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Seasonal infection in COLD patients
Joan M McGinnis, RN Marilyn B Rubin, RN
Seasonal infection in COLD patients A seasonal pattern of respiratory infection in patients with chronic obstructive lung disease (COLD) was identified in a study of admissions to a Midwestern university hospital during one year. Environmental data, including temperature, humidity, and selected pollutants, were analyzed for the same period of time. In this article, the findings of our study are discussed as well as the implications for professional nurses working in the operating room, recovery room, and intensive and surgical nursing care units. In this study, we examined the records of 361 patients admitted during 1973 with a diagnosis of chronic obstructive lung disease. The diagnosis Joan M McGinnis, R N , MSN, is an instructor in the accelerated curriculum program at St Louis (Mo) University School of Nursing. A diploma graduate of St Vincent School of Nurs-
ing in Toledo, Ohio, she received her bachelor's and master's in nursing from St Louis University. Marilyn B Rubin, RN, PhD, is professor of n u r s i n g and coordinator of the graduate medical-surgical nursing program at St Louis University. She received her diploma from the Lutheran Hospital Medical Center School of Nursing in St Louis, her bachelor's and master's in nursing from Washington University School of Nursing in St Louis, and her doctorate from Southern Illinois University, Carbondale, Ill. This paper was presented in part at the American Lung Association meeting in New Orleans in May 1976.
746
of COLD was assigned to the attending physician according to the criteria in the International Classification of Diseases. Among patients admitted with primary diagnosis of COLD and with infectious organisms identified in their sputum, the highest incidence of infection (33.4%)occurred during the winter months of J a n u a r y , February, and March. Summer months had the lowest incidence (18.4%),and spring and fall were similar (25% and 22%, respectively). In addition, when considering COLD as a primary or secondary diagnosis, admissions were highest in winter (34%). Admissions were classified according to four categories: I-COLD a primary diagnosis, with infectious organism(s1 identified in sputum; II-COLD a secondary diagnosis, with infectious organism(s) identified in sputum; IIICOLD a primary diagnosis, but no sputum tests done; and IV-COLD a secondary diagnosis, but no sputum tests done. Categories I1 and IV included many patients undergoing surgery, although number of patients, types of surgery, and other factors were not computed. Individuals in category I1 may have had respiratory infection as a secondary problem or may have contracted infection while in the hospital. A multiple regression analysis of the relation of the monthly incidence of infection to temperature, humidity, and selected pollutant concentrations (car-
AORN Journal, March 1978, V o l 2 7 , No 4
bony1 compounds, nitric oxide, nitrous oxide, hydrocarbons, and sulfur dioxide) did not reveal any significance a t the p = 0.05 level. Values for pollutant concentrations, temperature, and humidity were obtained from the St Louis Air Pollution Board and US Department of Commerce National Oceanic and Atmospheric Administration Environmental Data Service. A second multiple regression analysis was done on weekly 6 am humidity values (highest of the day). The pattern t h u s identified showed the occurrence of infection t o be greatest from Dec 1to March 15.This is when humidity is highest and temperature lowest; i t is also when sulfur dioxide levels are highest. Our analysis showed that temperature and humidity alone are not significant, but when considered together they account, at least in part, for the pattern of infection. The average subject of the study was male, white, and in his 70s. In this age range, the rib cage is less flexible and abdominal muscles are often in poor tone, adding to the generally inefficient breathing of the COLD patients. In addition to the physiologic aspect at this age, COLD patients may also be without adequate emotional support from family and friends because of death and chronic disease. Barstow has discussed a “significant other’’ as being the most important aspect of the maintenance of health in the COLD patient.2 Most subjects in the study had a productive cough on admission, but no data were available on duration or frequency. The organisms identified on sputum exams most frequently were Hemophilus influenzae (721, enterobacter (521, and pneumococci (50). Tager and Speizer showed that the bacteria most frequently causing purulent sputum and exacerbation of chronic bronchitis are H influenzae and Diplococcus p n e ~ m o n i a eAnother .~ cause of exacerbation of respiratory illness is
