Pasture Evidence-Based Practice Habits: Putting More Sacred Cows Out to

24 Pages·2011·0.45 MB·English

Evidence-Based Practice Habits: Putting More Sacred Cows Out to
Pasture
Mary Beth Flynn Makic, Kathryn T. VonRueden, Carol A. Rauen and Jessica Chadwick

Crit Care Nurse 2011;31:38-62 doi: 10.4037/ccn2011908
© 2011 American Association of Critical-Care Nurses
Published online http://www.cconline.org

Personal use only. For copyright permission information:
http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Subscription Information
http://ccn.aacnjournals.org/subscriptions/
Information for authors
http://ccn.aacnjournals.org/misc/ifora.shtml
Submit a manuscript
http://www.editorialmanager.com/ccn
Email alerts
http://ccn.aacnjournals.org/subscriptions/etoc.shtml
Critical Care Nurse is the official peer-reviewed clinical journal of the American
Association of Critical-Care Nurses, published bi-monthly by The InnoVision Group
101 Columbia, Aliso Viejo, CA 92656. Telephone: [phone],
ext. 532. Fax: [phone]. Copyright © 2011 by AACN. All rights reserved.
Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011
Feature
Evidence-Based Practice
Habits: Putting More
Sacred Cows Out to Pasture
Mary Beth Flynn Makic, RN, PhD, CNS, CCNS
Kathryn T. VonRueden, RN, MS, ACNS-BC
Carol A. Rauen, RN, MS, CCNS, CCRN, PCCN
Jessica Chadwick, RN, MSN, CCNS
For excellence in practice to be the standard for care, critical care nurses must in making decisions about the care
embrace evidence-based practice as the norm. Nurses cannot knowingly continue a of individualized patients.”1One
clinical practice despite research showing that the practice is not helpful and may even would hope that clinicians would
be harmful to patients. This article is based on 2 presentations on evidence-based strive for this goal in all practice
practice from the American Association for Critical-Care Nurses’ 2009 and 2010
decisions. Unfortunately, philosoph-
National Teaching Institute and addresses 7 practice issues that were selected for 2
ical goals and clinical realities are
reasons. First, they are within the realmof nursing, and a change in practice could
not always congruent. Many practice
improve patient care immediately. Second,these are areas in which the tradition and
decisions that were originally based
the evidence do not agree and practice continues to follow tradition. The topics to
on intuition and tradition have not
be addressed are (1) Trendelenburg positioning for hypotension, (2) use of rectal
changed despite compelling evidence
tubes to manage fecal incontinence, (3) gastric residual volume and aspiration risk,
that change is warranted. The classic
(4) restricted visiting policies, (5) nursing interventions to reduce urinary
example (addressed in the first arti-
catheter–associated infections, (6) use of cell phones in critical care areas, and (7)
accuracy of assessment of body temperature.The related beliefs, current evidence, cle in this series, “Seven Evidence-
and recommendations for practice related to each topic are outlined. (Critical Care Based Practice Habits: Putting Some
Nurse.2011;31:38-62) Sacred Cows Out to Pasture”2) is the
use of instillation of normal saline
into an endotracheal tube before
I
f we want excellence in prac- cannot knowingly continue a clini- suctioning to “loosen secretions.”
tice to be the standard for care, cal practice despite research that Not only does this practice not loosen
critical care nurses must shows that the practice is not help- secretions, it harms patients and
embrace evidence-based ful and may even be harmful to may be a major contributing factor
practice as the norm. We the patients we serve. This article to ventilator-associated pneumonia.2
is devoted to putting some clinical Cutting-edge practice decisions are
CEContinuing Education sacred cows out to pasture. It is commonly based on research or the
based on 2 presentations on best available evidence.3It is the
1. Understand how embracing evidence- evidence-based practice from the older practice habits or “sacred cows”
based practice can immediately improve
American Association of Critical- that are more challenging to change
patient care
2. Recognize 7 areas of clinical practice in Care Nurses (AACN) National because the practices are considered
which tradition and the evidence do not
agree Teaching Institute in 2009 and 2010. routine and beyond dispute.
3. Identify recommendations for practice The Institute of Medicine The implementation of evidence-
related to 7 older practice issues or “sacred
cows” defines evidence-based practice as based practice at the bedside takes
“The integration of best research, commitment and an effective process.
