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Risk Factors for the Development of Nosocomial Pneumonia and Its Clinical Impact in Cardiac Surgery

Abstract BackgroundThe development of nosocomial pneumonia after cardiac surgery is a significant post-operative complication that may lead to increased morbidity, mortality, and hospital cost. We aimed to identify risk factors associated with it and to determine its clinical impact in terms of in-hospital mortality and morbidity.MethodsThis is a retrospective cohort study conducted among all adult patients who underwent cardiac surgery from 2014-2019 in St. Luke’s Medical Center, Quezon City, Philippines. Baseline characteristics and possible risk factors for pneumonia were retrieved from medical records. Nosocomial pneumonia was based on the Centers for Disease Control and Prevention criteria. Clinical outcomes include in-hospital mortality and morbidity. Odds ratios from logistic regression was computed to determine risk factors associated with pneumonia using STATA 15.0.ResultsOut of 373 patients included in this study, 104 (28%) patients acquired pneumonia. Most surgeries were coronary artery bypass graft (CABG) (71.58%), followed by valve repair/replacement (29.76%). Neither age, sex, BMI, diabetes, LV dysfunction, renal dysfunction, COPD/asthma, urgency of surgery, surgical time, nor smoking showed association in the development of pneumonia. However, preoperative stay of >2 days was associated with 92.3% (95%CI 18–213%) increased odds of having pneumonia (p=.009). Also, every additional hour on mechanical ventilation conferred 0.8% (95%CI, 0.3–1%) greater odds of acquiring pneumonia (p=.003).Patients who developed pneumonia had 3.9 times odds of mortality (95%CI 1.51–9.89, p=.005), 3.8 times odds of prolonged hospitalization (95%CI 1.81–7.90,p<.001), 6.4 times odds of prolonged ICU stay (95%CI 3.59–11.35,p<.001), and 9.5 times odds of postoperative reintubation (95%CI 3.01–29.76,p<.001). ConclusionAmong adult patients undergoing cardiac surgeries, prolonged preoperative hospital stay and prolonged mechanical ventilation were both associated with an increased risk for nosocomial pneumonia. Those who developed pneumonia had worse outcomes with significantly increased in-hospital mortality, prolonged hospitalization, prolonged ICU stay, and increased postoperative re-intubation. Clinicians should therefore minimize delays in surgery to avoid unnecessary exposure to pathogenic organisms. Also, timely liberation from mechanical ventilation after surgery should be encouraged.

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A descriptive study of adverse childhood experiences and depression, anxiety, and stress among undergraduate nursing students.

The 10-point Adverse Childhood Experiences (ACEs) score measures childhood exposure to traumatic events. An ACEs score of 4 or higher has been associated with long-term physical and mental health problems, and increased mortality. It is unclear if the rates of undergraduate nursing students experiencing ACEs is different from the general population, and what impact ACEs has on nursing students' depression, anxiety and stress. The purpose of this study was to assess the rate of ACEs in nursing students and to examine the relationship between ACEs and perceived depression, anxiety, and stress among undergraduate nursing students. This is a descriptive correlational study to determine Adverse Childhood Experiences (ACEs) scores and Modified Depression Anxiety and Stress Scale (DASS-21) scores for undergraduate pre-licensure students at a private mid-western college. Students' ACEs scores were correlated with DASS-21 scores and demographic data. 409 students volunteered to participate in the study. Seventeen percent of students had high ACEs scores (≥4). Those students with high ACEs scores also scored statically significantly higher on the DASS-21 items relating to depression, anxiety, and stress. Results from this study demonstrated that many nursing students have experienced ACEs and nursing students with ACEs scores of 4 or higher had higher rates of depression, anxiety, and stress. These findings should drive faculty in nursing programs to acknowledge the prevalence of ACEs among their nursing students and recognize that impact on the mental health of students.

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Teaching Family Nurse Practitioner Students to Provide Mental Health Care to Older Adults

In recent years, FNPs have been challenged to deliver mental health services in the primary care setting. Over half of mental health services are provided in primary care, and one-quarter of all primary care patients have a mental disorder. Moreover, 20% of older adults have a mental or neurological disorder often not diagnosed. Nationally, it is estimated that 17% of older adults commit suicide, 15% have a mental condition, 11% have dementia, and 5% have a serious mental condition. There is a paucity of adequately prepared primary care providers trained in geropsychiatric treatment. A didactic course was developed to instruct FNP students in the skills needed to provide mental health treatment in primary care. We discuss mental illness in the context of culture to ensure that treatment is congruent with a patient’s unique cultural background and experiences. This shapes the patients’ beliefs and behaviors that influence the way they view their condition and what they perceive as acceptable solutions. We then go into detail about the common mental conditions that older adults exhibit. Through the case study method, students learn to identify the presenting problem, protocols for analyzing the case, which includes making differential diagnoses and a treatment plan including initial medications, non-medical treatments, and referral. Students are introduced to the DMS-5 to learn the criteria for mental health diagnosis with an emphasis on suicide, depressive disorders, anxiety disorders, bipolar disorders, substance use disorders, and neurocognitive disorders. We have found that students most often misdiagnose neurocognitive disorders.

