Getting up to speed: adjusting to the pace of accident and emergency

Michelle Gracia, Second Year Student Nurse (Adult), School of Health Studies, Gibraltar Health Authority looks reflects on the importance of communication with patients and colleagues.

Thrombin in combination with intensive nursing in treating upper gastrointestinal bleeding in children

Pediatric upper gastrointestinal bleeding, a commonly seen pediatric emergency, needs timely symptomatic treatment to avoid a worse outcome. To discuss the clinical effect of thrombin treatment in combination with intensive nursing on pediatric upper gastrointestinal bleeding, this study analyzed 128 children who were treated in the second ward of the Children’s Internal Medical Department in the First Affiliated Hospital of Zhengzhou University between February 2012 and December 2014. The patients were divided into two groups, an experimental group and a control group. Besides thrombin, the experimental group was given intensive nursing, consisting of regular nursing and targeted nursing, while the control group was given regular nursing only. Clinical indexes of the two groups, such as effective rate, nursing satisfaction and side effect rate, were compared. Relevant clinical indexes such as duration of hospital stay, time to stopping of bleeding and Self-Rating Anxiety Scale (SAS) score, as well as overall satisfaction level of the observation group were all better than those of the control group and differences between the two groups had statistical significance (P less than 0.05). Furthermore, difference of overall effective rate between the experimental group (90.63%) and the control group (68.75%) was significant. Difference of incidence of side effects between the two groups was statistically significant. Thus thrombin treatment in combination with intensive nursing proved to have a remarkable clinical effect and high safety level in treating pediatric upper gastrointestinal bleeding and, moreover, it shortens treatment time and enhances the patients’ quality of life.

Neonatal eosinophilic gastroenteritis: possible in utero sensitization to cow's milk protein

Rectal bleeding in neonates is an alarming sign that suggests a possible serious underlying condition, such as infection or bleeding disorder that would necessitate hospitalization and prompt intervention. We report a case of eosinophilic gastroenteritis caused by cow's milk protein allergy in a one-day- old infant, who presented with frankly bloody stools associated with massive gastrointestinal and peripheral blood eosinophilia prior to initiation of enteral feedings. The patient's outcome was favorable, with complete spontaneous recovery in one week, after a period of bowel rest, parenteral nutrition, and use of amino acid formula. The eosinophilia was also transient and gradually resolving by two months of age. Rectal bleeding secondary to allergic colitis caused by cow's milk sensitization may occur in neonates, and failure to appreciate this possibility may lead to inappropriate diagnostic or therapeutic intervention.

Management of patients with complications of cirrhosis

Cirrhosis results from repeated hepatocellular injury over time, leading to portal hypertension and the development of ascites, hepatic encephalopathy, and varices. Despite improvements in medical care for patients with cirrhosis, mortality from infection, renal failure, and hepatocellular carcinoma remain high.

Nurses' experiences with catastrophic upper gastrointestinal bleeding in patients with hepatocellular carcinoma: a qualitative study

PURPOSE

To explore how nurses experienced catastrophic upper gastrointestinal bleeding in hepatocellular carcinoma (HCC) patients.

METHODS

A qualitative descriptive method was used. Data were collected by semi- structured interviews. Twenty-one registered nurses who had taken care of HCC patients with catastrophic upper gastrointestinal bleeding were purposely recruited from the Department of Hepatobiliary Cancer, Tianjin Medical University Cancer Institute and Hospital located in mainland China.

RESULTS

Four themes explicated from the study were: feelings expressed during the process of rescuing the lives of patients, feelings expressed from succeeding or failing to save the lives of patients, feelings expressed from family members response to nurses' actions, the impact of the experience on the personal life, work and philosophy of life of the nurse subjects.

CONCLUSIONS

The findings of this study indicate that it is necessary for nursing leaders to take effective measures to improve nurses' nursing skills, to provide more education in care of the dying, to offer nurses services that address their psychosocial health and to provide them with emotional support.

[Applying uncertainty theory in caring for the family of a von Willebrand disease patient experiencing first time upper gastrointestinal bleeding]

The purpose of this report was to describe the nursing experience in helping a primary caregiver cope with uncertainty as his mother experienced upper gastrointestinal (UGI) bleeding underlying von Willebrand disease and Scleromyxedema in an Emergency Department between 10 and 18 July 2008. Mishel's Uncertainty Theory was applied to assess the caregiver's uncertainty and patient disease progression. Data were collected through clinical observation, chart review, and interviews. The caregiver's nursing problems were identified as (1) uncertainty caused by symptoms of the rare disease and the probability of recurrent bleeding in the future; (2) uncertainty caused by lack of knowledge about the disease; (3) uncertainty caused by lack of confidence in home caring issues after UGI bleeding. During the nursing period, we provided clinical information related to the disease and offered psychological support to the caregiver based on our Mishel's Uncertainty Scale assessment. Successful strategies utilized by our intervention helped the caregiver reduce level of uncertainty, increase confidence to care for his mother, and improve the quality of further home care.