©2011 American Association of Critical-
Care Nurses doi: 10.4037/ccn2011908 clinical expertise, and patient values Excellent process models to assist in
CriticalCareNurse
38 Vol 31, No. 2, APRIL 2011 www.ccnonline.org
Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011
Table 1 Table 2
Evidence-based practice Systems for evaluating levels of evidence
models
American Association for Critical-Care AACN levels of evidence: 6-level tool for
Iowa model4 Nurses (AACN)13 grading; level A is the strongest evidence
and M is manufacturer’s recommendation
Stetler’s model5
only
Rosswurm and Larrabee’s model6
Centers for Disease Control and Modified HICPAC Categorization Scheme for
Johns Hopkins Nursing model7 Prevention14 Recommendations: 5-scale system
ACE Star Model of Knowledge Society of Critical Care Medicine15 Grades of Recommendation, Assessment,
Transformation8 Development and Evaluation (GRADE System)
was used to evaluate evidence for Surviving
ARCC (Advancing Research and
Sepsis Guidelines
Clinical Practice Through Close
Collaboration) model9 American Heart Association16 Used an 8-level scale with 4 classifications
to support recommendations for Basic Life
AHRQ (Agency for Healthcare
Support and Advanced Cardiac Life Support
Research and Quality) model10
PARIHS (Promoting Action on
Research Implementation in Health
implementation is more challeng- could improve patient care immedi-
Services) framework11
ing, although not impossible. Once ately. Second, these are areas in which
Colorado model12
the research or evidence is collected, the tradition and the evidence do
it must be evaluated for strength not agree and practice continues to
this goal have been published. and quality by using levels of evi- follow tradition or “sacred cows.”
Table 14-12lists 9 evidence-based dence. AACN recently published an The topics to be addressed are as
practice models that offer step by updated guidefor level of evidence follows:
step approaches and frameworks inCritical Care Nurse.13Table 2 pro- 1. Trendelenburg positioning for
to use. The typical process pre- vides examples of other evaluation hypotension
scribed by the models is to ask a tools that may be used to assist cli- 2. Use of rectal tubes to manage
clinical question, determine whether nicians in the evaluation of research fecal incontinence
solid evidence exists to support a and evidence in deciding if the evi- 3. Gastric residual volume
particular practice, compare current dence is compelling enough to rec- (GRV) and aspiration risk
practice with the research recom- ommend a change in practice. 4. Restricted visiting policies
mendations, and make appropriate This article addresses 7 practice 5. Nursing interventions to
clinical changes based on the evi- issues that were selected for 2 rea- reduce urinary catheter–associated
dence. Although the process is sons. First, they are within the realm infections
seemingly simple, articulating the of nursing, and a change in practice 6. Use of cell phones in critical
care areas
7. Accuracy of assessment of
Authors
body temperature
Mary Beth Flynn Makic is a research nurse scientist in critical care at the University of
The related beliefs, current evidence,
Colorado Hospital and an adjoint assistant professor at the University of Colorado,
Denver, in Aurora, Colorado. and recommendations for practice
related to each topic are described.
Kathryn T. VonRueden is a clinical nurse specialist at the R. Adams Cowley Shock
Trauma Center at the University of Maryland Medical Center and an assistant professor
at the University of Maryland School of Nursing in Baltimore.
Trendelenburg Positioning
Carol A. Rauen is an independent clinical nurse specialist and education consultant and
for Hypotension
a staff nurse in the emergency department at Outer Banks Hospital in The Outer Banks
of North Carolina. Use of the Trendelenburg position
Jessica Chadwick is a clinical nurse specialist in the emergency department at Inova was originally intended to improve
Fairfax Hospital in Fairfax, Virginia. surgical exposure for abdominal
Corresponding author: Mary Beth Flynn Makic, RN, PhD, CNS, CCNS,7830 W. 72nd Place, Arvada, CO 80005 procedures. In the late 1800s,
(e-mail: [email protected]).
Friedrich Adolf Trendelenburg and
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, [phone] or [phone] (ext 532); fax, [phone]; e-mail, [email protected]. one of his students, W. Meyer, first
CriticalCareNurse
www.ccnonline.org Vol 31, No. 2, APRIL 2011 39
Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011
described the position as a supine Cardiovascular response to the tidal volume.28,29Lung compliance
head-down tilt of at least 45º.17Use Trendelenburg position appears to can decrease by 20%, PaCO increases,
2
of this position became common be influenced by the presence of and a mild metabolic acidosis may
practice in the operating room but hypotension and the patient’s ability develop.26Ventilation and perfusion
was associated with complications to maintain homeostasis. For exam- abnormalities, evidenced by an
such as increased central venous ple, in normotensive patients placed increase in intrapulmonary shunt-
pressure, engorgement of head and in the Trendelenburg position, little ing, are also reported in the Trende-
neck veins, increased cerebral spinal deleterious hemodynamic effect is lenburg position.21Not surprisingly,
fluid pressure, hypertension, retinal observed.21-23Even in elderly nor- as body weight increases, lung
detachment, impaired oxygenation motensive patients, who may have resistance and gas exchange abnor-
and ventilation, gastric secretions some degree of impairment of vaso- malities also increase signifi-
and mucus in the oropharynx caus- motor control owing to their age, cantly,28,29which has important
ing aspiration.17From a practical no deterioration was noted in car- clinical implications for obese criti-
aspect, patients placed in the Tren- diac hemodynamic parameters with cally ill patients; thus the Trende-
delenburg position had to be pre- use of the Trendelenburg position.24 lenburg position should be avoided
vented from sliding head-down off Hypotensive patients appear to in such patients.
