initiation and continuation, the practice persisted at a Level II hospital. This paper explores the process undertaken to decrease this practice. A flow chart designed to assist nursing staff with decision making regarding supplementation was developed and tested.

Changes in taste associated with intravenous administration of pentamidine (revised)

In this pilot study the authors set out to: (a) describe the incidence of taste changes associated with intravenous (i.v.) pentamidine treatment; and (b) determine the factors that are related to making the taste changes better and worse. A convenience sample (N = 18) of adult male outpatients with AIDS participated in this study. One hundred percent of the participants experienced an unpleasant taste after the administration of pentamidine. The largest percentage of patients had a metallic taste (89%, n = 16); while 67% (n = 12) experienced a bitter taste. These data suggest that healthcare providers need to assess for the unpleasant taste associated with i.v. pentamidine and develop appropriate management strategies.

Sclerosing mediastinitis: a report on 18 cases

BACKGROUND

Sclerosing mediastinitis is a rare condition which causes dense fibrosis of the mediastinum. Few large studies have been reported to date. The clinical and pathological features of cases have been studied in a specialist referral centre in the UK.

METHODS

The pathological files of the Royal Brompton Hospital were examined and 18 cases of sclerosing mediastinitis were identified between 1970 and 1993. The clinical notes were obtained and the pathological specimens analysed.

RESULTS

There were 12 men and six women of age range 9-64 years. Twelve patients presented with shortness of breath, six had haemoptysis, three had hoarseness, four had pleuritic chest pain, three general weakness, two had dysphagia, and one was asymptomatic. Nine patients had a previous history of pulmonary tuberculosis. Two had auto-immune disease--one rheumatoid arthritis and the other systemic lupus erythematosus. There were three cases of previous malignancy--two undifferentiated carcinoma of the lung and the other Hodgkin's disease. Serological tests revealed only one positive reaction to Histoplasma. The erythrocyte sedimentation rate and serum immunoglobulins were raised in nine patients. Diagnosis was usually by thoracotomy with biopsy. All cases had fibrosis and chronic inflammation with no active granulomas. No infective organisms or positive cultures were obtained in any case. Ten of the 18 cases are alive up to 15 years after diagnosis, with only two deaths and six lost to follow up.

CONCLUSIONS

Sclerosing mediastinitis is a slowly progressive condition associated with previous tuberculosis, mediastinal malignancy, and autoimmune disease. The outlook is excellent for those cases without underlying malignancy.

Mood states of oncology outpatients: does pain make a difference?

The purposes of this study were to determine if there were significant differences in the mood states of oncology outpatients who had cancer-related pain and those who were pain free, and to evaluate the relationships between pain intensity and duration and mood states in those patients with pain. Two hundred (54.2%) patients experienced cancer-related pain during the previous month and 169 (45.8%) patients were pain free. Those patients who experienced cancer-related pain scored significantly higher on all of the subscale scores of the Profile of Mood States, except vigor, and had a significantly higher total mood disturbance (TMD) score than did pain-free patients. In addition, the subscale scores of tension, depression, anger, fatigue, confusion, and TMD scores were moderately correlated with increases in pain intensity. Also, depression, fatigue, confusion, and TMD scores were moderately correlated with increasing duration of pain. These data suggest that there is a relationship between pain and mood in oncology outpatients and that health-care professionals need to assess for mood disturbances in this population and develop appropriate treatment strategies.

Changes in taste associated with intravenous administration of pentamidine

In this pilot study the authors set out to: (a) describe the incidence of taste changes associated with intravenous (i.v.) pentamidine treatment; and (b) determine the factors that are related to making the taste changes better and worse. A convenience sample (N = 18) of adult male outpatients with AIDS participated in this study. One hundred percent of the participants experienced an unpleasant taste after the administration of pentamidine. The largest percentage of patients had a metallic taste (89%, n = 16); while 67% (n = 12) experienced a bitter taste. These data suggest that healthcare providers need to assess for the unpleasant taste associated with i.v. pentamidine and develop appropriate management strategies.

Endothelial seeding of polytetrafluoroethylene femoral popliteal bypasses: the failure of low-density seeding to improve patency

PURPOSE

We compared 66 seeded polytetrafluoroethylene and 53 autologous vein grafts to determine whether endothelial seeding could improve the patency of polytetrafluoroethylene femoral popliteal bypass grafts and to determine whether endothelial seeding could be performed consistently in multiple institutions.

METHODS

Nine surgeons at four hospitals randomized patients to receive either a seeded polytetrafluoroethylene or a vein graft, but if no satisfactory vein (n = 26) existed, an "obligatory" seeded polytetrafluoroethylene graft was used.

RESULTS

Scanning electron microscopy confirmed satisfactory initial attachment of endothelium on the discarded ends of the grafts. Patency was compared with the use of log rank analysis and revealed better patency in vein grafts at 30 months (vein = 91.6% +/- 4.1%; seeded polytetrafluoroethylene = 37.8% +/- 9.4%; p = 0.006). Failed grafts revealed anastomotic hyperplasia.

CONCLUSIONS

(1) Vein graft patency was better than seeded polytetrafluoroethylene grafts; (2) seeding did not improve patency in below-the-knee bypasses as suggested by pilot studies; (3) the failure of seeded grafts was associated with anastomotic hyperplasia but not with the failure of initial endothelial attachment; and (4) each institution reported similar results.

