Introduction
In the environment of a coronary care unit (CCU), maintaining a focus on creating a sustainable environment for patients, noting signs that indicate change, and introducing immediate measures in the case of any worsening of a patient’s condition are all important. The issue under discussion is especially critical when a patient experiences a cardiac arrest and requires a quick response by a nurse. As a rule, resuscitation is used to bring the return of spontaneous circulation (ROSC) in the instance of a heart attack (Kuisma et al., 2017). However, to improve outcomes and reduce the threat of a fatal outcome, nurses need an approach that will allow control of external factors, especially during the process of CPR when dealing with cardiac arrest. Langhan, Shabanova, Bernstein, and Shapiro (2015) described one possible solution in the following terms: “Capnography, or continuous end-tidal carbon dioxide (ETCO2) monitoring, is a sensitive indicator of ventilation that can alert a provider to hypoventilation more often and earlier than other modalities” (p. 25). This means that the application of capnography can help determine changes in the levels of ETCO2, which can be used to evaluate the cardiac output of a patient. As a result, the quality of care will rise systematically, potentially reducing the number of adverse patient outcomes.
Purpose Statement
The paper is aimed at exploring the effects of capnography during resuscitation as a means of monitoring the well-being of patients in the CCU environment. It is believed that the suggested device will serve as a basis for delivering improved care and reducing the probability of a fatal outcome among CCU patients. In particular, the paper aims to prove that applying capnography during resuscitation will allow staff to pinpoint scenarios that can lead to the development of a threat. The use of capnography will help maintain the level of ETCO2 during resuscitation at the required 20mmHg and facilitate taking timely measures to prevent a decline to the 10mmHg level most likely to entail a patient’s death. Thus, the purpose of the paper is to show that capnography will ultimately lead to an improvement in patient outcomes in the CCU setting due to a more attentive control over the level of ETCO2 in patients.
Literature Review
Capnography as a tool for improving outcomes among CCU patients during resuscitation promises a viable solution since it provides a tool for measuring ETCO2 output in a patient (Venkatesh & Keating, 2017). Although the importance of capnography in terms of enhancing resuscitation and leading to ROSC is understudied, existing evidence indicates that capnography should be included within the set of devices used in the CCU context for monitoring changes in patients.
According to a recent study, capnography can be used to improve resuscitation outcomes in instances that involve patient intubation (Lui, Poon, & Tsui, 2016). Moreover, Bullock, Dodington, Donoghue, and Langhan (2017) explained that capnography should be used when managing the needs of juvenile patients: “An increased frequency of ROSC was noted among children in our study when capnography was present, however, we are unable to accurately time the initiation of capnography monitoring during resuscitations” (p. 461). Therefore, the proposed tool requires changes in the current approach toward time management in the CCU setting. As a result, a corresponding change in the existing guidelines for conducting resuscitation may be required.
The use of capnography in cases that involve cardiac arrest is especially important due to the fact that this tool allows medical staff to address the lack of opportunities for measuring the coronary perfusion pressure (CPP) rates (Sheak et al., 2015). The issues associated with the unavailability of CPP data include the failure to track alterations in the patient’s systemic and coronary blood flow, hence the problems managing changes in ETCO2 levels (Hamrick et al., 2017). Furthermore, due to the challenges related to proper control over chest compressions, nurses often fail to identify alterations in ETCO2 levels (Dioso et al., 2017). As a result, fatal outcomes are becoming increasingly common in the environment of the CCU during resuscitation.
The process of using capnography during a cardiac arrest, in turn, provides an opportunity to handle the specified scenario appropriately and avoid further complications. In particular, the use of capnography serves as a non-invasive method of measuring and assessing systemic and pulmonary circulation in the course of performing CPR, thus allowing staff to predict possible outcomes (Mader, Coute, Kellogg, & Harris, 2014). Specifically, the patient’s cardiac output can be forecasted with the help of a capnography-based approach along with the measurement of the stroke volume index (Kalmar et al., 2018). Consequently, a set of strategies based on the use of capnography is required. Recent studies have supported the specified expectations; in particular, Pantazopoulos et al. (2015) noted that the relevant research “compared the use of mechanical and manual chest compressions during cardiac arrest based on continuous monitoring of ETCO2 and reported that cardiac output produced with mechanical chest compressions is increased compared to manual compressions” (p. 1056). Therefore, the use of a tool that allows monitoring ETCO2 outputs and determining the slightest changes in the rates of this factor will be likely to exponentially increase the chances for ROSC among CCU patients.
