Critically ill patients in an intensive care unit (ICU) often require mechanical ventilation (MV). Humidification systems are essential devices for MV which replace the natural heat and moisture exchange process of inspired gases. A heat and moisture exchanger (HME) is commonly used for the humidification of MV patients in ICU. In contrast, a heated humidifier (HH) that is a more complicated device is used only for prolonged MV patients because of its higher cost and nurse workload. However, HME may increase the breathing workload of patients, thereby inflicting damage to their respiratory function, especially among respiratory failure patients. However, there was no evidence-based guideline that instructs nurses on choosing humidification devices in ICU. This dissertation aimed to 1) evaluate the current evidence and formulate evidence-based guideline in selecting a humidification device for mechanically ventilated acute respiratory distress syndrome (ARDS) patients in reducing the risks of breathing workload; 2) assess its implementation potential, as well as its feasibility and transferability; and 3) develop implementation strategies and evaluation plans for the use of this device in an adult ICU. Three electronic databases, namely, Proquest, Ovid, and Google Scholar, were searched for randomized controlled trials (RCTs) of humidification systems for MV. Eight articles were retrieved. Their reference lists were read and found two additional RCT. Four high-quality RCT showed that HH increased the breathing workload more than HME. Several studies showed that HME has potential drawbacks of significantly increase airway resistance, minute ventilation, CO2 retention, and respiratory discomfort. However, studies showed that no significant difference of ventilator-associated pneumonia (VAP) rate between HME and HH. The initial application of HME is safer and less costlyl. However, prolonged use of HME in ARDS patients may induce further workload on the respiratory system and worsen treatment progress. An evidence-based clinical guideline in choosing the humidification system was formulated and assessed using the appraisal instruments of Scottish Intercollegiate Guideline Network. It is deemed to be transferable with patient characteristics, clinical situation, and organizational infrastructure similar to studies evaluated the suggested innovation. Feasibility was also assessed and is considered to be high. The setup and running cost per year were HKD17450 and HKD6600. Although the humidification system had no actual cost reduction, non-material benefits such as prevention of tube blockage, reduction in breathing workload, and respiratory discomfort were more important than the cost. An implementation plan including a one-month communication plan with stakeholders and one-month pilot testing were developed. The evaluation of the guideline will last for 10 months. The effectiveness of the innovation will be determined by the reduction in breathing workload, cost and benefit ratio, and staff satisfaction level. / published_or_final_version / Nursing Studies / Master / Master of Nursing

M.Cur. / The South African Nursing Act (Act 50 of 1978) views the professional nurse as an independent practitioner, her independent function being the right to make decisions and taking the full responsibility for such liability. The professional nurse's liability depends on her authority, skills and responsibilities. Her role in the intensive care unit is aimed at optimal care of the ventilated patient, thus providing physical, psychological and spiritual well-being. The incidence of micro-organism colonization in the lower airway of the ventilated patient is researched in this study and nursing guide-lines are set out for the correct use of the ventilator. A contextual, descriptive study was carried out to: (a) determine the sterility of the humidifier reservoir and ventilator tubes; (b) determine which micro-organisms are present in the lower airways of patients after they have been ventilated; (c) set out guide-lines for the nursing staff on how to correctly use the ventilator. Sample analysis was done from the following: The sterile water in the reservoir prior to ventilation. Sputum obtained prior to extubation. Water from the reservoir after extubation (waterbasin of the humidifier). The water present in the ventilator tubes after extubation. The following conclusions were made: contamination is caused by the nursing staff; there was no migration of micro-organisms from the water reservoir to the circuit; the organisms in the ventilator circuit differed from those found in the lower airways of the patient...

Critical care nursing is a speciality that continues to evolve and transform. Critical care nurses of the 21st century routinely care for the complex, critically ill patient, integrating sophisticated technology with the accompanying psychosocial challenges and the ethical conflicts associated with critical illness – while, at the same time, addressing the needs and concerns of the family. Providing nursing care in such a dynamic and fast-track unit can pose various challenges for the critical care nurse. Professional nurses are the backbone of any health-care system. The quality of nursing directly affects the patients’ outcomes, and nursing care must therefore be rendered meticulously. Mechanical ventilator support is routinely needed for critically ill adults in these care units and is also a common therapy in sub-acute and long-term care settings. The care of the mechanically ventilated patient is the core of a professional nurse`s practice in the critical care unit. The mechanically ventilated patient presents many challenges for the professional nurse, while the critical care unit poses as a stressful environment for the professional nurse as well as the patient. The objectives of this study therefore were to explore and describe the lived experiences of professional nurses while caring for mechanically ventilated patients, and to develop recommendations to support professional nurses while caring for mechanically ventilated patients. A qualitative, explorative, descriptive and contextual research design was utilised. Data was collected by means of semi-structured interviews and analysed according to the framework provided by Tesch. Purposive sampling was used to select a sample of professional nurses working in a critical care environment. Guba’s model was utilised to verify data and to ensure trustworthiness of the study. Ethical principles were adhered to throughout this research study. With the analysed data, recommendations were to support professional nurses while caring for mechanically ventilated.

