2003 KNA Convention Poster Presentation Abstracts

2003 KNA Convention Poster Presentation Abstracts

Congratulations to all those who were accepted for and presented a poster at the 2003 KNA Convention! We are proud of your outstanding work. Following are the first set of abstraets; the remaining abstracts will be published in the next edition of the Kentucky Nurse.


Eliminating Illumination in the ULH NICU

Denise Barbier, OTR/L, MOT, Colleen Greenwell, RN, Malinda Guillon, RN, Pauline Hayes, RNC, Lynette Hornung, RN, Frankie Lamb, RN, BSN, Pramoda Ramachandra, MHA, MBA, Paul Rooprai, MHA, Dawn Shrider, RN, Linda Smith, RN, BSN, MBA, Reetta Stikes, RN, Phyllis Stribling, RN, Michael Tilford, CRT, Robin Wade, RRT, Marilyn Wolpert, RNC, FNP, MSN.

University of Louisville Hospital NICU

The purpose of this study is to measure the current light exposure in the University Hospital NICU. Based on the data collected and on published research studies the present environmental factors and infant care practices have been modified to improve developmental outcomes of the NICU patients. The conceptual definition of environmental stimuli in the NICU is stated as surroundings that can produce adverse physiological/behavioral effects on the neonate. The intervention to control the effects of light on the eyes of the neonate begins with the documentation of current nursery lighting levels. Historically the literature promotes a trend towards lower and ambient cycled light levels as noted in the 2003 Standards for Newborn ICU Design, which recommends a range of 10 lux to 600 lux. The light attributes assessed in this study include: outdoor sunlight, the room lights, phototherapy, procedure lights, indirect lighting from halls and indoor windows, types of light protection, and the effectiveness of the barriers, including eye shields, and incubator covers. Procedures that require excessive exposure of light require evaluation and intervention to assure that all light that falls on the neonate’s face is indirect.

Assessing darkness during sleep and maintaining low, muted light levels to support stable physiological states in the infant is an essential consideration of developmental care. Vision is the least mature sense at birth and the retina is susceptible to damage by light exposure. Retinal photochemical damage occurs with both long exposures to low light levels and to shorter duration exposures to high intensity light. In low lighting, infants are generally more stable and conserve more energy.

The methodology used by the project participants involved using a hand held light meter to collect data in lux. Light levels were measured in each of three rooms in the NICU every two hours for 6 days (24 hours a day). A total of 490 readings were collected on each variable. Different bed locations, types of beds and bed covers were assessed for light penetration.

The results of our NICU analysis show one single bill light delivers 138,000 lux, one bili blanket delivers 77,800 lux, and two bili blankets (a bili sandwich) deliver 201,000 lux. During admission and procédures our infants are exposed to 1523 lux while on the warmer. On a sunny day with no other lights on, the room receives 65 lux.

The location of the bed in the room provided the following information: Bed 8 with a mean = 18.13 lux and Bed 7 with a mean = 19.33 lux, are the most desirable bed locations. The bed position parallel to the wall (mean = 8.15) had the least exposure to light from the room than the bed position perpendicular to the wall (mean – 9.76 lux). The traditional bed cover provided the most protection from light (mean = 16.57 lux) than the non-conventional cover (mean = 28.35 lux). The comparison of nursing shifts and intensity of light resulted in the following data: day shift mean = 31.19 lux, evening shift mean = 17.21 lux, and night shift mean = 14.56 lux.

The implications for nursing care have been numerous. The policy to use purple washcloths for eyeshielding that only allows 2 lux of light to reach the infants eyes has been initiated. Additional blinds were placed on the exterior windows. Repositioning the beds to minimize light exposure is not an option because of the high census. Colorful bed covers were created to block the light, and to cycle the light to mimic the natural rhythms of sleep. Nursery staff was educated to minimize bedside lighting that decreases stimulation.


Sound Effects on the Neonate in the ULH NICU

Denise Barbier, OTR/L, MOT, Colleen Greenwell, RN, Malinda Guillon, RN, Pauline Hayes, RNC, Lynette Hornung, RN, Frankie Lamb, RN, BSN, Pramonda Ramachandra, MHA, MBA, Paul Rooprai, MHA, Dawn Shrider RN, Linda Smith RN, BSN, MBA, Reeta Stikes, RN, Phyllis Stribling, RN, Michael Tilford, CRT, Robin Wade, RRT, Marilyn Wolpert, RNC, FNP, MSN

University of Louisville Hospital NICU

There is a growing acknowledgement that sound can adversely effect the development of the infant in the NICU. The purpose of this study is to decrease stress in the neonate from a noisy environment. Adverse physiological/behavioral responses to excessive noise are demonstrated by increased heart rate, peripheral vasoconstriction, interference with sleep cycles, and potential for long-term hearing loss. The preterm infant’s brain appears to be exquisitely vulnerable to sensory overload and noise. The NICU can be highly arousing for the neonate, causing crying and agitation. Ambient noise levels in the NICU are reported to range from 50-80 dB (decibels) and much of the offensive environmental noise is related to caregiving activities. Prolonged exposure to noise louder than 90 dB has been demonstrated to be related to hearing loss. Because environmental Stressors such as noise can cause bradycardia and hypoxia, one cannot rule out the potential link between exposure to loud noise above 50 dB and sensorineural disorganization. Environmental noise also has an adverse effect on the NICU staff resulting in irritability, and altered perception which could result in slower response to monitor alarms.

