Pilonidal sinus: healing rates, pain and embarrassment levels.

OBJECTIVE: To identify the healing rates, wound hygiene practices, types of primary wound dressings used, antibiotics prescribed, pain intensity and embarrassment levels in patients with pilonidal sinus. METHOD: A prospective descriptive design was used. We followed 55 patients for three months following excision of pilonidal sinus. Digital photographs were taken and the wound area was calculated using the Alfred and Medseed Wound Imaging System on the first postoperative day, at 2-3 weeks and again at 12 weeks. Data were collected from the nurses and patients using piloted questionnaires. RESULTS: Sixty per cent of the participants had closed wounds within 12 weeks of surgery. Various dressing types were used. There was no significant correlation between dressing type and healing, or wound size and healing. There was no significant association between antibiotic usage and faster healing rates. A mean pain intensity score of 4.8 on a 0-10 scale was reported at the first dressing change for saline gauze dressings, which was the most painful experience with this wound. Average levels of embarrassment were low and decreased over time. CONCLUSION: Forty per cent of participants who had unhealed wounds at 12 weeks had other factors involved, which were not measured in this study.

Dwell time and functional failure in percutaneous endoscopic gastrostomy tubes: a prospective randomized-controlled comparison between silicon polymer and polyurethane percutaneous endoscopic gastrostomy tubes.

BACKGROUND: Silicone percutaneous endoscopic gastros-tomy (PEG) tubes are associated with more short-term complications and possibly fail sooner than those made of polyurethane. Understanding the deterioration and long-term complications leading to tube failure has important clinical and cost implications. AIM: To compare dwell time and patterns of failure ofsilicone polymer and polyurethane PEG tubes. METHODS: Participants randomized to receive a siliconepolymer (n = 76) or polyurethane (n = 62) PEG werevisited monthly for 540 days, until death or tube removal. Tube and exit site characteristics and reasons for removal were recorded. RESULTS: Tube failure occurred in 25% of silicone PEGs and 12.9% of polyurethane PEGs. Mean tube survival for silicone PEGs was 377.2 days (CI: 326-428) and for polyurethane 436.8 days (CI: 383-490; P = 0.13). A greater proportion of silicone PEGs developed intralumenal colonization and altered tube integrity than polyurethane (P < 0.001). Silicone PEGs blocked more frequently (P < 0.005) and were removed because of irreversible blockage more often than polyurethane PEGs (P < 0.05). Silicone PEGs with reversible blockage and tube integrity changes had a significantly greater probability of failure than silicone tubes without these changes (P < 0.005 and P < 0.05, respectively). CONCLUSIONS: Observations over time indicate that sili-cone PEGs are more susceptible than polyurethane PEGs to tube deterioration, resulting in substantially increased management demands to sustain patients' feeding and medication schedules.

Critical care dependency tool: monitoring the changes.

The critical care patient dependency system (CCPD) is a factorial patient acuity system developed in 1993 by Ferguson and Harris-Ingall' for use in adult critical care areas. It was developed specifically to help determine Australian nursing cost weights and was utilised to collect data from nine Sydney critical care units from October 1992 until May 1993. The St. George Hospital (SGH) general intensive care unit, one of the nine participating hospitals, continues to use and collect data with the CCPD. This paper describes the instrument and compares data on Australian national diagnosis related groups (ANDRGs), collected during the original study, to ANDRG information on the critical care population 3 and 6 years later. In addition, the paper examines and compares the demographics of the SGH critical care patient population, patient acuity (based upon CCPD patient scores) and intensive care nursing clinical practices collected over a 3 month period in 1996 and again in 1999. Demographic and patient acuity data for SGH in 1993 are unavailable and so comparisons were unable to be made. The findings demonstrate changes in the management of critically ill patients, especially in relation to ventilation management, wound care and invasive monitoring practices; this resulted in shifts to the nursing workload. For this reason, the instrument is useful in providing nurse managers with information about patient dependencies and nursing work.

Managing ventilatory insufficiency and failure in a patient with kyphoscoliosis: a case study.

This article reports a case study of 'Sue', a 37 year old female who was transferred to a metropolitan hospital's intensive care unit in acute respiratory failure secondary to severe kyphoscoliosis (KS). KS is defined as a deformity of the spine involving both lateral displacement (scoliosis) and anteroposterior angulation (kyphosis). Over time, this anatomical distortion results in ventilatory insufficiency due to muscle weakness. Sue displayed a restrictive lung pattern, evidenced by a decreased vital capacity and tidal volume with severe nocturnal dyspnoea, resulting in raised carbon dioxide levels in arterial blood and decreased oxygenation. This paper reviews Sue's progress throughout her hospitalisation and examines the key issues involved in her care. Particular attention is given to specific problems encountered on the acute care ward related to oxygen delivery, tracheostomy care, non-invasive ventilation and rehabilitation. The paper highlights the increased acuity of respiratory ward patients who require the use of substantial technological support to optimise their management. Nurses working in these wards need specialised knowledge, excellent patient communication ability and well-developed technical skills. The trend is to treat patients with respiratory failure, either chronic or acute, on wards rather than in critical care units' which has promoted the development of a specialised role in respiratory nursing.