M.Cur. / The intensive care nurse practising respiratory nursing care, is responsible for giving high quality nursing care. Due to the rising cost of health care more pressure is placed on the nurse to provide a high quality nursing care (Sanazaro, 1986:27) Bruwer (1986:220-245) states that there is a need for an orderly, methodical qua l Ity assurance approach on all nursing levels in South Africa, based on a South African model, as well as the development of nursing standards for public and private hospitals. Mechanical ventilation forms an important part of the nursing of the adult critically ill patient in the intensive care unit. To ensure that the patient benefits from mechanical ventilation and does not suffer from complications due to mechanical ventilation, standards must be developed to ensure the giving of a high quality of nursing care. Without these standards it is impossible to determine the quality of their nursing care given. The quality can furthermore,only be questioned and not be determined scientifically. Standards for providing high quality nursing care to mechanically ventilated patients do not exist in South Africa. The quality of the nursing care that these patients receive is therefore questioned.

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Thesis (Ph. D.)--University of Texas at Austin, 2004. / Supervisor: Angela P. Clark. Vita. Includes bibliographical references.

Patients who are critically ill get often admitted to intensive care units (ICUs). The majority of these patients require support with their breathing and are thus connected to a mechanical ventilator. One aspect to consider in the mechanically ventilated patient is endotracheal tube cuff pressure (ETT) management. The management of ETT cuff pressure entails that nurses working in ICUs have the responsibility of ensuring that ETT cuff pressure is kept within normal range of 20-30 cmH20 for the safety of the patients in order to avoid complication of over and under inflation. Poor management of ETT cuff pressure places the mechanically ventilated patients under risk of tracheal injury. Tracheal injury may also be caused by over or under inflation of the ETT cuff. Over inflation of the ETT cuff can lead to the occlusion of capillaries lining the trachea at the cuff site, tracheal stenosis, and can also lead to the death of mucus membranes around the area, just to mention a few. On the other hand, under inflation of the ETT cuff, can lead to air leaks as well as aspiration of gastric contents into the tracheal tree. Therefore, in order to maintain ETT cuff pressure within normal ranges, evidence-based guidelines related to the management of ETT cuff pressure should be used. However, in Malawi the management of endotracheal tube cuff pressure in mechanically ventilated adult patients by nurses in ICUs is not well explored and it is not clear whether this practice is based on evidence-based guidelines. Furthermore, strategies on how to implement evidence-based guidelines in the ICU might not be known and poorly defined because of the complexity of the context. The study is therefore aimed at implementing and evaluating the effect of an evidence-based guideline on the management of ETT cuff pressure in mechanically ventilated adult patients by nurses in ICUs in Malawi using active (printed educational materials and monitoring visits) and passive (printed educational materials only) implementation strategies. The research study used a quantitative approach with multi-designs. Four phases were used in order to achieve the four objectives that were set. Phase one was the pre-test and used a survey design, two was the expert panel review of the evidence-based guideline, three was the implementation of the reviewed evidence-based guideline using a randomised controlled trial design and phase four was the post-test which used a survey design. The RCT included 25 participants from the control and 27 from the intervention group. Each group had three ICUs of which one in each group was from a private hospital and the other were government. Data collection in phases one and four was by a hand delivered pre-and post-questionnaire. In phase two the expert panel members with experience in critical care used the AGREE II Instrument to review the evidence-based guideline that was implemented. In order to gather data during the monitoring visits, the researcher recorded field notes. The applications that were developed by the University statistician consultant using visual basic applications in excel were used to analyse data. Two different implementation strategies were used to implement the evidence-based guideline. The control group used passive implementation strategy which was printed educational materials thus the evidence-based guideline and algorithm. The intervention group used both active and passive implementation strategies which was the printed educational materials thus the evidence-based guideline and algorithm plus monitoring visits by the researcher. In order to establish the effect of the implemented evidence-based guideline on the nursing care practice for the management of endotracheal tube cuff pressure an evaluative posttest survey was conducted in phase four of the research study. The results revealed that the majority of participants had gaps in both groups regarding nursing care practice for the management of endotracheal tube cuff pressure for the mechanically ventilated adult patients in the pretest but improved in the posttest. In the control group 52% had very low knowledge score, 16% had low score, 28% average, and 4% high score while in the category of very high score there was nobody. However, in the posttest those in the very low score were only 44% while the percentage in the low score remained 16%. There was an improvement in the average scores in the posttest such that only 44% were in this category. There was no one in the high and very high score in the pretest. On the other hand, in the intervention group, 78% had a very low score, 9% low score, and 13% were in the category of average score, while in the high and very high score category there was zero percent in the pretest. However, there was also an improvement in the posttest such that only 44% a very low knowledge score. But 19% had a low score, there were 37% in the average category and no one was in the high and very high score. Statistical analysis revealed that the results were not significantly different between and within groups. Improvements were observed in the two groups regarding the scientific knowledge scores for the nursing care practices in the posttest. Upon qualitative analysis of the data from the open-ended question, two main themes emerged thus the need for documentation of endotracheal tube cuff and the process of implementation the evidence-based guidelines. Sub themes such as lack of documentation; no part of routine care and monitoring not done at all were identified under the main theme of the need for documentation of ETT cuff pressure. The Guideline itself need to be clear; implementation strategies; follow up; incentives; supervision; incentives; time factor; resources or equipment required for successful implementation; nurses buy-in critical for the implementation; training detrimental to EBP implementation; nurses attitude crucial to implementation of EBGs and knowledge of nurses for guideline essential for the implementation were the sub themes identified under the main theme of the process of implementing the evidence-based guideline. All appropriate ethical considerations such as principles of autonomy and self-determination, confidentiality and anonymity, voluntary participation, right to receive treatment, informed consent, were adhered to throughout the research study. The research study was unique in nature because it was the first of its kind in Malawi and it contributed to the awareness of the recommended practice for management of endotracheal tube cuff pressure in the ICUs in the country by implementing an evidence-based guideline. The unique contribution of the study is that it is a challenge to implement evidence-based guideline in poor and resource constraint countries like Malawi.