748
virus and/or pollution episode^.^ French, et al, have shown that living in highly contaminated areas over a period of three years increases acute respiratory i l l n e ~ s . ~ The role of cigarette smoking in the development of COLD is well established. Among the subjects in the study, 16 pack years was the average amount of cigarettes smoked. (A “pack year” refers to smoking one pack of cigarettes per day for one year.) This is a conservative estimate owing t o the percentage of persons who stated their smoking habit in terms not convertible to pack years. The amount of alcohol consumption was also analyzed. Jawetz, et al, have discussed the factors that decrease resistance to respiratory infectione6They emphasize that alcoholic intoxication causes decreased cough reflex, decreased phagocytic activity, and predisposition to easier aspiration of foreign material. Those who drink large amounts of alcohol are frequently malnourished and debilitated. In this study, 23% of subjects were classified in the category of heavy alcohol intake (more than six cans of beer or four alcoholic drinks per day or admitted heavy drinkers and known alcoholics). The average subject was classified as a light to moderate drinker (“social drinker” by own admission and/or one drink per day), Drinking habits were unknown in 22% of the subjects. Environmental factors and seasonal incidence of infection have implications for operating room nurses. OR nurses should prepare for the largest number of admissions of COLD patients for surgery during the winter months. This may vary in different parts of the country according to variance in seasonal climate. Preparation for winter months could be undertaken by inservice staff to provide formalized programs on such topics as the typical COLD patient or
AORN Journal, March 1978, V o l 2 7 , No 4
0
R nurses should be more visible in contributing to the care of COLD patients.
assessment of the COLD patient postoperatively. Operating room nurses, cognizant of the consequences of respiratory infection on COLD patients, can demonstrate how to care for the COLD patient. This could include such things as invasive monitoring in an optimum aseptic manner. While prevention of respiratory infection is most important, careful attention to surgical wound and catheter or drainage systems is also needed. Should broad-spectrum antibiotic treatment become necessary for any focus of infection, some bacteria in the lung may be suppressed, thus allowing proliferation of another usually held in check. Suggested approaches by OR nurses to enhance sterility in handling drainage systems, invasive monitoring, and endotracheal suctioning could become part of the nursing care plan for the COLD patient. On a more formal basis, OR nurses might offer other hospital nursing staff conferences or consultation on sterility when dealing with COLD patients (for example, the COLD patient on a respirator). The operating room nurse should be more visible in contributing to the comprehensive care of the surgical COLD patient. By performing his or her own preoperative assessments and contributing immediately to the nursing care plan of the COLD patient, the OR nurse is involved in the provision of better quality care and avoids duplication
750
of assessment as the patient moves from one nursing unit to another. Although primary responsibility for discharge planning lies with the surgical nursing staff, the OR nurse could visit the COLD patient postoperatively to ensure the process of resumption of independence in the COLD patient. The OR nurse may also note if respiratory infection has occurred and confer with the unit nurse assigned to the COLD patient. Reevaluation of patient and staff knowledge about prevention of infection may be needed. The nursing staff on surgical units should include time for a discussion of important influences on respiration with COLD patients. Before discharge, the COLD patient ought to demonstrate breathing exercises and a knowledge of medications and preventive measures against respiratory infection. Abstinence from smoking must be emphasized any time a COLD patient who smokes comes in contact with a health care professional. Where indicated, the nurse should discuss the effects of heavy drinking on the COLD patient's status. A manual such as Better Living and Breathing can be used by the patient a t home to reinforce the nursing care.' The COLD patient should be advised of environmental data available for his use. The nurse can discuss optimum times for shopping, errands, and work to avoid high humidity, lowest temperatures, and rush hour traffic patterns and routes. The location of the COLD pa-
