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Open Access Publications from the University of California

Scholarly Works (12 results)

  • Thesis
  • Peer Reviewed
UC San Francisco Electronic Theses and Dissertations (2011)

Background: Underfeeding is a common and severe problem for critically ill patients receiving enteral nutrition. There are many factors contributing to inadequate enteral nutrition intake in patients hospitalized in the intensive care unit (ICU). Little is known about the factors that impact adequacy of nutritional intake in Korean patients.

Objectives: This dissertation aimed to describe the adequacy of enteral nutritional intake and identify factors that impact adequate intake in critically ill patients receiving enteral nutrition. A particular focus was on identifying the contribution of the factors that had an impact on the adequacy of energy intake in the first four days after the initiation of enteral feeding in critically ill Korean patients.

Methods: The first paper was a literature review regarding barriers to adequate enteral nutritional intake. The second and third papers report data from a prospective cohort study. Data were collected from 34 critically ill adult patients hospitalized in the Korean medical ICU who were receiving bolus enteral nutrition. The data on nutritional intake, feeding methods, and feeding interruptions were recorded from medical records during the first four days after enteral feeding initiation.

Findings: The first paper demonstrated that under-prescription, late initiation, frequent interruptions of enteral nutrition and gradual progression of the feeding administration rate were barriers to adequate enteral intake. Nutrient-dense formulas and transpyloric feeding were associated with increased energy intake. The second paper showed that most critically ill Korean patients were underfed with enteral nutrition. Under-prescription, prolonged interruptions of enteral nutrition, and early initiation were associated with underfeeding in critically ill Korean patients. The third paper demonstrated that enteral nutritional intake was consistently insufficient across all four days. Prolonged feeding interruptions due to GI intolerance and procedures were the major contributors to inadequate nutritional intake in critically ill Korean patients. The findings suggest that healthcare providers awareness and knowledge of enteral nutrition should be improved. Standardized feeding protocols should be developed, tested, and implemented to provide adequate nutritional support to the critically ill.

    Cover page: Adequacy of nutritional intake and factors that impede adequate nutritional intake in ICU patients receiving enteral feeding
    • Thesis
    • Peer Reviewed
    UC San Francisco Electronic Theses and Dissertations (2013)

    THE EXPERIENCE OF OLDER MEN WITH HEART FAILURE WHO ARE RECEIVING PALLIATIVE CARE

    M. Janelle Culjis

    University of California, San Francisco, 2013

    ABSTRACT

    Purpose: The aim of this study was to describe the lived experiences of older men with heart failure who are managing symptoms near end-of-life, specifically to describe and learn how older men manage symptoms with those who support their care.

    Significance: The care of older persons with heart failure is a national priority. It is a leading source of hospitalizations in a growing older population. Older adult's ability to self-manage is a fundamental aspect of the care of heart failure; this dissertation builds on how self-management is accomplished in the home environment of older adults with heart failure near end-of-life.

    Design: An interpretive, qualitative design.

    Participants: Older men (n=15), age 75 to 95, and their caregivers (n=15) living in northern California. Men were Veterans with late stage heart failure receiving palliative care from an interdisciplinary home based primary care team.

    Methods: Semi-structured tape-recorded interviews and observation in the participant's homes. Data analysis consisted of thematic analysis influenced by interpretive interactionism and phenomenology. Emerging themes were analyzed to determine commonalities among participants. Data was collected over 2 years.

    Results: The meanings of the home environment in management of symptoms and the importance of congruence of goals of care during the transition to hospice were major findings of this study. Men experienced difficulties with symptom recognition in the presence of high symptom burden. The home environment has a pivotal role in supporting their abilities to manage symptoms and their desire to stay at home. Hospitalizations occurred with a watch and wait approach to symptom management. When faced with the transition to hospice care, men and their caregivers resisted hospice with a preference for continued hospitalizations. The men's goals of care were living while dying contrasted with health professionals goals, who view hospice as a supportive option for these men whom they regard as dying but still alive.

    Conclusion: The home environment plays a significant role in how older adults and their caregivers manage symptoms near end-of-life. Further research is needed to determine how best to provide concurrent palliative care based on the experiences of older persons with advanced heart failure.

