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  • 1. Critical Care Nurses’ Knowledge on Adult Mechanical Ventilation Management Mehta*1 RS, Bhattari*2 BK. B.P. Koirala Institute of Health Sciences, NepalAbstract:Introduction: Critical care nursing is that specialty within nursing that deals specifically withhuman responses to life-threatening problems. Critical care nurses account for an estimated 37%of the total number of nurses working in the hospital setting. B P Koirala Institute of HealthSciences (BPKIHS) has 700 bedded tertiary care hospital having 8 beds ICU and 6 beds CCUwith modern facilities.Objectives: The objective of this study was to find out the knowledge on adult mechanicalventilation management among the nurses working in Intensive care unit of B.P. Koirala Instituteof Heath Sciences.Methodology: It was hospital based descriptive study conducted among all the 35 nursesworking in critical care unit of BPKIHS having work experiences at least 3 months in the sameunit. Using pre-tested questionnaire having 50 items of knowledge, the data was collected duringthe period of 1-7-2010 to 7-7-2010 for a week maintaining all the formalities.Results: Most of the nurses had adequate knowledge on the items like, definition of mechanicalventilation (100%), care of tracheotomy (88.6%), risk of 100% oxygen (85.7%), management ofacidosis (91.4%), weaning (82.9%), where as the limited nurses had knowledge on indication ofCPR (25.7%), indication of laryngeal mask air-way (LMA) (5.7%), and indication of continuouspositive air-way pressure (CPAP) (5.7%). The association calculated with items of knowledgescore and other variables, it was found significant association between indication of non-invasivemechanical ventilation (MV) and training institute (p=0.034), LMA and ICU experiences(p=0.047), synchronized intermediate mandatory ventilation (SIMV) use and ICU experiences(p=0.042) and goal of tracheostomy care and ICU experiences (p=0.046).Conclusions: Most of the nurses had average (score-1,2) knowledge on common knowledgecomponents and very limited nurses had knowledge on the components that was not performedin our setting or very less frequently performed like, use of LMA, pacing and CPAP. RegularCNE is mandatory for the nurses working in ICU.Key Words: Knowledge, Critical Care Nurse, Mechanical VentilationKey: *1 Ram Sharan Mehta,, Associate Professor, Medical-Surgical 2Nursing Department, * Prof. Dr. Bal Krishna Bhattari, HOD, Department of Anesthesiology and CriticalCare. B. P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal. 1
  • 2. Introduction:A critical care nurse is responsible for ensuring that acutely and critically ill patients and theirfamilies receive optimal care. Critically ill patients are defined as those patients who are at highrisk for actual or potential life-threatening health problems. The more critically ill the patient is,the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring 1intense and vigilant nursing care.Critical care units, may be thought of as having context (the demographics and characteristics of the kindof work they do), structure (the grouping of people and the allocation of responsibility throughspecialization, expertise, formalization, and some degree of centralization or decentralization),process (intraorganizational relationships such as the flow of information and coordination), andoutcomes (productivity, goal attainment, morale, and satisfaction of the members. 2The first intensive care units emerged in the 1950s to provide care to very ill patients whoneeded one-to-one care from a nurse, from this environment the specialty of critical care nursingemerged.3 As issues relating to patient care become increasingly complex and new technologiesand treatments are introduced, critical care nurses will need to become ever moreknowledgeable. 