|Year : 2020 | Volume
| Issue : 3 | Page : 299-307
Effect of clustered nursing interventions on physiological responses in critically ill patients
Nadia T Mohamed1, Amr H Dahroug2, Intessar M Ahmed3, Samar A Younes3
1 Department of Critical Care and Emergency Nursing, Faculty of Medicine, Alexandria University, Egypt
2 Department of Critical Care Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
3 Department of Critical Care and Emergency Nursing, Faculty of Nursing, Damanhour University, Damanhour, Egypt
|Date of Submission||30-Nov-2019|
|Date of Acceptance||19-Jul-2020|
|Date of Web Publication||29-Sep-2020|
Amr H Dahroug
Department of Critical Care Medicine, Faculty of Medicine, Critical Care Medicine, 4 Adm Street, Ibrahimia, Alexandria
Source of Support: None, Conflict of Interest: None
Background Caring of the critically ill patients is a fundamental component of a nurse’s clinical practice in ICUs. Clustered nursing interventions are defined as a group of interventions of more than six for each patient in one nursing interaction. Physiological responses may be an immediate response or long-term effects of one or more of the body systems related to physiological condition and therapeutic interventions. Critical care nurses monitor physiologic patient parameters on a regular basis to ensure patient’s stability.
Objective The aim was to determine physiological responses related to clustered nursing interventions among critically ill patients.
Participants and methods The study was conducted on 80 mechanically ventilated adult patients admitted to ICUs of Alexandria Main University Hospital and Damanhour Medical National Institute. The most common procedures provided by nurses in direct care for those patients based on a pilot study of 10 patients were vital signs measurements, central venous pressure measurement, suctioning, feeding, laboratory sampling, general care, repositioning, and administration of medications. Physiological parameters measured were end-tidal carbon dioxide using capnography, vital signs using bed side monitor, and oxygen saturation using pulse oximeter. They were measured before, at 5 min and 10 min during clustered nursing interventions, immediately after, and 15 min after clustered nursing intervention performance.
Results Respiratory rate, systolic blood pressure, and oxygen saturation were significantly changed in relation to clustered nursing interventions.
Conclusion Clustered nursing interventions may worsen some physiological parameters in critically ill patients, and therefore, nonclustered interventions should be applied instead. Moreover, continuous monitoring of physiological responses during nursing care is crucial.
Keywords: clustered nursing interventions, end-tidal CO2, pulse oximetry
|How to cite this article:|
Mohamed NT, Dahroug AH, Ahmed IM, Younes SA. Effect of clustered nursing interventions on physiological responses in critically ill patients. Res Opin Anesth Intensive Care 2020;7:299-307
|How to cite this URL:|
Mohamed NT, Dahroug AH, Ahmed IM, Younes SA. Effect of clustered nursing interventions on physiological responses in critically ill patients. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 Oct 23];7:299-307. Available from: http://www.roaic.eg.net/text.asp?2020/7/3/299/296613
| Introduction|| |
Critically ill patients are at high risk for actual or potential life-threatening health problems, thereby requiring intense and vigilant nursing care .
Critical care nurses constitute the largest group of health care providers, and their care influences patient outcome. They have the responsibility in the continuous assessment and monitoring of critically ill patients . Approximately 20–25% of patients may receive potentially harmful care. One-third of hospital mortality occurs in critically ill patients inside ICU . A clinician has to consider many inter-related factors regarding prognosis in critically ill patients, including age, severity and irreversibility of the acute illness, physiological reserve, and response to therapy .
Patients in the ICU usually require ventilatory and cardiovascular support, and invasive monitoring, so intensive observation by nursing and medical staff is mandatory. Physiological responses may be an immediate response or long-term effects of one or more of the body systems related to physiological condition and therapeutic interventions. Monitoring helps in the early diagnosis of change in a physiological parameter and provides guidelines toward the institution of appropriate therapy .
Vital signs and other physiological measurements are a quick and efficient way of monitoring a patient’s condition or identifying problems and evaluating the patient’s response to intervention . End-tidal carbon dioxide (ETCO2) provides a more immediate reflection of physiological response experienced by the critically ill patients. It is the partial pressure of carbon dioxide in the airway at the end of expiration under normal ventilation/perfusion matching in the lungs .‘
Nursing management of the mechanically ventilated patient is challenging on many levels from the acquisition of highly technical skills, expert knowledge on invasive monitoring, and implementation of interventions to care for the patient. Clustered nursing interventions are defined as a group of interventions of more than six interventions for each patient in one nursing interaction .
Nursing-specific interventions include assessment, administering medications, suctioning, repositioning, hygiene, shampoo, shave, incontinence care oral care, bath, wound care, range-of-motion exercises, linen change, application of splints or binders, weighing, and/or others . Clustered nursing interventions may lead to change of physiological response such as increasing metabolism and raising partial pressure of carbon dioxide, which acts as a cerebral vasodilator, potentially increasing intracranial pressure that may lead to many health problems in critically ill patients .
