Translating Evidence into Clinical Practice – MN 566 Sample Essay

Infection Control Evidence-Based Practice

Medicine demands the highest standards of care and safest practice. It deals with human life and guarding it is the pillar of the entirety of its practice. EBP is defines as the approach and the blueprint of the research practice that is used to transition data from results of a research or investigation into safe practice and application of care protocols. DiCenso et al ., (2017) explains that EBP is the a mirror of the safe and high standards performance of patient care derived from research that is used to meet patient’s needs. There are several EBP methods used widely in nowadays medicine practice such as infection control, use of O2 in COPD patients, weight management in CHF patients…etc. For the purpose of this paper the subjectivity of it will be toward infection control and importance of EBP in raising it in such standards and why it should be used in or practice. Translating Evidence into Clinical Practice – MN 566 Sample Essay.

Leads to highest quality care and patient outcomes

Infection prevention in any healthcare facility is a safety process that is never overlooked by the organization itself. Not only does an infection acquired in hospital cost the institution enormous amount in healthcare, but it places the lives of the patient at risk. When considering providing care to patients and no exposure or contraction of infection was carried on during the service, the outcome should look into safe practice and proper utilization of the standards that assure prevention of infection and controlling it. Translating Evidence into Clinical Practice – MN 566 Essay Loveday et al., (2014) explains that use of PPE, hand washing hygiene and use of proper barrier precautions represent high quality of care and positive outcomes for patients that are fragile and in a weak status at the time of the care provided. There are two components of quality of care: accessibility and efficiency of it. If the care accessed was not efficient in getting patient better and instead added another infection to their condition, it failed to provide quality care. (Donabedian,1988). Preventing transmission of infection to patient does exactly that, maintains the standards of care and assures quality in delivering it. So another way of thinking of the infection control EBP is that is used as measuring tool as well, of how the institution provides and guarantees safe and effective care. Translating Evidence into Clinical Practice – MN 566 Sample Essay.

                                       Reduces health care costs

Trybou et al ,. (2016) states that: “Hospital Acquired Infections (HAIs) are considered to be one of the most serious patient safety issues in healthcare today. It has been shown that HAIs contribute significantly not only to morbidity and mortality, but also to excessive costs for the health care system and for hospitalized patients. Since possibilities of prevention and control exist, hospital quality can be improved while simultaneously the cost of care is reduced”. HAIs are used as a tool to measure the quality of health services an institution provides and the Center for Medicare Services (CMS) tracks and registers these. Based on their record the CMS determines their compensation or penalization of the place. Schmier (2016) Explains that: “HAI avoidance through use of health care antiseptics has a demonstrable and substantial impact on health care expenditures; the costs here are exclusive of administrative penalties or long-term outcomes for patients and caregivers such as lost productivity or indirect costs.”. If the spread of infection is controlled, the cost for its recovery is less and the sources of healthcare payment are not used up for it. This leads to reduces cost of care overall.

Reduces geographic variations in the delivery of care

Being used as a state-wide international standard, infection prevention is seeing as a practice of safe healthcare anywhere in the world. If all the places adopt efficient and qualitative EBP that aim to prevent infection spread, the geographic diversity of care provided will be eliminated and the delivery of care will be unanimous and safe anywhere. In a study conducted in Scutari, turkey, a decrease from 43% to 2% was noticed in a hospital where safe infection prevention practices were utilized. (Loveday, 2014) Translating Evidence into Clinical Practice – MN 566 Sample Essay.

Increases healthcare provider empowerment and role satisfaction

Other benefit of the infection prevention as part of the EBP strategy and practice is that it allows for an increased empowerment and satisfaction for the healthcare providers. With providers being the front line of delivery of care, being able to prevent the infection means that their year of hard work, expertise and extensive knowledge are functioning the expected way and quality care is being offered due to their performance, dedication and safe practice. This way the professionals take responsibility and charge in leading the projects that pioneer infection prevention, which then leads to quality care, customer satisfaction and reduced healthcare cost as well. Translating Evidence into Clinical Practice – MN 566 Essay.

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Reduces healthcare provider turnover rate

When infections are prevented and the tam of the providers is the one directing the safety practice, the workload for the staff is reduced as well. Loveday et al., (2014) explained that when the workload is decreased the staff, nurses and other providers have better outcomes in their performance due their balanced work-life schedule. Translating Evidence into Clinical Practice – MN 566 Essay. They don’t have to work extra due to complications from the infections, therefore, prevention is the best strategy in assuring low staff turnover and pleasant work environment with assured longevity in the positions occupied.

Increases reimbursement from 3rd party payers

CMS has enabled the requirements that any infection acquired while in the hospital, will not be covered by Medicare. The hospital will have to pay for the infection treatment itself. There has been a reported increase of hospital bills from 28 billion to 45 billion that is accrued due to hospital acquired infections. (Loveday & colleges,2014). Like Medicare, the majority of other private insurances, follow the same principles when it comes to compensating for HAIs. So controlled HAI rates, lead to an increase of reimbursement from the third-party payors compare to the decreased amount of payment they provide for the hospital when a HAI is contracted. Translating Evidence into Clinical Practice – MN 566 Sample Essay.

Reduces complications and payment denials

The Deficit Reduction Act of 2005, specified, that not only will Medicare not pay for any infection acquired while inpatient, but there cannot be even a billing send to the with claims of compensation for the treatment of the patient that encountered a HAI.(Melnyk, Gallagher-Ford, Long, & Fineout-Overholt,2014).The reasoning behind that is that I the patient did not present with these symptoms initially, he/she got the infection while there and the hospital failed to provide safe and quality care by preventing infection and not doing what they are supposed to do Translating Evidence into Clinical Practice – MN 566 Essay.

Meets the expectation of an informed public

Lastly, infection prevention based on EBP is a routine that can set an example for the public as to how to adopt safe and quality healthcare and prevent the spread of infection sin the community. EBP that streamlines all the quality measures, including infection prevention, can be found in abundance in media. That helps the community to be informed, compare data among institutions or providers, spread the knowledge and sensitize each other about precautionary steps.

References

DiCenso, A., Guyatt, G., & Ciliska, D. (2014). Evidence-Based Nursing-E-Book: A Guide to Clinical Practice. Elsevier Health Sciences.

Donabedian, A. (1988). The quality of care: how can it be assessed?. Jama, 260(12), 1743-1748.

Last Name, F. M. (Year). Article Title. Journal Title, Pages From – To. Translating Evidence into Clinical Practice – MN 566 Essay.

Last Name, F. M. (Year). Book Title. City Name: Publisher Name.

Loveday, H. P., Wilson, J., Pratt, R. J., Golsorkhi, M., Tingle, A., Bak, A., … & Wilcox, M. (2014). epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. The Journal of Hospital Infection, 86, S1-S70. doi: 10.1016/S0195-6701(13)60012-2.

Melnyk, B. M., Gallagher‐Ford, L., Long, L. E., & Fineout‐Overholt, E. (2014). The establishment of evidence‐based practice competencies for practicing registered nurses and advanced practice nurses in real‐world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence‐Based Nursing, 11(1), 5-15.

