Medical and Surgical Nursing

Introduction

Medical and surgical nursing has long been considered the foundation of nursing. Care of the adult is the keystone of medical-surgical nursing. This care can be in the acute care setting, in the home, in outpatient settings, or in the community. The care provided is holistic and is rooted in health promotion, disease prevention, health restoration, and health maintenance (Grindel, 2005).

Medical-surgical nursing focuses on nursing care of the adult client and is recognized as the bedrock of nursing practice. Nursing care in this specialty is not centered on a setting or a body system, but encompasses the domain of nursing care of adults. Medical-surgical nursing care is provided to adults around the world. In many situations, medical-surgical nurses are the only specialty nurses available to provide care for adults (Grindel, 2005).

 This paper focuses on the problems surgical medical nurses face, and the probable solution that one may come up with: surgical masks and sanitation.  Research on the increasing incidence of complications or infection after surgical tracheostomy and other surgical procedures are performed in critically ill patients in nursing care settings will be critiqued as well as how this problem can be solved by providing solutions designed for the apparent cause of the problem. The tools to be used to explore the issue will include researching many reading materials regarding the topic and put it together in a meaningful whole. A personal analysis on the problem will also be presented and as well as recommendations on how the quality of care can be improved regarding the particular problem in surgical medical nursing.

 

Research and Findings

In a nationwide study focusing on the state of research utilization in the United States, it revealed that the culture of healthcare institutions does not value research utilization. The study noted that nurses without a baccalaureate degree did not fully understand or value research, while some of the baccalaureate-prepared nurses who had classes on research in their program complained that the way in which nursing research was taught in the schools turned them off (Olade, 2003).

These are just some examples that depict the increasing lack of awareness and utilization of many health care professionals. The purpose if this paper is to identify the main reasons why nurses do not utilize research in their practice; discuss three of these reasons and why they exist; and make evidenced based recommendations for future nursing practice to overcome each of these three barriers.

            There are two major approaches to investigating diverse phenomena in the field of nursing research. These approaches originate from different philosophical perspectives and use different methods for collection and analysis of data.

Nurses who care for patients with brain injuries face unique challenges, especially when it comes to caring for the patient during recovery. Patient care can be time consuming and complex, with appropriate treatment and rehabilitation varying from patient to patient. Interactions with patients’ families place further demands on nurses’ time and energy. Ineffective communication between anxious family members and healthcare providers has been identified as a major source of stress for both nurses and families (Davis, Kristjanson, & Blight, 2003), as well as a factor in the success or failure of a patient’s recovery.

            Contemporary changes in the healthcare setting have created further challenges not only for the nurses but also for the patient recovering from the brain injury. Nursing shortages have led to increased patient care loads, and managed care has led to shorter hospitalizations. The result is that less time is available for healthcare providers to anticipate and meet the needs of those family members assuming caregiver responsibilities. Nurses require specialized training and resources to help families cope with the effects of brain injury upon recovery.

            Neuroscience nurses practicing in the community or within rehabilitation programs are well-positioned to assess and comprehensively refer and manage the brain injury survivor upon recovery. It is important to note that there are some negative effects on the patient after the brain injury. Physical changes may include sensory deficits (e.g., visual or heating impairment), diminished coordination and muscle control, fatigue, seizure disorders, and headaches. The physical changes are generally the most easily recognized by others. In addition, typical emotional changes include emotional liability, decreased inhibition, increased anger, depression, frustration, and anxiety.

These post- brain injury alterations become most apparent to family members or co-workers. Cognitive changes post- brain injury may create additional rehabilitation needs and include decreased short-term memory, inability to maintain attention/concentration, difficulty with receptive and/or expressive communication, and poor organization/planning. These changes once again are most noticeable to those who have close contact with persons who have brain injury (Kay & Lezak, 1990).