AORN Journal, March 1978, Vol27, No 4
tient's h o m e within a c i t y s h o u l d b e a n a l y z e d in r e l a t i o n t o highly p o l l u t i n g i n d u s t r y . Air p u r i f i c a t i o n systems a r e a v a i l a b l e for h o m e use. T h e o p e r a t i n g r o o m nurse, as a professional, c a n s u p p o r t l e g i s l a t i o n f o r quality air standards at a t i m e w h e n economic pressures a r e w o r k i n g a g a i n s t t h e quality e n v i r o n m e n t w e n e e d in t h e U n i t e d States. O p e r a t i n g r o o m n u r s e s p e r s o n a l l y c a n a v o i d s m o k i n g and encourage o t h e r s t o quit. OR nurses c a n also serve as v o l u n t e e r s with t h e i r l o c a l lung association and support mass screening for c h r o n i c lung disease. In s u m m a r y , o p e r a t i n g r o o m n u r s e s may plan f o r t h e h i g h e s t n u m b e r of surg i c a l p a t i e n t s w i t h COLD in w i n t e r m o n t h s w h e n humidity i s h i g h e s t and t e m p e r a t u r e lowest. O p e r a t i n g r o o m nurses c a n increase t h e quality o f care o f s u r g i c a l COLD p a t i e n t s t h r o u g h ind i v i d u a l i z e d assessment and m a i n t e n a n c e o f o p t i m u m s t e r i l e t e c h n i q u e in t h e o p e r a t i n g room. In addition, t h e y c a n offer c o n s u l t a t i o n t o o t h e r n u r s e s o n aseptic techniques. OR n u r s e s h a v e a r e s p o n s i b i l i t y f o r g r e a t e r v i s i b i l i t y and for t h e p r o v i s i o n o f c o n t i n u i t y of care. 0 Notes 1. lnternational Classification of Diseases, adapted, 7th revision (Geneva: World Health Organization, 1965) 2 vols. 2. Ruth E Barstow, "Coping with emphysema," Nursing Clinics of North America (March 1974) 137145. 3. Ira Tager, Frank Speizer, "Role of infection in chronic bronchitis," New England Journal of Medicine 292 (1 975) 563-571. 4. Gareth Green, "Cell dysfunction as pathogenic determinant in chronic bronchopulmonary disease," Archives of Environmental Health 21 (October 1970) 48 1-482. 5. Jean G French, et al, "The effect of sulfur dioxide and suspended sulfates on acute respiratory disease," Archives of Environmental Health 27 (September 1973) 129-133. 6. Ernest Jawetz, Joseph Melnick, Edward Adelberg, Review of Medical Microbiology (Los Altos, Calif: Lange Medical Publishers, 1966). 7. M Modrak, et al, Better Living and Breathing (St Louis: C V Mosby Company, 1975).
Test for paralysis after spinal surgery A test that avoids waking the patient in the midst of general anesthetic to determine whether any paralysis has occurred in a spinal column operation was described to the American Society of Anesthesiologists at its October meeting in New Orleans by I Cary Andrews, MD, director of anesthesiology, Hospital of the Albert Einstein College of Medicine, New York City. The presence of jerky muscle contractions immediately after surgery can provide one of the earliest signs that no injury to the spinal cord has occurred, he said. The spasm, called clonus, is tested at the ankle and induced by suddenly pushing up the sole of the foot while the leg is extended. The concern about paralysis occurs in surgery when the spinal column is fused to correct scoliosis by inserting Harrington rods, which are retained for several months or years. Sometimes the rods can stretch arteries supplying the spinal cord and cause a neurologic impairment, including paralysis of the legs. In other cases, there could be accidental injury to the spinal cord due to hemorrhage. "To prevent this complication, various authors have described the technique of awakening patients intraoperatively to check voluntary motor power of the limbs," said Dr Andrews. "This requires the use of special anesthetic techniques and always runs the risk of patients moving excessively and possibly dislodging the Harrington rod." Dr Andrews described the conditions under which clonus occurs, including recovery from general anesthesia. It is commonly associated with halothane, used alone or in combination with other agents. In a study of 200 patients having surgery under a variety of general anesthetics, all were tested for clonus before and at the end of surgery and during their stay in the recovery room. Fifteen of the 200 cases were spinal cord surgeries using Harrington rods. Of the 15 Harrington rod cases, 14 had clonus after surgery. The major factor determining the presence or absence of clonus was the degree of recoveryof wakefulnessfrom the anesthetic state.
