AACN clinical issues
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AACN clinical issues · May 2001
ReviewChronic critically ill dyspneic patients: mechanisms and clinical measurement.
Dyspnea is a multidimensional, subjective perception of breathing difficulty commonly seen in patients who are critically or terminally ill. Understanding the mechanisms and assessment of dyspnea will help nurses in advanced practice roles to successfully manage these patients. Major mechanisms of dyspnea include stimulation of the chemoreceptors, stimulation of chest wall and intrapulmonary receptors, and increased sense of effort (also termed increased respiratory motor command). ⋯ Assessment of dyspnea includes an accurate history of timing, precipitating factors, associated symptoms, alleviating factors, intensity and quality of the symptom. Measurement tools for dyspnea include both unidimensional and multidimensional tools, as well as tools that measure changes in the perception of dyspnea. Most tools have been tested for reliability and validity on healthy subjects or on patients with chronic obstructive pulmonary disease and, therefore, should be used with caution in critically or terminally ill patients.
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Postpyloric placement of feeding tubes into the duodenum or jejunum is often recommended to support early feeding, improve tolerance of enteral nutrition, and decrease the risk of aspiration pneumonia. Achieving small bowel feeding tube placement can be a difficult, time-consuming, and costly process that may delay the initiation of enteral nutrition. Various bedside techniques, including air insufflation, pH assisted, and spontaneous passage with or without motility agents are available to facilitate transpyloric feeding tube passage. A discussion of these methods is presented in this article, including a hospital-based quality initiative project designed to facilitate early enteral nutrition.
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AACN clinical issues · Nov 2000
ReviewNutrition for the critically ill child: enteral and parenteral support.
The requirements of growth and organ development create a challenge in nutrition management for the pediatric patient. The stress of critical illness further complicates the delivery of adequate nutrients. ⋯ Although feeding through the gastrointestinal tract is the preferred route for nutritional management, there are specific instances when PN as adjunctive or sole therapy is necessary to meet nutritional needs. With meticulous attention to fluid, caloric, protein, and fat requirements along with monitoring the metabolic status of the patient, it is possible to provide full nutritional support for the critically ill child within 24 to 48 hours of hospital admission.
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Parenteral nutrition (PN) is one of the most sophisticated forms of intravenous therapy in use today. Intravenous feeding is a life-saving technology for patients unable to maintain their nutritional status using the gastrointestinal tract. ⋯ Optimal parenteral nutrition demands expertise in caring for vascular access devices. A collaborative approach to care minimizes the risks associated with PN and ensures positive patient outcomes.
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AACN clinical issues · Nov 2000
Review Case ReportsUse of indirect calorimetry to optimize nutrition support and assess physiologic dead space in the mechanically ventilated ICU patient: a case study approach.
Indirect calorimetry (IC) is an accurate method of estimating a patient's energy expenditure, particularly the complex critically ill patient who benefits most from an individualized regimen of nutritional support. This bedside technique measures variables related to gas exchange and replaces assumptions about physiologic stress. When indirect calorimetry data are augmented by an arterial blood gas analysis of carbon dioxide (PaCO2), the dead space to tidal volume ratio (VD/VT) can be determined for an individual patient. ⋯ A case study approach to a 69-year-old man with acute respiratory distress syndrome and biliary sepsis will demonstrate the utility of this measurement. Attention to precise nutritional support and optimal gas exchange can influence the outcome of critically ill mechanically ventilated patients. This discussion highlights the potential benefits of indirect calorimetry for critical care nurses.