Biomedical subjects
Publications and source records attributed to G Hilton.
Fluctuations in inpatient census are occurring across the nation, necessitating innovative approaches to staffing. At our facility, fluctuations were most acute in the critical care units. In order to meet the staffing needs of these units and ensure competency of staff, a cross-utilization program was implemented.
Secondary brain injury is associated with high mortality and morbidity rates. Reversible causes of secondary injury, including hypoxemia, hypotension and increased intracranial pressure need to be anticipated and prevented, when at all possible. In addition, further understanding of the cellular and metabolic alterations associated with delayed brain injury and the role of neuroprotective agents in the prevention of said injury will hopefully result in improved neurologic care. One challenge for health care providers in the years ahead will be to limit the extent of injury after the initial event, thereby improving outcomes.
During these times of escalating health care costs and increased demand for critical care beds, hospitals are often unable to provide the intensive level of nursing care that is required. One large urban trauma center found that 36% of the surgical intensive care unit patients required a level of nursing care intermediate between the intensive care unit and the general ward. A multidisciplinary team met to plan and develop a surgical/trauma intermediate care unit to provide this level of care. Goals, objectives, specific admission, discharge criteria, and administrative responsibility were determined. An educational program was developed based on a needs assessment of the staff. During the implementation phase and throughout the unit's operation, advanced practice nurses performed an integral role as resource personnel. The purpose of this paper is to describe the multidisciplinary process used in the development of a new unit and to highlight the advanced practice role in this activity.
Antiphospholipid antibody syndrome includes a spectrum of autoantibody reactions associated with vascular thrombosis, thrombocytopenia and recurrent fetal loss. Neurologic manifestations include strokes, transient ischemic attacks and multi-infarct dementia. Treatment involves prolonged anticoagulation, and prognosis is poor. A case study of a 21-year-old female with antiphospholipid antibody syndrome is provided.
Treatment with high-dose intravenous methylprednisolone is safe and may be associated with significant neurologic improvement in acute spinal cord injury patients. Accurate calculation and administration of the prescribed therapy and identification and assessment of complications should be incorporated into the overall standard of care for the acute spinal cord injury patient.
Behavioral, cognitive, and memory deficits are frequently observed sequelae of brain injury. Yet in most critical care settings, neurologic assessment is limited to evaluation of arousal, pupillary response, orientation, and motor capability. Behavior, cognition, and memory are not routinely evaluated. Several brief, bedside assessment tools are reviewed. All may be used in the critical care setting to evaluate the type and extent of residual deficits in the neurologically impaired patient. Nursing implications, based on the evaluation of deficits, are also discussed.
The Second National Acute Spinal Cord Injury Study (NASCIS II), published in 1990, illustrated the benefits of high-dose steroids in the treatment of acute spinal cord injury. Research into the use of high-dose steroids is reviewed, and proposed mechanisms of action are addressed. Implications for nursing include method and timing of administration and expected complications. A case study is also provided.
The Neurobehavioral Rating Scale (NRS) has been used in the rapid bedside assessment of closed head-injured and stroke patients in the past and has been found to be highly predictive of long-term outlook. The NRS consists of 27 items in a Likert-type scale and measures cognition and behavioral parameters of brain disease. The NRS was administered to nine human immunodeficiency virus (HIV) positive individuals in a pilot interrater reliability study. Highly significant correlations (r .94 and r .97; p less than .001) were found between interviewers. Content and construct validity had already been established in prior research. To date, no quick, easy assessment tool measuring both cognitive and behavioral manifestations in this population has been widely used. Therefore, it becomes imperative that such a tool be available to nursing staff to aid in monitoring of neurologic deterioration, assist in appropriate placement of acquired immunodeficiency syndrome (AIDS) dementia complex patients and planning of care.
The Silicone Study is a multicentered, randomized surgical trial designed to compare the tamponade effectiveness of silicone oil versus long-acting gas in the treatment of proliferative vitreoretinopathy (PVR) by vitrectomy and associated techniques. Fundus photographs are taken to provide documentation of the anatomic status of eyes proposed for entry and are graded at an independent Reading Center. This article describes the protocol for photographic documentation of PVR as a continuum of increasing pathology, in which the pathology may only be present in the anterior retina, and the retina is usually highly elevated. In a validity and reliability study, agreement between photographic and clinical observation within one step was obtained for 88% of the eyes; intra- and inter-observer agreement within one step was 85 and 80%, respectively. Differences between the surgeon's grade and the Reading Center's were caused about equally by disagreement regarding extent of fixed folds and width of the funnel. Rarely did peripheral folds not visible in the photographs appear to be the sole explanation of the disagreement. Differences among readers were concerned mainly with differentiation of true full-thickness fixed folds from folds due to simple redundancy of the detached retina. These results demonstrate that complicated retinal detachment (RD) can be photographically documented and independently assessed.