AORN Journal, March 1978, V o l 2 7 , No 4
753
Seasonal infection in COLD patients A seasonal pattern of respiratory infection in patients with chronic obstructive lung disease (COLD) was identified in a study of admissions to a Midwestern university hospital during one year. Environmental data, including temperature, humidity, and selected pollutants, were analyzed for the same period of time. In this article, the findings of our study are discussed as well as the implications for professional nurses working in the operating room, recovery room, and intensive and surgical nursing care units. In this study, we examined the records of 361 patients admitted during 1973 with a diagnosis of chronic obstructive lung disease. The diagnosis Joan M McGinnis, R N , MSN, is an instructor in the accelerated curriculum program at St Louis (Mo) University School of Nursing. A diploma graduate of St Vincent School of Nurs-
ing in Toledo, Ohio, she received her bachelor's and master's in nursing from St Louis University. Marilyn B Rubin, RN, PhD, is professor of n u r s i n g and coordinator of the graduate medical-surgical nursing program at St Louis University. She received her diploma from the Lutheran Hospital Medical Center School of Nursing in St Louis, her bachelor's and master's in nursing from Washington University School of Nursing in St Louis, and her doctorate from Southern Illinois University, Carbondale, Ill. This paper was presented in part at the American Lung Association meeting in New Orleans in May 1976.
746
of COLD was assigned to the attending physician according to the criteria in the International Classification of Diseases. Among patients admitted with primary diagnosis of COLD and with infectious organisms identified in their sputum, the highest incidence of infection (33.4%)occurred during the winter months of J a n u a r y , February, and March. Summer months had the lowest incidence (18.4%),and spring and fall were similar (25% and 22%, respectively). In addition, when considering COLD as a primary or secondary diagnosis, admissions were highest in winter (34%). Admissions were classified according to four categories: I-COLD a primary diagnosis, with infectious organism(s1 identified in sputum; II-COLD a secondary diagnosis, with infectious organism(s) identified in sputum; IIICOLD a primary diagnosis, but no sputum tests done; and IV-COLD a secondary diagnosis, but no sputum tests done. Categories I1 and IV included many patients undergoing surgery, although number of patients, types of surgery, and other factors were not computed. Individuals in category I1 may have had respiratory infection as a secondary problem or may have contracted infection while in the hospital. A multiple regression analysis of the relation of the monthly incidence of infection to temperature, humidity, and selected pollutant concentrations (car-
AORN Journal, March 1978, V o l 2 7 , No 4
bony1 compounds, nitric oxide, nitrous oxide, hydrocarbons, and sulfur dioxide) did not reveal any significance a t the p = 0.05 level. Values for pollutant concentrations, temperature, and humidity were obtained from the St Louis Air Pollution Board and US Department of Commerce National Oceanic and Atmospheric Administration Environmental Data Service. A second multiple regression analysis was done on weekly 6 am humidity values (highest of the day). The pattern t h u s identified showed the occurrence of infection t o be greatest from Dec 1to March 15.This is when humidity is highest and temperature lowest; i t is also when sulfur dioxide levels are highest. Our analysis showed that temperature and humidity alone are not significant, but when considered together they account, at least in part, for the pattern of infection. The average subject of the study was male, white, and in his 70s. In this age range, the rib cage is less flexible and abdominal muscles are often in poor tone, adding to the generally inefficient breathing of the COLD patients. In addition to the physiologic aspect at this age, COLD patients may also be without adequate emotional support from family and friends because of death and chronic disease. Barstow has discussed a “significant other’’ as being the most important aspect of the maintenance of health in the COLD patient.2 Most subjects in the study had a productive cough on admission, but no data were available on duration or frequency. The organisms identified on sputum exams most frequently were Hemophilus influenzae (721, enterobacter (521, and pneumococci (50). Tager and Speizer showed that the bacteria most frequently causing purulent sputum and exacerbation of chronic bronchitis are H influenzae and Diplococcus p n e ~ m o n i a eAnother .~ cause of exacerbation of respiratory illness is
