1. Section Editor(s): Kennedy, Maureen Shawn MA, RN
  2. Ferri, Richard S. PhD, ANP, ACRN, FAAN
  3. Sofer, Dalia

Article Content

Pain Management in Older Adults

When will research evidence become practice?


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According to a recent study published in Applied Nursing Research, nurses who administer medications for acute pain to older adults don't always follow recommended guidelines. Researchers examined the medical records of 709 patients older than 65 who were admitted to one of 12 midwestern hospitals for hip fracture in 1999; they also surveyed 172 nurses who had provided care to these patients.


Results showed that the most frequently administered analgesics were acetaminophen (Tylenol and others) (28.4%), followed by meperidine (Demerol) (17%), and morphine (12.8%). However, acetaminophen was administered at doses well below the maximal recommended levels, while meperidine, which should not be used because of its possible toxicity-particularly if the patient has heart failure or renal impairment-was administered much more often than is recommended, even though the nurses who administered it said they knew it shouldn't be used.


Only 27% of patients received analgesia that they could control themselves, and only 22.3% received around-the-clock analgesia during the first 24 hours after admission, when they were likely to have acute pain. While the majority of nurses said they were aware that around-the-clock administration of analgesics is recommended, only 33.7% believed that they should be used. In addition, more than 50% of patients received intramuscular injections, even though that route of administration isn't recommended in older adults who are likely to have diminished muscle and fatty tissue, which compromises the drugs' bioavailability. Patients with dementia appeared to be at a further disadvantage: they received less pain medication than did those without dementia and were more likely to receive an intramuscular injection.


The nurses said the greatest barrier to proper pain management is difficulty contacting physicians and discussing the type and dose of analgesic that would work best in a given patient.


The researchers suggested several areas for change and called for additional studies to examine factors that can help clinicians better adhere to evidence-based practice.


Titler MG, et al. Appl Nurs Res 2003; 16 ( 4 ): 211-27.


Nursing Care Makes All the Difference

In managing chronic illness, nurses are vital.

Three recent studies demonstrate the value of nurse-led interventions in improving health, even in populations that have been seen as hard to reach.


Hypertension control.

The American Journal of Hypertension reports findings of a study examining hypertension control in a particularly high-risk and underserved group: young, urban, African American men. Researchers demonstrated that a treatment and education program involving an NP, a community health worker, and a physician yielded significantly better results after three years than a lessintensive approach did.


The 309 hypertensive men, ages 21 to 54 years, were randomized into two groups. Subjects in the intensive-intervention group received free antihypertensive medication managed by the NP, visits with the NP at least every three months, and at least one annual home visit by the health care worker (who also provided job referrals and housing assistance); a physician was available for consultation with the NP, as well. Those in the control group were referred to community resources for help with blood pressure management. Members of both groups were reminded every six months by phone and annually in person of the importance of blood pressure control (defined as maintaining a level of 140/90 mmHg or lower).


After three years, men in the intensive-intervention group showed a greater reduction in blood pressure and less progression to left ventricular hypertrophy and renal insufficiency than did men in the control group; also, a greater percentage of men in the intensive-intervention group achieved blood pressure control compared with those in the control group (44% and 31%, respectively).


Although poverty, unemployment, substance abuse, and prior incarceration were factors affecting some of the men studied, the authors said that health improvements were achieved because of the individualized interventions. "It is not enough to see these patients in a clinic and achieve beneficial results," said Martha N. Hill, PhD, RN, lead researcher, in a press release. She stressed that care should also address "lifestyle risk factors, such as poor nutrition and alcohol abuse."


Asthma management.

Researchers who studied 96 women hospitalized with asthma, most of whom were African American, reported lower rates of rehospitalization among those who received care managed by a nurse. Writing in the American Journal of Respiratory and Critical Care Medicine, researchers reported randomizing the women, ages 18 to 65 years, into two groups for six months: the usual-care group, in which subjects received primary care from their own physicians, or the nursing-intervention group, in which subjects received care from asthma nurse specialists. Nursing interventions included education, counseling, individualized treatment plans, outpatient follow-up by phone, home visits, and physician consultations regarding medication.


