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2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

2011-03-26T23:07:00.000+07:00

Robert A. Berg, Chair; Robin Hemphill; Benjamin S. Abella; Tom P. Aufderheide; Diana M. Cave; Mary Fran Hazinski; E. Brooke Lerner; Thomas D. Rea; Michael R. Sayre; Robert A. Swor

Introduction

Basic life support (BLS) is the foundation for saving livesfollowing cardiac arrest. Fundamental aspects of BLS includeimmediate recognition of sudden cardiac arrest (SCA) and activationof the emergency response system, early cardiopulmonary resuscitation(CPR), and rapid defibrillation with an automated external defibrillator(AED). Initial recognition and response to heart attack andstroke are also considered part of BLS. This section presentsthe 2010 adult BLS guidelines for lay rescuers and healthcareproviders. Key changes and continued points of emphasis fromthe 2005 BLS Guidelines include the following:

Immediate recognitionof SCA based on assessing unresponsivenessand absence of normalbreathing (ie, the victim is not breathingor only gasping)
"Look, Listen, and Feel" removed from the BLS algorithm
EncouragingHands-Only (chest compression only) CPR (ie, continuouschestcompression over the middle of the chest) for the untrainedlay-rescuer
Sequence change to chest compressions before rescuebreaths(CAB rather than ABC)
Health care providers continueeffective chest compressions/CPRuntil return of spontaneouscirculation (ROSC) or terminationof resuscitative efforts
Increasedfocus on methods to ensure that high-quality CPR (compressionsof adequate rate and depth, allowing full chest recoil betweencompressions, minimizing interruptions in chest compressionsand avoiding excessive ventilation) is performed
Continuedde-emphasis on pulse check for health care providers
A simplifiedadult BLS algorithm is introduced with the revisedtraditionalalgorithm
Recommendation of a simultaneous, choreographedapproach forchest compressions, airway management, rescue breathing,rhythmdetection, and shocks (if appropriate) by an integratedteamof highly-trained rescuers in appropriate settings

Despite important advances in prevention, SCA continues to bea leading cause of death in many parts of the world. SCA hasmany etiologies (ie, cardiac or noncardiac causes), circumstances(eg, witnessed or unwitnessed), and settings (eg, out-of-hospitalor in-hospital). This heterogeneity suggests that a single approachto resuscitation is not practical, but a core set of actionsprovides a universal strategy for achieving successful resuscitation.These actions are termed the links in the "Chain of Survival."For adults they include

Immediate recognition of cardiac arrestand activation of theemergency response system
Early CPRthat emphasizes chest compressions
Rapid defibrillation ifindicated
Effective advanced life support
Integrated post–cardiacarrest care

When these links are implemented in an effective way, survivalrates can approach 50% following witnessed out-of-hospital ventricularfibrillation (VF) arrest. Unfortunately survival rates in manyout-of-hospital and in-hospital settings fall far short of thisfigure. For example, survival rates following cardiac arrestdue to VF vary from approximately 5% to 50% in both out-of-hospitaland in-hospital settings. This variation in outcome underscoresthe opportunity for improvement in many settings.

Recognition of cardiac arrest is not always straightforward,especially for laypersons. Any confusion on the part of a rescuercan result in a delay or failure to activate the emergency responsesystem or to start CPR. Precious time is lost if bystandersare too confused to act. Therefore, these adult BLS Guidelinesfocus on recognition of cardiac arrest with an appropriate setof rescuer actions. Once the lay bystander recognizes that thevictim is unresponsive, that bystander must immediately activate(or send someone to activate) the emergency response system.Once the healthcare provider recognizes that the victim is unresponsivewith no breathing or no normal breathing (ie, only gasping)the healthcare provider will activate the emergency responsesystem. After activation, rescuers should immediately beginCPR.

Early CPR can improve the likelihood of survival, and yet CPRis often not provided until the arrival of professional emergencyresponders. Chest compressions are an especially critical componentof CPR because perfusion during CPR depends on these compressions.Therefore, chest compressions should be the highest priorityand the initial action when starting CPR in the adult victimof sudden cardiac arrest. The phrase "push hard and push fast"emphasizes some of these critical components of chest compression.High-quality CPR is important not only at the onset but throughoutthe course of resuscitation. Defibrillation and advanced careshould be interfaced in a way that minimizes any interruptionin CPR.

Rapid defibrillation is a powerful predictor of successful resuscitationfollowing VF SCA. Efforts to reduce the interval from collapseto defibrillation can potentially improve survival in both out-of-hospitaland in-hospital settings. Depending on the setting and circumstances,earlier defibrillation may be achieved by a variety of strategiesthat include rescuers who are laypersons, nontraditional firstresponders, police, emergency medical services (EMS) professionals,and hospital professionals. One of these strategiesis the use of an AED. The AED correctly assesses heart rhythm,enabling a rescuer who is not trained in heart rhythm interpretationto accurately provide a potentially lifesaving shock to a victimof SCA.

Immediate recognition and activation, early CPR, and rapid defibrillation(when appropriate) are the first three BLS links in the adultChain of Survival. BLS care in the out-of-hospital setting isoften provided by laypersons who may be involved in a resuscitationattempt only once in their lives. Thus, creating an effectivestrategy to translate BLS skills to real-world circumstancespresents a challenge. This section updates the adult BLS guidelineswith the goal of incorporating new scientific information whileacknowledging the challenges of real-world application. Everyone,regardless of training or experience, can potentially be a lifesavingrescuer.

The rest of this chapter is organized in sections that addressthe emergency response system, adult BLS sequence, adult BLSskills, use of an AED, special resuscitation situations, andthe quality of BLS. The "Adult BLS Sequence" section providesan overview and an abridged version of the BLS sequence. The"Adult BLS Skills" section provides greater detail regardingindividual CPR skills and more information about Hands-Only(compression-only) CPR. The "Special Resuscitation Situations"section addresses acute coronary syndromes, stroke, hypothermia,and foreign body airway obstruction. Because of increasing interestin monitoring and ensuring the quality of CPR, the last sectionfocuses on the quality of BLS.

Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest

2011-03-26T22:23:00.002+07:00

A Science Advisory for the Public From the American Heart Association Emergency Cardiovascular Care Committee

Michael R. Sayre, MD; Robert A. Berg, MD, FAHA; Diana M. Cave, RN, MSN; Richard L. Page, MD, FAHA; Jerald Potts, PhD, FAHA; Roger D. White, MD

Key Words: AHA Scientific Statement • cardiopulmonary resuscitation • death, sudden • heart arrest • resuscitation

Introduction
Bystanders who witness the sudden collapse of an adult shouldactivate the emergency medical services (EMS) system and providehigh-quality chest compressions by pushing hard and fast inthe middle of the victim’s chest, with minimal interruptions.This recommendation is based on evaluation of recent scientificstudies and consensus of the American Heart Association EmergencyCardiovascular Care (ECC) Committee. This science advisory ispublished to amend and clarify the "2005 American Heart Association(AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) andEmergency Cardiovascular Care (ECC)" for bystanders who witnessan adult out-of-hospital sudden cardiac arrest.

Ten years ago, the AHA commissioned a working group of resuscitationscientists to reappraise the Association’s inclusion ofventilations in the recommended sequence for bystander cardiopulmonaryresuscitation (CPR). The working group evaluated peer-reviewedreports of laboratory and human research and summarized theirfindings in a 1997 statement. The key conclusion of that statementwas that "Current guidelines for performing mouth-to-mouth ventilationduring CPR should not be changed at this time."