4 Nurses need to develop a thorough understanding of these modes includingtheir effects on underlying respiratory physiology to be able to deliver safe and appropriatepatient care.5Objective: The objective of this study was to find out the knowledge about adult mechanicalventilation management among the nurses working in Intensive Care Unit of B.P. KoiralaInstitute of Heath Sciences.Methodology: It was hospital based descriptive study, conducted among the nurses (staff-nurses) involved in the care of patients on ventilator, working in ICU for more than threemonths. Using total enumerative sampling technique all the 35 nurses working in ICU ofBPKIHS was selected for study. Informed verbal consent was obtained from the subjects prior todata collection. Subjects were assured about the confidentiality of the Informations they wereprovided and used for the study purpose only. Using pre-tested questionnaire having 50knowledge items, the data was collected during the period of 1-7-2010 to 7-7-2010 for one weekand special consideration was maintained to avoid the contamination of data. The collected datawas entered in Excel and analyzed using SPSS-11.5 software package.Results:Age and experiences of the subjects: it was found that most of the subjects (71.4%) were of agegroup of 21-25 years, with mean age 22.26, SD 2.187 and range 19-30 years. Only 3(5.7%)subjects had the ICU experiences of more than 3 years. The mean ICU experience was 13.29,with age SD 12.335 and range 3-60 months. Similarly, only (3)8.6% nurses had total nursingexperiences of more than 3 years, with mean 16.66, SD 123.604 and range 3-60 months. It wasfound that only 2(5.7%) nurses had received BLS as well as ALS training and 11(31.4%) nursesworking in PBKIHS was trained from this institute it self. The details are depicted in table 1-4. 2
  • 3. Knowledge about Adult Mechanical Ventilator: Using 50 MCQs the knowledge of nursesregarding adult mechanical ventilator was assessed. It was found that most of the nurses hadadequate knowledge regarding definition of mechanical ventilation (100%), care of tracheotomy(88.6%), risk of 100% oxygen (85.7%), drugs used to correct acidosis (91.4%), definition ofweaning (82.9%), indication of checking carotid pulse (88.6%), and respiratory status afterextubation (85.7%); where as the limited nurses had knowledge on indication of CPR(25.7%),indication of LMA (5.7%), management of accidently extubated patients (17.1%), and indicationof CPAP (5.7%). The details are depicted in table 5-11.Association between variables: the association calculated between the items of knowledgescore (0,1) with other variables and it was found significant association between indication ofnon-invasive mechanical ventilation and training institute (BPKIHS, Others) (p=0.034), similarlywith use of LMA and ICU experiences (≤ 6 months, > 6 months) (p=0.047), SIMV use and ICUexperiences (p=0.042), indication of non-invasive mechanical ventilation and ICU experiences(p=0.042), goal of tracheotomy care and ICU experiences (p=0.046), and correct positioning ofETT and total nursing experiences (≤ 6 months, > 6 months) (p=0.030). Except these mentionedvariables there is no significant association between other variables.Discussion:Most of the nurses working in critical care unit were below age 25 years (94.3%). Most of thenurses had job experiences in ICU is up to 3 years (94.3%), and had total job experiences up to 3years (91.4%). Only 2 nurses (5.7%) had received BLS and ALS training.Most of the nurses had average knowledge (score-1, 2) on common knowledge components andvery limited nurses had knowledge on the components that was not performed in this setting veryfrequently like use of LMA, pacing and CPAP. Most of the nurses had adequate knowledgeregarding definition of MV (100%), tracheotomy care (88.6%), correction of acidosis (91.4%),weaning (82.9%), and checking carotid pulse (88.6%). The limited nurses had knowledge onindications of CPR (25.73%), indication of LMA (7%), and indication of CPAP (5.7%). Thestudy conducted by Khatib6 among physicians, nurses, and respiratory therapists reported similarfindings. Similarly study conducted by Labeau7 among the European nurses reported that averagescore was 45.1% and knowledge about oral route of intubation among 55%, ventilator circuitshould be changed for each patients (35%), close suctioning (46%), and suction tube should bechanged in each patient separately, which is the similar findings to our study.Study conducted by Perrie8 reported pain management, glycemic control and weaning frommechanical ventilation are nursing care areas that can impact on patient outcome and arecommonly guided by protocols. However, in order to ensure safe, optimal management ofpatients even when care is guided by protocols, nurses require a sound knowledge base. 3
