Behavioral and Physiological Indicators of Pain During Nociceptive Procedures Among Mechanically Ventilated Patients at a University Hospital in Cairo

Critically ill mechanically ventilated patients experience significant and prolonged exposure to stressors from many sources related to injury or interventions. Pain is one of the stressors that can alter hemodynamics of such critically ill patients  Aim of the study: to assess behavioral and physiological indicators of pain during nociceptive procedures among mechanically ventilated patients. Research Design: A descriptive exploratory design was utilized. Research questions: a):What are different behavioral indicators of pain during nociceptive procedures among mechanically ventilated patients ? b):What are different physiological indicators of pain during nociceptive procedures among mechanically ventilated patients? Setting: selected intensive care units of a university hospital in Cairo. Sample: A convenience sample of 100 critically ill patients connected to mechanical ventilators. Tools of data collection: Three tools were utilized to collect data pertinent to the current study: tool 1:Mechanically ventilated patients' demographic and medical data, tool 2: Critical Care Pain Observation tool, tool 3: Physiological indicators of pain assessment tool Results:. The current study revealed that during nociceptive procedures ,patients displayed manifestations of pain such: facial expression ,body movement, compliance with ventilator and muscle tension in percentage of:(54%,58%,45%,45%) respectively. Concerning physiological indicators the current study revealed increased means of heart rate, systolic blood pressure ,MAP, diastolic blood pressure ,respiratory rate during endotracheal suction procedure (113.69±11.50,134±17.4,95.5±12.25,76.58±10.86,21.7±7.84) respectively as compared to before and after procedure with significant statically differences as(F/P=8.651/.005,2935.012/.000,2694.048/.000,201.993/.000,488.212/.00). Conclusion: Nociceptive procedures is extremely common in ICUs ,observation of critically ill patients' behavior during those procedures is crucial .Recommendations: There is a need to ensure that pain should be recognized in critical care settings for patients with communication difficulties. Ongoing monitoring of  critically ill patients vital signs during nociceptive procedures. Keywords: Mechanical ventilation, Behavioral indicators, Pain , Nociceptive procedure

Personal Lived Experience of Mechanically Ventilated Patients during the Recovery Period after Open-Heart Surgery at El Manial University Hospital

Patients on mechanical ventilators are subjected to extreme physical and emotional stress in the Intensive Care Unit .Less attention has been paid to patients' subjective experience of mechanical ventilation; even though psychological factors have been proposed as important determinants of outcomes in some patients. Thus Critical care nurses need to be cognizant of the importance of maintaining a close and supportive environment for the patient. Therefore the aim of this study was to explore the personal lived experience of Mechanically Ventilated patients during Recovery Period after Open-Heart Surgery. The following research question was stated; what are the personal lived experiences of patients connected to mechanical ventilator during recovery period after open-heart surgeries? A qualitative phenomenological design was used using purposeful sample. The data saturation occurred with fourteenth participants. In-depth Semi-structured interview was used to collect data using a pre-prepared interview question guide which was written in the lay Arabic language. All interviews were audio tape recorded. The interviews were transcribed verbatim and analyzed using Giorgi’s methods for phenomenological analysis. Two major themes were identified through analysis:  physical experiences and emotional experiences contain four and nine subthemes respectively. Physical experiences contains: breathlessness, mouth dryness, pain and physical discomfort. And emotional experiences contain; shock, bothering, near death, inability to endure, powerlessness, knowledge deficit, sense of safe/unsafe, body image, and spirituality. Participants responses centered on spiritual aspect. Ethical principles were maintained throughout the study. The participants' identified experiences formed the basis for formulation of recommendation guidelines to improve nursing management of mechanically ventilated patient during recovery period after open heart surgery. Keywords: Lived Experience, Mechanically Ventilated Patients, Recovery Period, and Open-Heart Surger

Effect of Modified Clinical Pathway Guidelines on Congestive Heart Failure Critically Ill Patient's Health Outcomes at Assuit University Hospital, Egypt