the table.17Despite these adverse have different and more varied car- Little research is available on
outcomes for patients, the practice diovascular responses to the head- the effect of Trendelenburg position
of placing patients in the Trendelen- down position,21,25and they show no on intracranial pressure; however,
burg position persists. improvement in blood pressure or some agree that it is likely to increase
cardiac index.18-21,24-26As well, key intracranial pressure because of
Related Beliefs and components of tissue oxygenation the increased central venous pres-
Current Evidence are not improved with the Trende- sure,17,24,30-32but the effects on cere-
The use of the Trendelenburg lenburg position.27Most investiga- bral blood flow are uncertain.
position for hypotension and shock tors have concluded that use of the Distension of the internal jugular
has been studied for more than 50 Trendelenburg position in hypoten- vein has been measured and is
years. The proposed physiological sive patients has no cardiovascular increased in head-down tilt, but
benefit is the shift of intravascular benefit.18-21,24-26 internal jugular blood flow is
volume from the lower extremities Hewer,17in his 1956 review of unchanged. Researchers disagree
and abdomen to the upper part of complications of the Trendelenburg on the effect of the Trendelenburg
the thorax, the heart, and the brain, position, discussed the untoward position on intracranial pressure
thus improving perfusion to heart effects on lung ventilatory mechan- and cerebral blood flow, with some
and brain. It is estimated that a head- ics and pulmonary gas exchange. concluding that those factors do
down position results in a 1.8% dis- These effects included reduced vital increase,32while others conclude
placement of blood volume.18In the capacity even at 20º head-down tilt, that cerebral hemodynamics are
1960s, however, Weil and Whigham19 increased work of breathing, and not affected.22One clinical protocol
reported deleterious effects of using impaired respiration causing that uses Trendelenburg position-
the Trendelenburg position in animals hypercarbia and hypoxemia. In the ing for postural drainage of the
and humans. In a hemorrhagic shock head-down tilt position, the cepha- lungs in patients with brain injury
model with rats, mortality and hemo- lad shift of abdominal contents originally incorporated criteria
dynamicresponsiveness were least increases abdominal pressure, based on changes in intracranial
favorable in the head-down position; impairs diaphragmatic function, pressure and cerebral perfusion
in humans with hypotensive shock, and impedes lung expansion. In the pressure33and now also includes
blood pressure decreased, lung vol- Trendelenburg position, mechanical reduced brain tissue oxygenation
umes were compromised, and the impedance of the lung and chest wall for more precision, as the basis for
risk of retinal detachment and cere- increases and is associated with returning the patient to supine or
bral edema increased.19,20 increased resistance and decreased head-up position.