In the animal studies cited in the 1997 statement, when ventricularfibrillation arrest was of short (under 6 minutes) duration,the addition of rescue ventilations to chest compressions didnot improve outcome compared with chest compressions alone (LOE6*). Analysis of human data from a national out-of-hospitalCPR registry documented no survival advantage to ventilationsplus compressions compared with the provision of chest compressionsalone during bystander resuscitation (LOE 4*). Althoughthese studies were not deemed sufficient to justify the eliminationof ventilations from the bystander CPR sequence, the 1997 statementstrongly encouraged further research that would focus on "...thetiming, rate, and depth [of ventilations] as well as conditionsunder which respiratory assistance should be used." The statementalso recommended "...more research on real-world obstacles tolearning, remembering, and actually performing CPR..." In addition,the statement contained a secondary conclusion that "...provisionof chest compression without mouth-to-mouth ventilation is farbetter than not attempting resuscitation at all."

The AHA’s recent Guidelines for CPR and ECC have reflectedthe primary and secondary conclusions of the 1997 statement:"Laypersons should be encouraged to do compression-only CPRif they are unable or unwilling to provide rescue breaths (ClassIIa), although the best method of CPR is compressions coordinatedwith ventilations." In addition, the Guidelines have recommendedcompression-only CPR for dispatcher-assisted instructions foruntrained bystanders."

The "2005 AHA Guidelines for CPR and ECC" noted the need toincrease the prevalence and quality of bystander CPR. The Guidelinesand training materials emphasized the importance of the deliveryof high-quality chest compressions, that is, compressions ofadequate rate and depth with full-chest recoil and minimal interruptions.To limit the frequency of interruptions, these Guidelines recommendedan increased compression-to-ventilation ratio of 30:2 for adultvictims. In addition, the AHA courses increased student practiceof high-quality chest compressions with interruptions (includinginterruptions to deliver rescue breaths) limited to 10 secondsor less.

The purpose of this science advisory is to clarify and elaborateon the "2005 AHA Guidelines for CPR and ECC," with a summaryof research published since 2005. In this advisory, the studiesthat were reviewed in preparation for the AHA’s 2000 and2005 CPR and ECC guidelines are denoted with an asterisk (*).The peer-reviewed studies that have been published since the"2005 AHA Guidelines for CPR and ECC" update are denoted bya double asterisk (**). This advisory uses the Level of Evidenceclassification scheme developed for the "2005 AHA Guidelinesfor CPR and ECC."

Efficacy of Treating Cardiac Arrest With Chest Compressions Alone

Animal Studies

In a porcine model of short-term cardiac arrest (3 minutes ofuntreated ventricular fibrillation arrest) comparison of chestcompressions to conventional CPR has yielded varying results.Dorph et al showed equivalent hemodynamics in the 2 groupsduring 10 minutes of CPR but reduced survival in the group thatdid not receive the rescue breaths (LOE 6*). Berg et al reportedreduced integrated coronary perfusion pressure and median leftventricular blood flow among those animals that received rescuebreaths during 12 minutes of high-quality 15:2 CPR but no differencein left ventricular myocardial oxygen delivery or 24-hour, neurologicallyintact survival between animals receiving chest compressionsalone and those receiving the conventional CPR (LOE 6*). Inanother swine study of simulated bystander CPR, Kern et aldemonstrated that 6 minutes of chest compressions alone witha clamped endotracheal tube resulted in equivalent 24-hour survivaland good neurological outcomes compared with standard CPR (LOE6*). Two animal studies mimicking single-rescuer bystanderCPR (using a 15:2 compression:ventilation ratio with 16-secondpauses in compressions to provide 2 rescue breaths in 1 studyand 30:2 in the other) have demonstrated better outcomes withcontinuous compressions compared with conventional CPR (LOE6*, **).

It is important to acknowledge that during cardiac arrest withoutlung inflation and ventilation, there is a continuous decrementof blood oxygen saturation. At some point in time, the possiblehemodynamic advantage conferred by continuous chest compressions(without ventilations) will be offset by this reduction in oxygensaturation, and the ultimate result will be a compromise inoxygen delivery. One porcine cardiac arrest study (3 minutesof untreated ventricular fibrillation, then 12 minutes of CPR)suggests that after 4 minutes of continuous chest compressionswithout rescue breathing, the delivery of 2 rescue breaths every100 compressions provides a survival advantage over chest compressionsalone (LOE 6*).

Animal studies mimicking bystander CPR with good qualitycompressions for asphyxia-precipitated cardiac arrests demonstratedthat the addition of rescue breathing to compressions resultsin much better outcomes than chest compressions alone (LOE 6*).Chest compressions alone, however, were superior to no CPR atall, even with asphyxia-precipitated cardiac arrest. These studiessupport the need for rescue breathing as a critical componentof CPR for asphyxia-precipitated cardiac arrests, such as thoseassociated with drowning, trauma, airway obstruction, acuterespiratory diseases and apnea (eg, with drug overdoses), pediatricarrests, and prolonged cardiac arrest.

Human Clinical Experience

Since the 1997 AHA ventilation statement, there have been 5key human studies comparing the efficacy of bystander compression-onlyCPR with conventional CPR. These studies are consistentwith the animal data and the human registry data cited previously.

In 2000, Hallstrom et al demonstrated equivalent survivalto hospital discharge in out-of-hospital cardiac arrest victimswho were randomized to receive dispatcher-assisted bystanderCPR instructions for compressions only or compressions and mouth-to-mouthventilations (LOE 2). Waalewijn et al reported that the provisionof chest compressions alone did not have a negative influenceon survival to hospital discharge, compared with conventionalCPR (LOE 3*).

Three nonrandomized observational studies of human bystanderCPR were published in 2007, and none of these 3 studies demonstratedany negative impact on survival when ventilations were omittedfrom the bystander sequence. Using the important end point of30-day survival with favorable neurological outcome, it wasreported that survival after bystander chest compressionsonly did not differ from survival after conventional bystanderCPR for adult patients with witnessed out-of-hospital cardiacarrests from both "cardiac" and "noncardiac" causes (LOE 4**).Iwami et al reported no difference in 1-year neurologicallyintact survival between victims of witnessed cardiac arrestof presumed cardiac etiology who received bystander compressionsonly and those who received conventional CPR (LOE 4**). Bohmet al also studied 1-month survival from a registry of alladult victims of out-of-hospital cardiac arrest who receivedbystander CPR and found no statistically significant differencebetween victims that received chest compressions alone and thosethat received conventional CPR (LOE 4**). These studies couldnot assess or control for the quality of bystander CPR delivered,and all bystanders were likely trained according to the recommendationspublished before the "2005 International Consensus on CardiopulmonaryResuscitation and Emergency Cardiovascular Care Science withTreatment Recommendations" or the "2005 AHA Guidelines forCPR and ECC." These 2005 publications emphasized the deliveryof more effective chest compressions with minimal interruptions.