Pharmacotherapies may be indicated, yet there is no substantive evidence on the most effective drugs. Because primary depression is best treated when pharmacotherapies are combined with strengthening interpersonal relationships, similar strategies should be employed with this population (Jean-Bay, 2000).

Kay & Lezak (1990) described cognitive changes with greater specificity by discussing the pervasive limitations that impaired executive functioning may present. Diminished executive functioning is connected to frontal lobe damage, and simply put, is “an organically based inability to plan, put into action, and carry through with an appropriate course of action.”

It is well established that irreversible tissue damage following brain trauma is a result of primary and secondary processes. The primary injury occurs at the time of the traumatic event and encompasses mechanical processes such as neuronal shearing, transection and axonal injury. Obviously, these primary events cannot be prevented once the trauma has occurred. However, secondary injury develops over time following the primary traumatic insult. Recent evidence suggests that much of the irreversible damage after brain injury is actually caused by these secondary events initiated at the time of trauma but taking hours to days after the insult to resolve. The time factor involved in the secondary injury process suggests that irreversible brain injury may be prevented or at least attenuated. As such, understanding the role of these secondary mechanisms in the injury process permits the implementation of nursing care practices that may potentially minimize irreversible tissue damage (Vink, 1999).  

            Training and inclusion of the family in patient care is a concept that most nurses felt would lessen negative encounters. Approaching care from the perspective of the nurse-family team helped instill a sense of control in family members. It should be pointed out, however, that “not all families want to be involved in care. Some are scared, and some think that the nurses are not doing their job if they ask the family to help. Although family involvement in care is needed, the critical care environment can be intimidating during the early phases of care, so family members must be approached cautiously and individual circumstances carefully assessed when involving them in physical care of the patient.

 

            Quantitative research progresses through systematic, logical steps according to a specific plan to collect numerical information, often under conditions of considerable control, that is analyzed using statistical procedures. The quantitative approach is most frequently associated with positivism or logical positivism, a philosophical doctrine that emphasizes the rational and scientific. Quantitative research is often viewed as “hard” science and uses deductive reasoning and the measurable attributes of human experience (Kozier & Erb, 2004).

            The qualitative approach is often associated with naturalistic inquiry, which explores the subjective and complex experiences of human beings. Qualitative research investigates the human experience as it is lived through careful collection and analysis of narrative, subjective materials. Data collection and its analysis occur concurrently. Using the inductive method, data are analyzed by identifying themes and patterns to develop a theory or by identifying themes and patterns to develop a theory or framework that helps explain the processes under observation (Kozier & Erb, 2004).

Tracheostomy refers to an opening into the trachea where an artificial airway (the tracheostomy tube) is inserted. This is usually performed to protect the patient from accidentally inhaling food, fluid or saliva. Such an airway may be necessary for patients when prolonged ventilation is required, or when an extended coma is anticipated. It may also be placed surgically to maintain the structure of the trachea–when threatened by cancer, infection or trauma, Placement of a tracheostomy is mainly used during the acute phase of an illness and later removed (Wright, 2005).

A client may have a tracheostomy to bypass an upper airway obstruction, prevent aspiration, manage tracheobronchial secretions, or allow for prolonged mechanical ventilation. Whatever the reason for tracheostomy, the client should be provided standardized care in tracheostomy management. Lately, the rising incidence of chest infections in patients undergoing tracheostomy in my place of employment had been largely blamed on the part of the nurses. Such poor quality of practice is a no-no in the healthcare field. If nurses are not aware of the recommended and safe procedure, then the lives of clients are in jeopardy.

Nurses are instrumental in helping tracheostomy patients cope through symptom management, emotional support, and patient education. By increasing their awareness of this disorder and the challenging nature of its diagnosis, nurses can help identify patients needing care.