Literature review cited that, congestive heart failure critically ill patients are suffering from different health problems which might endanger their lives and safety, compromise their quality of life, and burden hospital resources. Critical care nurses play major role together with the other health care team members in integrating and delivering multidisciplinary health care for such group of patients. This care approach can positively been reflected upon patient’s outcomes and other related variables. Therefore, the aim of this study is to investigate the effect of modified clinical pathway guidelines on congestive heart failure critically ill patients' health outcomes. Research hypothesis; critically ill congestive heart failure patients who are subjected to the modified clinical pathway guidelines in addition to the routine hospital care will Show; 1- More hemodynamic stability,2- Lesser exposure to chest pain and dyspnea attacks, 3- Fewer systemic complications, 4- Lesser CCU stay / days and the numbers of re-hospitalizations, 5- Lesser degree of dependent edema and grade of heart failure, and 6 - Report lesser numbers of negative variables than that of a matched control group of patients whom received the routine hospital care only. Quasi-experimental research design was used to conduct this study. Setting; the current study was conducted at the Coronary Care Unit of Assuit University Hospitals, Egypt. Sample; sixty adult male and female critically ill congestive heart failure patients were included in this study and assigned randomly into two equal and matched groups, (study and control of 30 patients each). Tools: Four tools were developed and tested by the investigators. These tools are; I: Congestive heart failure critically ill patient’s assessment sheet, II Congestive heart failure critically ill complications monitoring sheet, III: Congestive heart failure critically ill Patient’s health outcomes assessment sheet, and IV: Modified clinical pathway guidelines variances checklists Congestive heart failure critically ill Patient’s health outcomes assessment sheet. Setting: Coronary Care Unit (CCU) of El-Or man Hospital, Assuit University Hospitals, Egypt. Methods: The researchers trained, participated in coordinating, and supporting the implementation of the clinical pathway guidelines, and then evaluated its effects on the selected congestive heart failure critically ill patients’ health outcomes. Results of this study revealed that, patients in modified clinical pathway guidelines group got significantly lesser chest pain and dyspnea attacks, decreased weight gain, fewer systemic complications; shorter length of hospital stay / days, with lesser negative variables than that of the control group subjects. Thus the complex research hypothesis can be partially supported. Conclusion: Applying modified clinical pathway guidelines could significantly improve patient's health outcomes in congestive heart failure critically ill patients. Recommendations: Clinical pathway care approach needs to be supported and initiated in the CCU at Assuit University Hospitals with furthermore replications of this study and other related studies on a larger probability samples in relation to patient’s health outcomes, safety, and  hospital resources.             Keywords: Congestive Heart Failure Critically ill patients, Modified Clinical Pathway Guidelines, Clinical Pathway, and Patient's Health Outcomes

Mechanical Ventilation: Relationship Between Body Mass Index and Selected Patients’ Outcomes at a University Hospital in Cairo

Background: Mechanical ventilation is a life-saving management approach for critically ill patients. However, it has certain negative consequences which may affect patients' outcomes. Among factors that could adversely influence the prognosis of these patients is the body mass index (BMI). Aim of the study: to investigate the relationship between BMI and selected outcomes of critically ill mechanically ventilated patients. Research Design: A descriptive correlational research design was utilized Research questions: a) what is the BMI profile of mechanically ventilated patients admitted to critical care units over a period of six months? b) What is the relationship between body mass index and frequency of organ dysfunction, length of ICU stay, weaning from mechanical ventilation, and the mortality rate among adult critically ill mechanically ventilated patients? Setting: different intensive care units of a university hospital in Cairo. Sample: A purposive sample of 30 critically ill patients connected to mechanical ventilators for at least 72 hours. Tools of data collection: Three tools were utilized to collect data pertinent to the current study: tool 1: patients’ demographic and medical data, tool 2: BURNS Wean Assessment Program (BWAP) checklist, tool 3: Sequential Organ Failure Assessment (SOFA score) tool. Results: More than three quarters (77%) of the studied sample were males, and more than one quarter (26.7 %) were in the age group of 18-28 and 40-50 years old respectively, with a mean age of 39.766 ± 13.51. Two thirds (66.7%) of the studied sample had normal BMI. No significant statistical relationship was found between BMI and ICU length of stay and mortality rate among the studied sample, (X2= 11.31, P value < 0.79), (X2 = 0.15, P value < 0.928) respectively. No significant statistical relationship was found between BMI and the weaning trials from mechanical ventilation (X2= 0.15, P value < 0.928). No significant statistical relationship was found between BMI and the occurrence of organ dysfunction (X2 = 2.54, P value < 0.637). Conclusion: BMI in the current study was not found to have relationship to weaning from MV, length of ICU stay, occurrence of organ failure, and mortality rate. Recommendations: Nutritional status of critically ill mechanically ventilated patients must be considered in their management; meticulous nutritional assessment must be done for all critically ill mechanically ventilated patients to enable in monitoring their progress and outcomes; development of a comprehensive assessment tool that facilitates inspection and early detection of problems/complications among mechanically ventilated patients' documentation system must include patients' nutritional assessment data such as anthropometric measurements (height, weight) to facilitate calculation of BMI. Keywords: Mechanical ventilation, body mass index, organ dysfunction, length of ICU stay, weaning from mechanical ventilation, mortality rat

