Thermal comfort and safety of cotton blankets warmed at 130°F and 200°F.

BACKGROUND: In 2009, the ECRI Institute recommended warming cotton blankets in cabinets set at 130°F or less. However, there is limited research to support the use of this cabinet temperature. PURPOSE: To measure skin temperatures and thermal comfort in healthy volunteers before and after application of blankets warmed in cabinets set at 130 and 200°F, respectively, and to determine the time-dependent cooling of cotton blankets after removal from warming cabinets set at the two temperatures. DESIGN: Prospective, comparative, descriptive. METHODS: Participants (n = 20) received one or two blankets warmed in 130 or 200°F cabinets. First, skin temperatures were measured, and thermal comfort reports were obtained at fixed timed intervals. Second, blanket temperatures (n = 10) were measured at fixed intervals after removal from the cabinets. FINDING: No skin temperatures approached levels reported in the literature that cause epidermal damage. Thermal comfort reports supported using blankets from the 200°F cabinet, and blankets lost heat quickly over time. CONCLUSIONS: We recommend warming cotton blankets in cabinets set at 200°F or less to improve thermal comfort without compromising patient safety.

We silence our profession when we fail to identify ourselves as nurses.

The approach of health care publications to author credentials remains inconsistent.

Unplanned perioperative hypothermia and agreement between oral, temporal artery, and bladder temperatures in adult major surgery patients.

Accurate body core temperature measurement is essential in perioperative areas to quickly recognize and address abnormal temperatures. The purposes of this prospective, descriptive study were to accurately identify unplanned perioperative hypothermia (UPH) in 64 elective major surgery patients; to describe factors that increased the risk of UPH; to describe active/passive warming measures; to describe thermal comfort in patients with and without UPH; and to compare oral, temporal artery, and bladder temperatures. Based on bladder temperatures, 52% of the patients had UPH in the operating room (OR) and 42% on postanesthesia care unit (PACU) admission. The temporal artery thermometer did not detect any hypothermia. Descriptive data and Bland-Altman plots showed lack of agreement between the temporal artery thermometer readings and those of the oral and bladder thermometers. The patient's thermal comfort report did not accurately reflect hypothermia. Factors found to increase the risk of UPH included older age, BMI lower than 30, and OR ambient temperature lower than 68°F. All but one patient had active warming in the OR; active warming was infrequently used in the PACU. Based on our findings and findings in previous studies, we do not recommend using the temporal artery thermometer in perioperative areas. To prevent UPH, we recommend aggressive use of convective and conductive warming measures in perioperative areas and increasing OR ambient temperatures.

Use of a video-ethnographic intervention (PRECESS Immersion Method) to improve skin-to-skin care and breastfeeding rates.

PURPOSES: Skin-to-skin care after birth often is absent, interrupted, or delayed for routine procedures. The purposes of this project were to improve skin-to-skin care and exclusive breastfeeding at hospital discharge. METHODS: For Part 1, we used a descriptive observational design, with video-ethnography and interaction analysis (PRECESS-Practice, Reflection, Education and training, Combined with Ethnography for Sustainable Success), during a 5-day quality improvement pilot study in a U.S. hospital (August 13-17, 2010). For Part 2, we used electronic health record review to test for differences in monthly rates of skin-to-skin care and exclusive breastmilk feeding (baseline, July 2010; post-intervention, August-December 2010). RESULTS: In Part 1, 11 mothers and babies participated: 10 (91%) received immediate skin-to-skin care, eight (73%) received uninterrupted skin-to-skin care, nine (82%) planned to breastfeed, six (67%) of these babies were exclusively breastfeeding at hospital discharge, and five (83%) of the six babies who completed all nine instinctive stages during skin-to-skin care were exclusively breastfeeding at hospital discharge. In our subsequent review (Part 2), we found a significant improvement (25% above baseline) in the overall rate of skin-to-skin care across post-intervention months (Pearson χ(2)=23.798, df=5, p<0.000), predominantly from improvements in the cesarean section population. The rates of exclusive breastfeeding showed no significant change. CONCLUSIONS: The PRECESS immersion method may help to rapidly improve skin-to-skin care. Babies who undergo all nine stages during skin-to-skin care may be more likely to exclusively breastfeed. Mothers need support during skin-to-skin care to recognize their baby's readiness to breastfeed. Skin-to-skin care during cesarean surgery may reduce maternal stress and improve satisfaction with the surgical experience.

Preoperative fasting duration and medication instruction: are we improving?

Research has shown that preoperative fasting practices commonly are much longer than national guidelines, and medication instructions are not always given to patients before surgery. After implementation of an evidence-based preoperative fasting policy and educational efforts for health care providers at one facility, a follow up project was conducted to determine whether these efforts had improved fasting practices. The project findings indicate that preoperative fasting in excess of safe minimum guidelines persists. Improvements were found in the percentage of patients receiving specific instructions about whether to take their routine medications on the morning of surgery. Continued efforts must be made to implement best practices for preoperative fasting.

Graduated compression stockings in hospitalized postoperative patients: correctness of usage and size.