Lay Responder Performance

Hands-only (compression-only) bystander CPR may reduce the timeto initiation of CPR and result in delivery of a greater numberof chest compressions with fewer interruptions for the firstseveral minutes after adult out-of-hospital cardiac arrest.Several human studies suggest that trained rescuers performingtraditional 1-person CPR take much longer to initiate CPR thanthose trained to perform hands-only CPR. This can be explainedby the additional cognitive or emotional burdens associatedwith attempting the more complex psychomotor task of traditionalCPR (LOE 6*).

Studies of basic life support providers trained beforethe "2005 AHA Guidelines for CPR and ECC" showed that lay rescuersand healthcare providers who performed conventional CPR interruptedchest compressions for much longer than recommended (16±1seconds and 10±1 seconds, respectively) to provide ventilationsand delivered significantly fewer compressions over time thanrescuers performing continuous chest compressions (LOE 6*, **).In 1 study, there was more "decay" in posttraining performanceover time (18 months) among those trained in conventional CPRthan among rescuers trained in chest compressions only (LOE6*). However, the ability of bystanders to deliver adequaterate and depth of continuous chest compressions for prolongeddurations is unknown and requires further study.

Reducing Barriers to Bystander Action

Although bystander CPR can more than double survival from cardiacarrest, the reported prevalence of bystander CPRremains low in most cities, about 27% to 33%.Reducing barriers to bystander action can be expected to substantiallyimprove cardiac arrest survival rates. Reasons cited prospectivelyfor the reluctance to perform CPR often include concerns aboutdisease transmission related to performing mouth-to-mouth ventilation.In a study of actual bystanders, Swor et al reported thatCPR-trained bystanders at the scene of out-of-hospital cardiacarrests most often cited panic and fear of causing harm as reasonsfor failing to perform CPR; only 1.4% expressed reluctance toperform mouth-to-mouth ventilation, and none cited fear of infection(LOE 3**). Hauff et al also found that fear of infectiousdisease was not a prominent concern or obstacle when bystanderCPR instructions were provided by a dispatcher (LOE 4*).

Eliminating the expectation of mouth-to-mouth contact duringCPR is likely to improve esthetics and address the expressedconcern of potential bystanders about infection. SimplifyingCPR training also improves trainees’ ability to learnand perform, among other things, proper chest compressions (LOE6**). Finally, eliminating ventilation instructions in dispatcher-assistedCPR reduces the time required to commence compressions, as observedin simulated (LOE 6*,**) and actual out-of-hospital resuscitations(LOE 2*).

Who Should Receive Hands-Only CPR From Bystanders?

The AHA ECC Committee has carefully considered the relativelylow prevalence of bystander CPR and the potential that furthersimplification of CPR instructions might encourage more bystandersto take appropriate action. Furthermore, the Committee has concludedthat adult victims of out-of-hospital cardiac arrest who receivebystander hands-only (compression-only) CPR or conventionalCPR have a similar chance of survival. Thus, bystanders canuse either hands-only CPR or conventional CPR to achieve thegoal of providing effective chest compressions (of adequaterate and depth with minimal interruptions) to adult victimsof out-of-hospital sudden cardiac arrest. This "call to action"for bystanders does NOT apply to unwitnessed cardiac arrest,cardiac arrest in children, or cardiac arrest presumed to beof noncardiac origin.

The AHA ECC Committee acknowledges that all victims of cardiacarrest will benefit from delivery of high-quality chest compressions(compressions of adequate rate and depth with minimal interruptions)but that some cardiac arrest victims (eg, pediatric victimsand victims of drowning, trauma, airway obstruction, acute respiratorydiseases, and apnea [such as that associated with drug overdose])may benefit from additional interventions taught in a conventionalCPR course. Therefore, the Committee continues to encouragethe public to obtain training in CPR to learn the psychomotorskills required to care for a wide range of cardiovascular-and respiratory-related medical emergencies.

Limitations and Cautions

During the discussions and review of this science advisory,some experts raised concerns about basing recommendations onanimal studies and limited nonrandomized observational humanstudies. They also raised concerns about the possibility thatrecommending hands-only CPR for witnessed sudden cardiac arrestwill, in fact, increase the complexity of decision-making forbystanders or that unresponsive victims of noncardiac medicalemergencies (eg, drowning, drug overdose) will not receive rescuebreathing. The Committee acknowledges those views but considersthe hands-only CPR recommendation to be sufficiently focusedon a specific, easily identified patient population and bystandergroup. In addition, the Committee thinks that this clarificationis likely to increase the incidence of bystander action. Inthe studies of bystander CPR cited in this advisory, hands-only(compression-only) CPR was better than no attempt at CPR andproduced survival equivalent to conventional CPR.

Many questions remain unanswered. The ECC Committee acknowledgesimportant limitations in issuing these recommendations and thecall to action. These recommendations are based on the bestavailable evidence, but this evidence is far from complete.Although we believe that making CPR easier to perform will increasethe overall performance of CPR by bystanders, this remains unprovenin clinical trials. There may be situations in which ventilationalone could be life-saving but is not provided. There may bean interval after cardiac arrest when ventilations become absolutelycritical for survival. There could be confusion on the partof bystanders who have been previously trained in conventionalCPR. The impact of implementing these recommendations for adultvictims could adversely affect some pediatric victims (if incorrectlyapplied) or other victims of asphyxial arrest. New teachingmethods may emerge that improve the ability of bystanders tolearn and perform effective compressions and ventilations duringconventional CPR. After careful consideration, weighing allthe known evidence, and considering the many unanswered questions,the ECC Committee held that the likely advantages in favor ofthis recommendation outweigh the possible disadvantages.

Recommendations and Call to Action

All victims of cardiac arrest should receive, at a minimum,high-quality chest compressions (ie, chest compressions of adequaterate and depth with minimal interruptions). To support thatgoal and save more lives, the AHA ECC Committee recommends thefollowing.

When an adult suddenly collapses, trained or untrained bystandersshould—at a minimum—activate their community emergencymedical response system (eg, call 911) and provide high-qualitychest compressions by pushing hard and fast in the center ofthe chest, minimizing interruptions (Class I).

If a bystander is not trained in CPR, then the bystander shouldprovide hands-only CPR (Class IIa). The rescuer should continuehands-only CPR until an automated external defibrillator arrivesand is ready for use or EMS providers take over care of thevictim.
If a bystander was previously trained in CPR and isconfidentin his or her ability to provide rescue breaths withminimalinterruptions in chest compressions, then the bystandershouldprovide either conventional CPR using a 30:2 compression-to-ventilationratio (Class IIa) or hands-only CPR (Class IIa). The rescuershould continue CPR until an automated external defibrillatorarrives and is ready for use or EMS providers take over careof the victim.
If the bystander was previously trained inCPR but is not confidentin his or her ability to provide conventionalCPR includinghigh-quality chest compressions (ie, compressionsof adequaterate and depth with minimal interruptions) withrescue breaths,then the bystander should give hands-only CPR(Class IIa). Therescuer should continue hands-only CPR untilan automated externaldefibrillator arrives and is ready foruse or EMS providerstake over the care of the victim.

The ECC Committee strongly recommends that the AHA and otherresearch funding organizations (eg, the National Institutesof Health) act aggressively in the public’s interest tofund research that will answer the important unanswered questionscited in this advisory. Only with new research and additionalevidence will future guidelines be able to recommend optimalmethods for bystander CPR. Funding to conduct this high-impactresearch that directly affects so many lives should be prioritized.