Australian clinicians and educators identify gaps in specialist cardiac nursing practice.

Change is endemic in both the health care and higher education sectors in Australia. Consequently professional roles and educational pathways must also evolve and adapt, often catalysed by those in leadership positions. Two national Delphi panels, one of cardiac nurse educators and the other of cardiac nurses, were convened to answer the question 'What knowledge, skills and attitudes are required for an expert nurse practising in the highly technological cardiac care environment?' Respondents indicated on a Likert scale the importance of 107 items to the nurse's role in both the 'real' and 'ideal' worlds of practice. Overall there was very strong agreement between the two panels with results indicating that Australian nurses perform close to their ideal in many areas of practice. For 31 of the items, both panels identified that the reality of practice is quite far from their ideal. Both panels agree that 10 of the behaviours are carried out or valued very little in practice. Reasons why nurses are not carrying out these elements of the role to their satisfaction are discussed and remediation strategies suggested. The findings can inform both curriculum development and clinical practice. In the dynamic health care arena, the nursing profession continues to respond to community and professional needs, seeking to establish sound research-based practice and maintain a high quality of clinical care and nursing management. The development of competencies by the Confederation of Critical Care Nurses (1996) is a good example of professional groups taking the initiative both in defining the practice role and providing tools that assist educational bodies to develop programs appropriate for a practice based discipline. Specialty nursing practice is 'under the microscope' in Australia as the profession seeks the best methods to weight nursing activities, measure nursing outcomes and recruit, retain and justify the use of specialist practitioners.

A comparison of the awareness and utilisation of postoperative health services provided to women with breast cancer in public and private hospitals.

Nurses at a metropolitan Cancer Care Centre (CCC) noted that women who have had recent breast surgery for carcinoma had significantly different levels of knowledge and use of support services depending upon public or private hospitalisation. The public hospital participants were more aware of the range of available services (mean = 3.6) compared to women from the private sector (mean = 2.6). In addition, the public hospital participants were more likely to access a wider range of services post discharge (mean = 2.21) compared to the private hospital women (mean = 0.85). A significant difference was found between younger and older women's use of services.

Australian nurse educators identify gaps in expert practice.

In Australia, nurses face a double-barreled challenge to their role. With the rapid adoption of new health care technologies coupled with increasing economic constraints, they find themselves "doing more with less." In this context of continuous change, it is useful to determine what expert nurse clinicians deem the most essential skills, attitudes and knowledge required for practice in complex technological environments. Separate panels of 28 educators and 43 cardiac nurse clinicians participated in a national Delphi study rating the importance to the nursing role of 107 items drawn from the international literature on expert practice and technology. Indicating the importance of each item in both the "real" and "ideal" worlds of practice, educators identified 58 items where they felt actual practice was substantially far from the ideal. For 16 of these items relating to empowerment of patients, nursing research, and technology policy, the educators rated clinical behavior below the median of the real world scale, indicating substandard performance of a role or inadequate assimilation of a concept. The implications for the definition of expert practice and for curricula development are discussed.

Implantable defibrillator recipients' responses to device implantation and design.

The implantable cardioverter defibrillator (ICD) is a surgically inserted device that follows a well-established pattern of technology innovation and rapid adoption without extensive clinical trials. Few devices are as obviously life-saving in potentially fatal situations and deliver such sudden and sometimes painful therapy. Although patients' quality of life and adjustment to the device both physically and psychologically are relatively well-documented, few studies have explored recipients' responses to the device itself or elicited their thoughts on the technological design. The findings presented here are from a prospective Australian study that surveyed 110 ICD recipients pre-insertion and at 3, 12, and 18 months post-insertion. Recipients' responses to the device and their thoughts on design were sought. Respondents were overwhelmingly willing to: 1) accept the ICD, 2) recommend it to others, and 3) welcome such innovations as warning tones, device-controlled drug delivery, and telephone interrogation of the device.

Australian nurses and device use: the ideal and the real in clinical practice.