Schmier, J. K., Hulme-Lowe, C. K., Semenova, S., Klenk, J. A., DeLeo, P. C., Sedlak, R., & Carlson, P. A. (2016). Estimated hospital costs associated with preventable health care-associated infections if health care antiseptic products were unavailable. ClinicoEconomics and outcomes research : CEOR, 8, 197-205. doi:10.2147/CEOR.S102505 Translating Evidence into Clinical Practice – MN 566 Essay

Trybou, J., Spaepen, E., Vermeulen, B., Porrez, L., & Annemans, L. (2013). Hospital-acquired infections in Belgian acute-care hospitals: financial burden of disease and potential cost savings. Acta Clinica Belgica, 68(3), 199-205 Translating Evidence into Clinical Practice – MN 566 Sample Essay.

MN568 Unit 5 Discussion – begin Prostate Hypertrophy Essay

Topic 3

Mr. E.D. is a 63-year-old retired mail carrier who presents to his primary care provider for a routine follow up for his hypertension. He complains of a 4-day history of dysuria, increased urinary frequency, and nocturia. He states that he has been having fever and chills. Denies any recent sexual activity. On examination, his temperature is 99.5 F., pulse 75 and regular, respiratory rate 16 and unlabored, and blood pressure 135/85. He does not appear acutely ill and is in no apparent distress MN568 Unit 5 Discussion – benign prostate hypertrophy. Examination of the abdomen was normal. A digital rectal exam revealed a moderately enlarged, firm, non-tender prostate gland. He states that he has severe urgency and difficulty urinating MN568 Unit 5 Discussion – begin Prostate Hypertrophy Essay.

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Subjective Data

The use of questionnaire such as the American Urological Symptom Index is helpful to understand the severity of symptoms. The questionnaire reveals an overall score of mild, moderate and severe. Questions include asking the patient over the past month it is felt they did not fully empty the bladder, how often they have urinated in the past month within 2 hours, how often in the past month urinary flow started and stopped, how often in the past month it is difficult to urinate, how often in the past month urine flow is weak, how often in the past month staining with urination occurred, and how often in the past month they were woken in the night to urinate (Dunphy et al., 2015). MN568 Unit 5 Discussion – benign prostate hypertrophy.

Other subjective data would include questioning of when fever, chills first started and if the patient has taken anything to relieve the fever, chills. Family history of cancer and prostate cancer should be obtained from the patient. It is important to obtain history around any recent trauma to the urethral area and prostate.

Differential Diagnosis

1) Benign Prostate Hyperplasia

2) Urinary Tract Infection

3) Prostatitis

4) Urethral obstruction/stricture related to trauma

5) Unrelated etiologies- diabetes, neurogenic bladder.

MN568 Unit 5 Discussion – benign prostate hypertrophy

Physical Examination

A focused subjective data collection will assist in diagnosis of benign prostate hypertrophy. A focused physical examination on the suprapubic area with concentration on the bladder should be completed. The practitioner should assess for bladder distention and complaints of pain with palpation. A digital rectal exam (DRE) will assist in determination of nodules and size of prostate based on fingers breath during the DRE. This exam may be contraindicated in patients with neurological anal sphincter disorders (Deters & Kin, 2017). MN568 Unit 5 Discussion – benign prostate hypertrophy Measurement of the prostate gland can be assessed by fingers breath and reported in documentation. Caution should be taken when performing a digital rectal exam if infection is suspected because of the potential for sepsis by performing DRE.

Diagnostics

Diagnostic testing for this patient should include a prostate specific antigen (PSA) and consideration of a cystoscopy. A PSA level of 4.0ng/mL and lower is considered normal (National Cancer Institute, 2018). A PSA above 4.0ng/mL would be an indication for a referral to a urologist or a needle biopsy to be completed. The National Cancer Institute (2018) points out that twenty-five percent of men with an elevated PSA will not have prostate cancer (National Cancer Institute, 2018). The PSA can assist in helping a practitioner to not overtreat a patient with an enlarged prostate with medications that could affect the patients erectile function.

Laboratory diagnostics for urinalysis, urine culture, comprehensive blood panel and complete blood count are indicated to rule out infection and electrolyte imbalances.

The prostate symptom index is an eight-question test created by the American Urological Association to assist the practitioner by allowing the patient to rate how severe the symptoms can be affecting individual quality of life. An intravenous pyelogram can measure postvoid residual based on the severity of reported symptoms from the patient questionnaire. MN568 Unit 5 Discussion – benign prostate hypertrophy MN568 Unit 5 Discussion – begin Prostate Hypertrophy Essay.

Benign Prostatic Hypertrophy

Benign Prostatic Hypertrophy is a common condition that affects men after age forty. The prostate gland begins to enlarge during puberty through around age twenty and begins to enlarge again in older years (Dunphy, Winland-Brown, Porter, & Thomas, 2015). The enlarged prostate interrupts the flow of urine and affects a male’s quality of life.  Some studies suggest a high incidence of BPH with obesity and lack of physical activity (Belaynen & Korownyki, 2016). Education for prevention of BPH from the nurse practitioner should include regular physical activity, a low fat diet, and reduction of alcohol consumption. MN568 Unit 5 Discussion – benign prostate hypertrophy.

Evidence-based Treatment Plan

Evidence-based treatment plan for mild symptoms (severity score >7) scale and for those with moderate-severe symptoms (severity score >8) that is not affecting quality of life (Deters, 2017). For patients with symptoms affecting their quality of life medication therapy such as alpha blockers, 5-alpha-reductase inhibitors are supported as best practice once prostate cancer has been ruled out.

First line therapy selective alpha₁-adrenergic receptors include silodosin 4 to 8mg daily, or terazosin 1 to 10mg daily (Dunphy et al., 2015). Long-acting alpha₁-adrenergic blockers are also useful in daily dosing and should be titrated gradually. 5-alpha-reductase inhibitors helps to reduce the size of the prostate by blocking the conversion of testosterone to DHT (Dunphy et al., 2015). Slow titration to maximum dosing is important to prevent hypotension with these medications. MN568 Unit 5 Discussion – benign prostate hypertrophy.  Saw palmetto acts similar to 5-alpha-reductase inhibitors for nonpharmacological interventions. These pharmacological and non-pharmacological interventions can improve quality of life for patients with BPH.

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Patients with BPH should be reevaluated annually and screened for prostate cancer. The nurse practitioner should assess the effectiveness of pharmacological or nonpharmacological approach and severity of the symptoms affecting the patient’s quality of life. MN568 Unit 5 Discussion – benign prostate hypertrophy.

References

Belaynen, M., & Korownyki, C. (2016). Treatment of lower symptoms in benign prostatic

hypertrophy with α-blockers. Canadian Family Physician, 62, 523. MN568 Unit 5 Discussion – benign prostate hypertrophy

Deters, L. A. (2017). Benign Prostatic Hyperplasia (BPH) Treatment & Management. Medscape.

Retrieved from https://emedicine.medscape.com/article/437359-treatment#d18

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O. & Thomas, D. J. (2015) Primary Care: The

Art and Science of Advanced Practice Nursing. Philadelphia, PA: F. A. Davis Company.

National Cancer Institute. (2018). Prostate-Specific-Antigen (PSA) Test. Retrieved from

https://www.cancer.gov/types/prostate/psa-fact-sheet MN568 Unit 5 Discussion – benign prostate hypertrophy MN568 Unit 5 Discussion – begin Prostate Hypertrophy Essay.