The importance of process issues as predictors of time to endoscopy in patients with acute upper-GI bleeding using the RUGBE data

BACKGROUND

Early endoscopy has been shown to improve outcomes and optimize cost-effectiveness in nonvariceal upper-GI bleeding (NVUGIB). However, there is little information regarding clinical and process determinants that affect the time from onset of bleeding to performance of the endoscopy.

OBJECTIVE

The aim of this study was to identify factors that predict time to endoscopy in patients with new onset NVUGIB.

DESIGN

Linear regression models were constructed with time between triage (outpatients) or onset of bleeding (inpatients) and the performance of endoscopy.

SETTING

The RUGBE is a nationwide, multicenter database collected for the purpose of obtaining descriptive data on patients with NVUGIB.

PATIENTS

The study population consisted of 1500 patients (89.6%) who underwent gastroscopy within 48 hours.

RESULTS

Median time to endoscopy was 12 hours (95% CI 11.0, 13.0). Endoscopy after working hours (regression coefficient [beta] -3.52; 95% CI -5.47, -1.58), availability of an endoscopy nurse on-call for the procedure (beta -2.48; 95% CI -3.83, -1.14), and admission to a hospital unit were associated with a shorter interval to endoscopy. In contrast, the presence of chest pain (beta 3.65; 95% CI 1.64, 5.67) or dyspnea (beta 2.79; 95% CI 1.10, 4.48), absence of gross blood on rectal examination (beta 2.20; 95% CI 0.69, 3.71), and inpatient status at onset of bleeding (beta 14.6; 95% CI 8.70, 20.4) were independent predictors of a delayed endoscopy. Subgroup analysis showed that actual time intervals as well as independent predictors of time until endoscopy differed between inpatients and outpatients.

LIMITATIONS

Retrospective analysis.

CONCLUSIONS

The timing of endoscopy in patients with NVUGIB is dependent on both clinical and process parameters, which differ between inpatient and outpatient settings. They bear implications with regards to shaping practice and deciding on resource allocation in order to facilitate an early endoscopy, which is currently recommended for improved patient outcomes.

Efficacy and safety of nurse-administered propofol sedation during emergency upper endoscopy for gastrointestinal bleeding: a prospective study

BACKGROUND AND STUDY AIMS

Recent studies have documented the safety of propofol sedation for endoscopic procedures, but many endoscopists are reluctant to use propofol for high-risk patients because of adverse effects. The aim of this study was to demonstrate the safety and efficacy of nurse-administered propofol sedation during emergency upper endoscopy for patients with gastrointestinal bleeding.

PATIENTS AND METHODS

Over a period of 18 months, 120 patients suffering from acute upper gastrointestinal bleeding received propofol sedation administered by a registered nurse. Among these, 15 patients were classified into American Society of Anesthesiologists (ASA) class IV, 84 were ASA class III, and 21 were ASA class II. Patients without gastrointestinal bleeding, who also received propofol during the same period and were matched for age, gender, and ASA class, served as controls.

RESULTS

Endoscopic hemostasis was achieved in 98.3 % of patients, and 97.5 % were satisfied with the procedure. In patients with gastrointestinal bleeding, the rates of hypotension (systolic blood pressure < 90 mmHg) and hypoxemia (peripheral oxygen saturation < 90 %) were 8.3 % and 6.7 % respectively, values higher than those in the control group. However, neither mask ventilation nor endotracheal intubation was necessary. Although two patients with gastrointestinal bleeding developed pneumonia, most likely due to aspiration during the procedure, they recovered within 5 days of treatment. There were no sedation-associated severe complications or mortalities.

CONCLUSION

Using a strict protocol designed to protect the patient's airway and cardiovascular function, nurse-administered propofol sedation during emergency upper gastrointestinal endoscopy is safe and appropriate in cases of acute gastrointestinal bleeding.

Performing Capsule Endoscopy

Small bowel bleeding is difficult to locate with current technology and costly to treat because of repeated diagnostic workups and hospitalizations. Some patients will eventually undergo intraoperative enteroscopy, the current gold standard. If the cause of bleeding is found, they may then have a bowel resection to treat their condition. Capsule endoscopy is a new technology that may greatly increase the ability to diagnose patients with recurrent obscure gastrointestinal bleeding and help reduce their treatment time and cost.