At follow-up (12 months), subjects in the nursing-intervention group had fewer hospital readmissions for asthma compared with those in the usual-care group (21 and 42, respectively) and fewer work or school days lost compared with those in the usual-care group (246 days and 1,040 days, respectively). Researchers reported a savings in direct health care costs of $6,462 per patient in the nursingintervention group.FIGURE

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Smoking cessation.

Although stopping smoking after a myocardial infarction (MI) can reduce a smoker's risk of dying by 50% in three to five years, smoking cessation programs have had varied success. However, Norwegian researchers reported findings in the British Medical Journal indicating that patients hospitalized after MI, unstable angina, or cardiac bypass graft surgery had greater success in quitting smoking after participating in a nurse-led smoking-cessation program.


Two hundred forty smokers under age 76 were randomized to either an intervention group or a usual-care group. Both groups attended twice-weekly, informative group sessions, during which a videotape was played. In addition, those in the intervention group received a 17-page booklet, created for this study, that highlighted the many health benefits of stopping smoking after MI, and contained a "fear arousal message" that warned of the probability of another heart attack with continued smoking. Subjects in the intervention group also received group and individual support during hospitalization, a consultation with a cardiac nurse six weeks after discharge, and periodic telephone calls follow-up for five months after discharge.


After 12 months, 57% of those in the nursing-intervention group had stopped smoking, compared with 37% of those in the control group. Because there had been no difference in smoking-cessation rates between the groups at six weeks, the researchers suggest that the longer-term intervention was important in helping patients to quit smoking.


Hill MN, et al. Am J Hypertens 2003; 16 (11 Pt 1): 906-13Castro M, et al. Am J Respir Crit Care Med 2003; 168 ( 9 ): 1095-9Quist-Paulsen P, Gallefoss F. BMJ 2003; 327 ( 7426 ): 1254-7.



Supplements could help thousands ward off advanced age-related macular degeneration (AMD). A recent study in the Archives of Ophthalmology shows that if the 1.3 million Americans at risk for developing advanced AMD took a high-dose nutritional supplement of antioxidants and zinc, about 329,000 of them would likely prevent the onset of advanced illness and associated vision loss for at least five years.


Cigarette smoking is a powerful independent predictor of risk for sudden cardiac death in patients with coronary artery disease. In its October 27, 2003, issue the Archives of Internal Medicine published a prospective study of 3,122 patients with preexisting coronary artery disease. After eight years of follow-up, researchers found that among patients who continued to smoke, the risk of sudden death was significantly greater and that patients who quit smoking lowered the risk of sudden cardiac death to a level comparable to that in patients who had never smoked.


Ipecac no longer. The American Academy of Pediatrics (AAP) no longer recommends keeping a home supply of syrup of ipecac to induce vomiting (only with the advice of a physician or poison control center) in children who have ingested poisonous substances (See Drug Watch, page 75). Recent evidence suggests that ipecac isn't effective for removing harmful substances from the stomach, was being used inappropriately and without medical consultation, and can lead to drowsiness and lethargy and compromise diagnosis and treatment. In a policy statement issued in November 2003, the AAP now advises against the use of ipecac and says that those who keep it in their homes should safely dispose of it. Parents who fear their child may have swallowed a toxic substance should call the national poison control center at (800) 222-1222.


There are 300,000 sports-related concussions annually in the United States, and the question of how long a player should be kept on the sidelines before returning to play has long been debated. Two recent studies published in the November 19, 2003, issue of the Journal of the American Medical Association examining collegiate football players who sustained concussions report that, on average, it took five to seven days for players to recover fully. Also, a player who sustains one concussion is more likely to have subsequent ones, and recovery from those may take longer than seven days.


The American Association of Critical-Care Nurses (AACN) announces a new award. The Beacon Award for Critical Care Excellence recognizes exceptional hospital critical care units. Units will be evaluated on recruitment and retention practices, education and training, use of evidence-based practices and resources, patient outcomes, environment, and leadership and organizational ethics. For more information, go to the AACN's Web site, and click on the award logo.