Clinical nurses use an increasing number of technological devices when providing care. While the clinical devices themselves must undergo rigorous multidimensional assessment, it is the proficiency of the user that ultimately determines the devices' efficacy. Thus, the knowledge, skills and attitudes that nurses bring to their decision-making and use of technology are crucial elements in the technology assessment process. Technological proficiency is imperative in the current climate of rapid patient throughput in complex technological environments. This paper reports some of the findings of an Australian study, using two national Delphi panels, whose primary objective was to determine the knowledge, skills and attitudes required of expert clinicians for practice in cardiac care. Panels of 28 educators and 42 cardiac nurse clinicians completed a questionnaire indicating the importance of 107 characteristics of expert cardiac practice for both the 'real' and 'ideal' worlds of practice. Comparative results will be reported for 29 items within the thematic groups. Effective use of technology, Informed decisions regarding equipment and Critical approach to the use of technology. Both panels accepted all 29 items in these three thematic groups but indicated differences in the level of agreement on the importance of items between the 'real' and 'ideal' worlds of practice. Discussion centres around those areas where improvement is needed.

Determining and discerning expert practice: a review of the literature.

Although the nature and characteristics of expert practice have been described in the literature, the description is incomplete. How expertise is gained is not fully understood, and definitions of expert competencies have yet to be developed. Essential issues for education arise from the demand for knowledge for expert practice. Because expertise is gained in the context of practice, expertise cannot be achieved out of context or taught as an academic exercise. A clear picture of the practice of expert nurses is necessary so that those in the profession can know and articulate expert practice and direct it to the community.

The impact of the implantable cardioverter defibrillator on quality of life.

The implantable cardioverter defibrillator may prolong survival and prevent sudden cardiac arrest in patients with ventricular arrhythmias. Whereas previous research focused on mortality, attention is now turning to the impact of the device on the recipient. We reviewed the literature on the effects of the implantable cardioverter defibrillator on recipients and their families; our aim was to consolidate our current understanding and guide further research in this area. We found a number of effects on which researchers agree. Primarily, recipients are happy to have the device and generally feel more confident. However, recipients experience many psychological reactions such as fear and anxiety that can be related to the unpredictable nature of the shocks. Recipients also are affected by intellectual changes. Both recipients and their families experience similar effects and use a range of coping mechanisms; the most effective is optimism. Only one nursing intervention has been investigated that directly addresses these effects. Areas that need more research are the effects of the implantable cardioverter defibrillator during childhood, adolescence, and pregnancy; the impact of vigilance on recipients and their families; costs; and nursing interventions. More consistent, standardized quality-of-life measures are needed so that comparisons can be made between samples.

The cardiac nurse's role: an Australian Delphi study perspective.

In Australia, as in many parts of the Western world, technological advances in healthcare have affected the roles of healthcare professionals, including nurses. Cost constraints, efficiency, and effectiveness measures also influence staffing numbers, roles, and skill mix. Specialty nurse education programs are changing, and many are moving from the hospital environment to the higher education sector. Initiatives to introduce the American Advanced Nurse Practitioner role in some environments have begun, although the current advanced practice roles are proving problematic. Specialist professional groups are striving to develop competencies or standards for practice. An understanding of what is required of expert clinicians for practice in complex technological environments such as cardiac care would be useful for both practitioners and academics. A national Delphi study was undertaken to determine what knowledge, skills, and attitudes were required of expert cardiac nurses in relation to technology in the cardiac care environments in both the "real" and the "ideal" worlds of practice. Separate panels of 28 cardiac educators and 42 cardiac nurse clinicians were given a questionnaire of 107 items and asked to indicate on a 6-point Likert scale the importance of each item to the nursing roles in both the "real" and "ideal" worlds. On the final, third round, respondents ranked the three most important items in each of the 13 thematic groups. Overall, the clinicians accepted all 107 items as important to their role, and for the majority of these they, felt that they were performing quite close to their "ideal." This article presents the 32 items for which the clinicians felt the "real" world was quite far from the "ideal" as represented by a gap of > or = 2 between the real and ideal medians. Also, despite being accepted as part of the role through the ideal scores, 21 items achieved a real world median of 3.5 or less, which indicates that in the real world these aspects of nursing are not being valued or practiced to the level clinicians would like. These two sets of items should be of greatest interest to clinicians currently in the role and to those interested in specialty education at all levels.

Factors influencing accuracy in left ventricular volume determination.

The accuracy with which left ventricular volume is determined from contrast ventriculograms depends on the care with which the analysis protocol is followed. Therefore, the effect of variations in the method used for calculating the correction factor (CF) that adjusts for magnification and image distortion on volume calculation was measured. The results showed that error in the CF is caused by (in order of decreasing importance): filming the calibration figure at a different magnification mode from that of the ventriculogram, at a different height from the table than the level of the ventricle, or with the image intensifier at a different height than used during ventriculography; use of a calibration figure less than half the size of the ventricle; calculation of the CF from only 1 band pair of a banded catheter; or placement of the calibration figure at the periphery rather than the center of the imaging field. Error in volume determination was proportional to error in the CF. With care, the error in volume can be reduced to that due to interobserver variability in tracing the endocardial contours.