PICOT and EBP Assignment: Finding the Research Evidence Paper

Continuing on with step one of the Impact Model is the need to search for the studies to support your project. There are different classes of evidence that can guide changes in clinical practice.
To prepare for this Assignment, review the following:
Write a 2-page paper (exclusing title page and reference page) to address the following:
• For the evidence-based problem that you identified in Week 1 for your project, locate two different articles/sources representing two different types of evidence from the following categories: (a) systematic review, (b) national clinical guidelines and/or (c) peer-reviewed quantitative / qualitative studies. PICOT and EBP Assignment: Finding the Research Evidence Paper.

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• For each article/source of evidence:
o Summarize the article/source in your own words without the use of direct quotes.
o Using the Peterson et al., (2014) article located in Week 2 Resources address the level of evidence (hierarchy). Then discuss the usefulness of the evidence from the article/source in addressing the identified practice problem. Be sure to site evidence in-text and in a final reference page.
o Describe where your two sources fit into the hierarchy of evidence and explain why PICOT and EBP Assignment: Finding the Research Evidence.
o Describe the value of these two sources in better understanding and addressing your evidence-based problem.

Evidence-Based Practice Paper Guide

 Impact Model

(Source:  Brown, S. (2014). Evidence-based nursing: The research practice connection.  Burlington, MA:  Jones and Bartlett Learning.)PICOT and EBP Assignment: Finding the Research Evidence Paper.

Step 1                  Ask and Search

1. ASK– identify evidence-based practice (EBP) question

Write in PICO format

P –  patient population

I  –  intervention/issue

C – comparison intervention

O – outcome(s)

For example, in patients with acute myocardial infarction, does ambulation within the first 24 hours as compared to those who remain on bed rest for the first 48 hours result in increased participation in cardiac rehabilitation following discharge from the hospital?

Be sure to have your project approved by your Instructor before continuing with the steps.

Assignment Week 1:  Submit the completed Evidence-Based Problem and Question Template to the Week 1 Assignment link. (Refer to the grading rubric in Course Information for assignment details.)

1. SEARCH

Identify search terms and search engines.  Find a minimum of five EBP articles that have been published within the last 5 years.  Be sure to look at the systematic reviews and the national clinical practice guidelines. PICOT and EBP Assignment: Finding the Research Evidence Paper.

Assignment Week 2:  Submit a 1- to 2-page paper describing two sources
of evidence you have found, where they fit in the hierarchy of evidence, and the value of these sources in better understanding your evidence-based practice problem.  Summarize the findings in the literature that you retrieved. Submit to the Week 2 assignment link. (Refer to the grading rubric in Course Information for assignment details.)

Step 2                        Appraise the literature

Critique each article using the appropriate Appraisal Guide provided in Week 4 Resources. In the final paper, a critique of at least five of the articles used for your project will need to be submitted.

PICOT and EBP Assignment: Finding the Research Evidence Assignment Week 4:  Submit critiques of two of the articles using the appropriate Appraisal Guide provided to the Week 4 Resources. (Refer to the grading rubric in Course Information for assignment details.)

Step 3                         Design the project

Describe each step of the project clearly and completely.  Clearly explain the recommended evidence-based change including the setting, health care consumers affected, and the rationale for the change.

Assignment Week 5:  Submit a 2- to 3-page paper discussing your EBP plan.  Include the PICO clinical question, recommended change in practice, and the evidence to support the plan. (Refer to the grading rubric in Course Information for assignment details.)

Step 4                          EBP

The final step is to discuss how the outcomes from the plan will be evaluated.  Identify the criteria that will be used to measure the effectiveness of the change.  For example, how many individuals following an acute myocardial infarction are participating in or have participated in the cardiac rehabilitation program? The final EBP plan needs to be developed into a power point for posting in the classroom. PICOT and EBP Assignment: Finding the Research Evidence.

Assignment Week 6: Develop a voice over PowerPoint presentation.

Post the presentation in the Week 6 Discussion board by Day 3. Use the week 6 submission link to submit the final copy of the PowerPoint to your Instructor for grading. (Refer to the grading rubric in Course Information for assignment details.) PICOT and EBP Assignment: Finding the Research Evidence Paper