OBJECTIVE: Graduated compression stockings, when used correctly, have been shown to significantly reduce the risk of deep-vein thrombosis in surgical patients, but they can be harmful to skin and may even increase the risk of thrombosis if the wrong size is used. The authors sought to determine whether nurses correctly size and apply the stockings, whether problems were more common in knee- or thigh-length stockings, and whether nurses adequately educate patients on the usage of the stockings. METHODS: The researchers used a comparative, descriptive design to study 142 hospitalized postoperative patients; 37 had thigh-length and 105 had knee-length stockings. They assessed usage of the stockings and compared four separate leg measurements against the manufacturer's sizing chart to determine whether stockings that had been applied were the correct size. They also asked patients to rate the comfort of the stockings and to describe their purpose. RESULTS: The graduated compression stockings were used incorrectly (for example, they were wrinkled or the gusset was in the wrong place) in 29% of the patients and sized incorrectly in 26% of the patients. These problems were more common with the thigh-length stockings and in overweight patients. More patients who had thigh-length stockings found them uncomfortable than did those who had knee-length stockings, and 20% of patients didn't understand the stockings' purpose. CONCLUSIONS: The authors recommend that nurses ensure that graduated compression stockings are properly sized and used, that the education of both nurses and patients regarding the stockings be improved, and that knee-length stockings be the standard length used.

Actual versus instructed fasting times and associated discomforts in women having scheduled cesarean birth.

OBJECTIVES: To measure actual and instructed preoperative fasting durations in women undergoing scheduled cesarean birth, to compare these times with national guidelines for healthy patients undergoing elective procedures, and to describe discomforts associated with preoperative fasting. DESIGN: One group, nonexperimental, comparative, descriptive. SETTING: Nonprofit private medical center in Texas with 6,000 births/year. PATIENTS: Convenience sample of 51 hospitalized postpartum women. INTERVENTIONS: Participants were interviewed an average of 44 hours after their cesarean birth, and their medical records were reviewed for fasting information. MAIN OUTCOME MEASURES: Duration of actual and instructed fasting, comparison with national guidelines, and ratings of thirst and hunger. RESULTS: The participants fasted from liquids and solids an average of 11 and 13 hours, respectively. Both actual and instructed fasting durations were significantly longer than national guidelines. Most participants (70%) were instructed to be nulla per os after midnight whether they were to have a.m. or p.m. surgery. Thirst and hunger scores averaged 5 and 4, respectively, on a 0-10 scale. CONCLUSION: Patients having scheduled cesarean birth fast for unnecessarily long periods. Nurses should be knowledgeable about evidence-based preoperative fasting practices and collaborate with physicians to implement them.

Variables influencing intravenous catheter insertion difficulty and failure: an analysis of 339 intravenous catheter insertions.

BACKGROUND: Inserting an intravenous catheter (IV) is one of the most frequently performed invasive procedures by nurses. Little research has been conducted on ways to reduce the difficulty and failure, and enhance the ease and success, of IV insertion. We conducted this study to determine variables associated with IV insertion difficulty, failure, and success, and to learn special techniques nurses use to facilitate IV insertion. METHODS: Data were collected on 339 IV insertions in hospitalized patients by 34 registered nurses. The data included information about the nurse (eg, age, education, and self-rated IV insertion skill); the patient (eg, age and race); the IV (eg, site, gauge, and type); and the IV insertion, (eg, duration and difficulty). Data were analyzed to determine the effects of these variables on IV insertion outcome. In addition, nurses were asked to describe special techniques they used to facilitate IV insertion. RESULTS: A total of 77% of the IV insertions were successful. Nurses who were older, had more years of experience, were certified in a specialty, and rated themselves higher in insertion skill had significantly more successful insertions than their younger and less-experienced and less-skilled counterparts (P < .001). Successful IV insertions were significantly faster (mean 32 seconds) than unsuccessful ones (mean 66 seconds) (P < .001), and were rated as significantly less difficult (P < .001). Failed IV insertions were associated with higher degrees of difficulty arising from vein variables, such as vein rolled or vein was resistant to puncture, and patient variables, such as tough or dark skin and patient movement. The nurses described a wide variety of techniques to facilitate insertion success. The most frequently mentioned were getting self and patient in a comfortable position, using mechanical stimulation such as tapping the vein, and stabilizing the vein. CONCLUSION: Approximately one fourth of the 339 IV insertions in this study were unsuccessful. Repeated insertion attempts are painful and costly. This study identified nurse, patient, and IV variables associated with IV insertion success and failure. Future research is needed to confirm and expand these findings and to develop interventions to improve IV insertion skills and outcomes.

Preoperative fasting: old habits die hard.

OVERVIEW: Prolonged preoperative fasting is a time-honored tradition. The typical order of "npo after midnight" (or no liquid or food after 12 am on the day of surgery) has been challenged in recent years-so much so that in 1999 the American Society of Anesthesiology (ASA) revised its practice guidelines for preoperative fasting in healthy patients undergoing elective procedures. The newer, more liberal recommendations, based on studies showing that pulmonary aspiration occurs only rarely as a complication of modern anesthesia, allow the consumption of clear liquids up to two hours before elective surgery, a light breakfast (tea and toast, for example) six hours before the procedure, and a heavier meal eight hours beforehand. There is a well-known lag between the dissemination and implementation of practice guidelines, so the authors sought to determine whether the publication of the revised ASA recommendations had changed preoperative fasting practices. They interviewed 155 patients in one hospital about their preoperative fasting, comparing instructed, actual, and ASA-recommended fasting durations for liquids and solids. Their findings demonstrate that the majority of patients continued to receive instructions of npo after midnight for both liquids and solids, whether they were scheduled for early or late surgery. On average, the patients fasted from liquids and solids for 12 and 14 hours, respectively, with some patients fasting as long as 20 hours from liquids and 37 hours from solids. These fasts were significantly longer than those recommended by the ASA, indicating that inappropriate preoperative fasting is an issue that demands attention. The authors conclude that more collaboration between nurses and physicians is needed to assure that fasting instructions are consistent with the ASA guidelines and that patients understand these directives.