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A Pilot Randomized Controlled Trial Testing the Feasibility and Acceptability of a SystemCHANGE Intervention to Improve Medication Adherence in Older Adult Stroke Survivors.

Adhering to an antithrombotic medication regimen is essential to reducing recurrent stroke in adult stroke survivors. The purpose of this study was to evaluate the feasibility and acceptability of the SystemCHANGE (SC) and attention control (AC) intervention in older adult, nonadherent ischemic stroke patients. A pilot randomized controlled trial was conducted to determine the feasibility and acceptability of an SC versus AC intervention in older adult, nonadherent stroke survivors in the management of antithrombotic medication. Participants were masked to group assignment. Stroke survivors 50 years or older, taking at least 1 once-a-day antithrombotic medication, were recruited from a Midwest Comprehensive Stroke Center-affiliated neurology office. They were screened electronically using the Medication Event Monitoring System for 2 months to determine baseline medication adherence. Nonadherent stroke survivors (medication adherence < 0.97) were randomized to SC or AC intervention and monitored for 3 months. SC focused on redesigning the interpersonal environmental system and daily routines. The AC group was provided education materials on stroke that consisted of stroke risk factor reduction, stroke facts, rehabilitation, and nutrition with the primary investigator. Participation and intervention experience interviews were evaluated for themes. Thirty participants were recruited: median age was 64 years, 46.7% of them were male, and they took an average of 7.77 (SD, 3.191; range, 3-15) prescribed medications. The number of over-the-counter medications taken (excluding aspirin) on a regular basis averaged 1.9 (SD, 0.8; range, 1-4). Two participants were nonadherent and were randomized to the 2 arms. Both participants had positive feedback and were not inconvenienced by their participation in the study. Neither participant voiced concerns about the intervention, survey demands, time requirement, or completing the surveys on the primary investigator's laptop. The SC and AC intervention protocols were feasible and acceptable to the participants in this study. Additional pilot testing is needed to further evaluate the intervention and its effect on medication adherence in this population.

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Teaching spirituality to student nurses

Since Florence Nightingale, spiritual care has been embraced in professional nursing as the integration and promotion of purpose and meaning in life. Research reports that nurses have a prominent regard for spiritual care and acknowledge that it is part of their role. The intention of this literature review is to explore effective ways for nursing faculty to teach spiritual care. This in turn will help to advance spiritually educated nurses who can rise above obstacles to providing spiritual care to clients. During the nursing formation process, spiritual care must be integrated into the nursing curricula throughout the didactic and clinical nursing education. Numerous nurses today consider themselves underprepared to meet the spiritual needs of their clients, despite nursing’s past dedication to spiritual care. Research further supports the appeal of clients to have their spiritual needs addressed while hospitalized. Given the suitable resources and education, nurses can be positioned to address the spiritual care of clients. Relevant nursing education on more effective ways to teach spiritual care will enhance the delivery of this vital aspect of holistic nursing. The focus of holistic patient care is based on the Neuman systems model, where the spiritual variable considerations are necessary for a truly holistic perspective and caring concern for the patient. As part of a successful pedagogy, a course of action and theory-based approach must be translated into preparing student nurses to incorporate spiritual care into their emerging practices.

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The Lived Experience of Peripheral Neuropathy after Solid Organ Transplant

The immunosuppressants required after transplant cause peripheral neuropathy with an incidence of 10% to 60%. Peripheral neuropathy adversely affects health-related quality of life in other populations. To describe the lived experience of peripheral neuropathy after solid organ transplant. A qualitative phenomenological study with semistructured interviews. A purposive sample of 7 solid organ transplant recipients with peripheral neuropathy was recruited from 2 transplant clinics at a large Midwest tertiary care center. Interviews were audio taped and transcribed verbatim. Data were analyzed line-by-line and coded by using HyperResearch 2.0. Although participants' experiences were similar to those reported by others with peripheral neuropathy, there were also unique differences. Unique to this population was unexpected onset, rapid escalation of symptoms, lack of provider monitoring, and poor provider response to reported symptoms. Their experience demonstrated that peripheral neuropathy diminished health-related quality of life. Four themes emerged from the data: (1) nothing is supposed to happen after transplant; (2) neuropathy causes me more problems than my heart; (3) maybe there is something that could help; and (4) I've learned to live with certain limitations. Development of or worsening of peripheral neuropathy after solid organ transplant may decrease health-related quality of life. Follow-up care should include vigilant monitoring for signs of peripheral neuropathy. Providers need to provide early treatment, education, support, empathy, and understanding.

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