      Cover page: The Experience of Older Men with Heart Failure Who Are Receiving Palliative Care
      • Thesis
      • Peer Reviewed
      UC San Francisco Electronic Theses and Dissertations (2010)

      Symptomatic Hypotension, Venous Oximetry and Outpatient Hemodialysis

      H. Paul Smith

      Problem Statement: Symptomatic hypotension is the most common complication during hemodialysis. It can induce cardiac arrhythmias and predisposes patients to coronary, splanchnic, and/or cerebral ischemic events. Non-invasive intermittent blood pressure measurement is used to identify hypotension during dialysis, yet it is a post-facto indicator of intravascular hypovolemia. Continuous monitoring of central venous oxygen saturation (ScvO2) may offer an innovative approach to early detection of symptomatic hypotension during outpatient hemodialysis.

      Aims: The overall aim of this study is to determine whether ScvO2 is related to changes in systolic blood pressure (SBP) and acute signs and symptoms in outpatients undergoing hemodialysis. The specific aims of this study are to determine the: 1.) change in ScvO2 as fluid is removed during outpatient hemodialysis; 2) relationship between ScvO2 and changes in systolic blood pressure during hemodialysis; 3.) association between percent change in ScvO2 and acute signs and symptoms during hemodialysis; 4.) association between the percent change in SBP and acute signs and symptoms during hemodialysis; and 5.) change in ScvO2 in patients without symptomatic hypotension compared to those with symptomatic hypotension.

      Methods: In this prospective observational study, data were collected from adult hemodialysis outpatients with a central line dialysis catheter. ScvO2, blood pressure, blood volume change, total fluid removed and acute signs and symptoms were recorded during one week of consecutive hemodialysis treatments. Descriptive statistics, multi-level regression and multi-level negative binomial regression models were utilized to analyze data.

      Findings: Subjects (n=39) were mostly African American (49%) and White (28%) with a mean age of 60 ±17 years. There was a statistically significant linear and quadratic change in ScvO2 during hemodialysis and the change trajectory was significantly greater in those patients with symptomatic hypotension. ScvO2 was significantly associated with SBP and acute signs and symptoms. Acute symptoms associated with hypotension occurred in 38% of patients and 24% of dialysis treatments.

      Conclusion: ScvO2 may be used by dialysis nurses to guide therapeutic interventions to avoid symptomatic hypotension in the outpatient setting. Further research is warranted to replicate these findings and broaden our understanding of strategies to mitigate hypotensive symptoms.

        Cover page: Symptomatic Hypotension, Venous Oximetry and Outpatient Hemodialysis
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2013)
        Critically ill patients often report distressful episodes of severe thirst, but the complex biochemical, neurohormonal mechanisms that regulate this primal sensation still elude clinicians. The most potent stimuli for thirst are subtle increases in plasma osmolality. These minute changes in osmolality stimulate central osmoreceptors to release vasopressin (also known as antidiuretic hormone). Vasopressin in turn acts on the kidneys to promote the reabsorption of water to correct the increased osmolality. If this compensatory mechanism fails to decrease osmolality, then thirst is triggered to motivate drinking. In contrast, thirst induced by marked volume loss, or hypovolemic thirst, is subject to the tight osmoregulation of the renin-angiotensin aldosterone system and accompanying adrenergic agonists. Understanding the essential role that thirst plays in salt and water regulation can provide clinicians with a better appreciation for the complex physiology that underlies this intense sensation.
          Cover page: Thirst in Critically Ill Patients: From Physiology to Sensation
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2014)
          The aim of this study was to determine the prevalence, severity, location, aetiology, treatment and healing of medical device-related pressure ulcers (PUs) in intensive care patients for up to 7 days. A prospective repeated measures study design was used. Patients in six intensive care units of two major medical centres, one each in Australia and the USA, were screened 1 day per month for 6 months. Those with device-related ulcers were followed daily for up to 7 days. The outcome measures were device-related ulcer prevalence, pain, infection, treatment and healing. Fifteen of 483 patients had device-related ulcers and 9 of 15 with 11 ulcers were followed beyond screening. Their mean age was 60·5 years, and most were men, overweight and at increased risk of PU. Endotracheal (ET) and nasogastric (NG) tubes were the cause of most device-related ulcers. Repositioning was the most frequent treatment. Four of 11 ulcers healed within the 7-day observation period. In conclusion, device-related ulcer prevalence was 3·1%, similar to that reported in the limited literature available, indicating an ongoing problem. Systematic assessment and repositioning of devices are the mainstays of care. We recommend continued prevalence determination and that nurses remain vigilant to prevent device-related ulcers, especially in patients with NG and ET tubes.
            Cover page: A prospective window into medical device‐related pressure ulcers in intensive care
            • Article
            • Peer Reviewed
            UC San Francisco Previously Published Works (2013)