Symptom status and health-related quality of life: clinical relevance

BACKGROUND

Nursing continues to struggle to identify outcomes that measure quality of care. Health-related quality of life (HRQOL) has been identified as an outcome indicator that is sensitive to health-care interventions. However, clinicians remain skeptical about its relevance.

AIM

This article discusses the conceptual issues surrounding HRQOL research and provides an example that demonstrates how symptom status can serve as a clinically relevant and measurable dimension of HRQOL.

METHODS

The study sample (n = 99) were patients presenting to the emergency department of an academic medical centre in the United States of America (USA) between July 1997 and March 1999 with the diagnosis of gastrointestinal bleeding. The mean age was 57.86 (17.52) years and 62.6% of the sample was male. The Short Form-12 (SF-12) (measurement used for HRQOL) and a 15-item symptom checklist were administered within the first 24 hours following the emergency department visit and by phone 1 month after discharge.

RESULTS

Regression analysis controlling for age, gender, haematocrit and comorbidities was used to examine the relationships between symptom status and HRQOL. The analysis suggests that symptom status is a key predictor of HRQOL.

STUDY LIMITATIONS

The sample was a relatively small convenience sample from one emergency department in the USA.

CONCLUSIONS

Nurses are concerned with improving patients' HRQOL. Certainly, symptoms are amenable to nursing interventions. We provide one example that demonstrates the relationship between symptom status and HRQOL. By tracking and studying trends in the number of symptoms over time we can begin to track HRQOL as an outcome of care. Thus, we conclude that by helping patients manage their symptoms their overall HRQOL would improve.

A critical analysis of the routine testing of newborn stools for occult blood and reducing substances

Stool tests for occult blood or reducing substances were introduced in the neonatal intensive care unit (NICU) as potential aids in the early recognition of necrotizing enterocolitis (NEC) in high-risk neonates, and have been recommended by some as routine nursing procedures. Neither the performance characteristics of these tests with respect to NEC, nor their indirect impact, were evaluated formally before widespread adoption into clinical care. The published evidence suggests that these tests are not useful as diagnostic or screening tools. There is no evidence that routine stool screening for occult blood or reducing substances predicts NEC or decreases the rate or severity of this disease. The direct costs of the tests are significant. A greater concern is their potential unintended consequences, which include the cost of secondary tests, restricted nutritional intake, and the accumulation of distracting, useless data. The logistics of maintaining quality control, the demands on nursing time, and the cost of testing are increasingly important considerations. This installment of Focus on the Physical diverges from a step-by-step systematic physical assessment by addressing the utility of testing neonatal stools for occult blood and reducing substances as aids in the early diagnosis or prevention of NEC. Using the information from these tests requires a framework for understanding their rationale, the test performance characteristics in the NICU setting, and the potential benefits, costs, and risks of their routine use.

Nurse-led direct access endoscopy clinics: the future?

BACKGROUND

Many studies have shown that rectal bleeding is a good indicator of underlying colorectal pathology, and that ost of the lesions in patients presenting with rectal bleeding lie in the left side of the colon [1, 5, 9, 12, 23, 26]. The recent acceptance of the nurse-practitioner by the National Health Service may allow the use of nurse-endoscopists to develop throughout the United Kingdom. This study aimed to audit a unique nurse-led direct-access nurse-endoscopy service with regard to its efficacy and cost effectiveness, and to monitor patient satisfaction and direct referrals from the primary health sector.

METHODS

A nurse-led open-access flexible sigmoidoscopy (OAFS) service for patients reporting fresh rectal bleeding was established at our center in February 1996. A prospective audit of sigmoidoscopic findings and a retrospective analysis of referral patterns from local general practitioners were conducted. A questionnaire survey of both patient and general practitioner satisfaction also was conducted at the same time.

RESULTS

Since February 1996, 706 patients have been referred to our service. Rectal bleeding was by far the most common cause for referral, representing the dominant symptom in 92% of the referrals received. Although 99% of the patients underwent a complete sigmoidoscopic examination, 16% of these examinations were limited because of several factors combined. A cause for bleeding was identified in 91% of the patients, with 24% of them experiencing subsequent significant pathology. Of the patients surveyed, 99% were satisfied with the service provided. The results also show nurse-led OAFS to be a more effective use of financial resources, costing $90 less per patient than general practitioner referrals sent to a consultant for further action.

CONCLUSIONS

Rectal bleeding is a good indicator of underlying colorectal disease. Most of the significant lesions presenting with this symptom are found in the left side of the colon. A nurse-led OAFS is safe, effective, and acceptable to patients. It also is more cost effective than a consultant-led service.