Risk management is important. It is about identifying, measuring and controlling those risks that threaten quality or performance in the delivery of patient care (Metcalfe, 2002). Every day, nurses help patients through education, empowerment and expertise to avoid the recognized complications associated with tracheostomy care. They give practical advice and support to people with who underwent tracheostomy to manage risky situations such as an episode of chest infections, encouraging the patient and the family to learn from the event and employ tactics to prevent recurrence. This is a proactive risk management strategy that involves the recognition and identification of things that can go wrong as part of a systematic approach to patient care. Patients are empowered to respond appropriately in a risky situation.

While the existing literature points to the deep impact that surgical tracheostomy can have on patient’s lives, there is nonetheless a scarcity of research on the particular issues of infection after tracheostomy. Although surgical tracheostomy has become a procedure that is commonly performed in critically ill patients, the morbidity of the different surgical techniques currently used in ICUs is not well-known. For this reason the medical and mental health communities are unaware of the best way to assist surgical tracheostomy patients with infection in their recovery.

To address this gap in the literature, this particular study was conducted which specifically explored the incidence and severity of complications and infections associated with subthyroid tracheostomy and cricothyroidotomy when performed in the ICU.

For this proposal, the author employed a combination of qualitative methods. This study examined individual consecutive patients who were undergoing elective tracheostomy rather than experimental manipulation of these variables. Attending physicians elected the timing and technique of the tracheostomy. All procedures were performed at the bedside. A complete laryngeal examination was performed before ICU discharge, prior to decannulation, and 6 months after the tracheostomy. Over a 2-year period, all patients hospitalized in the 22-bed ICU of Limoges University Hospital (France) who underwent an elective tracheostomy were studied. Exclusion criteria included the following: (1) having undergone an emergency tracheostomy and (2) a history of previous tracheostomy, neck surgery, cervical irradiation, or laryngeal disease.

In each patient, the following parameters were noted: age; sex; body mass index; APACHE (acute physiology and chronic health evaluation) II score on ICU admission; reason for admission to the ICU; length of ICU stay; indication for tracheostomy; duration of mechanical ventilation prior to tracheostomy; number of endotracheal intubations prior to tracheostomy; duration of cannulation; as well as different factors that could result in a technically challenging surgical tracheostomy, including the presence of a distorted neck anatomy or coagulopathy. The ICU morbidity and mortality at 6 months after ICU discharge also were recorded.     

Patients were divided into two groups, according to the technique of tracheostomy used (subthyroid tracheostomy vs surgical cricothyroidotomy). Randomization was not performed since the technique of surgical tracheostomy was chosen by each attending physician based on anatomic or functional factors that are known to influence the feasibility of the procedure. Cricothyroidotomy was performed in the presence of at least one of the following criteria: (1) severe distortion of neck anatomy; (2) morbid obesity; or (3) patients with poor prognoses. In the absence of these criteria, a conventional subthyroid tracheostomy was usually performed.

The main limitation of this study is that the tracheostomy technique was chosen by the referring physicians based on anatomic and functional factors, rather than by randomization. This may have introduced a substantial bias since surgical cricothyroidotomy was more frequently performed in the presence of criteria that traditionally have been associated with the performance of technically difficult conventional subthyroid tracheostomies. However, with the exception of age and body mass index, both study groups were comparable for all other characteristics. In addition, the power analysis showed that the size of our study population was adequate to detect a difference of 20% in the incidence of major complications between groups.

Several cases of deaths have been note over the years. Deaths have been usually attributed to incidents like road accidents, fights, fires, natural catastrophes and other such happenings. But recently, a number of deaths have been attributed to medical “errors”- often referring to death by infection, or other medical complications (Black and Weinstein, 2000). Wearing a face mask greatly reduces the risk of acquiring deadly infections. But according to Derrick and Gomersall (2005), face masks do not filter much of the minuscule particles that needed to be kept out of the system. Face masks are designed to keep other people from transmitting infectious diseases and viruses to others, but  they themselves are not protected by the face masks they wear ( Derrick and Gomersall, 2005).

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