Question

You are a staff nurse working in an intensive care unit and assigned to care for a 75-year-old man who had coronary artery bypass graft surgery 4 days ago. The patient has a history of chronic obstructive pulmonary disease exacerbated by heavy smoking. His postoperative course has been difficult, and he has suffered a number of setbacks. The staff, despite their diligent efforts, have not been able to wean him off the ventilator since the surgery. He has required frequent suctioning throughout the shift, and he is being evaluated for the development of ventilator-associated pneumonia. Today, when returning from lunch, you observed that an experienced nurse was suctioning your patient. His secretions were thick, and you observed that the nurse was instilling saline into the patient’s endotracheal tube as she was suctioning him. The patient turned red and began coughing, and it was obvious he was in distress. You asked the nurse why she was instilling saline into his endotracheal tube. She replied that this was being done to loosen the secretions. You told her this was no longer an acceptable practice. She stated that she had lots of critical care experience and she didn’t care what anyone said, that the only way you could loosen the patient’s secretions would be to instill saline. She also said that would be the last time she would do something for one of your patients while you were at lunch. Questions

1. What tenets of the ANA Code of Ethics for Nurses (2001) can be applied to this particular situation?

2. What would be your immediate response to the nurse in this situation? Provide a rationale. a. If you are the staff nurse originally assigned to care for the patient b. If you are the charge nurse c. If you are the supervisor or the nurse manager

3. Identify at least one potential source for pre-processed evidence such as a clinical guideline.

4. What strategies would you use to search for evidence related to best practices for suctioning and whether the instillation of saline while suctioning is an acceptable technique?

6. Identify a source for grading the level of evidence located.

7. What are potential barriers to the utilization of research findings in this setting? a. The research itself b. Clinician c. Organization d. Presentation

8. What are potential resources in your institution to help with the translation of research into practice?

9. Who are potential community partners to assist with addressing this clinical practice problem?

10. Assuming that you located evidence to support the position that instilling saline into an endotracheal tube is ineffective, what would be included in a plan to translate research into practice in the intensive care unit? In the rest of the hospital?

11. What strategies would you use to determine whether indeed nurses and other healthcare professionals are adhering to the recommended practices for endotracheal suctioning?

12. What would you do if you found contradictory evidence regarding the instillation of saline before endotracheal suctioning such as increased dyspnea with saline instillation, but lower rates of ventilator-associated pneumonia?

Answer 1

1. The tenets of ANA code of ethics for Nurses that can be applied here are :-

Advocacy to protect the health, safety, and rights of the patient.

Responsibility and accountability for individual nursing practice to provide optimum patient care.

Maintenance of personal integrity, safety, competence, and professional growth.

Establishment, maintenance, and improvement of healthcare environments and conditions of employment in order to provide quality care.

Advancement of the profession through various contributions.

Collaboration with other healthcare professionals.

2. The immediate response to the nurse in this situation :-

If I am the original nurse caring the patient - you must have asked me before instillation of normal saline for suctioning . Normal saline usage in suctioning is no more practiced .

If I am the charge nurse - I would have asked that whether it was written in prescription to use normal saline while suctioning .

If I am the supervisor - was there any written order for use of normal saline during suctioning .

The practice of instilling normal saline into an artificial airway to loosen and improve removal of secretions prior to suctioning is no longer a recommendation. There is no conclusive evidence that it facilitates the removal of secretions. Some research even indicates that instilling normal saline can introduce micro-organisms into the lower respiratory tract, thus increasing the risk of infection.

3. The most well known source for evidence-informed clinical practice guidelines is the National Guidelines Clearinghouse (NGC) http://guideline.gov.

4. 1) Formulate a clear review question

2) Search the literature for relevant clinical articles and evidence

3) Critically appraise the evidence

4) Implement the evidence

5) Evaluate the impact of the evidence