Evaluation of outcome following open lung biopsy

The utility of open lung biopsy in the management of patients with acute pulmonary infiltrates and/or progressive respiratory failure remains controversial, particularly in regard to its timing and impact on therapy. We reviewed our most recent 10-year experience with open lung biopsies in 73 patients and evaluated its effect on patient management and outcome. A total of 62 biopsies were done for progressive infiltrating disease, 53 with diffuse bilateral disease, and 9 with more focal infiltrates; 11 biopsies were done for nodular disease. Overall mortality was 25 per cent (18/73), all from the group with infiltrates; there were no deaths in patients with nodular disease (P = 0.034). No patients died who did not have acute respiratory failure (ARF) preoperatively, but mortality was 38 per cent (18/47) in those with ARF (P < 0.001). Immune system status and timing of the biopsy did not affect survival. Clinical management was changed in 40 patients based on biopsy results, but this did not affect survival, with a mortality rate of 20 per cent (8/40) in the group with changed management versus 30 per cent (10/33) for those with no changes (P = 0.457). In those patients with ARF, changes in management based on biopsy results occurred in 31 patients, eight of whom died (26 per cent); no changes in management were made in 16 patients, ten of whom died (62%, P = 0.033).(ABSTRACT TRUNCATED AT 250 WORDS)

Small cell lung cancer: pathophysiologic mechanisms and nursing implications

PURPOSE/OBJECTIVES

To review current incidence and treatment perspectives for small cell lung cancer (SCLC).

DATA SOURCES

Published articles, book chapters, American Cancer Society materials.

DATA SYNTHESIS

SCLC constitutes 20%-30% of lung cancer cases and accounts for 40,000 deaths annually. Characterized by rapid cell division, SCLC is very sensitive to radiation and chemotherapy; however, long-term survival rates are very low. A number of paraneoplastic syndromes are associated with this disease, thereby increasing the medical and nursing management challenges.

CONCLUSIONS

Because SCLC usually is diagnosed late in the disease process and survival rates are poor, quality of life and palliation of metastatic symptoms (e.g., pain, breathing difficulties) are important focuses of care. Smoking deterrence and cessation programs, as well as early detection of lesions, are key to reducing incidence and mortality.

IMPLICATIONS FOR NURSING PRACTICE

Nursing care focuses on promoting comfort and preventing and managing disease and treatment complications. Nursing diagnoses include ineffective airway clearance, impaired gas exchange, pain, altered nutrition, activity intolerance, and ineffective coping. A patient care standard is presented.

Brugia malayi and Brugia pahangi: synthetic biotin labeling of oligonucleotide probes for use in species-specific detection assays

We have developed a novel, high-yield synthetic approach for the incorporation of multiple biotin residues into a series of species-specific oligonucleotide probes for the detection of filarial parasites. The probes are designed to detect species-specific regions of a highly repeated DNA sequence (HhaI repeat) found in all species of Brugia. The synthetic method described in this paper was used to construct oligomer probes tailed on the 5' end with 1 to 46 biotinylated uridine residues. Probes with 46 biotins were found to be more sensitive than probes with 30 or fewer biotins. We also found that alternating the biotinylated uridine residues with nonbiotinylated thymidine residues improved the sensitivity of the probes. Melting temperature studies indicated that the long tails (up to 91 nucleotides) had only a minimal effect on the Tm of the probes. Conditions were found that optimized the sensitivity of the probes while maintaining their species specificity. Using these conditions, the probes were shown to be sensitive enough to detect single parasites in blood using a chemiluminescent detection system. This method of nonradioactively labeling oligonucleotides for the detection of infectious agents will enable the use of such probes in endemic regions in developing countries.

Intussusception: prediction of outcome of gas enema

Gas has replaced barium as the preferred medium for enema reduction of intussusception in tertiary pediatric institutions. Previously, adverse clinical features that in combination predicted a low likelihood of successful reduction using barium had been identified and used to select patients suitable for attempted enema reduction. This study examines whether these adverse features are equally applicable to gas reduction of intussusception. For any given number of adverse features, gas enema reduction was found more likely to be successful than barium reduction and, in the absence of clinical evidence of peritonitis, multiple adverse features probably do not represent a contraindication to attempted gas enema reduction.

Supplementation of breastfeeding infants and weight loss in hospital

Charts were reviewed to determine the frequency of glucose water supplementation of breastfed babies during their hospital stay and to discover if glucose water supplementation affected weight loss. Babies who received glucose water supplementation lost more weight and stayed in hospital longer than babies who did not receive supplementation. These findings were statistically significant. Routine supplementation with glucose water is unnecessary and potentially harmful to the baby. Stopping this practice may increase the mother's milk supply, increase her confidence in the adequacy of her supply and decrease the length of hospital stay.

Growth and toxigenesis of C. botulinum type E in fishes packaged under modified atmospheres

Modified atmosphere packaging of fresh fish is used to market high quality products in some European countries. The potential risk of C. botulinum growth in these extended shelf-life foods is still a concern; especially since toxigenesis may precede organoleptic spoilage. This paper will present toxigenic data from rockfish, salmon and sole muscle tissues which were inoculated with a pool of non-proteolytic C. botulinum type E at seven levels (10(-2)-10(4) spores/sample), and stored under vacuum and 100% CO2, at incubation temperatures between 30 and 4 degrees C, for up to 60 days. Factorial experimental design allowed predictive formulae to be developed able to describe the lag time prior to C. botulinum toxigenesis and the probability of one spore to initiate toxigenesis based upon the storage conditions. Accurate characterization of the microbial ecology of C. botulinum in modified atmosphere-packaged fish, will support safe exploitation of these packaging systems in the market place, and identify critical control points for potential product or process abuses.