Readmission after Open Heart Surgery: Study of Predictors and Frequency

Background: Hospital readmissions after cardiac procedures are believed to be associated with higher in-hospital mortality and may predict poor outcomes. In addition high rate of readmission following discharge is associated with increased cost of care. Therefore, awareness of factors that predict increased risk for hospital readmission after cardiac surgery may improve the ability to reduce early readmission rates among this category of patients. Aim of the study; to assess predictors for hospital readmission after cardiac surgery. Design: A descriptive exploratory design was utilized in the current study. Subjects: A sample of Convenience including 115 adult male & female patients who were admitted to the cardiothoracic surgery departments at Kasr Al-Aini Hospital, Cairo University over a period of six months were recruited. Tools of data collection: Four tools were utilized to collect data pertinent to the current study: Socio-demographic/medical data sheet; Perioperative open heart surgery assessment Sheet; Hospital readmission assessment sheet; and the LACE index Scale (Lengths of hospital stay in days; Acuity of illness at the time of admission; Carlson co-morbidity score; and Emergency department visits numbers during previous six months. Results: the current study revealed that the majority of the studied sample were males, married, having an elective admission with percentages of (67.8%), (86.1%) & (87%) respectively, and nearly half of them were between 40–59 years & came from rural area in percentages of (50%) & (52.2%) respectively. Out of the 115 patients who discharged from the hospital 18 % required a second hospital and ICU readmission. Main reasons for readmissions were wound problems (42.9%), congestive heart failure (14.3%), atrial fibrillation (9.5%), pleural effusion (9.5%), renal failure (9.5%) and respiratory failure (4.8%). Binary logistic regression analysis revealed that preoperative renal failure, delayed extubation (mechanical ventilation > 8 h), re-exploration for bleeding, perioperative use of intraaortic ballon pump (IABP), postoperative dysrhythmias, postoperative heart failure and postsurgical (ICU) length of stay (> 3 day) were independent predictors for readmission. Conclusion & Recommendations: Based on findings of the current study, it can be concluded that readmission following discharge is an important adverse outcome of cardiac surgery that needs continued attempts to explore and manage the risk factors of readmission. So the study recommends identification & close monitoring of those at risk for readmission; Establishment of hot line services for providing proper consultation after hospital discharge, especially for emergent cases; and provision of surveillance units for detection of high risk patients. Keywords: Open Heart Surgery- Hospital Readmission-Predictors- Frequency

The Effect of two Schedules of Intermittent Enteral Feeding on the Development of Gastric Colonization

Nutritional support is an important aspect of the care of traumatized patients and it can result in improving wound healing, decreasing catabolic response to injury, enhancing immune system function, improving gastrointestinal structure and function, and improving clinical outcomes. However, many complications are associated with enteral feeding including gastric colonization. Routine enteral feeding schedule is not allowing time to acidify stomach with gastric pH. This may predispose the traumatized patients to acquire gastric colonization which may predispose to aspiration pneumonia. Aim: this study was carried out to investigate the effect of two schedules of intermittent enteral feeding on the development of gastric colonization Design: a quasi-experimental design. Setting: trauma ICU at Assiut University Hospitals, Egypt. Patients: A convenience sample of 80 adults' traumatized patients on enteral feeding constituted the study sample. The patients were assigned into two equal groups (group 1 and group 2, 40 patients each). Methods: The only manipulation was in the rest period and time interval in which the group 1 patients were rested 8hours at night as compared to 6hours for the group 2 ones, as well group 1 patients were having 4hours time interval between each two consecutive feeding as compared to 2hours for group 2 patients. Results: ninety percent of group 2 patients developed gastric colonization as compared to 40% of the group 1 patients with a highly significant statistical difference between both groups in this regard (p= 0.000).Conclusion: intermittent 4-hour interval enteral feeding schedule inhibit the development of gastric colonization. Keywords: intermittent enteral feeding, gastric colonization

Impact of a Designed Nursing Intervention Protocol about Preoperative Liver transplantation Care on Patients’ Outcomes at A University Hospital in Egypt

Background: Literature review cited that, Liver transplantation is now considered as the gold standard for treatment of patients with end-stage liver diseases and early liver tumors in cirrhotic livers. Patient education is vital to the safety and success of a transplant. Aim: the aim is to assess the impact of a designed nursing intervention protocol about preoperative liver transplantation care on patient’s outcomes as indicated by: patients` knowledge & practice mean scores, and complications developed. To fulfill the aim of this study, the following hypothesis was formulated: patients undergoing liver transplantation who will be exposed to the designed nursing intervention protocol about preoperative liver transplantation care will show better outcomes. Material and Methods: A convenient sample of 14 adult male and female patients admitted to Liver Transplant Unit at El Manial University Hospital were included, three of them were died with an attrition rate of 21.4%. Four tools were formulated to collect data pertinent to the study. 1- Sociodemographic and medical data sheet; 2- Pre/Post knowledge assessment questionnaire sheet, 3- Observational checklists, & 4- Complications assessment sheet. Structured interview, reviewing medical records, direct observation and physical examination were utilized for data collection. Results: a  significant statistical difference was found in relation to the total and subtotal mean knowledge and practice scores during different assessment periods  with P values (0.00 for both); as well, 45.5 %  of patients developed respiratory complications (pleural effusion) compared to 53.8 % of their correspondence who developed respiratory complications (pleural effusion, chest infection, and others), in addition, 9.1% of the studied subjects developed  rejection, and ascites as compared to (1.9 %, 5.7%) of their correspondence over the last consecutive three years respectively. Conclusion: Liver transplantation patients showed a positive improvement in their knowledge and practice in relation to breathing, coughing, & using respirometer exercises and range of motion. Replication of this study on a larger sample selected from different geographical areas is highly recommended. Key wards: liver transplantation, designed nursing intervention protocol, preoperative liver transplantation care, knowledge, complications, and patient`s outcome