Background Instillation of nonnal saline before suctioning is a common nursing intervention although little research supports the practice. Objectives To detennine when and how often saline is used during suctioning and to assess the knowledge of nurses and respiratory therapists of the advantages and dangers of using saline during endotracheal suctioning. Methods A survey of nurses and respiratory therapists working in adult and neonatal intensive care units was conducted in three large teaching hospitals in the UAE. Results Of the 81 respondents, 38 (47%) rarely instil saline before suctioning, whereas 20 (25%) frequently use saline. Seventy-four percent use saline to enhance retrieval of secretions, and 72% use it to stimulate cough. Nurses and respiratory therapists differ in their use and understanding of saline instillation. Most nurses (56%) rarely use saline before suctioning, whereas most respiratory therapists (37%) frequently use saline. Respiratory therapists (93%) were more aware than were nurses (61%) of the benefit of using nonnal saline to stimulate a cough. Respiratory therapists considered oxygen desaturation as a major adverse effect of saline instillation in comparison to nurses who stressed on pulmonary infection as a major side effect. Conclusion The results of the survey indicates that the practice of these professionals are not in line with most recent research results in the area and indicate a need for in-service education. / Thesis (M.Cur.)-University of Natal,Durban, 2002.

An evidence-based approach to clinical practice aims to deliver appropriate care in an efficient manner to individual patients. This approach entails the integration of research evidence, clinical expertise and the interpretation of patients' needs and perspectives in making decisions about the best care modalities. The increased emphasis internationally on improved patient care and cost effectiveness in health care delivery highlighted the need for quality health services that have to be built upon the use of best evidence to inform practice and patient-care decision-making (McKenna, Ashton and Keeney, 2004:178). Critical care nursing science, a specialised branch of nursing, focusing on the care of the critically ill patient in a designated unit, is no exception to the drive to provide improved quality and cost-effective patient care. Critical care practitioners are seen to have a specialised knowledge base, specific skills in delivering advanced health care and a commitment to serve the critically ill patient. It is expected of them to be aware of new and emerging evidence about health disease processes, treatment modalities and technology used in the critical-care units. Due to the dynamic nature of a critical care unit, it is essential that every practitioner working in the unit, whether a novice professional nurse or senior unit manager, needs to be aware of the current evidence guiding their practices (Elliot, Aitken, Chaboyer, 2007:18). With reference to the critically ill patient who is connected to a mechanical ventilator, practices related to the nursing care of this group of patients, who mostly occupy the critical care units, should be based on the best evidence in order to provide cost-effective and quality care. The research study aimed to explore and describe four identified nursing care practices related to safety of a mechanically ventilated patient as performed by professional nurses in the critical care units in the Nelson Mandela Metropole. The identified nursing-care practices include: endotrachael tube placement verification, endotracheal tube cuff pressure monitoring, endotrachael tube suctioning and mechanical ventilator settings. This objective was operationalized in Stage One of the study, by using a quantitative, explorative, descriptive and contextual approach. A structured questionnaire was utilised to collect data from professional nurses working in critical care units. From the analysed data, it was decided to select the two nursing care practices that were done least according to the best recommended practice, namely endotracheal tube suctioning and endotracheal tube cuff pressure monitoring. Based on the results, systematic reviews were done respectively on the two nursing care practices. On completion of Stage One of the study, evidence-informed clinical guidelines for the two identified nursing care practices were developed. The clinical guidelines were based on the evidence found in conducting the systematic reviews. The draft clinical guidelines were reviewed by an expert panel. Feedback from the reviewers was considered to prepare the final evidence-informed clinical guidelines. Based on the clinical guidelines, two clinical algorithms were developed, which might be used at the patient's bedside and can assist in quick dissemination of the recommendations for practice. Ethical considerations were maintained throughout the study. The quality of the study was ensured in applying the principles of validity and reliability as well as performing a critical appraisal of all data collected during the systematic review. It is envisaged that the study findings be disseminated in the critical care units in the Nelson Mandela Metropole and published in peer reviewed journals.