Frequency of Clinical Alarms in Intensive Care Units and Nurses' Sensitivity to Them: An Observational Study.

BACKGROUND: All clinical alarms require nurses to respond even if an intervention is not needed. Nurses are expected to respond appropriately to each alarm and establish priorities among their care practices accordingly. This study was conducted to examine the number and types of clinical device alarms used in intensive care units, the duration of their activation, and nurses' degree of sensitivity to them. METHODS: This observational study was conducted in 4 intensive care units in a university hospital in Turkey. A total of 20 nurses (5 from each unit) were observed for a total of 80 hours. The alarms were categorized as valid, false, or technical. RESULTS: During the study observation period, the mean number of alarms sounding per hour per bed was 1.8. A total of 144 alarms were recorded, of which 70.8% were valid, 15.3% were false, and 13.9% were technical. The mean duration of alarm activation was 8 minutes for valid alarms, 14 minutes for false alarms, and 53 minutes for technical alarms. CONCLUSIONS: Nurses' responses to alarms differ depending on alarm type; for alarms that do not require an emergency intervention, nurses tend to respond late or not at all.

Sacral Skin Temperature and Pressure Ulcer Development: A Descriptive Study.

Existing evidence is inadequate to assume increased skin temperature is a risk factor for the development of pressure ulcers (PUs). PURPOSE: The purpose of this prospective, descriptive study was to examine the relationship between sacral skin temperature and PU development. METHODS: Using convenience sampling methods, patients who were hospitalized in the tertiary intensive care unit (ICU) of the internal medicine department of a university hospital in Izmir, Turkey, between April and December 2015 were eligible to participate if they were ⟩18 years of age, had an expected hospital stay of at least 5 days, a Braden score ≤12, and were admitted without a PU. Demographic and clinical data collected included age, gender, body mass index, diagnosis, mattress type, length of follow-up (days), systolic and diastolic blood pressure, body temperature, hemoglobin level, sacral skin temperatures in the supine and lateral positions, room temperature, PU stage and duration, and Braden score. Temperature was measured the day of hospitalization as a baseline measurement (day 1) and once every day thereafter up to 22 days, until the patient did or did not develop a PU, died, was no longer undergoing position change, or was discharged. Sacral skin temperature was taken immediately after the patient was moved to a lateral position following 120 minutes of supine position (referred to as supine position sacral skin temperature measurement) and after 30 minutes in lateral position (referred to as lateral position sacral skin temperature measurement). Data were collected using paper-and-pencil questionnaires and entered into a software program for analysis. Descriptive statistics, Student's t test, one-way analysis of variance test, Pearson product-moment correlation analysis, and Spearman's rank-order correlation analysis were used for data analysis. RESULTS: Of the 37 patients who met the inclusion criteria and were monitored for at least 5 days, 21 (56.8%) developed PUs. No statistically significant difference in supine position sacral skin temperature on day 1 or day 5 was found between patients who did and did not develop a PU (36.90° C ± 0.29° C and 37.15° C ± 0.53° C, respectively, on day 1; t = -1.656, P = .112; and 37.37° C ± 0.53° C and 37.30° C ± 0.79° C, respectively, on day 5; t = 0.259, P = .798). Day 5 lateral position skin temperatures also did not differ significantly between the 2 groups (37.44° C ± 0.44° C and 37.31° C ± 0.75° C, respectively; t = 1.306, P = .621). A statistically significant difference was noted between mean sacral skin temperature in the supine position among patients ages 75 to 90 years compared with patients 38 to 64 years and 65 to 74 years (36.93° C ± 0.39° C; F = 13.221, P = .000) and with use of a viscoelastic mattress compared with an alternating pressure air mattress and continuous lateral rotation alternating pressure air mattress (37.85° C ± 0.54° C; F = 14.039, P = .000). No statistically significant differences in sacral skin temperatures were found for any of the of the other variables assessed. CONCLUSION: Sacral skin temperatures were not statistically different between ICU patients who did and did not develop a PU. Additional research may help increase understanding of the relationship between skin temperature and PU development.