CriticalCareNurse
40 Vol 31, No. 2, APRIL 2011 www.ccnonline.org
Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011
In reviewing the literature related delenburg posi-
Table 3
Physiological effects of Trendelenburg positioning
to the physiological effects of the tion.17,21,24,25,27-32
in hypotensive patients
Trendelenburg position and its use Alternatives
to treat hypotension and shock, we to Trendelen- Cardiovascular21-27
Slight increase in mean arterial pressure
encountered a number of limitations burg position-
No increased preload
that made it difficult to draw defini- ing, such as Dilated right ventricle
Decreased right ventricular ejection fraction
tive conclusions. Studies were con- passive leg lift,
Decreased cardiac output
ducted with a variety of populations may provide Increase in systemic vascular resistance
(eg, animals, healthy volunteers, or greater benefit
Pulmonary21,26,28,29
normotensive patients), sample sizes for initial man- Reduced vital capacity
Increased work of breathing
were relatively small, the methods agement of
Decreases in PaO2
used various degrees of head-down hypotension or Increases in mechanical impedance of lung and chest wall
positioning that ranged from 10º to prediction of Decreased tidal volume
Decreased lung compliance
30º and the length of time in this fluid respon-
Increases in PacO2
position also varied, and various siveness with
Tissue perfusion27
end points were measured. Despite minimal or no No change in oxygen delivery
No change in oxygen extraction
these study limitations, most of the untoward
No change in oxygen consumption
findings are consistent in that they effect.34,35Rais-
Gastrointestinal26,28,29
show no demonstrated benefit of ing the patient’s
Cephalad shift of abdominal contents
the Trendelenburg position for legs while keep- Increased abdominal pressure
Impaired diaphragmatic function
hypotension or shock. Thus the evi- ing the head of
Impeded lung expansion
dence does not support the use of the bed hori-
Neurological17,24,30-32
head-down tilt for hypotension. zontal relative Possible increase in intracranial pressure associated with increase
to the patient’s in central venous pressure
Distention of internal jugular vein
Recommendations for Practice trunk produces
Trendelenburg position increases an approximate
venous return but has little or no volume shift of 150 to 300 mL to Trendelenburg position for patients
beneficial effect on cardiac output the upper part of the thorax.34,35 with hypotension and/or hypo-
or blood pressure; the improvement, This shift increases aortic volume, volemic shock, and such positioning
if any, is temporary. Pulmonary gas may not activate baroreceptors, and is associated with impaired ventila-
exchange is impaired in the head- avoids risk of gastric aspiration. In tion and oxygenation and may have
down tilt position, thus overall oxy- one study,25researchers reported other deleterious effects as just men-
gen delivery may not improve at all. the same adverse cardiovascular tioned. Despite these findings, a
As well, the deleterious effects on and pulmonary effects for passive survey of critical care nurses about
lung mechanics and oxygenation are leg raising as for Trendelenburg practices related to use of Trendelen-
more exaggerated in obese patients. positioning in 18 cardiac surgery burg position conducted in the late
Cerebral blood flow and intracra- patients. Others have shown that 1990s showed that 80% of the
nial pressure most likely increase in this maneuver correlates with the respondents would consider using
the Trendelenburg position, and response to fluid loading and is Trendelenburg positioning to improve
the effect may be deleterious in predictive of the need for fluid hypotension.36Although little new
some patients with brain injuries. when a patient’s cardiac output, research has been done since that
The gravitational movement of stroke volume variation, or blood time, dissemination of information
mucus and gastric secretions to the pressure respond positively to the related to the deleterious effects and
oropharynx may increase the poten- leg lift maneuver.34,35 lack of benefit of this position has
tial for aspiration. Table 3 provides The evidence, despite the afore- continued.37A repeat survey would
a summary of the evidence and mentioned limitations, does not be useful to determine if this tradition-
physiological response to the Tren- show a demonstrated benefit of the based practice persists.
CriticalCareNurse
www.ccnonline.org Vol 31, No. 2, APRIL 2011 41
Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011
Use of Rectal Tubes to
Table 4
Possible risk factors to consider in evaluating the cause of acute
Manage Fecal Incontinence
fecal incontinence
Critically ill patients with incon-
Type Risk factor
tinence are at high risk for perineal
skin damage, which may also increase Disease processes45,47 Gastrointestinal and hepatic diseases
Sepsis
the patient’s risk for pressure ulcera- Spinal cord injury
tion, secondary dermal injury, and Enterotoxins
infection.38-40Urinary and fecal Medications48 Nonsteroidal anti-inflammatory drugs, antimicrobial agents,
angiotensin-converting enzyme inhibitors, β-blocking
incontinence harm the protective
agents, digoxin, lactulose, diuretics
skin barrier through excessive mois-
Nutrition49 Enteral tube feeding (consult nutritionist to determine optimal
ture that macerates the skin, com- tube feeding formula and rate to minimize diarrhea)
promising its defensive functions
for the body. Digestive enzymes and
bacteria inherently found in feces ulcers), starts with an evaluation of and factors believed to be associ-
alter the pH and irritate the skin, the cause of the diarrhea.41,45,46Begin ated with the diarrhea.