Evidence_based_practice

T
he idea of sharing clinical experiences to improve patient care is not new to
nurses. Florence Nightingale published her observations on cleanliness, nutrition,
and fresh air in Notes on Nursing1 in 1860. Her work was the start of evidence-based
nursing practice. More than 150 years and thousands of research studies later, the
use of evidence to guide nursing practice is the expected standard of practice for both
individual nurses and health care organizations. Scope and Standards of Practice2 and Code of Ethics3
of the American Nurses Association both call for nurses to incorporate research evidence into
clinical practice. Schools of nursing have added content on evidence-based practice to their curricula.4 Despite these efforts, barriers inhibit implementation of changes based on published evidence
into bedside patient care. Overall, the barriers involve the characteristics of the nursing profession,
organizational dynamics, and the nature of the research.5,6 Studies7,8 have consistently indicated
that a nurse’s inability to both determine what evidence is ready for implementation into practice
and then successfully develop processes to sustain an evidence-based practice change is a barrier.
Choosing the Best PICOT and EBP Assignment: Finding the Research Evidence
Evidence to Guide Clinical
Practice: Application of
AACN Levels of Evidence
MARY H. PETERSON, RN, DNP, MSN, NEA-BC
SUSAN BARNASON, RN, PhD, APRN-CNS, CEN, CCRN
BILL DONNELLY, RN, PMBA, BS, CCRN
KATHLEEN HILL, RN, MSN, CCNS
HELEN MILEY, RN, PhD, AG-ACNP, CCRN
LISA RIGGS, RN, MSN, APRN, CCRN
KIMBERLY WHITEMAN, RN, DNP, CCRN
©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014411
Evidence-Based Practice
Evidence-based nursing care is informed by research findings, clinical expertise, and patients’ values, and its
use can improve patients’ outcomes. Use of research evidence in clinical practice is an expected standard of
practice for nurses and health care organizations, but numerous barriers exist that create a gap between new
knowledge and implementation of that knowledge to improve patient care. To help close that gap, the American Association of Critical-Care Nurses has developed many resources for clinicians, including practice alerts
and a hierarchal rating system for levels of evidence. Using the levels of evidence, nurses can determine the
strength of research studies, assess the findings, and evaluate the evidence for potential implementation into
best practice. Evidence-based nursing care is a lifelong approach to clinical decision making and excellence in
practice. (Critical Care Nurse. 2014;34[2]:58-68)
58 CriticalCareNurse Vol 34, No. 2, APRIL 2014 www.ccnonline.org
In this article, we provide a brief history of the involvement of the American Association of Critical-Care
Nurses (AACN) in evidence-based practice, explain the
recent clarifications added to the 2009 AACN levels of
evidence, and provide examples of how to change bedside practice in the clinical setting.
History of AACN Involvement in
Evidence-Based Practice
Currently, AACN is the largest specialty nursing
organization and a leader in the movement to improve
patient care by applying the best scientific evidence. In
1995, AACN began to publish Protocols for Practice, an
evidence-based resource for clinical nurses. Each protocol provides a guide for appropriate selection of patients,
use and application of management principles, initial
and ongoing monitoring, discontinuation of therapies
or interventions, and selected aspects of quality control.
The protocols have covered topics such as hemodynamic
monitoring and care for patients treated with mechanical
ventilation. Subsequently, a volunteer workgroup was
formed to connect clinicians with research to improve
care of critically ill patients. The original research workgroup, known since 2007 as the Evidence-Based Practice
Resources Workgroup (EBPRWG), focused on developing resources that synthesized current research. Resources
were made readily available and in an easy-to-use format
for use in care decisions at the bedside (eg, laminated
pocket-sized cards for clinicians). The work of this group
has continued for more than 2 decades. Current products available to AACN members include protocols for
practice; practice alerts with tool kits, PowerPoint presentations, and audit tools; pocket card references; and
defined levels of evidence for clinical nursing practice.
Evolution of AACN Levels of Evidence
The amount and availability of research supporting
evidence-based practice can be both useful and overwhelming for critical care clinicians. Therefore, clinicians
must critically evaluate research before attempting to put
the findings into practice. Evaluation of research generally occurs on 2 levels: rating or grading the evidence by
using a formal level-of-evidence system and individually
critiquing the
quality of the
study. Determining the
level of evidence is a key
component of
appraising the evidence.5,9,10 Levels or hierarchies of evidence are used to evaluate and grade evidence. The purpose of determining the level of evidence and then
critiquing the study is to ensure that the evidence is credible (eg, reliable and valid) and appropriate for inclusion
into practice.10 Critique questions and checklists are
available in most nursing research and evidence-based
practice texts to use as a starting point in evaluation.
The most common method used to classify or determine the level of evidence is to rate the evidence according to the methodological rigor or design of the research
study.10,11 The rigor of a study refers to the strict precision
or exactness of the design. In general, findings from
experimental research are considered stronger than findings from nonexperimental studies, and similar findings
from more than 1 study are considered stronger than
results of single studies. Systematic reviews of randomized controlled trials are considered the highest level of
evidence, despite the inability to provide answers to all
questions in clinical practice.11,12 For example, AACN
and other organizations have done extensive research
on healthy work environments. This topic would not be
examined in a randomized controlled trial because of
ethical and practical considerations. Randomly assigning nurses to work in various healthy or unhealthy work
Authors PICOT and EBP Assignment: Finding the Research Evidence Paper.
Mary H. Peterson is an educator for Elsevier, Inc Live Review and
Testing, Houston, Texas and a cardiovascular clinical nurse specialist.
Susan Barnason is director of the DNP program at the University of
Nebraska Medical Center in Lincoln.
Bill Donnelly is a critical care staff nurse at Cooley Dickinson Hospital,
Northampton, Massachusetts.
Kathleen Hill is a clinical nurse specialist in the surgical intensive
care unit at Cleveland Clinic, Cleveland, Ohio.
Helen Miley is a specialty director adult-gero acute care nurse practitioner at Rutgers, The State University, Newark, New Jersey.
Lisa Riggs is director of cardiovascular quality at Saint Luke’s Hospital
of Kansas City, Kansas City, Missouri.
Kimberly Whiteman is codirector of the DNP program at Waynesburg
University, Waynesburg, Pennsylvania.
Corresponding author: Mary H. Peterson, 543 Westwood Road, Alexander City, AL
35010 (e-mail: petermh@uab.edu).
To purchase electronic or print reprints, contact the American Association of CriticalCare Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
www.ccnonline.org CriticalCareNurse Vol 34, No. 2, APRIL 2014 59
The purpose of determining the level of
evidence and then critiquing the study is
to ensure that the evidence is credible
(eg, reliable and valid) and appropriate
for inclusion into practice.
environments could have an adverse effect on the quality
and safety of patients receiving care. Therefore, most of
the studies on healthy work environments have involved
descriptive or qualitative study designs. Although the less
rigorous design places descriptive and qualitative studies
at a lower level than that of randomized control trials on
the AACN rating system, the lower level is the highest
level of evidence that the information on healthy work
environments can ethically and practically provide.
AACN Evidence-Rating System
As interest in promoting evidence-based practice has
grown, many professional organizations have adopted
criteria to evaluate evidence and develop evidence-based
guidelines for their members.5,12 A task force formed by
AACN developed the organization’s original rating scale,
which used Roman numerals; lower numerals represented
lower levels
of evidence. In
1995, the
time of the
original AACN rating scale, only a few other organizations had published levels of evidence. Other professional
hierarchies used a reverse order, with lower Roman
numerals reflecting higher levels of evidence. This difference led to confusion among practitioners who were trying to use the original rating system in the clinical setting.13
In 2008, AACN challenged the EBPRWG to review the
rating system and make recommendations for improvement. The result was an alphabetical hierarchy in which
the highest form of evidence was ranked as A and included
meta-analyses and meta-syntheses of the results of controlled trials. Evidence from controlled trials was rated
B. Level C evidence included findings from studies with
a variety of research designs (Table 1). As in the previously published rating system, the 2008 system included
results of theory-based evidence, expert opinion, and
multiple case reports as level E evidence. Rapid
advances in technology resulted in many products being
used solely on the basis of the manufacturers’ recommendations. M was used to represent the body of practice recommendations provided by industry.14
When the 2008 hierarchy of evidence was published,
AACN welcomed feedback from its members about the
changes. Since then, members have asked for clarification on the hierarchy, particularly an explanation of the
rating of systematic reviews. Most rating systems rank
systematic reviews of well-designed randomized controlled trials as the highest level of evidence. Many members thought that systematic reviews were misplaced at
level C within the AACN levels of evidence. The request