The scope of this recommendation is limited to a "call to action"for bystanders as they care for an adult who has experienceda witnessed, out-of-hospital cardiac arrest of probable cardiacorigin (eg, sudden collapse or collapse after signs consistentwith a myocardial infarction). As such, it is meant to clarifythe "2005 AHA Guidelines for CPR and ECC" on this topic. Thescience volunteers of the ECC Committee and the Basic Life SupportSubcommittee continue to participate in the internationallybased evaluation of resuscitation science spon-sored by theInternational Liaison Committee on Resuscitation (ILCOR) andthe AHA. As a part of both the ILCOR evaluation and ongoingAHA activities, ECC Committee members and Basic Life SupportSubcommittee members will continue to monitor and evaluate peer-reviewedstudies related to lay rescuer and healthcare provider resuscitationattempts for victims of all causes of cardiac arrest.

Chest Compression Rates During Cardiopulmonary Resuscitation Are Suboptimal

2011-03-26T22:02:00.001+07:00

A Prospective Study During In-Hospital Cardiac Arrest

Benjamin S. Abella, MD, MPhil; Nathan Sandbo, MD; Peter Vassilatos, MS; Jason P. Alvarado, BA; Nicholas O’Hearn, RN, MSN; Herbert N. Wigder, MD; Paul Hoffman, CRT; Kathleen Tynus, MD; Terry L. Vanden Hoek, MD; Lance B. Becker, MD

From the Emergency Resuscitation Center and Section of Emergency Medicine (B.S.A., J.P.A., T.L.V.H., L.B.B.), Section of Pulmonary and Critical Care (N.S.), and Department of Critical Care (N.O.), University of Chicago Hospitals, Chicago, Ill; Department of Computer Science (P.V.), University of Chicago, Chicago, Ill; Department of Emergency Medicine (H.N.W.) and Respiratory Care Services (P.H.), Advocate Lutheran General Hospital, Park Ridge, Ill; and Department of Internal Medicine (K.T.), MacNeal Hospital, Berwyn, Ill.

Correspondence to Dr L.B. Becker, University of Chicago Hospitals, Section of Emergency Medicine, 5841 S Maryland Ave, MC 5068, Chicago, IL 60637. E-mail lbecker@medicine.bsd.uchicago.edu

Received June 23, 2004; revision received October 8, 2004; accepted October 22, 2004.

Abstract
Background— Recent data highlight a vital link betweenwell-performed cardiopulmonary resuscitation (CPR) and survivalafter cardiac arrest; however, the quality of CPR as actuallyperformed by trained healthcare providers is largely unknown.We sought to measure in-hospital chest compression rates andto determine compliance with published international guidelines.

Methods and Results— We developed and validated a handheldrecording device to measure chest compression rate as a surrogatefor CPR quality. A prospective observational study of adultcardiac arrests was performed at 3 hospitals from April 2002to October 2003. Resuscitations were witnessed by trained observersusing a customized personal digital assistant programmed tostore the exact time of each chest compression, allowing offlinecalculation of compression rates at serial time points. In 97arrests, data from 813 minutes during which chest compressionswere delivered were analyzed in 30-second time segments. In36.9% of the total number of segments, compression rates were<80 compressions per minute (cpm), and 21.7% had rates <70cpm. Higher chest compression rates were significantly correlatedwith initial return of spontaneous circulation (mean chest compressionrates for initial survivors and nonsurvivors, 90±17 and79±18 cpm, respectively; P=0.0033).

Conclusions— In-hospital chest compression rates werebelow published resuscitation recommendations, and suboptimalcompression rates in our study correlated with poor return ofspontaneous circulation. CPR quality is likely a critical determinantof survival after cardiac arrest, suggesting the need for routinemeasurement, monitoring, and feedback systems during actualresuscitation.

Key Words: cardiopulmonary resuscitation • death, sudden • heart arrest

Chest Compression Fraction Determines Survival in Patients With Out-of-Hospital Ventricular Fibrillation

2011-03-26T22:01:00.001+07:00

Jim Christenson, MD; Douglas Andrusiek, MSc; Siobhan Everson-Stewart, MS; Peter Kudenchuk, MD; David Hostler, PhD; Judy Powell, BSN; Clifton W. Callaway, MD, PhD; Dan Bishop; Christian Vaillancourt, MD, MSc; Dan Davis, MD; Tom P. Aufderheide, MD; Ahamed Idris, MD; John A. Stouffer; Ian Stiell, MD, MSc; Robert Berg, MD; the Resuscitation Outcomes Consortium Investigators

From the University of British Columbia (J.C., D.A.), Vancouver, British Columbia, Canada; Emergency and Health Services Commission of British Columbia (J.C., D.A., D.B.), Vancouver, British Columbia; University of Washington (S.E.-S., P.K., J.P.), Seattle, Wash; University of Pittsburgh (D.H., C.W.C.), Pittsburgh, Pa; Department of Emergency Medicine (C.V., I.S.), University of Ottawa, Ottawa, Ontario, Canada; University of California at San Diego (D.D.); Medical College of Wisconsin (T.P.A.), Milwaukee, Wis; University of Texas Southwestern Medical Center at Dallas (A.I.); Central Washington University (J.A.S.), Ellensburg, Wash; and University of Arizona (R.B.), Tucson, Ariz.

Correspondence to Dug Andrusiek, MSc, Emergency and Health Services Commission of British Columbia, 302–2955 Virtual Way, Vancouver, British Columbia, Canada V5M 4X6. E-mail dug.andrusiek@gov.bc.ca

Received January 23, 2009; accepted July 10, 2009.

Abstract

Background— Quality cardiopulmonary resuscitation contributesto cardiac arrest survival. The proportion of time in whichchest compressions are performed in each minute of cardiopulmonaryresuscitation is an important modifiable aspect of quality cardiopulmonaryresuscitation. We sought to estimate the effect of an increasingproportion of time spent performing chest compressions duringcardiac arrest on survival to hospital discharge in patientswith out-of-hospital ventricular fibrillation or pulseless ventriculartachycardia.

Methods and Results— This is a prospective observationalcohort study of adult patients from the Resuscitation OutcomesConsortium Cardiac Arrest Epistry with confirmed ventricularfibrillation or ventricular tachycardia, no defibrillation beforeemergency medical services arrival, electronically recordedcardiopulmonary resuscitation before the first shock, and aconfirmed outcome. Patients were followed up to discharge fromthe hospital or death. Of the 506 cases, the mean age was 64years, 80% were male, 71% were witnessed by a bystander, 51%received bystander cardiopulmonary resuscitation, 34% occurredin a public location, and 23% survived. After adjustment forage, gender, location, bystander cardiopulmonary resuscitation,bystander witness status, and response time, the odds ratiosof surviving to hospital discharge in the 2 highest categoriesof chest compression fraction compared with the reference categorywere 3.01 (95% confidence interval 1.37 to 6.58) and 2.33 (95%confidence interval 0.96 to 5.63). The estimated adjusted lineareffect on odds ratio of survival for a 10% change in chest compressionfraction was 1.11 (95% confidence interval 1.01 to 1.21).

Conclusions— An increased chest compression fraction isindependently predictive of better survival in patients whoexperience a prehospital ventricular fibrillation/tachycardiacardiac arrest.

Key Words: heart arrest • cardiopulmonary resuscitation • fibrillation • survival

Pulmonary Arterial Hypertension

2011-03-20T06:07:00.000+07:00

For most patients in early stages of pulmonary arterial hypertension, the use of bosentan (Tracleer) seems able to inhibit the development of worsening symptoms of pulmonary arterial hypertension, the researchers said.