increasing the risk of incontinence- by reviewing the patient’s medical Fecal collectors, also called anal
associated dermatitis and infec- history, current medications, and bags/pouches, when applied cor-
tion.38,40,41Nursing management of treatments that may increase gastric rectly are an effective option to
critically ill patients with acute diar- motility or diarrhea. Table 445,47-49 control and contain liquid feces.38,40,57
rhea is focused on protecting the provides a list of factors to consider Fecal collectors are external devices
skin as well as containing the diar- in evaluating the etiology of the that consist of a self-adhering skin
rhea. Research to effectively manage patient’s diarrhea. barrier and attached pouch that
acute fecal incontinence is limited; Fecal incontinence may be a sec- connects to a drainage bag, provid-
however, evidence is evolving and ondary consequence of the patient’s ing a closed system to move liquid
best practice guidelines are available disease or treatment (eg, antibiotics), stool away from the skin. This sys-
to guide practice.40,42 so several interventions can be tem is external, providing less risk
implemented to protect the skin to the patient’s rectal sphincter and
Related Beliefs and before placement of a device in the internal mucosa.40,57When applied
Current Evidence rectum to divert stool. Nursing correctly, fecal collectors can pre-
Use of rectal tubes to divert fecal interventions to minimize skin vent skin breakdown, minimize
material away from the skin and breakdown from fecal incontinence odor, track output accurately,
into a collection bag, a traditional should be implemented early by decrease exposure to fecal material,
approach, is the least safe interven- anticipating excessive moisture or minimize caregiver time, enhance
tion and the procedure is poorly diarrhea on the basis of the patient’s patients’ comfort, and save money.40
defined.40,42,43Little research exists to current plan of care (Table 5). In a study57conducted in Europe,
support the use of traditional rectal When fecal incontinence is the fecal collector was evaluated in
tubes (eg, mushroom catheter with excessive or incontinence-associated 120 hospitalized patients. The vast
a soft flared tip, urinary catheter dermatitis is progressing, the use of majority (96%) of nurses reported
with a balloon); however, these fecal containment devices may be that the device preserved perineal
devices have been used in practice indicated. These devices can be skin integrity, and none of the
without clear evidence of the efficacy divided into 2 categories: fecal patients had adverse skin break-
and safety of the devices for manage- pouches or indwelling retention down while the device was in place.
ment of fecal incontinence.44 devices (tubes). When choosing a Additional benefits of a fecal collec-
Best practice for the management fecal containment device to move tor include the following: it can be
of fecal incontinence, to minimize effluent away from the perigenital used indefinitely, as needed, to
skin breakdown (ie, incontinence- skin, critical care nurses should manage diarrhea; it will not inter-
associated dermatitis and pressure assess the patient’s perineal skin fere with gastrointestinal activity as
CriticalCareNurse
42 Vol 31, No. 2, APRIL 2011 www.ccnonline.org
Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011
Table 5
Evidence-based management of fecal incontinence
Assessment Evidence-based intervention
Assess patient’s risk for fecal incontinence; anticipate Protect the skin with moisture barrier products in anticipation of diarrhea
fecal incontinence associated with disease, medica-
tions, interventions40,42,44,48
Assess the patient for risk of pressure ulcers and Complete a risk assessment daily and with a change in patient’s condition39;
excessive moisture and prolonged immobility by implement interventions based on specific findings on risk assessment
using a valid and reliable risk assessment tool39,46
Assess skin during the cleansing process Using soap and water with a washcloth is not optimal for basic skin care40,42
Cleanse theskin with no-rinse cleanser, moisturize Soaps are frequently alkaline and further damage the protective acidic mantle
and protect the skin with each episode of inconti- of the skin40,42
nence38,42,45,50 Washcloths may increase friction and damage fragile skin40,42
No-rinse bathing/perineal cleansing wipes are pH balanced, gentle on the skin,
and enhance removal of organic debris38,42,45,51
Research shows that no-rinse bathing products are effective in reducing
bacteria on the skin50
Incontinence overhydrates skin but removes essential oils that need to be
replenished by applying moisturizers and moisture barrier products38,40,41,51
Assess the need for moisture absorbing incontinence Use a single moisture-absorbing or wicking underpad under the patient to pull
pad to wick effluent away from the skin42,44 effluent/moisture and liquid stool away from skin38,51,54-56
Assess the need for air flow near the skin and advanced Avoid the use of diapers, especially with immobile patients, as diapers trap
bed redistribution technology (follow hospital proto- fecal material against the skin and exacerbate skin damage40,51
col for advanced bed therapy); avoid excessive Limit layers of linens beneath the patient; multiple layers of linen can inhibit
linen52,53 bed redistribution technology and air flow from reaching the skin39,52,53
Excessive linen entraps moisture, creates crinkles and pressure, and may
increase the risk of pressure ulcers52,53
Assess patient’s mobility and encourage toileting Obtain bedside commodes and implement a toileting schedule to minimize
incontinence epidose47
Assess nutritional needs and evaluate tolerance of Consider consult a nutritionist for diarrhea believe to be related to tube
tube feeding feeding49
Evaluate skin for fungal infection associated with Fungal infection may be managed effectively with the application of topical
fecal incontinence38,51 antifungal barrier creams
Assess skin, development of incontinence-associated Consider fecal collectors or bowel-management system42,44,57-62
dermatitis, as well as frequency and consistency of
stool to determine need for a fecal containment