The effect on pain of three different nonpharmacological methods in peripheral intravenous catheterisation in adults.

AIMS AND OBJECTIVES: To compare the effectiveness in reducing pain during peripheral intravenous catheterisation of coughing, blowing into a spirometer and squeezing a stress ball. BACKGROUND: Peripheral intravenous catheterisation is widely performed by nurses; it causes pain and discomfort to patients. DESIGN: This was a single-blind randomized controlled study. METHODS: The sample of the study consisted of 120 males who came to donate blood. Before the peripheral intravenous catheterisation, the individuals were divided by a simple randomisation method into four groups: a coughing group, a blowing into a spirometer group, a stress ball squeezing group and a control group. During the procedure, the pain levels felt by the individuals were assessed using the visual analog scale by a nurse who was blinded to the procedure. FINDINGS: The mean pain of the individuals in the coughing group was found to be 19.5 mm (SD: 13.6), that of the spirometer group was 28.3 mm (SD: 20.2), that of the stress ball group was 32.1 mm (SD: 23.8) and that of the control group was 45.5 mm (SD: 19.5). Statistical analysis showed a significant difference between the mean pain scores of individuals in the control group and those of individuals in the coughing, spirometer and stress ball groups. CONCLUSION: The techniques of squeezing a stress ball, blowing into a spirometer and in particular coughing, depending on the potential mechanism of the Valsalva manoeuvre and diverting attention, are effective techniques in reducing the pain of peripheral catheterisation procedures. RELEVANCE TO CLINICAL PRACTICE: It is important that nurses should be aware of pain and stress experienced by patients during invasive procedures. For this reason, nurses should have knowledge of proven nonpharmacological methods which can reduce pain to a minimum.

Evaluation of oxygen saturation values in different body positions in healthy individuals.

AIMS AND OBJECTIVES: The research was conducted to evaluate oxygen saturation values measured in healthy individuals in different body positions. BACKGROUND: Changes in position affect ventilation-perfusion rates, oxygen transport and lung volume in normal lungs. There have been few studies and not enough information about which positioning of a healthy individual can increase oxygenation. DESIGN: A descriptive study. METHODS: A sample of 103 healthy individuals with no chronic disease, anaemia or pain was included in the research. Individuals were positioned in five different positions: sitting upright, supine position, prone position, lying on the left side and lying on the right side. Oxygen saturation and pulse rates were then measured and recorded after the individuals held each position for ten minutes. RESULTS: It was found that the average oxygen saturation value when measured while sitting in an upright position in a chair was significantly higher than that measured when the individual was lying on the right or left side of the body. Oxygen saturation values measured in the five different body positions were significantly higher in women, in individuals below the age of 35, in those with Body Mass Indexes of below 25 kg/m(2), and in nonsmokers. CONCLUSION: All of the oxygen saturation values measured in the five different body positions were in the normal range. Although oxygen saturation values were within the normal range in the five different body positions, post hoc analysis showed that the best oxygenation was in the 'sitting upright' position while the lowest oxygenation was in the supine position. RELEVANCE TO CLINICAL PRACTICE: Based on the results of this research, it can be concluded that the differences among oxygen saturation values according to the different body positions were statistically significant.

Predictive validity and reliability of the Turkish version of the risk assessment pressure sore scale in intensive care patients: results of a prospective study.