Isolation: Does It Keep Clinicians Away?

The goal is infection control, but the result can be poorer care.

The common practice of isolating patients who have communicable diseases as a means of controlling infection has recently come under scrutiny: is it a factor in the high rate of medical errors made in hospitals? A recent study revealed it to be; isolated patients sustained more preventable injuries, expressed greater dissatisfaction with care, and received less documented care than did patients who weren't isolated.


The researchers compared two cohorts of patients in the study. Each cohort consisted of two groups of hospitalized patients-one isolated for at least two days with methicillin-resistant Staphylococcus aureus (MRSA) infection and one not isolated. The first "general" cohort matched 78 patients admitted for MRSA infection with 156 nonisolated controls; the second "disease-specific" cohort matched 72 patients admitted for congestive heart failure as well as previously documented MRSA infection with 144 nonisolated controls admitted for congestive heart failure only.


In both cohorts, the isolated patients had significantly greater numbers of adverse events, longer hospital stays, greater dissatisfaction with care, fewer documented readings of vital signs, and fewer physician progress notes. Also, patients who had both congestive heart failure and MRSA were less likely to receive information about congestive heart failure than were nonisolated patients who had only congestive heart failure.


The researchers acknowledge that isolation helps in preventing patient-to-patient disease transmission, but they emphasize that the practice has serious unintended consequences. They call for a judicious review in hospitals of policies concerning the isolation of patients.


Stelfox HT, et al. JAMA 2003; 290 ( 14 ): 1899-905.


Improving Pain Control in Older Adults


* Administer analgesics prescribed as "prn" on a scheduled basis.


* Avoid the use of meperidine (Demerol).


* Use routes of administration other than im injection, whenever possible. Discuss with physicians the possibility of using patient-controlled analgesia.


* Review organizational policies and procedures, and update them to reflect evidence-based pain control practices.


Chief Cuddler in Iraq


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Major Michael Greenly, head nurse, left, and staff sergeant Adam Irby, of the surgical intensive care unit of the 28th Combat Support Hospital in Fort Bragg, North Carolina, on duty in Iraq with the "chief cuddler," a makeshift device they assembled to warm patients who have sustained severe blood loss. The box is placed over the patient to conserve body heat. Irby came up with the idea of the covered box and Greenly added a hair dryer to speed up the warming process.


New Magnet Facilities

The American Nurses Credentialing Center has recognized five more organizations with its Magnet Award for excellence in nursing services: Sioux Valley Hospital USD Medical Center (Sioux Falls, South Dakota); the Johns Hopkins Hospital (Baltimore, Maryland); Winchester Hospital (Winchester, Massachusetts); and two hospitals in the Carilion Health System, Roanoke Community Hospital and Roanoke Memorial Hospital (both in Roanoke, Virginia).



New Red Flags Are Raised

Warning signs and acute symptoms of coronary heart disease in women.

Coronary heart disease is the leading cause of death in women, yet many of them-and many clinicians-fail to recognize possible early signs of an approaching problem. While it's now generally known that women's symptoms of such disease can differ from men's, little is known about what they are and how early they might occur.


Researchers conducted a telephone survey of 515 women, most of whom were white (93%) and older (mean age, 66) who had suffered a myocardial infarction (MI) within the preceding six months and asked them to recall the symptoms. They found that while almost all (95%) had experienced prodromal symptoms during the month prior to the MI, fewer than a third of them reported chest discomfort or pain during that time; the symptoms most commonly reported were unusual fatigue (70%), sleep disturbance (47%), and shortness of breath (42%). At the time of the MI, almost 60% of the women reported experiencing shortness of breath; other symptoms cited by many of them were weakness and unusual fatigue. Chest pain and discomfort, when present, occurred primarily in the high chest and back and was most often characterized as pressure, aching, or tightness. It's important to note, however, that 43% of the women reported that they'd had no chest discomfort. The authors urge clinicians to consider these symptom descriptions in their assessments of women and not to rule out cardiac disease in the absence of chest pain.


McSweeney JC, et al. Circulation 2003; 108 ( 21 ): 2619-23.