device42,44,57-62
Assess resolution of cause of diarrhea, changes in diar- Remove fecal containment devices when liquid stool resolves57-62
rhea flow, consistency, and skin condition to deter-
mine need for ongoing fecal containment device57-62
diarrhea resolves; and it will not indicate that the device was well tol- inflating the balloon or mushroom
compromise the rectal sphincter erated by patients, was practical for tip of the catheter. Table 6 outlines
and mucosa. nurses, and effectively contained the advantages and disadvantages
The nasopharyngeal airway fecal matter without untoward of these traditional devices for fecal
(nasal trumpet) has been studied effects for patients.47 diversion. The use of balloon tubes
as a device to contain fecal inconti- Traditional rectal tubes (eg, or mushroom catheters is an adap-
nence in critically ill patients.58 mushroom catheter with a soft flared tation of the device for fecal con-
With this method, a soft nasopha- tip, urinary catheter with a balloon) tainment, and because of the lack
ryngeal airway is inserted into the for management of liquid stool are of evidence to support their safe
rectum and connected to a drainage considered the least safe approach and effective use and the availability
collection system. Research on this for management of diarrhea.38,40,44 of other fecal containment systems,
method of fecal containment is These devices are inserted into the these devices should be avoided in
limited; however, initial results rectal vault and held in place by current practice.38,40,42,44
CriticalCareNurse
www.ccnonline.org Vol 31, No. 2, APRIL 2011 43
Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011
the BMS and the reduction in fre-
Table 6
Advantages and disadvantages of traditional rectal tubes (mushroom
quency of pressure ulcers, use of a
catheter with soft flared tip, urinary catheter with a balloon)a
BMS to contain diarrhea and man-
Advantages Disadvantages
age excessive moisture combined
Diverts liquid stool away from skin Fecal material must be liquid to pass through tube
with strategies for preventing pres-
Tubes may leak and create perirectal skin damage sure ulcers resulted in good out-
As diarrhea resolves, the tube may block stool comes for patients. Critical care
Ballooned devices require strict periodic deflation nurses should assess the need for a
to prevent rectal mucosal injury
BMS to manage severe diarrhea with
Injury of anal sphincter is not easily assessed
the goal of removing the devices as
Duration for use of the device has not been soon as possible.
established
a Based on evidence from Gray et al,38,41Wishin et al,40Petterson,41Beitz,42Beekman et al,44and Grogan and Recommendations for Practice
Kramer.58
Management of fecal inconti-
nence to minimize incontinence-
Bowel management systems of using BMSs for diarrhea man- associated dermatitis and pressure
(BMSs), also called fecal manage- agement. Padmanabhan and col- ulcers begins with an accurate nurs-
ment systems, are medical device leagues60evaluated the outcomes of ing assessment of the patient’s risk
systems designed to direct, collect, 42 patients in whom a BMS was used for fecal incontinence, early proac-
and contain liquid stool in immobile to contain diarrhea. The researchers tive perineal skin hygiene to protect
patients. Several BMSs are commer- found that the device did not harm skin and minimize irritation, and
cially available and approved by the the rectal mucosa (by performing critical evaluation of when an exter-
Food and Drug Administration for endoscopy at baseline and after nal fecal containment device or
up to 29 days of use for manage- removal of the BMS), perigenital BMS is needed. Evidence-based
ment of liquid stool.42,59BMSs have skin condition improved in 92% of interventions (Table 5) should be
unique characteristics and specific the patients, and the health care used in the care of patients with
insertion techniques (readers are providers reported that the system fecal incontinence.
referred to device instructions for was easy to manage. Keshava et al61
insertion); however, the indications conducted a prospective study of Gastric Residual Volume
and contraindications are similar inpatients admitted for burn man- and Aspiration Risk
across device manufacturers. BMSs agement or to the geriatric unit. Little evidence supports the use
are soft flexible catheters with con- Twenty-two patients with diarrhea of measurement of GRV to assess
tainment drainage systems. The bal- were managed with a BMS. Mean gastric emptying and tolerance of
loon used to inflate and secure the duration of therapy was 14 days. tube feeding, yet the practice of
catheter within the rectum is soft Proctoscopy after tube removal assessing GRV while a patient is
and conforms to the rectal vault, showed normal rectal tissue, and receiving tube feeding persists.63,64
reducing the risk of anorectal the health care providers in that Several assumptions may exist
trauma.42,44When used properly, study also reported ease of use of related to the assessment of GRV.65-67
the BMS contains liquid stool, the device. In a quality improve- First, the nurse may assume that
allows accurate measurement of out- ment study,62researchers found that GRV provides information about
put, decreases health care providers’ the combination of interventionsto normal and abnormal gastric
exposure to body fluids, and may prevent pressure ulcers along with emptying. Second, the nurse may
protect perirectal skin or denuded the introduction of a BSM in their think that an elevated GRV indi-
perigenital skin or wounds, thus critical care unit resulted in a signif- cates delayed gastric emptying
enhancing healing.38,42,44,59Several icant decrease in the frequency of and intolerance of enteral tube
studies have been conducted to pressure ulcers. Although a direct feeding. Third, a high GRV may be
evaluate the effectiveness and safety correlation cannot be made between believed to result in a higher risk
CriticalCareNurse
44 Vol 31, No. 2, APRIL 2011 www.ccnonline.org
Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011
for aspiration that may lead to aspi- cases.69Frequent monitoring (eg, underfeeding critically ill patients.