Multiple pressure ulcer (PU) risk assessment instruments have been developed and tested, but there is no general consensus on which instrument to use for specific patient populations and care settings. The purpose of this study was to determine the reliability and predictive validity of the Turkish version of the Risk Assessment Pressure Sore (RAPS) instrument, which includes 12 variables--5 from the modified Norton Scale, 3 from the Braden Scale, and 3 from other research results--for use in intensive care unit (ICU) patients. The English version of the RAPS instrument was translated into Turkish and tested for internal consistency and predictive validity (sensitivity, specificity, positive predictive value, and negative predictive value) using a convenience sample of 122 patients consecutively admitted to an ICU unit in Turkey. The patients were assessed within 24 hours of admission, and after that, once a week until the development of a PU or discharge from the unit. The incidence of PUs in this population was 23%. The majority of ulcers that developed were Stage I. Internal consistency of the RAPS tool was adequate (Cronbach's α = 0.81). The best balance between sensitivity and specificity for ICU patients was reached at a cut-off point of ≤ 27 (ie, sensitivity = 74.2%, specificity = 31.8%, positive predictive value = 38.7%, and negative predictive value 91.3%). This is lower than the cut-off point reported in other studies of the RAPS scale. In this population of ICU patients, the RAPS scale was found to have acceptable reliability and poor validity. Additional studies to evaluate the predictive validity and reliability of the RAPS scale in other patient populations and care settings are needed.

A comparison of 3 wound measurement techniques: effects of pressure ulcer size and shape.

PURPOSE: The aim of this study was to examine the levels of agreement among 3 techniques used in wound measurement comparing more spherical versus irregularly shaped wounds. DESIGN: The design of this study is evaluative research. SUBJECTS AND SETTING: Sixty-five consecutive patients with 80 pressure ulcers of various sizes referred from a university hospital in Izmir, Turkey, were evaluated. METHODS: The 80 pressure ulcers identified on the 65 participants were divided into 2 groups based on pressure ulcer shape and wound surface area. Twenty-four of the 80 ulcers (30%) were characterized as irregularly shaped and greater than 10 cm. Fifty-six were regularly shaped (approximating a circle) and less than 10 cm. Pressure ulcer areas were measured using 3 techniques: measurement with a ruler (wound area was calculated by measuring and multiplying the greatest length by the greatest width perpendicular to the greatest length), wound tracing using graduated acetate paper, and digital planimetry. The level of agreement among the techniques was explored using the intraclass correlation coefficient (ICC). RESULTS: Strong agreement was observed among the techniques when assessing small, more regularly shaped wounds (ICC = 0.95). Modest agreement was achieved when measuring larger, irregularly shaped wounds (ICC = 0.70). CONCLUSION: Each of these techniques is adequate for measuring surface areas of smaller wounds with an approximately circular shape. Measurement of pressure ulcer area via the ruler method tended to overestimate surface area in larger and more irregularly shaped wounds when compared to acetate and digital planimetry. We recommend digital planimetry or acetate tracing for measurement of larger and more irregularly shaped pressure ulcers in the clinical setting.

The validity and reliability of the Turkish version of short-form McGill Pain Questionnaire in patients with leukemia.

AIMS AND OBJECTIVES: To assess reliability and validity of the Turkish version of the Short-form McGill Pain Questionnaire. BACKGROUND: Pain is one of the most frequent and significant problems encountered by nurses practice across the world. The Short-form McGill Pain Questionnaire was widely translated and used to assess the pain experience of several types of patients because it combines the properties of the standard McGill Pain Questionnaire but takes substantially less time to administer. DESIGN: The study used psychometric testing to establish reliability and validity of the Turkish version of Short-form McGill Pain Questionnaire. METHODS: A convenience sample of 160 patients with leukaemia in Turkey was used to collect data regarding pain evaluation. The original version of the Short-form McGill Pain Questionnaire, adapted into Turkish, was tested for internal consistency, content validity, construct validity and concurrent validity. RESULTS: Internal consistency was found adequate at both assessments with Cronbach's α 0.88 for test and 0.91 for retest. For reliability of the total, sensory, affective and evaluative total pain intensity, high intraclass correlations were demonstrated (0.85, 0.84, 0.82 and 0.70, respectively). Correlation of total, sensory and affective score with the numerical rating scale was tested for construct validity demonstrating r = 0.61 (p < 0.01) for test and r = 0.68 (p < 0.01) for retest. Correlation with blood pressure values for concurrent validity was found to be r = 0.78 (p < 0.001) for test and r = 0.73 (p < 0.001) for retest. CONCLUSION: Turkish version of the Short-form McGill Pain Questionnaire has shown statistically acceptable levels of reliability and validity for pain evaluation in patients with leukaemia. RELEVANCE TO CLINICAL PRACTICE: This study provided evidence that the Turkish version of the Short-form McGill Pain Questionnaire is a reliable and valid instrument for assessing pain. This scale can be used to assess nursing interventions aimed at decreasing pain and efficacy of the treatment.