"Our experimental results confirm the first diagnosis and early treatment of pulmonary arterial hypertension have an impact on the outcome such as clinical deterioration, even for patients with pulmonary arterial hypertension who currently suffering from symptoms of being," said Nazzareno Galie Kardialog, MD, of University of Bologna in Italy.

Approximately 100.0000 patients in the United States who suffer from pulmonary arterial hypertension that increased right heart pressure, causing enlargement and eventually heart failure.

Dr. Galie and colleagues recruited 185 patients with pulmonary arterial hypertension, aged 12 years and more, into the endothelin antagonist Trial in Mildly symptomatic patients. They set in 1993 granted with bosentan 62.5 mg twice daily for four weeks and then 125 mg twice daily after one month during the study. 92 patients pulmonary arterial hypertension were given placebo.

For determine a decrease of conditions, patients pulmonary arterial hypertension are given values according to the level of lung vascular resistance at the beginning of the experiment and at the end of the study. Among patients with pulmonary arterial hypertension using bosentan, resistance decreased to 33.5%, while resistance decreased 10% occur among patients pulmonary arterial hypertension who received placebo.

He said with bosentan dose of 2 mg / kg and 4 mg / kg for children aged two to 11 can survive well in 36 children with pulmonary arterial hypertension in the study.

"This study is a continuation of the important developments in the field," commented Daniel Jones, MD, dean of the faculty of medicine University of Mississippi in Jackson, and president of the American Heart Association. New drugs such as bosentan has improved dramatically in patients with pulmonary arterial hypertension.

The References :

1. www.topnews.in

2. www.jdokter.com

Hypertension Treatment

2011-03-20T02:27:00.004+07:00

For hypertension treatment, the following practical suggestions can you do

Reduce consumption of salt in your food. If you already suffer from high blood pressure you should avoid foods that contain salt for hypertension treatment.
Consumption of foods containing potassium, magnesium and calcium. Potassium, magnesium and calcium can reduce high blood pressure.
Reduce drinking alcoholic beverages or food. If you suffer from high blood pressure, should avoid excessive alcohol consumption for hypertension treatment.
Regular exercise can reduce high blood pressure. If you suffer from high blood pressure, choose light exercise such as walking, cycling, running relaxed, and swimming. Do it for 30 to 45 minutes a day 3 times a week for hypertension treatment.
Eat vegetables and fruits are high in fiber such as leafy green vegetables, bananas, tomatoes, carrots, melons, and oranges for hypertension treatment.
Run anti-stress therapy for reducing stress and you are able to control your emotions.
Quitting smoking also plays a major role to reduce high blood pressure or hypertension.
Control your cholesterol levels.
Take control of your diabetes for hypertension treatment.
Avoid drugs that can increase blood pressure for hypertension treatment. Consult your doctor if you are receiving treatment for certain diseases, to ask for drugs that do not increase blood pressure.

The References :

1. www.kumpulan.info

2. www.princeshand.blogspot.com

Pulmonary Hypertension

2011-03-20T01:47:00.003+07:00

Pulmonary hypertension is a fatal disease that attacks many people at the productive age.Pulmonary hypertension incidence in women is two and a half times more than men.Pulmonary hypertension derived or associated with genetic factors .Estimated one to two million people per year diagnosed pulmonary hypertension.In Indonesia and Asia Pacific, people with pulmonary hypertension under-diagnosed and less treatment due to lack of patient awareness of pulmonary hypertension.

More over many sufferers are not aware that he had pulmonary hypertension.If pulmonary hypertension and left untreated, life expectancy is usually less than three years.Majority a sufferer pulmonary hypertension is the productive age between 20 to 40 years.

As technology advances, treatment with inhaled claimed as the only treatment that works selectively in the lungs that can increase life expectancy and eliminate the symptoms and side effects of pulmonary hypertension.Iloprost which is a type of inhaled drug for pulmonary hypertension that has been ratified.It works almost the same as prostaglandins, which opens blood vessels in the lungs to improve blood flow to vital organs, so that breathing becomes more relieved because more oxygen to flow to the heart and other organs.

The References :
1. www.katrinatribute.info
2. www.hanyawanita.com

Nursing Diagnosis in Education

2011-03-13T22:33:00.000+07:00

The use of nursing diagnoses is central to nursing education. The assessment and diagnosis of individuals, families, and communities teach students hypothetical reasoning and critical thinking. Further, those who come to nurses for assistance expect the achievement of improved health outcomes for which nurses are increasingly held accountable. Outcomes and the selection of interventions rest on accurate and valid nursing diagnoses.

Teaching nursing students to use nursing diagnoses begins with assessment and history-taking. As students assess and collect data (information) about individuals, families, and communities, they are identifying the “signs and symptoms” or defining characteristics of the nursing diagnosis concepts. The factors or variables influencing diagnoses are integrated with the history, charts, and other evidence. These variables provide the context, the “related factors”, that are combined with the defining characteristics to make nursing diagnoses. When possible, nurses treat related factors with interventions to prevent or reduce their impact. When it is not possible for nurses to treat a related factor, they treat the defining characteristics with selected nursing interventions.

Assessment and Identifying Defining Characteristics

The defining characteristics are those characteristics in individuals, families, and communities that are observable and verifiable. They serve as cues or inferences that cluster as manifestations of an actual illness or wellness health state, or nursing diagnosis. Suppose, for example, that an individual (Sarah) states to nursing student that she is “sick to my stomach” and asks for emesis basin. The nursing student further observes that Sarah is swallowing a great deal and gagging. These defining characteristics are suggestive of the nursing diagnoses Nausea.

History and Identifying Related Factors

The related factors provide the context for the defining characteristics. Related factors are factors that appear to show some type of patterned relationship with the nursing diagnosis. These factors may be described as antecedent to, associated with, related to, contributing to, or abetting the diagnosis. They are identified as characteristics or history of individuals, families, and communities. In the case of Sarah, she may tell us that she is taking large doses of aspirin on the advice of her physician, and that she takes the aspirin on an empty stomach. In this case students can establish an outcome of “freedom from nausea” and use the NIC nursing intervention of “Nausea Management” (Dochterman and Bulechek, 2004) especially the activity of “Reduce or eliminate personal factors that precipitate or increase the nausea (taking aspirin on an empty stomach)”.

Selecting the Nursing Diagnosis Label

The nursing diagnosis label is selected based on two characteristics. First, the definition of the diagnosis label should convey a combination of the defining characteristics and related factors. Second, the diagnosis selected is the term with defining characteristics and related factors that fits the data that students collect on assessment and history-taking. In this case the definition of Nausea is “A subjective unpleasant, wave-like sensation in the back of the throat, epigastrium, or abdomen that may lead to the urge or need to vomit”. In the example, Sarah stated that she is “sick to my stomach” and exhibited other defining characteristics. Her history provided an antecedent of nausea – the ingestion of large doses of aspirin on an empty stomach.

Risk Diagnoses

Nurses have always been responsible for identifying individuals, families, and communities at risk and protecting them from this risk. A risk diagnosis “describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability”. For example, the diagnosis of Risk for Impaired Skin Integrity includes both internal and external factors that influence vulnerability. The interventions that a nurse selects to reach the out comes are based on these influencing factors.