748
virus and/or pollution episode^.^ French, et al, have shown that living in highly contaminated areas over a period of three years increases acute respiratory i l l n e ~ s . ~ The role of cigarette smoking in the development of COLD is well established. Among the subjects in the study, 16 pack years was the average amount of cigarettes smoked. (A “pack year” refers to smoking one pack of cigarettes per day for one year.) This is a conservative estimate owing t o the percentage of persons who stated their smoking habit in terms not convertible to pack years. The amount of alcohol consumption was also analyzed. Jawetz, et al, have discussed the factors that decrease resistance to respiratory infectione6They emphasize that alcoholic intoxication causes decreased cough reflex, decreased phagocytic activity, and predisposition to easier aspiration of foreign material. Those who drink large amounts of alcohol are frequently malnourished and debilitated. In this study, 23% of subjects were classified in the category of heavy alcohol intake (more than six cans of beer or four alcoholic drinks per day or admitted heavy drinkers and known alcoholics). The average subject was classified as a light to moderate drinker (“social drinker” by own admission and/or one drink per day), Drinking habits were unknown in 22% of the subjects. Environmental factors and seasonal incidence of infection have implications for operating room nurses. OR nurses should prepare for the largest number of admissions of COLD patients for surgery during the winter months. This may vary in different parts of the country according to variance in seasonal climate. Preparation for winter months could be undertaken by inservice staff to provide formalized programs on such topics as the typical COLD patient or
AORN Journal, March 1978, V o l 2 7 , No 4
0
R nurses should be more visible in contributing to the care of COLD patients.
assessment of the COLD patient postoperatively. Operating room nurses, cognizant of the consequences of respiratory infection on COLD patients, can demonstrate how to care for the COLD patient. This could include such things as invasive monitoring in an optimum aseptic manner. While prevention of respiratory infection is most important, careful attention to surgical wound and catheter or drainage systems is also needed. Should broad-spectrum antibiotic treatment become necessary for any focus of infection, some bacteria in the lung may be suppressed, thus allowing proliferation of another usually held in check. Suggested approaches by OR nurses to enhance sterility in handling drainage systems, invasive monitoring, and endotracheal suctioning could become part of the nursing care plan for the COLD patient. On a more formal basis, OR nurses might offer other hospital nursing staff conferences or consultation on sterility when dealing with COLD patients (for example, the COLD patient on a respirator). The operating room nurse should be more visible in contributing to the comprehensive care of the surgical COLD patient. By performing his or her own preoperative assessments and contributing immediately to the nursing care plan of the COLD patient, the OR nurse is involved in the provision of better quality care and avoids duplication
750
of assessment as the patient moves from one nursing unit to another. Although primary responsibility for discharge planning lies with the surgical nursing staff, the OR nurse could visit the COLD patient postoperatively to ensure the process of resumption of independence in the COLD patient. The OR nurse may also note if respiratory infection has occurred and confer with the unit nurse assigned to the COLD patient. Reevaluation of patient and staff knowledge about prevention of infection may be needed. The nursing staff on surgical units should include time for a discussion of important influences on respiration with COLD patients. Before discharge, the COLD patient ought to demonstrate breathing exercises and a knowledge of medications and preventive measures against respiratory infection. Abstinence from smoking must be emphasized any time a COLD patient who smokes comes in contact with a health care professional. Where indicated, the nurse should discuss the effects of heavy drinking on the COLD patient's status. A manual such as Better Living and Breathing can be used by the patient a t home to reinforce the nursing care.' The COLD patient should be advised of environmental data available for his use. The nurse can discuss optimum times for shopping, errands, and work to avoid high humidity, lowest temperatures, and rush hour traffic patterns and routes. The location of the COLD pa-