Effect on pain of changing the needle prior to administering medicine intramuscularly: a randomized controlled trial.

AIM: This paper is the report of a study to determine whether changing the needle before administering an intramuscular injection could reduce pain, and to investigate gender differences in pain perception. BACKGROUND: A skilled injection technique can make the patient's experience less painful and avoid unnecessary complications, and the use of separate needles to draw up and administer medication ensures that the tip of the needle is sharp and free from medication residue. METHOD: A randomized controlled trial was carried out between January 2009 and May 2009 with 100 patients receiving diclofenac sodium intramuscularly in an emergency and traffic hospital in Izmir, Turkey. The primary outcome was pain intensity measured on a numerical rating scale. Each patient received two injections by the same investigator using two different techniques. The two techniques were randomly allocated and the patients were blinded to the injection technique being administered. After each injection, another investigator who had no prior knowledge of which injection technique was used immediately assessed pain intensity using a numerical rating scale. Descriptive statistics, paired t-test and t-test were used to evaluate the data. RESULTS: Findings demonstrated that changing the needle prior to intramuscular medication administration significantly reduced pain intensity. A statistical difference in pain intensity was observed between the two injection techniques. CONCLUSION: The results supported the hypothesis that changing the needle prior to administering the medicine significantly reduced pain intensity.

Comparison of agreement between different measures of blood pressure in normotensive females.

The aim of this study was to determine whether there are differences between nurse-taken blood pressure (BP), physician-taken BP, and automated device. BP was measured in 163 normotensive females. In a center for family planning and mother-child health, measurements were taken by a male physician and by a nurse and by using a validated automatic device. The difference between the systolic and diastolic BP recordings at the three measurement modalities was statistically significant (p < .001). BPs taken by the physician were markedly higher than the measurements taken by the nurse and the automated device. The results from this study show that systolic and diastolic BP taken using an automated device in normotensive females are significantly lower than the readings obtained by the physician and are almost identical to those taken by the nurse. Physicians should therefore not make any decisions based on BP measured manually during a first encounter and should rely on BP reported by well-trained observers or by validated automatic devices.

A study of Turkish critical care nurses' perspectives regarding family-witnessed resuscitation.

AIM: . This paper reports a study to determine the experiences and attitudes of Turkish critical care nurses concerning family presence during cardiopulmonary resuscitation. BACKGROUND: The debate surrounding family-member presence in resuscitation areas has been evolving since the 1980s. The practice of performing resuscitation of adults in the presence of family members is controversial and has stimulated discussion and debate worldwide. DESIGN: A descriptive survey. METHOD: The survey was carried out in 2007 with 135 critical care nurses from two university hospitals in Izmir. A structured questionnaire was used, which incorporated a series of attitude statements that were rated using a three-point Likert scale. The attitudes of the nurses were explored in three areas: decision making, processes and outcomes of resuscitation. RESULTS: Of the nurses, only 22.2% experienced a situation where family members were present during cardiopulmonary resuscitation. Most of these nurses (n = 20) had one or more negative experiences. The majority disagreed that family members should always be offered the opportunity to be with the patient during cardiopulmonary resuscitation. The most common concerns for not favouring family-witnessed resuscitation were reported as performance anxiety, fear of causing psychological trauma to family members and increased risk of litigation. CONCLUSIONS: Many Turkish critical care nurses have no knowledge of family-witnessed resuscitation and do not support the practice. We suggest that Turkish critical care nurses should be informed by the international literature on the concept of family-witnessed resuscitation and the culturally appropriate policies concerning this subject should be changed in Turkish hospitals. RELEVANCE TO CLINICAL PRACTICE: Most critical care nurses in Turkey are not supportive of family-witnessed resuscitation. All critical care nurses should be informed by the international literature on the concept of family-witnessed resuscitation.

