Use of Scheduled Nonopioid Analgesia to Decrease Inpatient Opioid Consumption After Scheduled Cesarean Birth.

OBJECTIVE: To compare opioid use and pain scores in women who had scheduled cesarean birth before and after implementing a scheduled nonopioid analgesia practice guideline. DESIGN: Quality improvement project with a comparison of pre-/postintervention. SETTING/LOCAL PROBLEM: A 170-bed community hospital where the administration of postcesarean pain medications was unstandardized. PARTICIPANTS: Convenience sample of 175 individuals who were scheduled for cesarean birth (106 in preintervention group and 69 in postimplementation group). INTERVENTION/MEASUREMENTS: All participants had received a dose of 150 mcg of intrathecal morphine intraoperatively. Care of participants in the postimplementation group included a new practice guideline using preoperative oral acetaminophen 1 g and postoperative intravenous ketorolac 30 mg that transitioned to ibuprofen 600 mg orally every 6 hours until discharge. Acetaminophen 1 g every 6 hours also continued until discharge. For breakthrough pain, oxycodone 5 mg to 10 mg was available. RESULTS: Results were analyzed using the chi-square and t test. There was a statistical difference in the mean milligram morphine equivalent consumed after scheduled cesarean birth (preintervention = 21.15 vs. postintervention = 3.91, p < .001). Postimplementation, 84.1% of participants did not consume any opioids beyond the intrathecal dose compared to 47.2% of participants preintervention. Mean pain scores decreased from 2.49 to 1.62 (p < .001), and there was an observed decrease of the highest reported pain score from 5.39 to 4.03 (p < .001). CONCLUSION: The results of this project support the current literature indicating that the administration of a scheduled nonopioid multimodal analgesia regimen to individuals with scheduled cesarean birth is an effective postoperative pain management strategy. This approach to managing surgical birth pain can decrease subjective reports of pain and overall opioid consumption during the hospital stay.

Is it Noise? Factors Linked With Sleep Interruption in Hospitalized Patients.

PURPOSE/AIM: The aim of this study was to explore the perceived quality of sleep and sleep disturbances in hospitalized patients. DESIGN: A prospective descriptive, exploratory, cross-sectional study was conducted at a 172-bed community hospital in Northeast Ohio. A convenient sample of 100 hospitalized patients was recruited from medical/surgical, progressive care, and intensive care units. METHODS: Participants used the Richards-Campbell Sleep Questionnaire to report sleep. A quality of sleep assessment survey was used to collect information regarding 17 factors leading to decreased quality of sleep. RESULTS: Mean sleep score was 47.92 for each question regarding sleep depth, latency, awakenings, time spent awake, and overall sleep quality. Pearson's correlation showed a significantly positive correlation between measure of noise and sleep score. Five environmental factors were identified as most disruptive to sleep: pain, laboratory draws, staff, blood pressure checks, and intravenous alarms. CONCLUSION: The positive correlation between sleeping well and higher noise levels is noteworthy. Raising awareness about the importance of sleep in the hospital setting and introducing interventions to promote a quiet environment and minimize sleep-disturbing factors may increase patient satisfaction scores and improve healing.

Considerations When Using Telemedicine As the Advanced Practice Registered Nurse.

Accessibility to health care is crucial to management of chronic and acute conditions. Although the severe acute respiratory syndrome coronavirus 2 pandemic significantly impacts the issue of access to health care, with the introduction of Waiver 1135, telehealth has become a positive strategy in increasing safe access to health care. This report addresses considerations to take into account when advanced practice registered nurses use telehealth to facilitate access to care.

Childhood obesity and dental caries in homeless children.