Case/Situation/Conditions
A Theoretical Perspective (Conceptual Model for Nursing and Nursing Theory of Self-Efficacy)
As the existing definition explains, the resuscitation process is “the use of therapeutic interventions primarily designed to restore spontaneous circulation following cardiac arrest” (Tobi & Amadasun, 2015, p. 132). The latter, in turn, is described as the “cessation of cardiac mechanical activity confirmed by the absence of a detectable pulse, unresponsiveness, and apnea (or agonal respirations)” (Tobi & Amadasun, 2015, p. 132). Since the specified process requires careful measurement of the expired carbon dioxide, it is believed to provide additional opportunities for ensuring the efficacy of “chest compressions and duration of cardiopulmonary resuscitation” (Kodali & Urman, 2014, p. 332).
Numerous factors can contribute to developing a condition requiring resuscitation, which suggests that using a combination of two theoretical perspectives may be conducive to positive outcomes. By deploying two middle-range theories that allow focusing on both the promotion of interdisciplinary communication and the acquisition of new skills among nurses, it will be possible to determine whether the use of capnography in the course of resuscitation leads to improved patient outcomes and creates more favorable conditions for a vulnerable population.
The case under analysis needs to be explored based on the tenets of the Conceptual Model for Nursing (CMN) and the Middle Range Nursing Theory of Self-Efficacy (NTSE). The CMN offers a multidisciplinary perspective on the subject matter, emphasizing the significance of multidimensional analysis (Lin, Guerguerian, Laussen, & Trbovich, 2015). From this perspective, the problem of managing the needs of CCU patients during resuscitation stems from a lack of skills related to cooperation, the ability to coordinate individual actions within a cross-disciplinary team, and the lack of clear guidelines for promoting change in the context of the CCU (specifically, the coordination of capnography and resuscitation).
The NTSE framework, in turn, allows seeing the problem of managing the needs of the target demographic from the position of building competence among the nursing staff. For example, in promoting positive changes in the nursing setting, the transition from the old to a new approach should be accompanied by changes in the nursing leadership framework and the enhancement of learning among nurses. As a result, this process will facilitate the acquisition of skills required for conducting capnography along with resuscitation.
Combining the two frameworks will provide a foundation for discussing the significance of capnography during resuscitation in patients in the CCU. Thus, it is possible to create opportunities for coordinating the actions of the nursing staff and ensuring that all available data is processed and taken into consideration when making a decision. Incorporating the theories in question will allow improvement in the existing guidelines and address any lack of knowledge among the nursing staff, while at the same time encouraging compliance with a new rigid set of standards.
Discussion and Synthesized Literature Findings
Although the use of capnography as a method of improving patient outcomes in the environment of the CCU is not currently regarded as the most common framework for increasing the possibility of a positive outcome, this approach should be integrated into the current system of CCU guidelines for resuscitation techniques. The identified change, however, will require rearranging existing roles among nurses in the target setting. In particular, the recommended procedure will require nurses to have the capability of monitoring capnography results, which will inform further choices in terms of techniques for increasing patients’ levels of ETCO2 and creating a more favorable setting for patients.
The issue in question requires a multimodal approach that implies rearranging the current set of priorities in the CCU environment as well as an alteration in the tasks that nurses perform. A nurse administrator will have to focus not only on including appropriate instructions for handling capnography-related processes, especially data management, but also on encouraging nurses to acquire the necessary skills to handle the new requirements. Nurses will have to monitor the changes in the data provided during capnography, which will furnish a guide for further choices to be made in a specific scenario. As a result, mortality rates among CCU patients undergoing resuscitation are expected to drop significantly, with a corresponding rise in the levels of ROSC.
The literature findings have also indicated that the process of incorporating capnography into the current set of strategies used by nurses in the CCU setting will require the use of tools that will contribute to a detailed analysis of all factors affecting the changes in patients’ ETCO2 rates. The identified task affects changes in chest compression levels, monitoring of circulation status, and evaluating factors that pose an immediate threat to the well-being of patients (Pantazopoulos et al., 2015). Therefore, a multifaceted approach to assigning staff members roles and responsibilities in the CCU setting is needed.