A prospective study evaluating the Pressure Ulcer Scale for Healing (PUSH Tool) to assess stage II, stage III, and stage IV pressure ulcers.

Many valid and reliable tools and techniques are available for wound measurement. However, few prospective clinical studies assessing these instruments have been conducted. A prospective, methodological study was conducted between September 2006 and November 2007 to evaluate use of the Pressure Ulcer Scale for Healing (PUSH) version 3 in patients with one or more pressure ulcer. A convenience sample of 72 persons (mean age 66.9 +/- 12.8 years) with 86 pressure ulcers (49% Stage II, 47% Stage III, and 4% Stage IV) was recruited and assessed weekly until healing, transfer, patient death, or end of study for a maximum of 8 weeks. Most ulcers (77%) were in the sacral area and 56% had been present for 1 month or longer. Repeated measures analysis revealed that PUSH total scores decreased significantly (P < 0.001) over the 8-week study, with significant differences in PUSH total scores between healed and unhealed ulcers each week, starting on week 1. The total PUSH score as well as the length x width item in the tool accurately differentiated between healed and nonhealed ulcers. Although the PUSH tool is practical, easy-to-use, and generally sensitive to change, some modifications would improve its value--ie, a wound size/depth subscale. Additional studies to help clinicians more accurately evaluate the effectiveness of their interventions, including studies to determine whether wound measurements alone may suffice to monitor healing, are needed.

Does the body temperature change in older people?

AIM: The aim of this study was to determine the mean body temperatures in older people using mercury-in-glass thermometer. BACKGROUND: Older people are unable to regulate their body temperatures to the same degree as young adults because their responses to changes in body temperature are altered. Several published reports suggest that body temperature decreases with advancing age and has a greater variability in older populations. The aim of this study was to determine the mean body temperatures in older people. DESIGN: Non-experimental. METHODS: Axillary body temperatures were taken in 133 older subjects in a nursing home for older people using mercury-in-glass thermometer. Temperatures were measured at 8 a.m., 2 p.m., and 6 p.m., over three consecutive days. Each subject had all three measurements taken on the same day. RESULTS: The mean age of the subjects was 77.2, SD 7.3. In the 133 older subjects, the mean axillary temperatures ranged from 35.1 to 36.4 degrees C (95.3-97.6 degrees F). The mean temperatures for those aged 65-74 was higher than in those aged 75-84 (p < 0.001) and those aged 85 and older (p < 0.001) at 6 p.m. but not at 8 a.m. or 2 p.m. We concluded that older people have mean axillary body temperatures lower than the reference point of 36.5 degrees C (97.7 degrees F). RELEVANCE TO CLINICAL PRACTICE: When assessing body temperature, it is important to take the age of the patient into consideration. Also, the reference point of 36.5 degrees C is inappropriate in older people, especially when diagnosing a febrile illness.

A descriptive study of pressure ulcer pain.

Despite increased emphasis on addressing patient pain, knowledge and information about pressure ulcer pain remains limited. To describe the quantitative and qualitative characteristics of pain related to pressure ulcers, a study was conducted among 47 hospitalized patients with pressure ulcers using the McGill Pain Questionnaire and Revised Faces Rating Scale. Volunteer participants, admitted for neurological disorders, ranged in age from 38 to 72 years (mean age 60.1 years +/- 8.23; 29 men, 18 women), six with Stage II, 32 with Stage III, and nine with Stage IV pressure ulcers. All but three (44, 94.6%) reported pressure ulcer pain; of those, 28 (59.5%) reported constant pressure ulcer pain and 41 (87.2%) did not specify when pain occurred. Dressing change, movement of the afflicted area, and pain at rest were reported by 32 (68.1%), nine (19.1%), and three (6.4%) patients, respectively. "Hot-burning" was the sensory descriptor most frequently used to describe the pain in 52%, 56%, and 67% of Stage II, Stage III, and Stage IV patients, respectively. Three out of six patients with Stage II ulcers rated their pain "discomforting," 32 of 32 with Stage III ulcers rated pain as "distressing," and nine out of nine with a Stage IV ulcer rated their pain as "horrible". Based on the Revised Faces Rating Scale, mean pain intensity was 6.04 +/- 2.78 (range 1 to 10), corresponding to moderate pain. For overall pain intensity, Patient Pain Index and Faces Rating Scale-Revised scores were highly correlated (r = 0.90, P <0.001). Pressure ulcers are painful, most patients report pain as "constant", and pain assessment should be included in all patient care plans.

