You are a staff nurse working in an intensive care unit and assigned to care for a 75-year-old man who had coronary artery bypass graft surgery four days ago. The patient has a history of chronic obstructive pulmonary disease exacerbated by heavy smoking. His postoperative course has been difficult, and he has suffered a number of setbacks.
Staff members, despite their diligent efforts, have not been able to wean him off the ventilator since the surgery. He has required frequent suctioning throughout the shift, and he is being evaluated for the development of ventilator-associated pneumonia.
Today, when returning from lunch, you observed that an experienced nurse was suctioning your patient. His secretions were thick, and you observed that the nurse was instilling saline into the patient’s endotracheal tube as she was suctioning him.
The patient turned red and began coughing, and it was obvious he was in distress. You asked the nurse why she was instilling saline into his endotracheal tube. She replied that this was being done to loosen the secretions.
You told her this was no longer an acceptable practice. She stated that she many years of critical care experience and she didn’t care what anyone said, that the only way you could loosen the patient’s secretions would be to instill saline. She also said that would be the last time she would do something for one of your patients while you were at lunch.
Outline the strategies you will use to search for evidence related to best practices for suctioning and whether the instillation of saline while suctioning is an acceptable technique.
Search for evidence related to best practices and provide a summary of all evidence.
Develop a PICO question for the instillation of saline during endotracheal suctioning.
Consider how you could apply PICO to problems in the workplace to influence things in clinical practice.
Sample Solution
Transportation There is currently a wide variety of vehicles that utilize hydrogen fuel cells to power their electric motors. The most common one is an FCV (fuel cell vehicle), and over the past few years, more car manufacturers have been investing in the production of these vehicles. Toyota, a current industry giant, revealed that in 2014 it would have cost about 1 million USD to make a hydrogen fuel cell powered electric vehicle, but thanks to rapid development of this technology, in 2015 can be made for as little as $50,000 USD, enabling consumers to seriously consider switching to this technology. When the technology was new, you could not actually buy an FCV; only lease one for a few years; due to the cost of the fuel cell technology within the vehicle. Another leader in the segment, Hyundai, currently leases its Tuscon FCVâs for $499 USD per month in a 3-year lease term, which includes a fuel card that provides free fuel to cover 12,000 miles per year. However, the main problem with FCVs is the lack of infrastructure, thus a company called âFirst Elementâ began installing hydrogen pumps at pre-existing gasoline stations, dramatically cutting down costs when compared to building a whole new station just for hydrogen.7 The other main method of transport that currently utilises this technology is electric buses, called fuel cell electric buses (FCEB). They are currently operating in multiple cities across the world and ultimately provide a clean and environmentally friendly method of transport for the masses. An advantage of FCEBs over battery powered electric buses is the efficiency, as a major problem with battery technology is its lack of effectiveness in extreme cold temperatures. Whereas hydrogen is much more stable and is not affected by extreme temperatures. A third application for the fuel cells is in warehouses and manufacturing plants that require the use of forklift trucks and cargo handling machinery. Hydrogen fuel cells are powering this machinery and providing a clean alternative to gasoline or diesel-powered alternatives. Also, they have an advantage over battery operated units since there is no lengthy charging times which means that less units need to be bought in order to keep up with the workload.8>
Transportation There is currently a wide variety of vehicles that utilize hydrogen fuel cells to power their electric motors. The most common one is an FCV (fuel cell vehicle), and over the past few years, more car manufacturers have been investing in the production of these vehicles. Toyota, a current industry giant, revealed that in 2014 it would have cost about 1 million USD to make a hydrogen fuel cell powered electric vehicle, but thanks to rapid development of this technology, in 2015 can be made for as little as $50,000 USD, enabling consumers to seriously consider switching to this technology. When the technology was new, you could not actually buy an FCV; only lease one for a few years; due to the cost of the fuel cell technology within the vehicle. Another leader in the segment, Hyundai, currently leases its Tuscon FCVâs for $499 USD per month in a 3-year lease term, which includes a fuel card that provides free fuel to cover 12,000 miles per year. However, the main problem with FCVs is the lack of infrastructure, thus a company called âFirst Elementâ began installing hydrogen pumps at pre-existing gasoline stations, dramatically cutting down costs when compared to building a whole new station just for hydrogen.7 The other main method of transport that currently utilises this technology is electric buses, called fuel cell electric buses (FCEB). They are currently operating in multiple cities across the world and ultimately provide a clean and environmentally friendly method of transport for the masses. An advantage of FCEBs over battery powered electric buses is the efficiency, as a major problem with battery technology is its lack of effectiveness in extreme cold temperatures. Whereas hydrogen is much more stable and is not affected by extreme temperatures. A third application for the fuel cells is in warehouses and manufacturing plants that require the use of forklift trucks and cargo handling machinery. Hydrogen fuel cells are powering this machinery and providing a clean alternative to gasoline or diesel-powered alternatives. Also, they have an advantage over battery operated units since there is no lengthy charging times which means that less units need to be bought in order to keep up with the workload.8>