Prolonged exposure of patients to change of physiological responses as a result of clustering nursing care events together rather than spacing them out over time may lead to many complications to the body systems, such as stress, anxiety, insomnia, diabetes, heart diseases, stress ulcer, and increasing oxygen consumption . So, increasing number of nursing interventions will increase the physiological responses experienced by patients as measured by ETCO2 and vital signs .
Nursing guidelines have recommended allowing such rest periods without specifying whether the nurse should do a multitude of interventions in a concentrated period of time or limit the number of interventions per interaction to permit rest between episodes of nursing care .
| Aim|| |
The aim of the study was to determine physiological responses related to clustered nursing interventions among mechanically ventilated patients.
| Participants and methods|| |
An official letter from the Faculty of Nursing was sent to the administrative authority in the intended study hospitals, and a written approval to conduct this study was obtained after providing explanation of the aim of the study.
The study tool was developed by the researcher after reviewing the related literature.
Clustered Nursing Interventions Assessment Record (tool II) was tested for reliability using Cronbach’s α reliability method on a sample of 18 participants. The correlation coefficient was 0.730, which was accepted.
A pilot study was done on 10% of sample before starting the data collection to test the feasibility and applicability of these tools, and they were excluded from the study.
This observational descriptive study was conducted on 80 mechanically ventilated patients after sample size calculation using power analysis Epi Info 7 (statistical software for epidemiology developed by Centers for Disease Control and Prevention in Atlanta, Georgia) program using the following parameters: population size (480 for three months), expected frequency 50%, acceptable error (equal 10%), and confidence coefficient (equal 95%).
Selected patients of either sex were aged 18 years and above admitted to the ICUs of Alexandria Main University Hospital, the casualty ICU (unit I) and the general ICU (unit III), and general ICU of Damanhur Medical National Institute. However, patients with the following criteria were excluded including lung disorder (e.g. chronic obstructive pulmonary disease, asthma, lung cancer, pneumonia, and acute respiratory distress syndrome) and pregnancy.
Full detailed consent was taken from nurses and patients or their relatives before conducting the study after explaining the aim of the study. Approval for the study was obtained from the Ethical Committee of Faculty of Nursing.
Patients’ demographic data were obtained, which included patient’s age, sex, diagnosis, date of ICU admission, and date of institution of mechanical ventilation.
To collect the necessary data, two tools were used:
Tool I: physiological response measurement
It included vital signs which were measured manually or by using bedside monitor; ETCO2, which was measured by using bedside capnogram; and oxygen saturation, which was measured by using pulse oximeter.
Tool II: clustered nursing interventions assessment record
Based on a pilot study of ten patients in different settings, the most common procedures provided by the nurses in providing direct care for those patients were the following:
- Vital signs, including measurement of axillary’s temperature, pulse, and blood pressure.
- Central venous pressure measurement.
- Feeding (orogastric or nasogastric tube).
- Laboratory investigation sampling including Arterial Blood Gas (ABG) sample.
- General care.
- Reposition and range of motion exercises.
- Administration of medication.
This tool was developed by the researchers after reviewing the relevant literature ,,, to record the type and number of nursing interventions and the start time and duration of the each procedure.
The Statistical Package for the Social Sciences was used for data analysis and tabulation. The level of significance selected for this study was ‘P’ equal or less than 0.05.
| Results|| |
[Table 1] shows the distribution of critically ill patients according to their characteristics, length of stay, and diagnosis. The mean age of patients was 49.6±6.94 years. More than half of the study samples (61.25%) were male. The mean length of stay was 16.8±5.4 days, whereas the mean duration of mechanical ventilation was 13.8±4.9 days. The most frequent diagnosis was related to neurological disorders (35% of cases).
|Table 1 Distribution of critically ill patients according to their characteristics|
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[Table 2] shows distribution of critically ill patients according to number of clustered nursing interventions in the intended study ICUs. Mean values of number of clustered nursing interventions at ICU Damanhur and at ICU I and ICU III at Alexandria main university were 10.9±1.6, 10.8±1.8, and 10.8±1.3. There was no significant difference between these units (P=0.483%). We can also notice that the majority of cases (77, 96.3%) had received high number of clustered nursing interventions (8–15 intervention), whereas only three (3.8%) cases received low number of clustered nursing interventions (0–7 intervention).
|Table 2 Distribution of critically ill patients according to number of clustered nursing interventions in the intended study ICUs|
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[Figure 1] shows that the most common frequent nursing intervention performance was measuring vital signs (100.0%), whereas the least common frequent nursing intervention performance was cardiopulmonary resuscitation (2.5%) in the intended study ICUs.