Health-Promotion Diagnoses

A health-promotion diagnosis is a clinical judgment of a person’s, family’s, or community’s motivation and desire to increase well-being and actualize human health potential as expressed by a readiness to enhance specific health behaviors such as nutrition and exercise. Health-promotion diagnoses can be used in any health state and do not required current levels of wellness. This readiness is supported by defining characteristics. Interventions are selected in concert with the individual/family/community to best ensure the ability to reach the stated outcomes.

Wellness Diagnoses

A wellness diagnosis describes human responses to levels of wellness in individual, family, or community that have a readiness for enhancement. This readiness is supported by defining characteristics. As with all diagnoses, nurse-sensitive (sensitive to nursing interventions) outcomes are identified and nursing interventions are selected that provide a high likelihood of reaching the outcomes.

Prioritizing Diagnoses

Prioritizing diagnoses is one type of critical thinking that most nursing educators expect from students. Faculty members often request a list of nursing diagnoses from students. Students compile this list while they are reading the history of individuals, families, and communities. After assessment, the students need to make decisions about prioritizing diagnoses. Priorities are established based on the needs of individuals, families, and communities. When nursing students are assigned to clinical experience for a short period of time, faculty members may ask them to choose nursing diagnoses that they can address during this time frame.

Linking Nursing Diagnoses to Outcomes and Interventions

Accurate and valid nursing diagnoses determine the nurse-sensitive outcomes. These outcomes guide the selection of interventions that are likely to produce the desired treatment effects. Again, interventions will treat either related factors (or risk factors) or defining characteristics. Faculty members and their students can use the linkage book (Johnson et al., 2006) or the linkages to nursing diagnoses provided in the back of the NIC (Dochterman and Bulechek, 2004) and NOC (Moorhead et al., 2004) books. These lingkages

Martha Craft-Rosenberg, PhD, RN, FAAN and
Kelly Smith, MSN, RN

NURSING DIAGNOSES

Definitions and Classification 2009-2011

Validating Diagnoses

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As human behavior is complex and nurses cannot truly “know” what other people are experiencing (Munhall, 1993), it is important for nurses’ thinking and technical processes to be accompanied by collaborative processes with consumers and the other providers. In most instances, nurses should decide on diagnoses with health care consumers; a nurse may say, “From the information you have just given me, it seems that you are experiencing Fear associated with surgery. Is that correct?” Based on the patient’s response, the nurse validates or rejects the diagnosis. In cases when patients are unable to collaborate with nurses because they are too sick, developmentally unable, or mentally incompetent, nurse can validate diagnoses with family members or other providers; a nurse may say, “From the information you have given me about your son, it seems that he having difficulty coping with the stress of the illness. Is that correct?” To validate with another provider, a nurse may say, “From my physical examination, I concluded that Mary’s airway clearance is impaired. Do you agree?” Validation of diagnoses with others helps to ensure the accuracy of diagnoses as the bases for subsequent stages of the nursing process. To save the time, energy, and costs associated with interventions for diagnoses, diagnoses should be validated as highly accurate.

Comparing Cues to Possible Diagnoses

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Cues are analyzed in relation to possible diagnoses through a mental process of evaluation. Evaluation involves a process of mental matching wherein the existing cues are matched with the expected cues for the diagnoses being considered. Information about the expected cues for diagnoses is found in this book and current literature on specific phenomena such as pain, coping, and fluid volume. During the evaluation of cues and related diagnoses, nurses may decide that there is not enough evidence to make diagnostic decision or that there is enough evidence for one likely diagnosis. If a nurse decides that there are not enough data to make a diagnosis, the next step involves a focused search for additional cues. If a nurse decides that there is enough supporting evidence, a diagnosis is made and then validate.

Conducting a Focused Data Collection

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To confirm or rule out diagnoses that are under consideration, additional cues may be collected by focusing questions to obtain data for one or more diagnoses. With the preoperative patient mentioned above, for example, the nurse might ask the patient how she feels about the surgical procedure. The answer to a broad question such as this can yield data to support many possible diagnoses in the psychosocial realm. If the patient mentions fear of death or fear of the unknown in relation to the surgery, the nurse can begin to confirm fear as the diagnosis and eliminate some of the other possibilities such as anxiety. When the nurse conducts a medical history and physical examination, biological reasons for the fast rate of breathing can also be confirmed or ruled out. A focused data collection concludes when the nurse synthesizes available data and selects one or more of the diagnoses being considered, rules out all of the diagnoses being considered, or revises the diagnoses being considered to incorporate new ones. If a diagnosis under consideration is supported through focused data collection, the next step is to validate the diagnosis. If all of the diagnoses are ruled out or not confirmed, new diagnoses are considered or the nurse concludes that there is no diagnosis. If new diagnoses are considered, a focused data collection continues until the revised set of diagnoses are confirmed or ruled out through supporting evidence (cues).

Mentally Generating Possible Diagnoses

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The meaning that nurses assign to cues noticed early in the diagnostic process can be understood only if there are possible and plausible explanations for the cues within the context of the situation. This is an active thinking process whereby the nurse explores knowledge in memory for possible explanations of data. Often, there are many possible diagnoses or explanations that may be considered. Sometimes, there is only one plausible meaning of cues noticed early in the diagnostic process, for example, if a woman who is newly admitted to a hospital unit for a surgical procedure is rapidly asking the nurse many questions, and exhibits a fast rate of breathing, the cues are not specific enough to consider only one possible diagnosis. The nurse in this instance would consider a number of possible explanations for this set of cues such as fear, anxiety, ineffective breathing pattern, and other. A nurse diagnostician avoids deciding on a diagnosis prematurely: before sufficient data to support a diagnostic judgment. Flexibility of thinking enables nurses to make a broad search of the mind for possible diagnoses. Logical reasoning in collaboration with the patient enables nurses to drive the most accurate diagnosis when the data are sufficient to do so.

Recognizing the Existence of Cues

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Nurses mentally recognize cues early in the diagnostic process and continue to integrate cue recognition throughout the process. Cues are until of data, (e.g., a person’s rate of breathing), which a nurse collects during intentional or unintentional assessment. Intentional assessment involves deliberate collection of data as a foundation for nursing actions. Unintentional assessment involves noticing cues that are important without planning to do so. In clinical situations, nurses notice cues to diagnoses by thinking about what they see, hear, smell, touch, and taste. Information pertaining to the health care consumer is thought about in relation to the nurse’s knowledge of the health state or life situation of the consumer. Nurses attend to information based on established ideas of what should occur in various situations. A nurse may not notice a person’s rate of breathing, for example, unless it looks unusual in the context of a health problem (e.g., the individual is one day post-abdominal surgery), or other aspects of the clinical situation (e.g., the individual has just completed vigorous exercise). A nurse’s recognition of a unit of data as a cue with special meaning is dependent on knowledge stored in memory. Knowledge bases in memory are used for comparison of current data with expected data.

Diagnostic Reasoning Associated with Nursing Assessment

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Principles should include:

Diagnostic hypotheses are considered throughout the assessment process and are used along with the formal assessment guide to generate the data needed for diagnoses.
In a comprehensive assessment, diagnoses are not finalized until completion of the assessment. Assessment of each pattern informs the nurse and patient about the diagnostic hypotheses.
When possible, the individual, family or community is involved from start to finish with the assessment and diagnostic processes.