for clarification was referred to the 2011 annual meeting
of the EBPRWG for review and discussion.
Changes to the AACN Levels of
Evidence in 2011
The 2011-2012 EBPRWG responded to the concerns of
AACN members by revising the 2008 levels of evidence.
In recognition that the strength of a systematic review
depends on the rigor of the studies included in the review,
the workgroup distinguished between the 2 types of systematic reviews: randomized control trials and reviews of
other studies. Systematic review of randomized controlled
Category
Experimental evidence
Recommendations PICOT and EBP Assignment: Finding the Research Evidence Paper.
Level
A
B
C
D
E
M
Description
Meta-analysis or metasynthesis of multiple controlled studies with results that consistently support
a specific action, intervention, or treatment (systematic review of a randomized controlled trial)
Evidence from well-designed controlled studies, both randomized and nonrandomized, with results
that consistently support a specific action, intervention, or treatment
Evidence from qualitative, integrative reviews, or systematic reviews of qualitative, descriptive, or
correlational studies or randomized controlled trials with inconsistent results
Evidence from peer-reviewed professional organizational standards, with clinical studies to support
recommendations
Theory-based evidence from expert opinion or multiple case reports
Manufacturer’s recommendation only
Table 1 2012 American Association of Critical-Care Nurses levels of evidence with revisions to 2008 hierarchy
60 CriticalCareNurse Vol 34, No. 2, APRIL 2014 www.ccnonline.org
Clinicians must determine the clinical relevance
of the research (ie, if the results are applicable
to and feasible in clinical practice).
trials was added to level A, the highest level of evidence.
This change makes the AACN system consistent with
other published hierarchies used to rate evidence (eg,
American Heart Association15). Systematic reviews of
qualitative, descriptive, or correlational studies remained
within level C, the highest level for nonexperimental
studies. Also, the distinction between experimental and
nonexperimental studies in the hierarchy was clarified.
A schematic was developed to illustrate that levels
A and B are for studies with an experimental design.
Levels A, B, and C are all based on research (either experimental or nonexperimental designs) and are considered
evidence. Levels D, E, and M are considered recommendations drawn from articles, theory, or manufacturers’ recommendations (see Figure). Table 2 gives an
overview of the different types of research study designs
and the definitions that were used by the workgroup
to guide placement of study designs within the levels of
evidence system.
Levels of Evidence and
AACN Practice Alerts
The level of evidence is used to rate the strength of
the study design, but it does not give clinicians information about relevance to practice. In addition to rating
the studies on the basis of the design used, clinicians
must also analyze and critique the individual studies for
strengths and weaknesses. For instance, the results of a
randomized controlled trial (level B) that did not follow
strict criteria for selecting participants or patients might
be biased. The findings of this type of study would not
be as strong as those of a randomized controlled trial in
which adherence to random selection was rigorous.
Before implementing research into practice, clinicians
Figure American Association of Critical-Care Nurses evidence-based care pyramid: levels of evidence 2012.
a Experimental: testing the effects of an intervention or treatment on selected outcomes.
b Nonexperimental: data are collected, but not to test the effects of an intervention or treatment on specific outcomes.
Based on data from Melnyk and Fineout-Overholt.10
A and B: Experimentala
C, D, E, and M:
Nonexperimentalb
A, B, and C: Evidence-based
recommendations
D, E, and M:
Expert opinion or
manufacturer’s
recommendations
A
B
C
D
E
M
www.ccnonline.org CriticalCareNurse Vol 34, No. 2, APRIL 2014 61
should examine individual studies to determine if the
results were obtained by using sound (reliable and valid)
scientific methods. Last, clinicians must determine the
clinical relevance of the research (ie, if the results are
applicable to and feasible in clinical practice). This evaluation or critique takes time to complete and is a learned
skill that is developed with guided practice.
The purpose of each AACN practice alert is to
address both nursing and multidisciplinary activities of
importance. The topic selected for each alert is important to the care of acutely and critically ill patients or
their environments. Practice alerts do the following:
• Close the gap between research and practice
• Provide guidance
• Standardize practice
• Identify and inform about new advances and
trends AACN practice alerts are defined as “succinct,
dynamic directives supported by authoritative evidence
to ensure excellence in practice and a safe and humane
work environment.”16 The alerts are short directives
designed for easy reference. Each one includes the
scope and impact of a problem or topic, expected practice and nursing actions, supporting evidence for
change, additional resources for implementation, and
references. Because practice is dynamic, the practice
alerts are reviewed and updated to reflect any researchbased changes.16
To help members use research findings and apply
them to practice, AACN began to develop practice alerts
that present an overview of the current research evidence PICOT and EBP Assignment: Finding the Research Evidence Paper.
62 CriticalCareNurse Vol 34, No. 2, APRIL 2014 www.ccnonline.org
Level of
evidence
A
A
C
B
C
C
C
C
C
Type of study
Meta-analysis
Systematic review
If quantitative study
If qualitative study
Randomized
controlled trial
Cohort study
Case-controlled
study
Integrative review
Metasynthesis
Qualitative research
Definitionsa
A technique for quantitatively integrating the results
of multiple similar studies addressing the same
research question
A rigorous synthesis of research findings on a
particular research question obtained by using
systematic sampling and data collection procedures and a formal protocol
A full experimental test of an intervention, involving
random assignment to treatment groups
A nonexperimental design in which a group of
people (a cohort) is followed over time to study
outcomes
A nonexperimental research design involving the
comparison of a case and a matched control5
Reviews of qualitative studies, often taking the form
of metasyntheses, which are rich sources for
evidence-based practice
Interpretive translations produced from the
integration or comparison of findings from
qualitative studies on a specific topic
Investigation of phenomena, typically in an
in-depth and holistic fashion, through the
collection of rich narrative materials by using a
flexible research design
Strengths
Statistical summary of articles of the same topic in research;
process of using quantitative methods to summarize the
results from multiple studies
Review by experts in the field of all the research on a
topic, who rigorously appraise the studies and offer the
conclusion to support an intervention or not
True experimental study in which the researchers are often
blinded to which patients or participants are receiving an
intervention; the strongest design for examining the
cause and effect of an intervention; reduces bias
Prospective longitudinal study that examines 2 groups of
patients or participants (the cohort)
Longitudinal study that retrospectively compares characteristics of an individual who has a certain type of condition that may not be very common; often used to
identify variables that may predict the etiology or the
course of a disease
Compilation of studies that are reviewed and summarized;
may incorporate research and nonresearch articles
Compilation of qualitative studies looking for the common
themes among similar research studies
Method to develop a greater understanding of a topic using
many different methods such as observation or interview
Table 2 Level of evidence, types of research studies, definitions, strengths, limitations, and examples
a Based on Polit and Beck.5 In an experimental design, the researcher controls the variable by randomly assigning patients or participants to different treatment conditions.
In nonexperimental studies, the researcher collects data without introducing an intervention (also called observational).
in a practical, easy-to-read guide for critical care nurses.
The first practice alerts were published in 2004.
A process was developed to ensure that the alerts
represent a translation of evidence and best practices.
Ideas for topics are generated from questions that AACN
members have asked the organization’s clinical practice
experts, AACN leaders, other members, and/or the
EBPRWG. A modification of the Delphi technique, a
widely used method for achieving unified opinion, is used
to rank the importance of clinical questions. Criteria for
ranking include incidence, prevalence, patient care implications, and timeliness.
After topics are generated, the EBPRWG and AACN
determine the names of experts in the clinical area of
interest and commission the writing of the practice alert.
Using standard guidelines prepared by AACN, the clinical experts write the practice alert and submit it to the
EBPRWG for review and feedback. EBPRWG members
seek feedback from their clinical peer network to assess
the congruency of the proposed practice alert with clinical practice and available research. Clinicians are also
asked to comment on the applicability of the practice
alert’s recommendations to patient care.
When the clinical review has been completed, revisions are completed if indicated. Then, communications
experts at AACN prepare the practice alert for distribution to AACN members via the AACN website. Sample
PowerPoint presentations to be used for education are
prepared and can be downloaded for immediate use
(eg, see the presentation for venous thromboembolism
www.ccnonline.org CriticalCareNurse Vol 34, No. 2, APRIL 2014 63
PICOT and EBP Assignment: Finding the Research Evidence Limitations
Usually lengthy; combines like research studies
Only as good as the search methods and