|Figure 1 Frequency distribution of nursing interventions performance in the intended study ICUs.|
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[Table 3] reveals the relationship between number of clustered nursing interventions and patients’ characteristics. It was found that there was no significant difference between age or sex and number of clustered nursing interventions. Moreover, there was no significant relation between duration of mechanical ventilation or length of stay in the intended ICUs and number of clustered nursing interventions. However, there was a significant difference between those who had neurological disorders and other medical diagnosis regarding number of clustered nursing interventions (P=0.001).
|Table 3 Relationship between number of clustered nursing interventions and patients’ characteristics|
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[Table 4] clarifies the mean value of physiological parameters status before, during, and after clustered nursing interventions performance. Regarding the mean value of ETCO2 before, 5 min and 10 min during clustered nursing interventions, immediately after clustered nursing interventions performance, and after 15 min from clustered nursing intervention performance were 27.8±9.5, 31.5±20.4, 32.0±10.2, 37.7±11.2, and 27.3±9.8 mmHg, respectively. The mean value of ETCO2 immediately after clustered nursing interventions performance was significantly higher than the mean value before performing clustered nursing interventions (P=0.001).
|Table 4 Mean value of physiological parameters status before, during and after clustered nursing interventions performance|
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Concerning the mean respiratory rate, values were 20.3±4.9, 19.8±4.9, 18.2±4.5, 16.3±3.9, and 21.5±4.5, respectively. The mean value of respiratory rate immediately after clustered nursing interventions performance was significantly lower than the mean value before performing clustered nursing interventions (P=0.002).
Regarding the mean value of oxygen saturation, values were 98.4±1.8, 97.7±2.0, 96.2±2.4, 92.3±3.7, and 98.1±1.9%, respectively. The mean value of oxygen saturation immediately after clustered nursing interventions performance was significantly lower than the mean value before performing clustered nursing interventions (P=0.028).
In relation to heart rate, the mean values were 94.3±18.7, 96.3±19.4, 99.5±21.2, 103.4±22.5, and 95.2±19.0 beats/min, respectively. The mean value of heart rate immediately after clustered nursing interventions performance was significantly higher than the mean value before performing clustered nursing interventions (P=0.022).
Regarding the mean value of systolic blood pressure, values were 130.4±27.0, 130.4±27.1, 130.2±26.9, 137.5±28.0, and 130.3±27.4 mmHg, respectively. The mean value of systolic blood pressure immediately after clustered nursing interventions performance was significantly higher than the mean value before performing clustered nursing interventions (P=0.005).
Concerning the mean body temperature, values were 36.9±0.5, 36.9±0.6, 37.1±0.5, 36.7±0.5, and (36.9±0.4°C, respectively. The mean value of body temperature immediately after clustered nursing interventions performance was lower than the mean value before performing clustered nursing interventions, but this was not significant (P=0.086).
[Table 5] reveals that relationship between physiological responses and number of clustered nursing interventions among different study phases. There was a significant increase in the mean respiratory rate and the mean systolic blood pressure with the increase number of clustered nursing care performance (P=0.050 and 0.002, respectively). Moreover, the mean oxygen saturation was significantly decreased with the increase number of clustered nursing care performance (P=0.003).
|Table 5 Relationship between physiological responses and the number of clustered nursing interventions among different study phases|
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[Table 6] shows the duration of each procedure (time taken for each procedure performed for critically ill patients by nurses). It was observed that the 92.5% of measuring vital signs lasted less than 5 min, with mean duration of 3.88±0.51, whereas 83.8% of central venous pressure measuring lasted between 5 and 10 min, with the mean duration of 4.95±2.35 min. Moreover, it was observed that 45.0% of bed bathing lasted more than 10 min, with the mean duration of 8.41±7.54 min.
|Table 6 Duration of procedures performed to critically ill patients by critical care nurses|
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[Table 7] shows the correlation between duration of procedures performed to patients by critical care nurses and physiological responses. It was observed that there was a negative correlation between duration of measuring central venous pressure and respiratory rate (r=−0.327, P=0.003). Moreover, there was a negative correlation between duration of bathing and oxygen saturation (r=−0.256, P=0.022), whereas there was a positive correlation between duration of suctioning and level of respiratory rate (r=0.236, P=0.035).
|Table 7 Correlation between duration of procedures performed to patients by critical care nurses and physiological responses|
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| Discussion|| |
Clustered nursing interventions (defined as clustering several routine or nursing care events together rather than spacing them out over time without providing them periods of rest) may be considered one of the most important causes of alterations on physiological responses among mechanically ventilated patients. Most of our ICUs have limited number of nurses in relation to patient number, which make them obliged to do clustered interventions toward patients rather than nonclustered ones. In this work, we studied the effect of clustered nursing interventions on physiological responses of 80 mechanically ventilated patients.
