Nurses' Attitudes, Practices, and Barriers to Assessing Symptoms of Discomfort in Mechanically Ventilated Patients: A Cross-Sectional Study.

Introduction: Critically ill patients experience various stressful symptoms of discomfort, including dyspnea, pain, and sleep disruption. Notably, ventilated patients have difficulty self-reporting discomfort symptoms. Nurses need to assess discomfort symptoms to alleviate them, but limited research exists on discomfort symptom assessment and management in critically ill patients. Objective: To identify the practices, attitudes, and barriers among nurses related to the assessment of discomfort symptoms in mechanically ventilated patients. Methods: Using a cross-sectional, descriptive study design, a web-based survey was conducted between May and June 2022 with critical care nurses sampled through Japanese academic societies and social networking services. The survey contained questions relative to the above-stated objective. Descriptive statistical analysis was performed without sample size calculation because of the descriptive and exploratory nature of this study. Results: There were 267 respondents to the questionnaire. The discomfort symptoms that nurses perceived as important to assess were pain (median 100 [interquartile range, IQR 90-100]), insomnia (99 [80-100]), and dyspnea (96.5 [75-100]). Most participants (89.8%) routinely assessed pain in mechanically ventilated patients using a scale; however, other discomfort symptoms were assessed by less than 40% (dyspnea [28.4%], fatigue [8.1%], thirst [13.1%], insomnia [37.3%], and anxiety [13.6%]). Two major barriers to assessing discomfort symptoms were lack of assessment culture within the intensive care unit and lack of knowledge of the relevant evaluation scales. Conclusions: Nurses were aware of the importance of using scales to assess the discomfort symptoms experienced by mechanically ventilated patients. However, except for pain, most nurses did not routinely use scales to assess discomfort symptoms. Barriers to routine discomfort symptom assessment included the lack of an assessment culture and the lack of knowledge of the assessment scales. Clinicians should be educated regarding the existence of validated rating scales and develop additional rating scales utilizable for minor discomforts in mechanically ventilated patients.

The proportion of clinically relevant alarms decreases as patient clinical severity decreases in intensive care units: a pilot study.

OBJECTIVES: To determine (1) the proportion and number of clinically relevant alarms based on the type of monitoring device; (2) whether patient clinical severity, based on the sequential organ failure assessment (SOFA) score, affects the proportion of clinically relevant alarms and to suggest; (3) methods for reducing clinically irrelevant alarms in an intensive care unit (ICU). DESIGN: A prospective, observational clinical study. SETTING: A medical ICU at the University of Tokyo Hospital in Tokyo, Japan. PARTICIPANTS: All patients who were admitted directly to the ICU, aged ≥18 years, and not refused active treatment were registered between January and February 2012. METHODS: The alarms, alarm settings, alarm messages, waveforms and video recordings were acquired in real time and saved continuously. All alarms were annotated with respect to technical and clinical validity. RESULTS: 18 ICU patients were monitored. During 2697 patient-monitored hours, 11 591 alarms were annotated. Only 740 (6.4%) alarms were considered to be clinically relevant. The monitoring devices that triggered alarms the most often were the direct measurement of arterial pressure (33.5%), oxygen saturation (24.2%), and electrocardiogram (22.9%). The numbers of relevant alarms were 12.4% (direct measurement of arterial pressure), 2.4% (oxygen saturation) and 5.3% (electrocardiogram). Positive correlations were established between patient clinical severities and the proportion of relevant alarms. The total number of irrelevant alarms could be reduced by 21.4% by evaluating their technical relevance. CONCLUSIONS: We demonstrated that (1) the types of devices that alarm the most frequently were direct measurements of arterial pressure, oxygen saturation and ECG, and most of those alarms were not clinically relevant; (2) the proportion of clinically relevant alarms decreased as the patients' status improved and (3) the irrelevance alarms can be considerably reduced by evaluating their technical relevance.

Determining the optimal inner air cell pressure for the effective reduction of interface pressure.

Alternating-pressure air mattresses can reduce interface pressure and prevent pressure ulcer development. However, bottoming out sometimes occurs, resulting in an increase in interface pressure. Therefore, optimal settings should be determined based on interface pressures and inner air cell pressures. The purpose of this study was to investigate the most effective inner air cell pressure to reduce interface pressure without causing bottoming out. A new alternating air mattress was used, which comprised three layers: a base layer, fitting (F) layer, and alternating layer. The alternating layer comprises inflated (I) cells and deflating (D) cells. The study participants were 13 healthy volunteers over 18 years of age, each of whom adopted supine position on the mattress. The pressures in the D cells were gradually deflated under different I cell and F layer pressure settings. We measured peak sacral pressure and inner air cell pressure to obtain the bottoming out cut-off values by using receiver-operating-characteristic (ROC) curves. We then investigated the effectiveness of different settings to reduce the peak sacral pressures. A number of test conditions were evaluated. Results indicated that the D cell pressure cut-off points were 1.26 kPa and 1.21 kPa, for phases 1 (F = 4 kPa, I = 4 kPa) and 4 (F = 1 kPa, I = 4 kPa), respectively. These settings significantly reduced the interface pressure (P < 0.001, P = 0.026, respectively). Our results suggest that appropriate configuration of inner air cell pressure could reduce interface pressure without causing bottoming out.

Relationship between morphological characteristics and etiology of pressure ulcers in intensive care unit patients.

PURPOSE: Pressure ulcer (PU) prevention is crucial for critically ill patients in the intensive care unit, but etiologic factors leading to their development have not yet been completely elucidated. This study explores the relationships among etiologic factors, interventional nursing care, and morphological characteristics of PUs in intensive care unit patients. DESIGN: We used a qualitative exploratory method to link morphological characteristics of specific PUs to etiologic factors. METHODS: Details of individual PUs were described by sketching the PU photograph and categorized to characterize the morphology of PUs. After identification of characteristics, the development process was evaluated by in-depth review of medical records. RESULTS: The morphological characteristics of 30 PUs were organized into 4 categories. This process revealed a type of PU not previously described, which we labeled "leaf-type." These PUs were located on the lower sacrum, rhombic-oval in shape, and characterized by purpura and PU wrinkles. Possible etiologic factors for the specific PUs were divided into 4 categories: (1) the occurrence of PU risk episodes, (2) failure of the peripheral circulation, (3) periods of critical immobility, and (4) position change techniques inducing skin deformation. CONCLUSION: PU can be categorized into 4 morphological types, including a new category of leaf-shaped PU. We found that frequently repeated position changes such as lateral tilt and repeated head elevation caused deformation of the sacral skin that may play a role in PU development.