ration pneumonia. In fact, the evi- every 4 hours) of GRV is indicated Elpern et al76studied enteral feed-
dence has demonstrated that as one method to monitor gastric ings in an intensive care unit and
checking a GRV in enterally fed tube location. After obtaining found that tube feedings were fre-
patients does not improve patients’ radiog raphic confirmation of accu- quently withheld or stopped for
outcome or reduce complications.65-71 rate placement of a gastric tube, procedures, changes in patients’
So why do we continue to check observing the appearance and body positions, high GRV, and diar-
GRV, and what evidence supports changes in the volume of gastric rhea. Of the patients studied, a mean
continuing this practice? aspirate may assist in monitoring of 64% of the patients had their
for migration of the gastric tube.75 nutrition goals met, and the mean
Related Beliefs and Another debate about the moni- length of interruptions for enteral
Current Evidence toring and interpretation of GRV feeding was 5.23 hours per patient
The lack of definition of how to is defining what constitutes a high per day. McClave and colleagues67
measure GRV accurately creates a gastric residual.64,66-68Under normal reported similar results. In their
challenge in clinical practice.68,69 conditions, saliva and gastric flu- study, only 14% of the patients
Most guidelines suggest the use of ids accumulate at approximately received 90% goal feeding within 72
a large-volume syringe (60 mL) for 188 mL/h in the stomach; thus any hours of starting enteral feeding.
aspiration of fluid because smaller order to withhold tube feedings for Reasons reported in this study for
syringes may collapse the gastric a GRV less than 188 mL is inappro- stopping enteral feeding included the
tube.64,66However, use of a syringe priate.64Published reports vary in following: placement of the patient
may not consistently result in aspi- providing guidance for what consti- supine for procedures or nursing
ration of the total volume of fluid tutes a high gastric residual, rang- care, high GRV, and preprocedure
present in the stomach.70,73GRV is ing from 150 mL to 500 mL of protocols. Little evidence supports
more easily obtained from large-bore aspirate.64,65,66,68,71,72Best evidence the practice of stopping or withhold-
gastric tubes (eg, 14F-16F diameter) suggests that a single high GRV ing tube feeding to reposition patients
than small-bore gastric tubes (8F-12F should be monitored for the fol- or when placing patientssupine
diameter). Metheny and colleagues74 lowing hour, but enteral feeding briefly for routine care.67Current
reported that larger GRVs were should not be ceased or withheld evidence suggests reducing the time
detected 2 to 3 times more often for an isolated GRV greater than that enteral feedings are withheld
with large-bore gastric tubes than 250 mL.65,68Serial hourly elevated before procedures to minimize
with gastric tubes with a smaller GRVs greater than 250 mL may underfeeding critically ill patients.66,67
bore. Other variables that affect require withholding enteral feeding The primary belief associated
measurement accuracy include the for an hour in conjunction with with high GRV is risk for aspiration
position of the tube port in the gas- evaluation for prokinetic agents to by the patient. Aspiration has been
tric antrum, the patient’s position, promote gastric motility and assess- demonstrated with GRVs from 5 mL
and the tube’s location near the mentof possible causes for decreased to 500 mL.67Aspiration is often clin-
gastroesophageal junction.68,72GRV gastric tolerance, including a ically silent. No reliable clinical
with enteral feeding tubes placed change in the patient’s acuity.64,66,68 marker has been found for risk of
beyond the pylorus is questionable Elevation of GRV is anticipated to aspiration, including GRV assess-
because of the small size of these be greatest in the first few days of ment.65,68,72,76Risk for aspiration is
tubes and the physiological proper- enteral feeding. Questions remain increased with hemodynamic insta-
ties of the small bowel to continu- unanswered on when to stop check- bility, increased acuity or critical
ously propel gastric contents ing GRV to evaluate tolerance of illness (eg, sepsis), altered level of
forward, unlike the gastric antrum.66 enteral feeding. consciousness, neurological com-
Similarly, if a gastric tube migrates The greatest concern with with- promise, sedation, and mechanical
near the gastroesophageal junction, holding enteral feeding because of ventilation. Interventions to mini-
GRV will be negligible in most GRV or concern for aspiration is mize aspiration include elevating
CriticalCareNurse
www.ccnonline.org Vol 31, No. 2, APRIL 2011 47
Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011