The most frequently documented neurologic manifestation in human immunodeficiency virus (HIV) seropositive patients is known as acquired immunodeficiency syndrome (AIDS) dementia complex. Three stages of dementia progression have been identified with impairment noted in cognitive, behavioral and motor function. Specific diagnostic findings include diffuse cortical atrophy on computed tomography (CT) scan and magnetic resonance imaging (MRI) and alterations in cerebrospinal fluid (CSF) findings. Current research hypothesizes that AIDS dementia is the result of direct HIV infiltration of the central nervous system (CNS) and autopsy studies have addressed this theory. Nursing's role in the care of the patient with AIDS dementia focuses on neurologic assessment, counseling of patient and family, supportive care and prevention of complications. Recognition of disease progression and the maintenance of the patient's self-worth are essential. Nursing diagnoses with respect to this patient population have been provided.
Neuroprotective agents are investigational drugs that can potentially suppress the development of secondary brain injury following cerebral traumatic injury. Currently, critical care nurses in research centers are challenged to care for these patients during the clinical trial phase of these drugs. Soon, if these drugs pass the trial phase and are approved, critical care nurses in all settings may be administering neuroprotective agents to brain injury patients, identifying side effects, and evaluating their effects on secondary brain injury.
Traumatic brain injury accounts for many deaths each year. Those who survive stand a high chance of sustaining permanent cognitive and behavioral sequelae that will impact not only their own lives, but those of family and friends. The most frequently observed cognitive manifestations include memory loss, decreased rates of information processing, and cognitive rigidity. The most common behavioral manifestations are lack of impulse control, increased agitation, and mood lability. While these deficits are often permanent, cognitive retraining and behavioral management can modulate responses. The focus of care is on reorganization of existing abilities rather than modification of abnormal responses.
Diffuse axonal injury (DAI) is a severe form of traumatic brain injury that is seen almost exclusively following motor vehicle accidents. It is associated with immediate coma lasting from six hours to prolonged coma. The author reviews the mechanism of injury, significant neurological findings, neuropathology, and diagnostic criteria. Priorities for nursing care in the emergency department, critical care, and inpatient and rehabilitation units are outlined.
We examined breast fine needle aspiration cytology's role as a screening tool in addition to mammography and clinical examination for palpable breast lesions, circumventing operative biopsy of benign lesions while identifying cancer for definitive treatment and significant ductal proliferations that need histologic evaluation, such as atypical ductal hyperplasia and marked ductal hyperplasia. Five hundred thirty-three consecutive palpable breast lesions in 498 patients referred to cytopathologists were aspirated and the cytologic findings reported as follows: (1) malignant, treat as any histologic diagnosis of breast cancer (85); (2) suspicious, intraoperative or biopsy confirmation before therapy (11); (3) atypical, biopsy recommended to exclude breast cancer or significant ductal proliferation (atypical ductal hyperplasia and marked ductal hyperplasia) (45); (4) benign, excision not necessary (334); and (5) nondiagnostic, no ductal cells, and biopsy recommended if indicated clinically (58). Excision of 57/85 malignant lesions confirmed cancer in all cases. Follow-up of the remaining 28 patients showed: 17 were undergoing treatment for cancer without surgery, 8 were dead of the disease, and 3 were lost to follow-up. Biopsy of 11/11 suspicious lesions confirmed cancer. Biopsy of 27/45 atypical lesions showed: 1 carcinoma, 12 significant ductal proliferations (1 atypical ductal hyperplasia and 11 marked ductal hyperplasia) and 14 benign, nonproliferative breasts; 18 atypical lesions from 14 patients were not biopsied. Biopsy of 61/334 benign lesions showed 51 benign nonproliferative breasts, 7 missed significant ductal proliferations (6 marked ductal hyperplasia and 1 atypical ductal hyperplasia) and 3 false negatives (3 carcinomas). The three false negatives and the atypical ductal hyperplasia had a biopsy because of an abnormal mammogram. Review of material from false-negative cases showed underinterpretation of cells present on cytology slides in two cases and carcinoma missed by the aspiration needle in one case. The atypical ductal hyperplasia was in a separate, nonpalpable area in the same breast. Biopsy was avoided in 273/334 benign lesions from 249 patients: 86 had no follow-up, 160 had stable lesions, and 3 reported a change in their lesions (mean follow-up, 13 months). One of these three had a biopsy that showed a benign, nonproliferative breast. Biopsy of 11/58 nondiagnostic lesions showed 9 benign nonproliferative breasts, 1 atypical ductal hyperplasia and 1 carcinoma. No biopsy was performed on 47/58 nondiagnostic lesions from 45 patients: 1 had a repeat aspiration that was malignant, 10 had no follow-up, 33 had stable lesions, and 1 had an increase in the size of her lesion (mean follow-up, 13 months).(ABSTRACT TRUNCATED AT 400 WORDS)