Esophageal varices: treatment and implications

The purpose of this article is to present an overview of esophageal varices. The causes of esophageal varices and the current treatments are examined. Information is provided regarding surgical and nonsurgical forms of treatment. Various aspects of nursing care are discussed, including the implications involved in the emergency setting, psychological needs, and education for patients and their families.

Acute gastrointestinal bleeding

Acute gastrointestinal bleeding is responsible for 1% to 2% of all hospital admissions in the United States annually. An awareness of common and uncommon pathologies will allow the clinician to develop a plan for the diagnostic evaluation that will lead to a diagnosis and localization of the bleeding site. Successful diagnosis and subsequent treatment are dependent on selecting the diagnostic tests that pinpoint the bleeding source accurately and in the most cost-effective manner.

Gastrointestinal bleeding in children. Implications for nursing

Gastrointestinal (GI) bleeding is a common reason for a pediatric surgical consult. Nurses who care for children can gather important data in their patient assessments. An understanding of the cause, diagnosis, and management of select disease entities that result in GI bleeding will aid the nurse in the assessment and care of pediatric patients. This article provides an overview of these conditions.

Selected complications in the patient with cancer: spinal cord compression, malignant bowel obstruction, malignant ascites, and gastrointestinal bleeding

The growth rate of a tumor, patterns of tumor growth and metastatic spread, and toxicity of therapy contribute to the type and severity of complications. Four common critical care complications resulting from compressive and invasive properties of tumors include spinal cord compression, malignant bowel obstruction, malignant ascites, and gastrointestinal bleeding. Knowledge of the clinical presentations of each of these complications provides a foundation for nursing assessment.

Evaluation and revision of a vasopressin/nitroglycerin protocol for use in variceal bleeding

BACKGROUND

Continuous infusion of IV vasopressin have been widely used to lower portal pressure and reduce bleeding from esophageal varices. Recently, the combination of vasopressin and nitroglycerin has been noted to be superior to vasopressin alone. This is due to the ability of nitroglycerin to reduce the detrimental effects of vasopressin while preserving its beneficial effects. In September 1989 the authors initiated a protocol in the medical intensive care unit of a large university teaching center that directed caregivers in the simultaneous use of vasopressin and nitroglycerin for use in variceal bleeding.

OBJECTIVE

To determine whether the protocol was being used correctly and whether the addition of nitroglycerin produced the desired cardiovascular effects.

METHOD

Nineteen patients (25 separate episodes) assigned to the vasopressin/nitroglycerin protocol were monitored retrospectively over a 20-month period for a total of 1068 hours of vasopressin/nitroglycerin infusion. Twenty-four patients received nitroglycerin at 10 to 50 micrograms per minute, 13 at 50 to 100 micrograms per minute and 6 at 100 to 400 micrograms per minute.

RESULTS

Nitroglycerin dosage was not advanced appropriately in 78% of episodes despite evidence of bradycardia, hypertension and peripheral vasoconstriction.

CONCLUSIONS

Revision of the protocol, giving additional guidance to clinicians on assessment and nitroglycerin advancement, was necessary and was accomplished.

The adult with bleeding esophageal varices

Bleeding esophageal varices are a life-threatening complication of portal hypertension. During the emergent phase, nurses have an important role in assessing the patient's response to volume replacement and in monitoring interventions to control hemorrhage. Complications contribute to the high mortality associated with variceal hemorrhage. Knowledge of the pharmacologic side effects of vasopressin and of the potential complications associated with endoscopic injection sclerotherapy and esophagogastric balloon tamponade is critical for successful nursing management of the adult with bleeding esophageal varices. The goal of long-term management is to prevent recurrent hemorrhage. This is accomplished by repeated injection sclerotherapy and strategies to reduce portal pressure. Patient education is focused on modification of behaviors that increase the risk for bleeding and on the early recognition of recurrent bleeding.

A new approach to esophageal varices: endoscopic variceal ligation

Bleeding from esophageal varices is a devastating complication of portal hypertension and is associated with a high mortality rate. The management goals for this group of patients are to achieve hemostasis in the acute phase, reduce variceal size, reduce the potential of rebleeding and eliminate varices with a follow-up program. For the past two decades, the gold standard of treatment has been endoscopic sclerotherapy but at the expense of many complications, which often cause serious morbidity. Endoscopic variceal ligation was developed as an alternative to endoscopic sclerotherapy. The experience to date shows that the goals of therapy can be achieved with fewer complications than those associated with sclerotherapy.

VP/NTG therapy in the patient with variceal bleeding

VP has long been used in patients with acute variceal bleeding. While NTG has generally only been added to offset the serious side effects of VP, it potentiates the hemodynamic effects of VP in the portal bed. It is imperative that the critical care nurse understand the combination use of VP and NTG so that intelligent assessment, care planning, and evaluation can occur.