Assessment Framework

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For nursing, assessment frameworks need to be broad enough to yield data to guide nursing care for health promotion, health protection (primary, secondary, and tertiary prevention), and health restoration. “Health promotion is directed toward increasing the level of well being or self actualization of a given individual or group. Health promotion focuses on efforts to approach or move toward a positive balanced state of high level health and well being” (Pander et al., 2006). An example of health promotion diagnosis is Readiness for Enhanced Sleep. Health protection is a process of helping people to reduce risks to health and protect themselves from existing risk states (Pander et al., 2006). An example of health protection diagnosis is Risk for Infection. Health restoration, also referred to as illness management, is a process of helping people to manage health problems. The actual nursing diagnoses such as Pain, Anxiety, Fear, and Ineffective Self Health management are examples of diagnoses in the realm of health restoration.

A nursing assessment framework that is widely used to generate accurate nursing diagnoses is the functional health pattern framework (Gordon, 2007). This framework includes 11 patterns of individuals, families, or communities.

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Assessment, Clinical Judgment, and Nursing Diagnoses

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Diagnostic Reasoning Associated with Nursing assessment

Recognizing the Existence of Cues

Mentally Generating Possible Diagnoses

Comparing Cues to Possible Diagnoses

Conducting a Focused Data Collection

Assessment and Nursing Diagnosis

2011-02-24T17:15:00.001+07:00

Nursing assessment at all levels of analysis (individuals, families and communities), consist of subjective data from the person or persons and objective data from diagnostic tests and other sources. Assessments of individuals consists of a health history (subjective data) and a physical axamination (objective data) (Weber and Kelly, 2007). Assessments of families consist of obtaining specific information from the family (subjective data) and observing family interaction (objective data) (Wright and Leahey, 2005). Assessment of communities consist of obtaining information from key informans within the community (subjective data) and statistical data (objective data) (Anderson and McFarland, 2006).

There are two types of assessment that are done to generate accurate nursing diagnoses: comprehensive and focused. Comprehensive assessment cover all aspects of a nursing assessment fremework such as the 11 functional health patterns to determine the health status of the individual, family, or community. Comprehensive assessment of individuals are done, for example, when admitting patient to a hospital or home care services. Focused assessments focus on a particular issue or concern, such as pain, sleep, or respiratory status. Focused assessments are done when specific symptoms need to be explored further, e.g., a person says “I am having difficulty with breathing”, or something generates increased risk of a particular problem, e.g., when a person needs the medication of coumadin, there is increased risk of bleeding.

The goals for a nursing assessment are that:

It focuses on the data needed to identify human responses and experiences
It is conducted in partnership with the idividual, family or community, wherever possible
The findings are based on reseach and other evidence.

Personal Strengths: Tolerance for Ambiguity and Reflective Practice

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The personal strengths of tolerance for ambiguity and reflective practice need to be developed because decisions are so complex in nursing and the use of clinical judgment needs to be an ongoing learning process. Each decision that a nurse makes is relatives to the context of the situation and to the specific nature of the individual, family or community with whom they are working. With experience, nurses become familiar with many types of contextual situations that can positively influence diagnostic abilities. Tolerance for ambiguity and reflective practice enable nurses to incorporate these contextual experiences to advance their professional development from novice to expert (Benner 1984; Benner et al., 1996).

Tolerance for Ambiguity

Tolerance for ambiguity is needed because there are numerous factors that influence clinical situations such as agency policies, the nurse’s job description, and the availability of resources. Tolerance for ambiguity enables nurses to consider the broad range of influencing factors within the diagnostic process and be able to focus on the most accurate diagnoses for quality-based services to individuals, families and communities.

In addition, the human beings for whom nurses provide care are extremely complex and diverse, especially when the focus is the person’s response or experience and not the illness itself. Thus, ambiguity is expected, so nurses need to adjust to the ambiguity. Nurse leaders and teachers can help by pointing out the ambiguity, treating it as a fact of life as a nurse, and being role models for tolerance for ambiguity.

Reflective Practice

Reflective practice is the ability to introspectively examine our own behaviors in relation to thinking, interpersonal events, and technical skills. This is a prerequisite to self-evaluation and, to accomplish it, to some extent we must expose ourselves, our frailties and our mistakes. There are good book and articles available that address the concept of reflection, (Jhons, 2007). Reflective practice supports continuous development or growth with the assumption that we benefit by thinking about our own behaviors and our own thinking.

Intellectual, Interpersonal and Technical Competencies

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Intellectual Competencies

Intellectual competencies are discussed first because this is an invisible aspect of nursing that is very important for becoming a diagnostician. Intellectual skills include both knowledge of nursing diagnoses and the mental processes for use of knowledge. Nurses need to attain knowledge of diagnoses, their definitions and defining characteristics, especially those that are common to the populations with which they work, the interventions to treat the diagnoses, and the diagnostic processes that are used to interpret patient data. This knowledge is extensive and complex, so nurses should not be expected to memorize the available knowledge, but rather they need to know how to access the information that they need; the resources to obtain this knowledge should be available when needed.

Besides knowledge, thinking ability is the other important aspect of the intellectual domain. Even through, traditionally, thinking processes have not been emphasized in nursing, they are critical to use of nursing diagnoses. The cognitive skills of analyzing, logical reasoning, and applying standards are just thee of thinking processes that are needed for accurate diagnosis in nursing. These skills are developed, for example, through discussions of how data should be clustered to generate accurate diagnoses, the relation of data clusters to diagnoses, and comparisons of existing data to expected data based on research findings. Research findings in cognitive science and nursing show that adults at the same levels of education and experience vary greatly in thinking abilities (Lunney, 1992; Sternberg, 1997).

Research finding from cognitive science and other disciplines also show that thinking processes can be improved (Sternberg, 1997; Willingham, 2007). In Nursing, research studies have shown that critical thinking abilities vary widely and that critical thinking can be improved with education and effort (Tanner, 2006). This done through energy, focus, and support. To do this, students and nurses need to think about their thinking, referred to as metacognition (Pesut and Herman, 1992), by using the concepts of thinking that are relevant to nursing practice. A Delphi study of nurse experts in critical thinking (Scheffer and Rubenfeld, 2000) generated 7 cognitive skills and 10 habits of mind that were considered to be highly relevant to nursing practice. These 17 concepts of thinking should be used by nurses to think about their thinking. In any nursing situation, two or more cognitive skills are probably being used. The habits of mind support the cognitive skills. The combination of these critical thinking abilities that are needed for clinical situations are probably unique, so nurses need to cultivate all of these critical thinking processes and not just focus on a few of them.

Critical thinking abilities are essential to achieve accurate interpretations of patient data and appropriate selection of interventions and outcomes, so developing high-level thinking abilities is a high priority. To do this, nurses and nursing students can:

§ Use thinking processes, rather than just receiving knowledge from others

§ When learning, think about the concepts, not just memorize knowledge

§ Seek support from others, e.g., teachers, other nurses, patients, to validate thinking processes

§ Develop confidence in ability to think.

Interpersonal Competencies

Nursing diagnoses are best used by nurses who have exquisite interpersonal communication skills. Such skills are needed so that patients will trust nurses enough to tell them about their responses to health problems and life processes. Trust is enhanced through a mature ability to communicate with others.