INTRODUCTION: Childhood obesity and dental caries are increasing epidemics, especially among children who are living below the poverty level. This study was conducted to determine the relationship between body mass index (BMI) and caries in homeless children. METHODS: A secondary data analysis with a correlational design was used. A convenience sample of 157 children was recruited from a homeless shelter. RESULTS: Pearson's and partial correlations were used to explore the relationships among age, BMI, and caries. Most of the children were girls and were African American. Slightly more than half of the children were overweight (19.7%) or obese (30.6%) and had caries (50.3%). Significant positive correlations between age and BMI (p = .03) as well as between age and caries (p = .003) were found. As BMI increased, so did caries (p = .08). DISCUSSION: Consistent with reports from the Centers for Disease Control and Prevention, homeless children had higher BMI and caries rates than the national averages. Although a definitive conclusion between obesity and dental caries cannot be drawn, these two health issues are important areas for all pediatric health care providers to address at every visit.

Changes in gastric mucosa, submucosa, and muscularis IC pH may herald irreversible tissue injury.

Previously we noted an abrupt rise in gastric intracellular pH (IC pH) and bicarbonate buffering between 15 and 30 min of cardiac arrest which we termed agonal alkalinization, failure of pH regulation. Agonal alkalinization may represent the transition point between reversible and irreversible injury. We asked the question, what is the sequence of change in IC pH within the gastric layers, mucosa, submucosa, and muscularis, and which layer is most sensitive? This research explored changes in IC pH within the stomach layers, mucosa, submucosa, and muscularis, at 0, 5, 15, 30, and 40 min, under three conditions, normoxia (control), ischemia (cardiac arrest), and eucapnic hypoxia (12 % oxygen). The mucosa was the most alkalotic gastric layer at baseline. Ischemia and hypoxia at 40″ produced different layer responses with the mucosa and submucosa the most sensitive layers during ischemia and the muscularis during hypoxia. Further study to examine the mechanism of changes between gastric layers using spatial-temporal techniques may assist in understanding the transition to irreversible injury.

Differences in women's psychological well-being based on infertility treatment choice and outcome.

INTRODUCTION: The empirical foundation regarding women's experiences with infertility is influenced by the use of clinically based populations of women who are seeking medical assistance to conceive. Although the experience of infertility and involuntary childlessness is recognized as a significant life stressor characterized by a loss of control, bodily integrity, and identity, little is understood about women who perceive an infertility problem but do not seek treatment. METHODS: A secondary analysis was conducted by using a national probability sample from the National Survey of Fertility Barriers. Women (N = 142) who self-reported perceptions of fertility problems were placed in 1 of 3 groups based on the decision to seek/not seek treatment and treatment outcome. RESULTS: When we controlled for marital status, women who conceived with medical assistance reported significantly higher levels of life satisfaction and held parenting as more important than women who sought treatment and did not conceive and women who did not seek treatment. DISCUSSION: Women who did not seek treatment for perceived infertility problems reported a decreased sense of the importance of parenthood but also reported lower levels of self-esteem and life satisfaction than women who sought treatment, regardless of treatment outcome.

A pilot study comparing two developmental screening tools for use with homeless children.

Homelessness and poverty can present serious health issues for children, including those associated with developmental delays. Early identification and intervention may decrease risk associated with delayed development. Parent-completed measures have been used to help screen for children's development, but little is known about how they may enhance early detection with homeless children. The primary aims of this pilot study were to describe growth and developmental characteristics of homeless children and to compare a parent-completed measure with professionally-conducted developmental screening results. A prospective, comparative study was conducted with 20 homeless mothers and their 21 children. Health professionals used the Denver Developmental Screening Test II, identifying nine children with possible language delay. Mothers completed the Ages and Stages Questionnaires and identified three areas of concern: fine motor (n = 9), communication/language (n = 4), and problem solving (n = 4). The percentage agreement between these two tools was strongest in gross motor (95%) and personal social development (95%) but weakest in language development (67%). While it is essential for all children, developmental screening is particularly crucial for homeless children because of increased risks related to poverty and homelessness. Nurses and nurse practitioners are in a unique position to assess applicability of such instruments and to provide critically needed interventions for these children.

Maternal voice and short-term outcomes in preterm infants.