It was apparent after the literature search that certain noises could be eliminated. Interventions initiated included the physicians’ cell phones placed on vibrate, and the physician rounds away from the immediate bedside. Radios and usage of cell phones by staff were prohibited. The telephone system has been adjusted to eliminate “ringing” in the nursery rooms. The engineering department is involved in determining if the intercom system noise can be reduced.

Methods of data collection involved the use of a Dosimeter, Model Q300, which is a small battery operated, lightweight data logger that can be used as a virtual noise dosimeter. The dosimeter constantly measures sound-pressure levels over small increments of time (seconds or minutes) and averages the accumulated data overtime. Peak sound level, Lpk, is the highest instantaneous level reached during testing. While taking measurements, efforts were made to hold the meter away from the body and other surfaces to reduce the effect of echoes. Nursing activities were measured intermittently for 5 days during periods of rest and activity. Activities included baseline sounds in the nursery rooms, physician rounds, admissions, shift change, nursing procedures, mechanical noise, respiratory therapy noise, general conversation, and other events.

Results of the noise generating nursing activities in the NICU surpassed 118 dB during admission. Baseline sound in the nursery room (109 dB), rounds (105 dB), admission (119 dB), shift charge (92 dB), nursing procedures (107 dB), mechanical noise (83 dB), respiratory noise (90 dB), general conversation (94 dB), and other events (92 dB). Events include: writing on top incubator (112 dB), bottle on top of incubator (109 dB), clipboard (110 dB), monitor alarms (79-88 dB), pump alarms (79-88 dB), and use of intercom (86 dB).

Implications for practice are many. “Quiet Signs” have been posted in each unit. “No cell phones” signs were posted outside the unit. General conversations were moved away from the bedside. The noise from trash removal by Environmental Services has been reduced. Parents were educated, as well as staff, about the influence of the environment on infant development. This knowledge facilitates parents’ efforts to talk and sing to their own babies at levels comfortable to both. Future data collection will extend the recording of data over longer periods and during the night shift post these interventions.


Utilization of Research Findings on Health Literacy

Marilyn Lewis Graves

Western Kentucky University

(6151 834-2678: graves2912@bigzoo.net

Background: Health literacy is the ability to read and understand health information and to use it effectively. Research suggests that health literacy is related to health outcomes and medical costs. However, little information is found in the literature that provides evidence of adequate ways to meet this challenge. This literature review identifies the significance of the issue of health literacy and analyzes proposed solutions for increasing health literacy.

Methods: Health literacy poses a great challenge for nurses. Orem’s Self-Care Deficit Theory of Nursing proposes a relationship between self-care agency and self-care demands. Health literacy is a contributing factor to the health care deficit that occurs when there is a lack of self-care agency to meet the need of selfcare demands. As more health care activities are turned over to patients to carry out on their own, patients must increase in health literacy to be successful in their self-care.

Findings: The 1993 National Adult Literacy Survey (NALS) found that 40-44 million adults (21-23%) in the United States were functionally illiterate. Another 50 million had only somewhat better skills (Ziegler, 1998; The National Work Group on Literacy and Health [NWG], 1998). Also found in the literature is information that relates low health literacy to high costs in health care. However, only one economic study has been conducted on the overall costs of health literacy.

Differences in the literature are found related to recommendations to improve health literacy. A variety of methods are suggested but only one study (n=21) using pictographs offers evidence that supports effectiveness. Gaps in the research include the relationship between literacy and health promotion, health protection, and disease prevention. Also, literacy links to health outcomes related to the care of children or elderly were not found. Clearly, further research of health literacy is indicated. The findings of the literature review support the fact that health literacy is an important concern for health care providers and educators and that further research and program evaluations are needed.


Teaching Psychiatric Nursing?

Hollywood Can Help!