            Objectives

            To describe perceptions of smoking in men hospitalized with cardiovascular disease (CVD).

            Background

            Smoking is a major risk factor and associated with the high prevalence of CVD in Jordan.

            Methods

            The study design was cross-sectional with a convenience sample. A structured interview was conducted in 112 men who were hospitalized with CVD.

            Results

            The study showed that 91% of men hospitalized with CVD smoked daily. The majority (83%) had attempted to quit smoking in the past without help from others, and intended to quit in the future using the same previously unsuccessful method. They were unaware of the hazards of smoking such as stroke; or the long term health benefits of quitting smoking. Logistic regressions showed that men were more confident in quitting smoking if they had a high income (OR: 7.7; 95% CI: 2.7, 22.3), longer hospitalizations (OR: 2.6; 95% CI: 1.3, 5.3), or were hospitalized in acute cardiac settings (OR: 3.9; 95% CI: 1.2, 12.7), and admitted with a diagnosis of MI or angina (OR: 3.0; 95% CI: 1.1, 8.3).

            Conclusion

            Assessment of smoking status with smoking cessation counseling is paramount in hospitalized men with CVD who smoke.
              Cover page: Knowledge and beliefs about smoking and goals for smoking cessation in hospitalized men with cardiovascular disease
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2014)
              Thirst, as a symptom, has long been considered the most prevalent clinical complaint patients voice in healthcare settings. Yet, rarely have researchers examined thirst by its correlation with physiologic factors. This review was undertaken to examine the relationships between thirst ratings and factors mediating its primary physiologic correlates: plasma osmolality (pOsm) and arginine vasopressin peptide (AVP). A literature search was undertaken to identify clinical studies in human subjects that investigated the relationship of thirst to specific physiologic thirst-related correlates and associated thirst mediators. Thirst was induced in 17 selected clinical studies by hyperosmolar infusion, through water deprivation or exercise weight-loss regimens. Positive linear relationships between the subjects' thirst ratings and rising serum pOsm levels confirmed the presence of intact osmotic thirst drives. However, there were significant variations in normal compensatory rises in AVP levels that followed the rises in plasma osmolality after the subjects were exposed to cold, physical pre-conditioning and water immersion tests. Notably, older adults in the studies reported diminished thirst ratings. Weak correlations suggest that angiotensin II may play only a minor role in thirst mediation. Atrial natriuretic hormone's inhibitory effect on thirst was inconsistent. Findings indicated that older adults are at higher risk for profound dehydration due to sensory deficits along with failure to correct volume losses. The thirst trials results support the close correlation between serum pOsm values and patients' thirst ratings, with the exception of the older adult.
                Cover page: Quench the Thirst
                • Article
                • Peer Reviewed
                UC San Francisco Previously Published Works (2014)

                Purpose

                To test an intervention bundle for thirst intensity, thirst distress, and dry mouth, which are among the most pervasive, intense, distressful, unrecognized, and undertreated symptoms in ICU patients, but for which data-based interventions are lacking.

                Methods

                This was a single-blinded randomized clinical trial in three ICUs in a tertiary medical center in urban California. A total of 252 cognitively intact patients reporting thirst intensity (TI) and/or thirst distress (TD) scores ≥3 on 0-10 numeric rating scales (NRS) were randomized to intervention or usual care groups. A research team nurse (RTN#1) obtained patients' pre-procedure TI and TD scores and reports of dry mouth. She then administered a thirst bundle to the intervention group: oral swab wipes, sterile ice-cold water sprays, and a lip moisturizer, or observed patients in the usual care group. RTN#2, blinded to group assignment, obtained post-procedure TI and TD scores. Up to six sessions per patient were conducted across 2 days.