AORN Journal, March 1978, Vol27, No 4
tient's h o m e within a c i t y s h o u l d b e a n a l y z e d in r e l a t i o n t o highly p o l l u t i n g i n d u s t r y . Air p u r i f i c a t i o n systems a r e a v a i l a b l e for h o m e use. T h e o p e r a t i n g r o o m nurse, as a professional, c a n s u p p o r t l e g i s l a t i o n f o r quality air standards at a t i m e w h e n economic pressures a r e w o r k i n g a g a i n s t t h e quality e n v i r o n m e n t w e n e e d in t h e U n i t e d States. O p e r a t i n g r o o m n u r s e s p e r s o n a l l y c a n a v o i d s m o k i n g and encourage o t h e r s t o quit. OR nurses c a n also serve as v o l u n t e e r s with t h e i r l o c a l lung association and support mass screening for c h r o n i c lung disease. In s u m m a r y , o p e r a t i n g r o o m n u r s e s may plan f o r t h e h i g h e s t n u m b e r of surg i c a l p a t i e n t s w i t h COLD in w i n t e r m o n t h s w h e n humidity i s h i g h e s t and t e m p e r a t u r e lowest. O p e r a t i n g r o o m nurses c a n increase t h e quality o f care o f s u r g i c a l COLD p a t i e n t s t h r o u g h ind i v i d u a l i z e d assessment and m a i n t e n a n c e o f o p t i m u m s t e r i l e t e c h n i q u e in t h e o p e r a t i n g room. In addition, t h e y c a n offer c o n s u l t a t i o n t o o t h e r n u r s e s o n aseptic techniques. OR n u r s e s h a v e a r e s p o n s i b i l i t y f o r g r e a t e r v i s i b i l i t y and for t h e p r o v i s i o n o f c o n t i n u i t y of care. 0 Notes 1. lnternational Classification of Diseases, adapted, 7th revision (Geneva: World Health Organization, 1965) 2 vols. 2. Ruth E Barstow, "Coping with emphysema," Nursing Clinics of North America (March 1974) 137145. 3. Ira Tager, Frank Speizer, "Role of infection in chronic bronchitis," New England Journal of Medicine 292 (1 975) 563-571. 4. Gareth Green, "Cell dysfunction as pathogenic determinant in chronic bronchopulmonary disease," Archives of Environmental Health 21 (October 1970) 48 1-482. 5. Jean G French, et al, "The effect of sulfur dioxide and suspended sulfates on acute respiratory disease," Archives of Environmental Health 27 (September 1973) 129-133. 6. Ernest Jawetz, Joseph Melnick, Edward Adelberg, Review of Medical Microbiology (Los Altos, Calif: Lange Medical Publishers, 1966). 7. M Modrak, et al, Better Living and Breathing (St Louis: C V Mosby Company, 1975).
Test for paralysis after spinal surgery A test that avoids waking the patient in the midst of general anesthetic to determine whether any paralysis has occurred in a spinal column operation was described to the American Society of Anesthesiologists at its October meeting in New Orleans by I Cary Andrews, MD, director of anesthesiology, Hospital of the Albert Einstein College of Medicine, New York City. The presence of jerky muscle contractions immediately after surgery can provide one of the earliest signs that no injury to the spinal cord has occurred, he said. The spasm, called clonus, is tested at the ankle and induced by suddenly pushing up the sole of the foot while the leg is extended. The concern about paralysis occurs in surgery when the spinal column is fused to correct scoliosis by inserting Harrington rods, which are retained for several months or years. Sometimes the rods can stretch arteries supplying the spinal cord and cause a neurologic impairment, including paralysis of the legs. In other cases, there could be accidental injury to the spinal cord due to hemorrhage. "To prevent this complication, various authors have described the technique of awakening patients intraoperatively to check voluntary motor power of the limbs," said Dr Andrews. "This requires the use of special anesthetic techniques and always runs the risk of patients moving excessively and possibly dislodging the Harrington rod." Dr Andrews described the conditions under which clonus occurs, including recovery from general anesthesia. It is commonly associated with halothane, used alone or in combination with other agents. In a study of 200 patients having surgery under a variety of general anesthetics, all were tested for clonus before and at the end of surgery and during their stay in the recovery room. Fifteen of the 200 cases were spinal cord surgeries using Harrington rods. Of the 15 Harrington rod cases, 14 had clonus after surgery. The major factor determining the presence or absence of clonus was the degree of recoveryof wakefulnessfrom the anesthetic state.
AORN Journal, March 1978, V o l 2 7 , No 4
753