databases used
Time-consuming
May require more sophisticated statistical
analysis
Observational
No intervention performed
May include attrition
Retrospective
Not as rigorous as systematic reviews; review
limited to the literature
Interpreted by the researcher
Some believe it to be less rigorous
Examples
Cochrane Reviews
Coventry et al
Sex differences in symptoms presentation in acute myocardial infarction: a systematic review
and meta-analysis. Heart Lung. 2011;40(6):477-491.
Colnaghi et al
Nasal continuous positive airway pressure with heliox in preterm infants with respiratory
distress syndrome. Pediatrics. 2012;129(2):e333-e338.
Dickson
The relationship of work, self-care, and quality of life in a sample of older working adults
with cardiovascular disease. Heart Lung. 2012;41(1):5-14.
Cox
Predictors of pressure ulcers in adult critical care patients. Am J Crit Care. 2011;20(5):364-375.
Fisher
Opioid tapering in children: a review of the literature. AACN Adv Crit Care. 2010;21(2):139-145.
Palacious-Ceña et al
Patients, intimate partners and family experiences of implantable cardioverter defibrillators:
qualitative systematic review. J Adv Nurs. 2011;67(12):2537-2550.
Hall et al PICOT and EBP Assignment: Finding the Research Evidence
The experiences of patients with pulmonary artery hypertension receiving continuous intravenous infusion of epoprostenol (Flolan) and their support persons. Heart Lung.
2012;41(1):35-43.
prevention17). Audit tools to help monitor compliance
with a change in practice are provided and help clinicians determine if a change is being implemented as
planned. For example, the audit tool for venous thromboembolism prevention provides 3 questions to use
during a chart review to determine if best practices have
been implemented at the bedside.17
Understanding how the evidence in a practice alert is
evaluated and how the recommendations are made provides users the confidence to implement the Actions for
Practice section of the practice alert in individual care
settings. Case 1 is an example of a practice alert and how
information in the alert might be used in clinical practice.
Published practice alerts are reviewed and revised by
the EBPRWG on a cyclical basis (at least every 3 years)
to determine the relevance to practice, the need to
update the references, and to ensure that the recommendations reflect the current evidence. Each practice
alert is reviewed and evaluated by selected members of
the EBPRWG by using a standardized evaluation tool.
The findings are shared with the 10-member EBPRWG
for feedback. Recommendations are made to continue
publishing the practice alert with minimal changes or
to make major revisions based on new evidence. Either
the original expert author or a newly commissioned
expert completes major revisions, and the practice alert
goes through the approval process as if it were a new alert.
Future new and revised practice alerts will also
include information on the search strategy used for the
systematic review conducted by the author of the practice
Some staff members in the intensive care unit
(ICU) wanted to modify the visitation guidelines
for the unit and so approached the nurse manager with their concerns. Many families of ICU patients
desire unrestricted contact with their loved one, and
the hospital guidelines currently allowed 24/7 family
presence in the ICU. However, patients cannot always
communicate their desire for family presence. Some
nurses in the unit were concerned about patient privacy and interruption of therapies, whereas others welcomed the 24/7 family presence. The manager
reviewed the AACN practice alert on family presence in
the adult ICU18 and did the following:
1. Summarized the 4 expected practices in the alert
and compared them with the ICU’s policies.
• Facilitate unrestricted access to hospitalized
person for a chosen support person
• Ensure that hospital policy promotes the presence of a chosen support person
• Evaluate policies to be sure they are nondiscriminatory
• Establish policies to limit family presence when
safety is a concern or presence would be
detrimental to medical therapies
2. Shared the Supporting Evidence section from the
practice alert with the staff members who raised
concerns about the current policy. Discussed the
recommendations for nursing actions and tried to
help the staff gain perspective on the controversies and history behind the recommendations.
3. Asked staff/unit governance members (practice
council) to develop recommendations based on the
Actions for Nursing Practice in the practice alert.
• Are there practices that could be adopted
from the recommendations?
• Is there an opportunity to introduce this topic
during orientation?
• Are there other units who would want to collaborate on this issue?
• Is there a compliance problem with visitation/presence on the part of staff or on the
part of visitors?
After deliberation and discussion, the nurses who
originally brought up the concerns identified several
practice areas on which to focus. They convinced the
nurse educator and preceptors to add content from the
practice alert on family presence in the ICU to the orientation checklist. A multidisciplinary team, including the
medical director and a social worker, participated in
enhancing and clarifying the visitation policy. Staff members determined that the mandate for open access had
caused the original dissatisfaction. After review, they
found a way that fit their workflow to identify the family
spokesperson and communicate the current evidence.
CASE 1
Using a Practice Alert to Revise Current Practice
64 CriticalCareNurse Vol 34, No. 2, APRIL 2014 www.ccnonline.org
alert. This useful information allows the user to examine
the comprehensiveness of the review, databases searched,
publication years included in the search, and the specific
search terms that were used in deriving the evidence
reported in the recommendations of the alert.19-21
With practice alerts, critical care nurses have evidencebased guidelines and implementation strategies at their
fingertips and know the strength of the evidence on
which the recommendations were based. Case 2
describes using the AACN practice alert on delirium22 to
Patients are often hospitalized and admitted
to critical care units unexpectedly because of
life-threatening illnesses. After admission, the
patient’s environment, daily routines, and control of
activities of daily living are completely changed. The clock
and calendar on the wall are both reminders of time
and date, but the surroundings and the many health care
workers that a patient encounters are unfamiliar. With
the addition of unknown procedures and outcomes and
a wakeful noisy environment, anxiety prevails. These
circumstances all culminate in the patient experiencing
a sense of unknown and a loss of independence,
changes that can lead to challenging, unsafe behaviors.
New studies conclude that awareness and early
recognition of delirium may be key components in care
and management of patients when the goal of care is
fewer hospital days and decreased mortality.23-26 A patient
may awaken in the night, think he or she is at home, and
get out of bed with the intent of going to the kitchen.
Although this behavior may be normal for the patient, it
might be assessed by health care providers as confusion
and the patient might be given a benzodiazepine. Historically, nursing practice to prevent the onset of delirium and
falls has been to reorient the patient to circumstances, institute early mobilization when possible, discontinue use of
invasive devices (eg, urinary catheter), and provide a sitter if
necessary. Calling one of the patient’s family members to
visit or sit with him or her was another common strategy.
Nurses in this medical-surgical ICU recently noticed an
increased use of lorazepam (Ativan) and self-extubations
that they think are related to delirium. A small team of
nurses decided to explore evidence-based interventions
to decrease the incidence of delirium on their unit PICOT and EBP Assignment: Finding the Research Evidence Paper.
The first step was to search the AACN website and
find the practice alert on assessment and management
of delirium. The nurses reviewed the practice alert, found
the information helpful and credible, and decided to post
the practice alert in the ICU. Nurses on the unit noticed
that a gap existed between their current practices in caring for patients with delirium and the evidence. Input
from the nurses was solicited for possible improvements
in practice. Next a committee was formed to make recommendations for changes in practice to nurse leaders
and the medical director. With consensus from nursing
and medical leaders, a new nursing policy was written,
and education about the practice change was planned.
In an educational offering, the nurses explained the
clinical problem to ICU staff members and demonstrated
use of the Richmond Agitation-Sedation Scale27 and the
Confusion Assessment Method for the ICU.28 Information
was provided on predisposing and precipitating factors
of delirium and on medications that put patients at risk.
Spontaneous awakening trials; spontaneous breathing
trials; and involvement of respiratory, physical, and occupational therapies for patients receiving mechanical ventilation were included in the planned practice change.
The results of specific research trials discussed in the
practice alert were reviewed for relevance to the clinical
problem; these trials included Maximizing Efficacy of Targeted Sedation and Reducing Neurological Dysfunction
(MENDS),29 Safety and Efficacy of Dexmedetomidine
Compared With Midazolam (SEDCOM),30 Awakening
and Breathing Controlled (ABC),31 and Modifying the
Incidence of Delirium (MIND).32
Plans were made to sustain the change, including
presentation of evidence-based care of ICU patients
with delirium during nursing orientation and clinical competency requirements. The Richmond Agitation-Sedation
Scale27 and the Confusion Assessment Method for the
ICU28 could be included in patients’ assessments at the
time of admission if a patient had predisposing factors
for delirium. The assessment results were included in
daily rounds of those patients who met the criteria for
delirium PICOT and EBP Assignment: Finding the Research Evidence Paper.