                Results

                Multilevel linear regression determined that the average decreases in TI and TD scores from pre-procedure to post-procedure were significantly greater in the intervention group (2.3 and 1.8 NRS points, respectively) versus the usual care group (0.6 and 0.4 points, respectively) (p < 0.05). The usual care group was 1.9 times more likely than the intervention group to report dry mouth for each additional session on day 1.

                Conclusion

                This simple, inexpensive thirst bundle significantly decreased ICU patients' thirst and dry mouth and can be considered a practice intervention for patients experiencing thirst.
                  Cover page: A randomized clinical trial of an intervention to relieve thirst and dry mouth in intensive care unit patients
                  • Article
                  • Peer Reviewed
                  UC San Francisco Previously Published Works (2015)

                  Objective

                  This study modeled the predictive power of unit/patient characteristics, nurse workload, nurse expertise, and hospital-acquired pressure ulcer (HAPU) preventive clinical processes of care on unit-level prevalence of HAPUs.

                  Data sources

                  Seven hundred and eighty-nine medical-surgical units (215 hospitals) in 2009.

                  Study design

                  Using unit-level data, HAPUs were modeled with Poisson regression with zero-inflation (due to low prevalence of HAPUs) with significant covariates as predictors.

                  Data collection/extraction methods

                  Hospitals submitted data on NQF endorsed ongoing performance measures to CALNOC registry.

                  Principal findings

                  Fewer HAPUs were predicted by a combination of unit/patient characteristics (shorter length of stay, fewer patients at-risk, fewer male patients), RN workload (more hours of care, greater patient [bed] turnover), RN expertise (more years of experience, fewer contract staff hours), and processes of care (more risk assessment completed).

                  Conclusions

                  Unit/patient characteristics were potent HAPU predictors yet generally are not modifiable. RN workload, nurse expertise, and processes of care (risk assessment/interventions) are significant predictors that can be addressed to reduce HAPU. Support strategies may be needed for units where experienced full-time nurses are not available for HAPU prevention. Further research is warranted to test these finding in the context of higher HAPU prevalence.
                    Cover page: Modeling Hospital‐Acquired Pressure Ulcer Prevalence on Medical‐Surgical Units: Nurse Workload, Expertise, and Clinical Processes of Care
                    • Article
                    • Peer Reviewed
                    UC San Francisco Previously Published Works (2015)

                    Context

                    Thirst is a pervasive, intense, and distressing symptom in intensive care unit (ICU) patients. Although thirst may be avoided and/or treated, scant data are available to help providers identify patients most in need.

                    Objectives

                    This study was designed to identify predictors of the presence, intensity, and distress of thirst in ICU patients.

                    Methods

                    This descriptive cross-sectional study enrolled 353 patients from three ICUs (medical-surgical, cardiac, and neurological). To measure outcomes, patients were asked to report the presence of thirst (yes/no) and, if present, to rate its intensity and distress on zero to 10 numeric rating scales (10=worst). Predictor variables were demographic (e.g., age), treatment-related (e.g., opioids), and biological (e.g., total body water). Data were analyzed with logistic regression and truncated regression with alpha preset at 0.05.

                    Results

                    Thirst presence was predicted by high opioid doses (≥ 50 mg), high furosemide doses (>60 mg), selective serotonin reuptake inhibitors, and low ionized calcium. Thirst intensity was predicted by patients not receiving oral fluid and having a gastrointestinal (GI) diagnosis. Thirst distress was predicted by mechanical ventilation, negative fluid balance, antihypertensive medications, and a GI or "other" diagnosis.

                    Conclusion

                    Thirst presence was predicted by selected medications (e.g., opioids). Thirst intensity and/or thirst distress were predicted by other treatments (e.g., mechanical ventilation) and medical diagnoses (e.g., GI). This is one of the first studies describing predictors of the multidimensional characteristics of thirst. Clinicians can use these data to target ICU patients whose thirst might warrant treatment.
                      Cover page: Predictors of Thirst in Intensive Care Unit Patients
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