Impact of a Designed Nursing Intervention protocol on Myocardial Infarction Patient's Outcome at a selected University Hospital in Egypt

Background: Myocardial infarction is a life threatening disease that influences the physical, psychological and social dimensions of the individual. Improper lifestyle is one of the causes of this disease.  The  designing and implementing  of  nursing  intervention protocol for MI patients could  be  one  of  the  important  and fundamental steps in improving MI patients outcomes. Aim: The aim of this study was to examine the impact of a designed nursing intervention protocol on myocardial infarction patient’s outcomes as indicated by higher post total mean knowledge scores, higher post total mean practices scores and high level of compliance to lifelong instruction. Research hypotheses: H1. Patients who will be exposed to a designed nursing intervention protocol will have a higher post total mean knowledge scores; H2. Patients who will be exposed to a designed nursing intervention protocol will have a higher post total mean practices scores; H3. Patients who will be exposed to a designed nursing intervention protocol will have a high level of compliance to lifelong instruction. Design: A quasi-experimental research design was utilized in this study Sample: A convenience sample of 40 adult male and female MI patients. Setting: The cardiac care units at a selected Cairo University Hospital were recruited to fulfill the aim of this study. Tools: Four tools were formulated& tested to collect data pertinent to the study; Socio-demographic and medical data sheet, Pre/Post knowledge questionnaire sheet, an Observational checklist and Compliance assessment sheet. Structured interview, reviewing medical records and direct observation were utilized for data collection. Results: The study results revealed that the post total mean knowledge scores of the studied subjects is increased significantly with value of t= 20.6 at p=0.000, higher post total practice scores among the studied subjects with t& p values (t=5.6 at p= 0.000 ) also, studied subjects had mild to high compliance level regarding the lifelong instructions. Conclusion: It can be concluded that, enrichment of patients' knowledge and practices in relation to their condition and utilization of the effective nursing intervention protocol as an approach of care could have a positive impact upon improvement of patients' outcome. Recommendations: The study recommended Conduction of further studies in order to assess the effectiveness of the designed protocol on patients' outcome regarding different cardiac disorders with replication of this study on a larger probability sample from different geographical locations at the Arab Republic of Egypt, in addition to establishment of cardiac rehabilitation center in the different heath care organizations. Keywards: Nursing intervention protocol, Myocardial Infarction, Outcomes, Cardiac care units

Effect of Earplugs and Eye Mask on Sleep Quality Among Patients with Acute Coronary Syndrome at Assiut University Hospital

Background: Sleep disturbance can cause multiple negative cardiovascular effects among patients with Acute Coronary Syndrome (ACS). Aim: this study carried out to investigate effect of earplugs and eye mask on sleep quality among patients with ACS. Design: a quasi-experimental design. Setting: Coronary Care Unit at Assiut University Hospital. Subjects: Convenience sampling of 60 male and female adult patients were assigned randomly to two equal groups (30 each). Tools: Four tools were utilized to collect data of study, which were: Tool I Acute Coronary Syndrome patient assessment sheet Tool II: Factors affecting sleep quality among patients with ACS during night Tool III: 0–10 Numeric Pain Rating Scale Tool IV: ST Mary’s Hospital Sleep Questionnaire (SMHSQ). Methods: Researcher assessed factors affecting sleep quality during night as base line data and on daily basis for 3 consecutive days. Then, earplugs and eye mask were placed for study group between 7:10 PM. On morning, sleep quality was assessed for study and control groups by using (SMHSQ) between 7:8 AM. Results: Finding of this study supported stated research hypotheses with statistical significant difference between study and control groups regarding total mean of sleep quality score during 1st and 2nd nights of intervention (P=0.000**, P= 0.014*) respectively as well as some of environmental factors affecting sleep quality with P. value < 0.05. Conclusion Earplugs, eye mask significantly improve sleep quality of patients with ACS. Therefore, offering earplugs and eye mask as a part of routine nursing practice for all ACS patients is highly recommended.                                                                                        Key words: earplugs and eye mask, sleep quality, acute coronary syndrome patient

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112