Regarding sociodemographic data, the results of the current study showed that there was no significant difference between the number of clustered nursing intervention performance and patient’s age or sex. This may be owing to the fact that critical care nurses were providing the same nursing care regardless of patient’s age and sex. This finding is in agreement with Al Sutari et al.  who found that there was no significant difference between younger and older patients and nursing procedures performed.
The present study revealed that there was a significant relationship between patients‘ neurological disorders and physiological responses regarding number of clustered nursing interventions performance. This finding is in similarity with Olson et al.  in a study titled the effects of nursing interventions on intracranial pressure. It was concluded that a wide variety of nursing interventions performance for neurological patients were directly affecting intracranial pressure and physiological parameters. Moreover, Ugras and Yuksels  in a study titled factors affecting intracranial pressure and nursing interventions concluded that one of the factors associated with increased intracranial pressure was clustering of all nursing interventions within the same time period.
Regarding the mean patient’s ETCO2, the results of current study denoted that the mean patient’s ETCO2 increased during and immediately after clustered nursing interventions performance compared with before performing clustered nursing interventions and return to baseline after 15 min from clustered nursing interventions performance. This finding may be owing to the stress response with increased CO2 production induced by the effect of clustered nursing interventions.
This finding is supported by Genzler et al.  in a study titled ETCO2 as a measure of stress response to clustered nursing intervention in neurologic patients. The study reported that mechanically ventilated patients who had six or more clustered interventions experienced a higher mean change in ETCO2 than patients who received fewer than six interventions. Yet, this finding is in opposition to Szabo et al. , who demonstrated that there was no significant difference between ETCO2 value in patients who had clustered nursing interventions and patients who had rest periods.
Moreover, the most three physiological responses influenced significantly by the number of the clustered nursing care were mean systolic blood pressure, mean respiratory rate, and mean oxygen saturation. This may be owing to the stress and pain induced by multiple nursing procedures in mechanically ventilated patients such as suctioning, bathing, measuring central venous pressure, nasogastric tube insertion, obtaining arterial sample, and routine sampling at the same time which results in increasing systolic blood pressure, respiratory rate, and decrease oxygen saturation.
This finding is in agreement with Holsti et al.  who demonstrated that the mean value of physiological responses changed significantly at clustered care after invasive multiple procedures compared with rest.
Moreover, the mean percent change of heart rate immediately after clustered nursing interventions performance was significantly higher than the mean value before performing clustered nursing interventions. This finding is in agreement with Hamers et al.  who found that there was a significant difference between heart rate and clustered nursing interventions performance.There was a significant relationship between physiological responses and duration of procedures. The current study revealed that suctioning resulted in oxygen desaturation and tachypnea during and after suctioning performance. This may be owing to that tracheal suctioning is an invasive and blind procedure. Moreover, nurses took a long time in performing suctioning procedure without contest monitoring of oxygen saturation during procedure which resulted in oxygen desaturation and tachypnea.
This finding is in line with Afshari et al.  who stated that less knowledge of nurses about suctioning is the main cause for most of suction complications. Moreover, Asfour et al.  in a study titled nursing practices and oxygen desaturation in critically ill patients reported that there were negative correlations between the duration of suctioning and oxygen saturation.
Results of the current study illustrated that there was a negative correlation between duration of bathing and patient’s oxygenation. This finding may be owing to that improper water temperature and the long duration on supine position during bathing. Similarly, Asfour et al.  revealed that there was a significant negative correlation between duration of bathing and oxygen saturation.
Results of the current study revealed that there was no significant correlation between duration of positioning and respiratory rate and oxygen saturation. This finding may be owing to that critical care nurse did not take a lot of time to change patient’s position. These findings are in opposition to Vollman et al.  and Scholes et al.  who revealed that there was a significant correlation between oxygen saturation and changing patients’ positions.
Moreover, results of this study revealed that there was no significant difference between different ICUs and the number of clustered nursing interventions performance. This may be owing to the general shortage of the ICUs staff, lack of resources, and lack of supervision.
The relatively smaller number of the cases may affect the results of the study. More important, there is a very small number of the comparative control group of nonclustered nursing interventions (three cases only), which may have led to bias in the results. This could be explained by the fact that this study is observational one and carried out in university and teaching hospitals with limited resources, either personnel or equipment.
| Conclusion|| |
Clustered nursing interventions have a worse effect on most of the physiological responses, especially mean respiratory rate, mean systolic blood pressure, and mean oxygen saturation, without significant effect on duration of mechanical ventilation and length of stay in ICUs. So, we recommend that nonclustered nursing interventions should be applied in different ICUs which may allow periods of rest for critically ill patients to prevent physiological response alteration.
Importantly, the attending ICU physician should not take an immediate action toward a slight change in the physiological responses during nursing interventions as a reaction. Meanwhile, he/she should wait till the intervention is finished and then reassess the patient condition.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]