the head of bed more than 30º, initi- evaluating the patient’stolerance of practices of nurses with regards to
ating continuous enteral feedings, tube feeding.65,66,71Assessment of visitation. Using the Critical Care
using medications to promote gas- GRV is not an effective method of Family Needs Inventory, the pri-
tric motility, and consideration of determining aspiration risk.64-68,70,74 mary needs of families of critically
postpyloric feeding.64-66,68,69Ongoing Table 7 outlines the evidence for ill patients were identified to be
evaluation of patients’ tolerance of GRV monitoring and interventions related to the need for information,
enteral feeding is also necessary to to prevent aspiration. Implement- support, comfort, assurance, and
interpret GRV. Signs of intolerance ing an evidence-based enteral feed- proximity to the patient. A subse-
may include bloating, abdominal ing protocol inclusive of increased quent study reported that in addi-
pain, nausea, vomiting, and emesis. acceptance of higher GRV along tion to these needs, families also
Implementing and adhering to with physical assessment of the have a need to be present in order
enteral feeding protocols (Figure 1) patient’s tolerance and intolerance to provide reassurance and support
to minimize unnecessary cessation of tube feeding will maximizethe to the patient and to protect the
of enteral feeding is needed to opti- delivery of adequate nutrition to patient.82
mize nutrition in critically ill patients. critically ill patients. The needs, preferences, and
Isolated high GRVs should be stressors of critically ill patients also
reassessed in subsequent hours and Restricted Visiting Policies: have been examined.83In a survey
accepting higher GRVs in the absence A Thing of the Past? of critical care patients, 40 stressors
of signs of intolerance is necessary Restriction of visitors for hospi- were identified; number 4 was
in clinical practice.65Increasing GRV talized patients has been practiced “missing your spouse,” and number
may be a symptom of another under- for many decades. For example, in 8 was “only seeing family and
lyingproblem manifesting itself as the late 1800s, restricted visiting friends for a few minutes each
delayed gastric emptying.68If serial hours were implemented in some day.”83(p100)These investigators con-
measurements of GRV remain ele- hospitals and applied to nonpaying cluded that although some visiting
vated, the cause should be explored patients to establish order in gen- restrictions were appropriate, the
rather than simply withholding eral wards. In the early 1900s, pay- policies should be modified and
enteral feeding, which is likely to ing patients were permitted to have flexibility should be exercised.
result in underfeeding of critically visitors anytime, anywhere. The Perceived barriers to liberalized
ill patients.67,68,76 advent of intensive care units dur- visiting and the rationales for restrict-
ing the 1960s saw restricted visiting ing visiting in critical care units are
Recommendations for Practice implemented to protect patients multifactorial (Table 8).80,84-86These
Critically ill patients are at risk and family from exhaustion caused concerns were distilled into 3 major
of aspiration because of severity of by too many visitors.77The spec- groups in a recent study87of 171
illness and interventions that com- trum of “visiting” can be thought of hospitals, of which 32% had unre-
promise the gag reflex. Variables that as a continuum (Figure 2). Current stricted, open visiting. The cate-
increase a patient’s risk for aspiration attitudes and practices in critical gories are (1) Space: interference
include sedation, mechanical venti- care units span this continuum.78,79 with patients right to privacy and
lation, neurological compromise/ confidentiality in instance of shared
altered level of consciousness, hemo- Related Beliefs and rooms; (2) Conflict: crowding and
dynamic instability, and sepsis. Pre- Current Evidence traffic, hindering the ability to care
venting aspiration begins with Evaluation of the evidence for patients and loss of structure
accurate and ongoing assessment of related to friends and family visiting and authority for nurses; and (3)
feeding tube placement (see AACN patients reflects both practitioner Burden: to provide care for both
Practice Alert: Verification of Feed- preferences and a focus on patient- patients and their visitors.
ing Tube Placement75), maintaining and family-centered care.80A land- In the past several decades,
the elevation of the head of the mark study by Molter81in 1979 many studies have been conducted
patient’s bed at greater than 30º, and began to change the attitudes and related to the psychological and
CriticalCareNurse
48 Vol 31, No. 2, APRIL 2011 www.ccnonline.org
Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011