An Evaluation of the Use of Feature Films in the Teaching of Psychiatric Nursing

Joan C. Masters, MA, MBA, RN

Assistant Professor, Lansing School of Nursing and Health Sciences, Bellarmine University, 2001 Newburg Rd., Louisville, KY 40205

Contact: jmasters@bellarmine.edu

This study describes the use of feature films in a psychiatric mental-health nursing course. Films have been widely used in many disciplines to teach both graduate and undergraduate students but there have been only three minor articles reporting on the use of film in nursing education. Advantages of films are that they are engaging, well accepted by students, inexpensive, target the visual rather than the language areas of the brain, are more realistic than educational films, can be watched repeatedly, promote group cohesion, increase participation by quiet students, and provide all students with the same experience at the same time. Disadvantages include the long time it takes to watch, the possibility the film is more engaging than faculty, and the trivialization of real problems. Sample: Two classes of accelerated BSN students (n = 50). Instrument: A 12-item, seven-point Likert scale (r = .95) was used to assess student perceptions of the film component of the course. Procedure: Films were selected to include major course content. Films included were The fisher king, Clean shaven, Fatal attraction, Ordinary people, Sleeping with, the enemy, and Clean and sober. Detailed handouts were developed for each film. Results: Students (n = 50) rated feature films highly on learning and enjoyment and preferred the films to an extended clinical experience. Films offer faculty an opportunity to teach content in a creative and engaging way.


Behavioral Health Nursing Staff With Conducting Patient Education Groups: A Needs Assessment

Joan C. Masters, MA, MBA, RN, Bellarmine University and University Hospital, Behavioral Health, Paula Carmouche, BSN, RN, University Hospital, Behavioral Health, and Jodie Peres, BA, University Hospital, Behavioral Health.

Patient education is an essential nursing responsibility and is mandated by the Joint Commission on Accreditation of Health Care Organizations. While the University Hospital Behavioral Health nursing staff recognized this responsibility there has been widespread reluctance to conduct patient education groups. As part of the Behavioral Health Practice Development Unit (PDU) initiative, a needs assessment was conducted to explore staff concerns related to patient education groups.

Based on staff conversations and a review of the literature a two-page questionnaire was developed. Four registered nurses (RNs) and two mental health technicians (MHTs) reviewed the questionnaire for content validity. Their suggestions were incorporated into the questionnaire.

Questionnaires were distributed to 71 staff in their individual mailboxes in the staff lounge and collected anonymously. Twenty-three questionnaires (32%) were returned. RNs and MHTs had positive attitudes about doing groups and their ability to do groups; LPNs were less positive.

The primary reasons given for not doing groups were (a) lack of resources, (b) discomfort in talking in front of other people, and (c) lack of time. Staff were most interested in learning about (a) group dynamics, (b) managing disruptive behavior, and (c) discussing sensitive and difficult topics. Based on these results it is recommended that (a) patient education videos and reproducible handouts be purchased for staff use and (b) unit-based continuing education specifically addressing their concerns about group be offered to all staff.


Audubon Hospital Music Therapy Cardiac Demonstration Program

June 10-August 20, 2003

Barbara L. Wheeler, PhD, MT-BC

Consultant Music Therapist, Norton Audubon Hospital

Professor and Director of Music Therapy, University of Louisville

A program was developed during the summer of 2003 to increase the number of music therapy sessions provided to cardiac patients at Audubon Hospital and to assess the results. Shabnam Cyrus, a UofL music therapy student, was employed 20 hours a week (4 hours a day) for 10 weeks as music therapy assistant, supervised by Dr. Barbara Wheeler, MT-BC Audubon consultant music therapist, who also saw patients.

Approximately 90 patients were seen with a total of 270 patient contacts. This included 98 patient contacts on the Open Heart Unit, 83 on the Cardiovascular Unit, 51 on the Progressive Open Heart Unit, 20 on the Transitional Care Unit, 10 on the Skilled Care Unit, and 8 on other Medical Surgical Units.

Patients used a visual analog scale to assess their pain, anxiety, depression, stress, and relaxation before and after the music therapy sessions. Data were available on 70 patients. All five measures showed statistically significant differences from the beginning to the end of the session, as analyzed by a paired samples t-test. All differences were significant beyond p

These data provide information on patients’ responses to the music therapy, although there is no experimental control so other factors may be influencing the ratings. So while it cannot be stated with certainty that the changes reported were caused by the music therapy, it is clear that patients overwhelmingly rated their feelings of anxiety, relaxation, stress, pain, and depression as improve’d after the music therapy sessions, providing strong support for the value placed on the music therapy services.

Mini case Studies

Mr. A, who had experienced a dramatic decrease in functioning that seemed to be caused by brain damage, was seen five times for music therapy. The main goal was to decrease anxiety and increase stimulation and awareness. In the first session, songs were sung and Mr. A was given the tambourine to play, with assistance. He responded to the music by tapping the tambourine with his hand. In the second session, there was no response to the music as Mr. A was almost completely unaware. In the third session, he showed minimal response to live music, but when a country music CD was put on, he raised his head and looked around. When the maraca was put in his hand, he shook it vigorously, showing his enthusiasm for the music. The last two sessions were similar to the third, where Mr. A accompanied the country CD by playing musical instruments. These were important steps for him, as he was unable to speak and remained very still most of the time. The music helped him to increase his awareness and was an opportunity for him to move and express himself.