  • 4. Conclusions:Most of the nurses were younger (<25) years and had lesser critical care experiences (<3Yrs) andvery limited had received BLS and ALS training. The nurses had deficiencies in knowledge andapplication of mechanical ventilation, as evidenced by low scores on the assessment test. It is inthe recognition of knowledge gaps that a foundation for remedial education can be built. Thissuggests that the quality of patient care cannot be assumed. More importantly, continuedobjective-based professional staff development that measures content, educational method andretention rate is critical to guide the teaching of concepts that are associated with lower mortality,improved patient outcomes and reduced health care costs.Recommendations:Regular continuous nursing education is mandatory for the nurses working in ICU. Periodicalcontinuous medical education by the Anesthetics and other doctors from specialty departmentwill be beneficial for the nurses to keep up to date the knowledge required for quality patientcare in the unit.References: 1. Yaseen A, Venkatesh S, Samir H, Abdullah Al S, Salim Al M. A Prospective Study of Prolonged Stay in the Intensive Care Unit: Predictors and Impact on Resource Utilization. International Journal for Quality in Health Care, 2002, 14:403-410. 2. Weissman C. Analyzing intensive care unit length of stay data: problems and possible solutions. Crit Care Med. 1997; 25: 1594–1600. 3. Mehta NJ, Khan IA. Cardiologys 10 greatest discoveries of the 20th century. Texas Heart Institute J. 2002; 29:164-71. 4. Wong DT, Gomez M, McGuire GP, Kavanagh B. Utilization of intensive care unit days in a Canadian medical-surgical intensive care unit. Crit Care Med. 1999; 27: 1319–1324. 5. Brilli, R. J., A. Spevetz, R. D. Branson, et al. Critical Care Delivery in the Intensive Care Unit: Defining Clinical Roles and the Best Practice Model. Critical Care Medicine. 2001, 29:7-9. 6. Khatib MF, Zeineldines, Ayoub C, Husan A. Critical care clinicians’ knowledge of evidence-based guidelines for preventing ventilator associated pneumonia. American journal of critical care. 2010; 19: 272-276. 7. Labeau S, Vandijck D, Rello J et al. Evidence-Based guidelines for the prevention of ventilator associated pneumonia: results of a knowledge test among European Intensive care nurse. Journal of Hospital Infection. 2008; 70(2): 180-5. 8. Perrie H, Schmollgruber S. Knowledge of ICU nurses regarding selected care areas commonly guided by protocols. Critical Care. 2010; 14:446. 4
  • 5. Table 1 Knowledge about Various Aspects of Mechanical Ventilation N=35 SN Knowledge about Adult Mechanical Ventilation Correct Responses1 Basic Knowledge on Mechanical Ventilation Number (%) Indication of MV 26(74.3) Responsibility of care for MV 7(20) Indication of Non-invasive MV 12(34.3) Oxygen concentration in mouth to mouth respiration 10(28.6)2 Knowledge about air-way management Indication of LMA 2(5.7) Confirmation of ETT placement 23(65.7) Communication during artificial airway 19(54.3) Goal of tracheotomy 22(62.9)3 Drugs used during MV Indication of potassium 14(40) Use of sedation and neuromuscular blockage 23(65.7) Advantages of neuromuscular blockage 20(57.1) Drugs used to correct acidosis (sodium bicarbonate) 32(91.4)4 Modes of MV Differences between SIMV with AC 12(34.3) Effects of PEEP 26(74.3) Modes of Ventilator 26(74.3) Knowledge about supported ventilator 22(62.9)5 Knowledge about weaning Definition of weaning 29(82.9) Components of weaning criteria 14(40)6 Management of complications Management of ETT bite 22(62.9) Management of suctioning complications 6(17.1) ABG values during acidosis 23(65.7) Management of accidently extubated patients 6(17.1) Complications of high I:E ration 9(25.7) Complications of high level PEEP 9(25.7) Decrease in TV 13(37.1) Results of circuit leak, disconnection, & T-tube 10(28.6) Indication of detoriation of patient on ventilator 18(51.4)7 Knowledge CPR Displacement of sternum during CPR (4-5 cm) 10(28.6) Indication of checking carotid pulse 31(88.6) Drug of choice during CPR (adrenaline) 17(48.6) 5