This study explored effects of exposure to maternal voice on short-term outcomes in very low birth weight preterm infants cared for within an neonatal intensive care unit (NICU) without an ongoing program of developmental care. Using a comparative design, 53 infants born during their 27th to 28th postmenstrual week were sampled by convenience. Experimental groups were exposed to maternal voice during two developmental time periods. Group 1 listened to a recording of their mothers reciting a rhyme from 28 to 34 postmenstrual weeks. Group 2 waited 4 weeks and heard the recording from 32 to 34 weeks. The control group received routine care. The primary analysis of combined experimental groups compared to the control group revealed that the experimental infants experienced significantly fewer episodes of feeding intolerance and achieved full enteral feeds quicker compared to the control group. Further, in an analysis evaluating all three groups separately, it was noted that Group 1 experienced significantly fewer episodes of feeding intolerance compared to the control group. Study findings warrant further investigation of exposure to maternal voice and the developmental timing at which exposure is begun.

Effect of early skin-to-skin contact on mother-preterm infant interaction through 18 months: randomized controlled trial.

BACKGROUND: Preterm birth often negatively influences mother-infant interaction. Skin-to-skin contact postbirth has positive effects on maternal feelings toward their preterm infants and on infant development and family interaction. However, little is known about the long-term effects of skin-to-skin contact on mother-late preterm infant interaction when skin-to-skin contact was experienced early postbirth and intermittently throughout the next five days. OBJECTIVE: The purpose of this report was to examine the effect of skin-to-skin contact on mother-late preterm infant interaction through 18 months. DESIGN: Randomized controlled trial with follow-up. SETTING: Two hospitals in the United States of America. PARTICIPANTS: 100 mothers and their late preterm infants, 32 to <37 weeks' gestation, were recruited. Mother-preterm infant interactions were assessed in 69, 70, and 76 dyads at 6, 12, and 18 months. METHODS: Mothers and their preterm infants were videotaped during a feeding session at 6 and 12 months, and a teaching session at 6, 12, and 18 months. Their interactions were then scored using the Nursing Child Assessment Satellite Feeding Scale and Teaching Scale. RESULTS: Skin-to-skin contact and control dyads had comparable feeding scores at 6 and 12 months. Skin-to-skin contact infants had lower infant teaching scores at six months, a difference that disappeared thereafter. CONCLUSIONS: These inconclusive results call for additional studies with larger doses of skin-to-skin contact, larger sample sizes, and other outcome measures of mother-late preterm infant interactions. Such measures include the Parent-Child Early Relational Assessment and behavioral coding during play.

Skin-to-skin contact for culturally diverse women having breastfeeding difficulties during early postpartum.

BACKGROUND: Early breastfeeding (BF) cessation is more common in black women and women who experience BF difficulties during early postpartum. Skin-to-skin contact (SSC) during early postpartum promotes and sustains BF. The focus of this secondary analysis is on BF status and maternal race/ethnicity. METHODS: Data were collected in a prospective exploratory study with 48 healthy and culturally diverse mother-full-term infant dyads. These dyads were selected because they were experiencing BF difficulties postbirth (mean, 16.9 hours). Following informed consent, the SSC intervention was given with four BFs: the next three after enrollment plus one before hospital discharge. BF status (duration and exclusivity) was measured using a six-category instrument, the Index of Breastfeeding Status, at hospital discharge and by telephone interview 1 week and 1 month later. RESULTS: BF status was generally similar in this culturally diverse sample, except that at 1 month black mothers had lower exclusive BF (33%) and higher BF cessation (46.7%). These mothers were all high risk for poor BF outcomes, with black mothers at highest risk. Even so, BF outcomes exceeded those in studies that included all BF mothers whether or not they were having difficulties. CONCLUSIONS: Based on these findings, we propose that this SSC BF intervention, provided in hospital in a time-sensitive manner by a warm perceptive person, can transcend the likelihood of early BF cessation for most mothers regardless of race/ethnicity.

Newborn temperature during skin-to-skin breastfeeding in couples having breastfeeding difficulties.