Mr. E was seen five times for music therapy. The original goal was to provide a soothing effect for Mr. E in his last days. However, by the third session a big change was seen, and Mr. E was more alert and awake. he responded to the music through facial expressions and attempting to talk. In the last two sessions, he was able to talk and give positive verbal comments about the music. His friends and family believe that music therapy was a significant factor in Mr. E’s improved communication.

Ms. J had five music therapy sessions with the goal of decreasing anxiety. In all of these sessions, the music caused great changes in Ms. J’s levels of anxiety and stress, lowering them quite a bit as measured by the visual analog scale. A relaxation exercise was used in most of the sessions, after which ‘the patient always reported feeling more calm and relaxed. By the second time this technique was used, Ms. J went through the exercise mostly herself, with little assistance from the music therapy assistant; by the third time, she did it completely herself, showing that she could now use the relaxation exercise herself anytime she needed to relax her body. In the last session, Ms. J expressed her appreciation for having music therapy, saying it helped her very much. She had shared this with a doctor, after which the doctor told her that many patients were saying that music was helping them.

Mr. K was seen three times for music therapy, with the goal of decreasing anxiety and increasing stimulation. Mr. K was always responsive to the music, playing musical instruments along with the songs, and smiling and giving positive verbal feedback. A relaxation technique was used twice, after which he reported feeling calmer and more relaxed. The second time it was used, the music therapy assistant went over the steps with the patient so he would be able to use the relaxation technique on his own and gave him a sheet describing the technique. At the end of the sessions, Mr. K’s levels of anxiety and depression always decreased, as measured by the visual analog scale. He always expressed his gratitude for having the music.


Improving Patient Outcomes by Changing Clinical Practice

Charlene Woodward, RN

Allyson Skaggs RN

Georgetta Interland, RN

Linda Stewart, RN

Background: This study was conducted from April 2002 to August 2003 on a 3Q-bed Cardiovascular Unit. The study evaluated the clinical practice of the bedside nurse in the removal of the femoral arterial sheath post-interventional cardiology procedures. It was initiated by staff members who believed the incidence of complications had increased. No prior complication rate had been established to that date.

Objective: The purpose of this study was to identify problems related to the removal of the femoral arterial sheath by the bedside nurse, to develop and implement changes in clinical practice to reduce the incidence of complications and to evaluate those changes made to the clinical practice.

Methodology: The study was divided into three separate phases. A Data Collection Tool was developed during Phase I. This phase involved identifying the complication rate post femoral arterial sheath removal of 100 consecutive patients receiving postinterventional cardiology procedures. This phase looked at the clinical practice of the bedside nurse in the removal of the femoral arterial sheath. A literature review was conducted to review other clinical practices. With the analysis of the data collection, changes in clinical practices is proposed during Phase II and implemented. These changes in clinical practices was evaluated during Phase III with a sample size of 85 patients using the same criteria as Phase I and the Data Collection Tool. Patients were chosen consecutively during the time frame and no exclusion criteria was used. The need for an informed consent was evaluated and determined unnecessary as the study was evaluating established clinical practices.

Results: Complications were identified as hematorna, pseudoaneurysm, continual oozing of blood, infection and vasovagal response. The results of Phase I indicated a complication rate of 20% compared to the national norm of 21.4%. Of the 20% of complications 2% presented patients experiencing pseudoaneurysm, one which required surgical intervention.

Phase I involved a literature review with the following recommendations:

1. Establish a 30-minute time frame from an ACT of less than 170 to the time the femoral sheath was removed.

2. Promote the use of the C-Clamp as the compression device preferred.

3. Establish a 20-minute minimal time for compression.

4. Evaluate establishing and utilizing a RN to coordinate and facilitate the femoral arterial sheath removal, other than the primary care.

5. Revision of the order set for femoral arterial sheath removal.

6. Revision of the hospital policy.

Development and implementation of the changes in clinical practice occurred during Phase II. Phase III was the evaluation of the changes in clinical practice which resulted in a decrease from 20% to 11.7%. No patients experienced a pseudoaneurysm during Phase III.

Discussion: The changes in the clinical practice of the bedside nurse in the removal of the femoral arterial sheath following post-interventional cardiology procedures were effective. No reduction was noted in vasovagel responses. Establishing and utilizing a RN to coordinate and facilitate the removal of the femoral arterial sheath was the most effective component of the plan according to staff nurses. Delays in the sheath removal still occurred, and further investigation and changes in clinical practices are recommended.

Copyright Kentucky Nurses Association Jan-Mar 2004

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