ORDER HERE

CASE 2
Using a Practice Alert to Institute a New Practice
www.ccnonline.org CriticalCareNurse Vol 34, No. 2, APRIL 2014 65
initiate a new practice with high level of evidence on a
medical-surgical ICU.
Use of Evidence From
Nonexperimental Research
The AACN levels of evidence tool also guides nurses
in rating evidence based on nonexperimental research.
Nurses often must make practice decisions that are
based on the recommendations of experts or manufacturers. Experts in nursing practice have a comprehensive
and
authoritative knowledge of a
particular
area of
nursing. These experts are regionally, nationally, or
internationally recognized as authorities and have
published supporting scholarly work related to their
areas of nursing. Although manufacturers may sponsor
research related to their products, bias due to implicit
financial interests is an overriding factor when considering the research findings and recommendations.
In itself, a low level of evidence such as level M
(manufacturers’ recommendations) does not mean that
the recommendations are not the current best practices.
Often manufacturers’ recommendations are specific
ways to use the equipment based on internal quality
assurance, for example, a blood filter that is manufactured to last for a certain number of hours or a patient
warmer that is calibrated so that a specific setting warms
the patient to a normal temperature. In addition, many
pieces of equipment used by clinicians have been approved
by the Food and Drug Administration and have practice
recommendations related to the approval process to
ensure patients’ safety. Typically approval requires a
Anurse in a spinal trauma unit recognized that
the incidence of skin breakdown was high.
Patients in the unit were acutely ill and immobile,
making them at increased risk for pressure ulcers.
Fecal incontinence adds to that risk. A new fecal containment device was purchased, and a nurse was
charged with developing a procedure for use of the
device. The nurse and his team of caregivers began to
explore what needed to be done to write the new procedure and disseminate it to the ICU staff members.
The vendor agreed to offer in-service education on the
product, but the guidelines for nursing care extend
beyond the specific practical details of product insertion.
The nurse reviewed the AACN Procedure Manual for
Critical Care33 and the manufacturer’s instructions for use
of the fecal containment device. The evidence found was
rated as level D (expert opinion) and level M (manufacturer’s recommendations). Procedures that are developed
on the basis of evidence gleaned from expert opinion and
manufacturers’ recommendations may be the only information available for new products and practices. The
nurse recognized that publications may be outdated and
that a search of the most current literature for pertinent
research was a priority. He was obligated to do a thorough literature search to verify concurrence among
sources and findings.
The nurse appreciated that the practices might be
fluid and could change over time as clinical use of the
product led to new clinical studies and outcomes analysis. After reviewing all the available recommendations for
the use of the fecal containment device, he decided to
adapt or adopt the procedure from the AACN Procedure
Manual for Critical Care. He wrote the procedure and
included references from the manufacturer’s recommendations, the AACN manual, and other current research.
He was careful to note on the procedure that the levels of
evidence were D and M. He made plans for disseminating
and educating staff about the new procedure. When
exploring the literature on the subject of fecal incontinence
containment, the nurse recognized that the use of this
device would present an opportunity for clinical research
that would add a higher level of evidence to the knowledge base. He made a note to discuss this prospect with
his colleagues and the clinical nurse specialist.
CASE 3
Change in Clinical Practice Based on Expert Opinion and
Manufacturers’ Recommendations
66 CriticalCareNurse Vol 34, No. 2, APRIL 2014 www.ccnonline.org
With practice alerts, critical care nurses have
evidence-based guidelines and implementation
strategies at their fingertips and know the
strength of the evidence on which the
recommendations were based.
considerable body of research and consensus of recognized experts. Case 3 describes using the AACN levels of
evidence to assess information obtained from expert
opinions or manufacturers’ recommendations.
Summary
The 2011-2013 EBPRWG continued the tradition of
previous workgroups to move research to the patient
bedside. Member of AACN provided feedback about the
AACN levels of evidence published in 2009 that prompted
a revision to further assist clinicians. The AACN rating
system for levels of evidence is illustrated by the evidencebased care pyramid. The purpose of the schematic is to
help bedside nurses determine the strength of evidence
on the basis of the research methods and design. Clinicians must critically evaluate research before attempting
to implement the findings into practice. The clinical relevance of any research must be evaluated as appropriate
for inclusion into practice.
The process for preparing practice alerts has been
standardized so that clinicians can trust the recommendations and put them to immediate use at the bedside.
Typically, practice alerts are reviewed and/or revised
every 3 years, but new research may elicit an immediate
review and revision. Members of the current workgroup
have focused on shifting the use of scientific evidence
from a research or evidence-based practice project to a
practical guide for everyday nursing practice. Each practice alert has current resources for managers and clinicians
to use for education, implementation, and evaluation of
best practices. These resources include PowerPoint presentations, audit tool kits, and access to current literature. To that end, evidence-based patient care becomes a
lifelong approach to clinical decision making to improve
clinical outcomes and includes use of best evidence, clinical expertise, and values of patients and their families.
The goal to implement best evidence to guide clinical
practice is possible for the AACN community. CCN
Now that you’ve read the article, create or contribute to an online discussion
about this topic using eLetters. Just visit www.ccnonline.org and select the article
you want to comment on. In the full-text or PDF view of the article, click
“Responses” in the middle column and then “Submit a response.”
www.ccnonline.org
To learn more about evidence-based practice, read “EvidenceBased Practice Habits: Putting More Sacred Cows Out to Pasture”
by Makic et al in Critical Care Nurse, April 2011;31:38-62. Available
at www.ccnonline.org.
25. Lin SM, Liu CY, Wang CH, et al. The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med. 2004;32(11):
2254-2259 PICOT and EBP Assignment: Finding the Research Evidence Paper.
26. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors
and consequences of ICU delirium. Intensive Care Med. 2007;33(1):66-73.
27. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over
time in ICU patients: the reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289(22):2983-2991.
28. Ely EW. Confusion Assessment Method for the ICU: the complete training manual. http://www.mc.vanderbilt.edu/icudelirium/docs/CAM
_ICU_training.pdf. Published 2002. Revised October 2012. Accessed
January 16, 2014.
29. Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with
dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial.
JAMA. 2007;298(22):2644-2653.
30. Riker RR, Shehabi Y, Bokesch PM, et al; SEDCOM (Safety and Efficacy
of Dexmedetomidine Compared With Midazolam) study group.
Dexmedetomidine vs midazolam for sedation of critically ill patients: a
randomized trial. JAMA. 2009;301(5):489-499.
31. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients
in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9707):126-134.
32. Girard TD, Pandharipande PP, Carson SS, et al; MIND Trial Investigators. Feasibility, efficacy, and safety of antipsychotics for intensive care
unit delirium: the MIND randomized, placebo-controlled trial. Crit
Care Med. 2010;38(2):428-437.
33. Wiengard DL, ed. AACN Procedure Manual for Critical Care. 6th ed. St
Louis, MO; Saunders Elsevier; 2011.
68 CriticalCareNurse Vol 34, No. 2, APRIL 2014 www.ccnonline.org
Financial Disclosures PICOT and EBP Assignment: Finding the Research Evidence
None reported.
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MN568 Headaches Sample Essay