BACKGROUND: Kangaroo (skin-to-skin contact) care facilitates the maintenance of safe temperatures in newborn infants. Concern persists that infants will become cold while breastfeeding, however, especially if in skin-to-skin contact with the mother. This concern might be especially realistic for infants experiencing breastfeeding difficulties. The objective was to measure temperature during a study of mothers and infants who were having breastfeeding difficulties during early postpartum and were given opportunities to experience skin-to-skin contact during breastfeeding. METHOD: Forty-eight full-term infants were investigated using a pretest-test-posttest study design. Temporal artery temperature was measured before, after, and once during 3 consecutive skin-to-skin breastfeeding interventions and 1 intervention 24 hours after the first intervention. RESULTS: During skin-to-skin contact, most infants reached and maintained temperatures between 36.5 and 37.6 degrees C, the thermoneutral range, with only rare exceptions. CONCLUSIONS: The temperatures of study infants reached and remained at the thermoneutral range during breastfeeding in skin-to-skin contact. The data suggest that mothers may have the ability to modulate their infant's temperature during skin-to-skin contact if given the opportunity. Hospital staff and parents can be reassured that, with respect to their temperature, healthy newborn infants, with or without breastfeeding difficulties, may safely breastfeed in skin-to-skin contact with their mothers.

Grief, anxiety, stillbirth, and perinatal problems: healing with kangaroo care.

A young, anxious mother's first pregnancy was eclamptic, her placenta was underperfused, and her son was stillborn. She carried grief, guilt, anxiety, and hypervigilance into her next preeclamptic pregnancy, birth (of her small-for-dates son), and early postpartum period. When breastfeeding difficulties developed, the authors intervened with three consecutive (skin-to-skin) breastfeedings. During the first skin-to-skin breastfeeding, the mother stopped crying, shared self-disparaging emotions, and then began relaxing and "taking-in" her new baby. Breastfeeding continues at 1 year.

Development of an observational instrument to measure mother-infant separation post birth.

The importance of the timing, quality, and quantity of early maternal-infant contact has gained prominence over the years. However, no researcher has adequately documented the nature of maternal-infant contact and separation. This study assessed the psychometric properties of the Index of Mother-Infant Separation (IMIS), pronounced "I miss," which is a 37-item observational measure of the process of mother-infant contact or separation post birth. Assessment of reliability and validity of the IMIS was conducted using data collected in a randomized clinical trial with 224 healthy newborn infants assigned at 1 hour post birth to self-regulatory or routine nursery care (control) groups. Time-sampled observations occurred every 15 minutes. Content validity indices of the IMIS, determined by nine nationally known perinatal experts, were 77% to 100% for instrument items. Construct validity was supported through known-groups hypothesis testing (p < .0001). Interrater reliability was from 86% to 90%. The IMIS is a valid observational measure of maternal contact when raters are trained to score it reliably.

Mother-newborn contact in a randomized trial of kangaroo (skin-to-skin) care.

OBJECTIVE: To describe the type and percent time of contact 0-48 hours postbirth for mother-preterm newborn (infant) dyads given kangaroo care (skin-to-skin) or standard care (controls). DESIGN: Randomized controlled trial with assignment by computerized minimization to kangaroo care (n = 48) or control (n = 43). SETTING: Postpartum units and neonatal intensive-care units (NICU). PARTICIPANTS: Preterm infants 32 to less than 37 weeks gestation and their mothers. INTERVENTION: Kangaroo (skin-to-skin, SS) care (KC). MAIN OUTCOME MEASURES: Type and percent time of mother-infant contact (SS versus holding wrapped in blankets). RESULTS: Analyses were based on four groups: assignment for infants in each group to postpartum or NICU. For KC dyads, SS postpartum was 22.0%; SS NICU was 7.5%. KC wrapped holding postpartum was 11.6%; NICU was 1.8%. For control dyads, wrapped holding postpartum was 13.9%; NICU was 6.1%. CONCLUSION: Amount of SS was much less than expected. Reasons include unavailability of infants or mothers and hospital staff interrupting contact. However, KC postpartum dyads were held wrapped almost as often as control postpartum dyads. Total contact time for KC dyads (SS plus wrapped) was more than double that of controls. These data suggest that hospital and social supports for families are needed to facilitate early initiation of SS, prolonged periods of mother-infant SS contact, and reduction of maternal stress.