Nurses must assume that they do not know other people (Munhall, 1993). The only way other people can be known is through interpersonal processes, especially listening. Nurses who assume that they know patients without listening to them will not achieve diagnostic accuracy. They best use of nursing diagnoses is in partnership with patients and families. To work in partnership, nurses need to speak to people with respect and care, effectively listen, respect other people’s opinions and views, and know how to validate perceptions with patients and families. Learning these skills is challenge, so the interpersonal aspects of nursing need to be an integral part of learning to use nursing diagnoses.

Technical Competencies

Another baseline competency is the technical skill of conducting a nursing assessment. Obtaining valid and reliable data is the backbone of using nursing diagnoses, so nurses’ development of their ability to conduct comprehensive and focused health histories and physical examinations is essential. This technical skill is learned in courses on the topic and using nursing textbooks on health assessment. For example, the diagnosis and treatment of pain requires sophisticated assessment knowledge, including ways to explore the types and locations of pain, factors that make the pain worse or better, etc. The same is true of many of the diagnostic concepts such as body image disturbance.

An Assessment is a “nursing” assessment if it yields the data that are needed for nursing care. The assessment data that are generated by a biological systems review, which is done to yield medical diagnoses, are insufficient to yield the data needed for nursing diagnoses. Thus, other assessment frameworks such as the functional health patterns (Gordon, 2007) are being used in health care systems where the accuracy of nurses’ diagnoses is considered important. The functional health pattern framework is used later in this chapter to demonstrate how to generate nursing diagnoses from assessment data.

Bronchiolitis

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Bronchiolitis is a lower respiratory viral infection,which typically is most severe in young infants.Bronchiolitis occurs in annual epidemics,and is characterized by airways obstruction and wheezing.Respiratory syncytial virus is the most important cause.At bronchiolitis secondary bacterial infection may occur and is common in some settings.The management of bronchiolitis associated with fast breathing or other signs of respiratory distress is therefore similar to that pneumonia.Episodes of wheeze may occur for months after an attack of bronchiolitis,but eventually will stop.(WHO)

picture : easypediatrics.com

Kaposi Sarcoma

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Consider Kaposi sarcoma in children presenting with nodular skin lesions,diffuse lymphadenopathy and lesions on the palate and conjunctiva with periorbital bruising.Diagnosis of Kaposis sarcoma is usually clinical but can be confirmed by a needle biopsy of skin lessions or lymph node biopsy.Suspect of Kaposi sarcoma also in children with persistent diarrhoea,weight loss,intestinal obstruction,abdominal pain,or large pleural effusion.Consider referral to a larger hospital for management Kaposi sarcoma.(WHO).
Picture : ndt-educational.org

Congenital Syphilis

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Babies of mother with infections congenital syphilis have clinical signs : often low birth weight,abdominal distension due to big liver and spleen,jaundice,anemia.Some VLBW babies with congenital syphilis have signs of severe sepsis with lethargy,respiratory distress,skin petechiae,or other bleeding.Congenital syphilis also shows palm and soles : red rash,grey patches,blisters or skin peeling.If you suspect syphilis,do VDLR test if possible.Treat the mother and partner for syphilis and check for other sexually transmitted infections.(WHO)

Picture : cnewellnessctr.org

Malaria Symptoms

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Malaria is a kind of infectious disease in humans around 350-500 million people are infected and more than 1 million deaths every year, especially in the tropics and in Africa below the Sahara desert.Malaria symptoms include fever, shivering, arthralgia (joint pain), vomiting, anemia (caused by hemolysis), hemoglobinuria, retinal damage, and convulsions.Other malaria symptoms are jaundice,shock,and bleeding tendency.(WHO)
Picture : wikipedia

Asthma Attack

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Asthma attack is a chronic inflammatory condition with reversible airways obstruction.Asthma attack is characterized by recurrent episodes of wheezing,often with cough,which respond to treatment with bronchodilators and anti-inflammatory drugs.Antibiotics should be given for asthma attack only when there are signs of pneumonia.On examination of asthma attack may include hyperinflation of the chest,lower chest wall indrawing,prolonged expiration with audible wheeze,absence of fever,and reduce air intake when obstruction is severe.(WHO)

Pleural Effusion

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A child with severe or very severe pneumonia may develop pleural effusion or emphyema.On examination of pleural effusion,the chest is dull to percussion and breath sounds are reduced or absent over the affected area.Patient with pleural effusion,a pleural rub may be heard at an early stage before the effusion is fully developed.A chest X-ray pleural effusion shows fluid on one or both sides of the chest.When empyema is present,fever persist despite antibiotic therapy and the pleural fluid is cloudy or frankly purulent.Pleural effusion should be drained,unless they are very small.(WHO)

Nurses are Diagnosticians

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With use of the term “nursing diagnosis”, it became apparent that nurses are diagnosticians. Before that time, the clinical judgment used in clinical practice to decide the focus of nursing care was invisible or not named. Today, in health care agencies where nurses do not use nursing diagnoses, or use them without a concern for accuracy, the invisibility of the nurse’s role as a diagnostician may still exist. With the start of this formal classification of nursing diagnoses, however, it was broadly accepted that nurses are diagnosticians who use diagnostic reasoning in collaboration with patients to identify the best diagnoses to guide nursing interventions to achieve positive patient outcomes.

The diagnostic process in nursing differs from the diagnostic process in medicine in that, in situations when it is possible to do so, the person or persons who are the focus of nursing care should be intimately involved as partners with nurses in the assessment and diagnostic process. This is because the focus of nursing care is the person’s achievement of well-being and self-actualization. People’s experiences and responses to health problem and life processes have specific meanings to them and these meaning s are identified with the help of nurses. It is also assumed that nurses do not make people healthy with their diagnoses and interventions; people make themselves healthy with their own behaviors. Thus, to achieve changes in behaviors that affect health, people and nurses together identify the most accurate diagnoses that have the potential to guide nursing care for achievement of positive health outcomes. Nursing interventions for diagnoses of human responses offer additional ways, besides treating medical problems, that the health of people can be promoted, protected and restored.

The focus of nursing is the “health” of “human beings” two of the most complex scientific concerns: more complex, for example, than chemistry and astronomy. Health-related phenomena, such as sleep, comfort, or nutrition, are complex because they involve human experiences. We can never know for sure what other human beings are experiencing; yet the goal of nursing is to identify people’s experiences or responses in order to support them. With human responses, there is also a tremendous overlap of cues to diagnoses and many contextual factors such as culture that can change the perspective of “what is the diagnosis?” Many studies have verified that interpretations of clinical cases have the potential to be less accurate than indicated by the data (Lunney, 2008)

With nursing diagnoses as the foundation of nursing care, nurses need to develop diagnostic competencies in order to become good diagnosticians. Diagnosticians are people who interpret data within their fields of expertise in order to provide needed services, e.g., an automobile mechanic must be able to diagnose why the car will not start in order to be able to fix it. A key element of data interpretations is that they are subject to error. A good diagnostician must be mindful that there are always risks to the accuracy of data interpretations. Becoming a nurse diagnostician, therefore, requires development of professional and personal skills and characteristics.

Two propositions are the basis for development of diagnostic competencies:

1. Diagnosis in nursing requires competencies in intellectual, interpersonal, and technical domains.

2. Diagnosis in nursing requires development of the personal strengths of tolerance for ambiguity and use of reflective practice.