Headaches

Headaches are classified as primary and secondary. Primary headaches include migraine, tension-type, cluster, and other such as sinus-related or hormonal. Secondary headaches are red flags for trauma, metabolic, neurological or substance withdrawal (Hainer & Matheson, 2013). Secondary headaches can be emergent because of intracranial pressure, infection, or disturbance of homeostasis (Hainer & Matheson, 2013). Sudden onset of headaches and the patient describing the headache as “the worst headache they have ever had” require immediate attention for potential life-threatening causes such as subarachnoid hemorrhage, post lumbar puncture dissection or TIA’s (Dunphy, Windland-Brown, Porter, & Thomas, 2015). MN568 Headaches Sample Essay

Pathophysiology

The pathophysiology of headaches is poorly understood. Migraine headaches are believed to be caused by a neurological dysfunction with involvement of the cranial nerves (Ferri, 2018). Not every patient with migraine headaches have been found to also have a neurological dysfunction. Migraine headaches are also believed to have a genetic disposition with an instability of the nervous system; specifically, with serotonin and neurotransmitters (Diener, Holle, Solbach, & Charly, 2016). Migraine headaches are often debilitating to patients. Patients with migraine headaches can experience photophobia, nausea, vomiting and an aura.

Patients with cluster headaches are believed to have an overactive parasympathetic nervous system (Hainer & Matheson, 2013). The headache causes mild-moderate pain and pressure. Hainer and Matheson (2013) describe tension headaches as pericranial myofascial tissues as the likely cause of these headaches.

Cluster headaches are commonly rare and involve brief episodes of severe pain that is unilateral and disturbance of routine activities of daily living. The headache involves a short duration of severe pain. Dunphy et al. (2015) describe triggers of these painful headaches caused by hypersensitized ophthalmic nerve (Dunphy et al., 2015).

Episodic

Cluster headaches are episodic and short duration. MN568 Headaches Essay. The pain is severe and often does not last longer than an hour. The headaches are often misdiagnosed within one year of the first episode (Hainer & Matheson, 2013). The pain of these headaches is deep and may involve the eyes and nose. The patient may experience tearing or nasal congestion MN568 Headaches Sample Essay.

Acute

Acute headaches are an onset of a severe headache and can be classified as a red flag. Red flag headaches or primary headaches present related to an emergent underlying condition. This type of headaches is often described as the worst headache the patient has ever had MN568 Headaches Essay. A patient who reports this type of headache, especially in the age group of fifty and older are red flags for intracranial hemorrhage, hypertensive emergencies, or potential carotid dissections (Hainer & Matheson, 2013). Acute headaches could also be caused by meningitis, head trauma, or cancerous tumors MN568 Headaches Sample Essay.

Chronic

Chronic headaches are daily tension-type headaches or migraine headaches. The headaches can be hormonal related in nature. Common trigger of a migraine headache may include: hormones such as low estrogen, disturbance in sleep cycle, food/drink agents such as caffeine, artificial sweeteners, processed or canned foods (Dunphy et al., 2015).

Physical Assessment

The nurse practitioner can assist in the determination of an old versus new headache by questioning the patient of the duration and frequency of the headache. Hainer and Matheson (2013) describe criteria of duration and frequency of primary headaches as a migraine is a headache that last of four to seventy-two hours, a cluster headache is brief with a fifteen to one hundred eighty-minute episode that occur numerous with a period of relapse (Hainer & Matheson, 2013). The nurse practitioner should ask specific questioning of duration and frequency of the patients headache for subjective data collection MN568 Headaches Essay.

Hainer and Matheson (2013) describe subjective data that would be a red flag symptom includes: complaints of a sudden severe headache, headache triggers with exertion or cough, neurological symptoms, new onset of headache during or after pregnancy, and complaints of neck stiffness (Hainer & Matheson, 2013).

The collection of an open-ended history and focused questions will assist the nurse practitioner in determining if the headache is primary or secondary. If the headache is primary focused questions will lead diagnostics of a migraine, tension, cluster or other headache MN568 Headaches Essay. A physical assessment with concentration on the neurological system and laboratory tests are essential before a final diagnosis. The physical exam should include assessment of the neurological system and cranial nerves II-X An assessment of the patient’s head and neck in attempts to mimic the pain is important. The physical assessment should be focused to alleviate muscular and skeletal disorders.

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It is important for the nurse practitioner to obtain vital subjective data from the patient and complete a thorough physical assessment to distinguish between benign and headaches that require urgent attention.

Red flags through patient data collection and physical assessment that require urgent attention include complaints of a sudden onset of a severe headache, papilledema, altered mental status, high fever, muscle rigidity, nuchal rigidity, and symptoms of a CVA, or TIA (Dunphy et al., 2015).

Evidence-Based Treatment Plan

Diagnostic testing for a definite diagnosis should include a comprehensive blood panel, with electrolytes. Consideration should be taken to check the female patient’s hormone level, thyroid levels and urinalysis to rule out infection. The patient should have a computed tomography (CT) scan with or without contrast completed to the brain to rule out any abnormalities and diagnosis of secondary headaches, or a magnetic resonance imaging (MRI).

Secondary headaches are treated mainly with over-the-counter analgesics. Evidence-based treatment for non-responsive conservative and over-the-counter treatment supports six classifications of medications: beta blockers, antidepressants, calcium channel blockers, antiepileptic, anticonvulsants, and nonsteroidal anti-inflammatory medications (Ferri, 2018). MN568 Headaches Sample Essay

Patient Education

            Management of headaches is patient-centered. Headaches can be managed with drug therapy. Patient education should include the proper use of the drug therapy and over-the-counter analgesics. Patients should be encouraged to participate in stress relieving activities such as meditation or physical activity that does not aggravate a headache. Complementary therapy such as acupuncture, herbal therapy, and plenty of sleep should be encouraged by the nurse practitioner (Dunphy et al., 2015). MN568 Headaches Essay. The nurse practitioner should encourage the patient to drink plenty of fluids, and to eat a healthy diet rich in vitamin C foods.

Discussion

Headache management should always be closely monitored and follow-up from the nurse practitioner is essential. Treatment plans should be closely monitored for the effectiveness of drug therapy, and potential referral to a specialist for the management of the headaches. MN568 Headaches Essay.

References

Diener, H. C., Holle, D., Solbach, K., & Charly, G. (2016). Medication-overuse headache: risk

factors, pathophysiology, and management. Nature Reviews: Neurology, 12(10), 575-

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O. & Thomas, D. J. (2015) Primary Care: The

Art and Science of Advanced Practice Nursing. Philadelphia, PA: F. A. Davis Company.

Ferri, F. (2018). Ferri’s Clinical Advisor 2018: 5 books in 1. Philadelphia, PA:  Elsevier.

Hanier, B. L., & Matheson, E. M. (2013). Approach to Acute Headaches in Adults. American

Family Physician, 15(87), 682-687. MN568 Headaches Sample Essay