Does obesity prevent the needle from reaching muscle in intramuscular injections?

AIM: This paper is a report of a study to measure subcutaneous tissue thickness at the dorsogluteal and ventrogluteal sites and to determine optimal needle length for dorsogluteal and ventrogluteal intramuscular injections in adults with a body mass index of more than 24.9 kg/m2. BACKGROUND: Problems can arise if drugs designed to be absorbed from muscle are only delivered into subcutaneous tissue. Increasing obesity in all developed and many developing countries makes this an increasing concern. METHOD: Ultrasound measurements were made of the subcutaneous tissue of overweight, obese and extremely obese people at the dorsogluteal and ventrogluteal sites with the probe held at a 90 degrees angle to the plane of the injection site. Subcutaneous tissue thickness was measured in 119 adults whose body mass index was >or=25 kg/m2. The data were collected in 2005-2006. RESULTS: Mean subcutaneous tissue thickness at the dorsogluteal site was 34.5 mm for overweight adults, 40.2 mm for obese adults and 51.4 mm for extremely obese adults, and at the ventrogluteal site was 38.2 mm for overweight adults, 43.1 mm for obese adults and 53.8 mm for extremely obese adults. CONCLUSION: Intramuscular injections administered at the dorsogluteal site in 98% of women and 37% of men, and at the ventrogluteal site in 97% of women and 57% of men, would not reach the muscles of the buttock. A needle longer that 1.5 inches should be used in women whose body mass index is more than 24.9 kg/m2, the dorsogluteal site may be used in all overweight and obese men, and the ventrogluteal site may be used in overweight men only.

The effect of different body positions on blood pressure.

AIM: The aim of the present study was to test the effects of different body on BP readings in a Turkish healthy young adults. BACKGROUND: It is known that many factors influence an individual's blood pressure measurement. However, guideliness for accurately measuring blood pressure inconsistently specify that patient's position and they should keep feet flat on the floor. Although there are more information on arm position in blood pressure measurement, surprisingly little information can be found in the literature with respect to the influence of body position on the blood pressure readings in healthy young people. METHODS: A total of 157 healthy young students who had accepted to participate in the study were randomly selected. In all subjects the blood pressure was measured subsequently in four positions: Sitting blood pressure was taken from the left arm, which was flexed at the elbow and supported at the heart level on the chair. After at least one minute of standing, the blood pressure was then taken standing, with the arm supported at the elbow and the cuff at the heart level. After one minute of rest, the blood pressure was subsequently taken supine position. Finally, after one minute the blood pressure was again taken in this last position with supine position with crossed legs. RESULTS: The blood pressure tended to drop in the standing position compared with the sitting, supine and supine with crossed legs. Systolic and diastolic blood pressure was the highest in supine position when compared the other positions. There was a difference between systolic blood pressures and this was statistically significant (P < 0.001) but the difference between diastolic blood pressure was not statistically significant (P > 0.05). All changes in systolic blood pressure were statistically significant except those from supine to supine position with crossed legs. RELEVANCE TO CLINICAL PRACTICE: When assessing blood pressure it is important to take the position of the patient into consideration. Also, blood pressure measurement must be taken in sitting position with the arms supported at the right a trial level.