Summary
In the CCU setting, resuscitation often results in unfavorable consequences for patients, ranging from drastic aggravation of their condition to a fatal outcome. Therefore, the necessity of applying new tools that will help to improve the situation has become evident. Capnography can be seen as an important addition to the existing set of strategies for addressing the needs of patients in the CCU environment as it offers the capability to provide opportunities for normalizing and controlling the levels of ETCO2. The chances for monitoring crucial factors that may catastrophically affect a patient define the significance of capnography in the CCU context, yet this approach will also mandate rearranging the current guidelines for nurses. Therefore, significant alterations in the existing framework are needed. The focus on improving the quality of nurses’ skills should also be combined with a focus on managing a vast range of data and precisely assessing the situation.
Solutions: A Theoretical Approach
To properly address the needs of patients, a DPN will have to employ two middle-range theories to provide a multidimensional interpretation of the problem. Specifically, to ensure that a patient should be the focus of the process, it is appropriate to deploy the Conceptual Model for Nursing (CMN). Designed by Evelyn Adam, the proposed framework allows expanding the area of a DNP’s influence and challenging existing approaches to care by broadening the scope of nursing (Jaffe, 2017). In particular, the model encourages nursing inquiry and leads to the discovery of innovative techniques. Given the fact that adding capnography as a tool for managing the needs of CCU patients requiring lung ventilation is an unconventional approach toward resuscitation, the CMN will help establish a platform for changing the existing method involved in the resuscitation of CCU patients.
Specifically, the framework allows improving the existing set of guidelines for handling the needs of CCU patients that need lung ventilation and require active nursing support in the CCU setting. The theory allows not only improving the quality of care by placing emphasis on communication between nurses and other healthcare staff members in the CCU context but also developing more specific theories based on the outcomes of these interactions. Due to the vast range of factors that shape the outcomes of interventions performed in the CCU setting, it is critical to ensure that the participants are fully aware of the new strategies that should be used when performing resuscitation. In addition, the CMN framework will provide an opportunity to increase the efficacy of interdisciplinary communication in the CCU setting, thus helping nurses to cooperate more efficiently and avoid misunderstandings due to time pressure and responsibility when using the new technology.
Among the benefits of using the CMN framework as a middle-range theory that can be applied to the specified scenario, it is also important to mention the opportunities that it opens for interdisciplinary communication. As stressed in the previous discussion, any deficiency in quality communication between nurses and other staff members during resuscitation in the CCU setting negatively impacts the outcomes of the process to a significant degree. Furthermore, the fact that the suggested approach requires the acquisition of new skills, particularly prowess in using capnography and interpreting its results, speaks in favor of using the CMN framework in the CCU environment.
Finally, representing a general framework for managing patients’ needs and arranging the workflow within the selected setting, the theory will stimulate the development of minor theoretical frameworks that can be applied to patient-specific cases. As a result, when tailored to the needs of the specific demographic, CMN will help reduce the instances of information mismanagement and medical errors that ensue from mishandled communication.
Another theoretical framework that will need to be applied to the specified analysis is the Middle Range Nursing Theory of Self-Efficacy (NTSE). Also belonging to the list of middle-range theoretical frameworks, the NTSE manages disorder from the perspective of quality improvement. The NTSE tool provides the capability to shift the focus from handling a single process to multitasking and arranging available data into categories to determine the effects of identified factors (Smith & Liehr, 2018). As a result, a nurse can develop a comprehensive approach toward managing information flow within the CCU context.
The proposed approach will help portray the process of capnography through the lens of encouraging professional growth among nurses and allowing them to acquire new competencies that will help them coordinate the process of resuscitation with the addition of capnography and interpretation of its results. Specifically, the NTSE model introduces nurses to the process of aligning the management of resuscitation and performing capnography with the simultaneous monitoring of the described tasks (Hassankhani, Aghdam, Rahmani, & Mohammadpoorfard, 2015). Yen et al. (2016) posited that “the related concepts of concurrent multitasking, dual-task performance, parallel task performance, interleaved multitasking, and sequential multitasking describe various aspects of the cognitive processes believed to be associated with multitasking” (p. 1264). The specified framework allows viewing capnography as an inseparable part of the CCU nursing framework, making the process of arranging the workflow and prioritizing tasks significantly easier.
Therefore, by combining the CMN and NTSE theories and incorporating them into the analysis, it will be possible to identify strategies for improving the quality of care. The theories under discussion will contribute to a better understanding of how capnography can be used to improve the performance of nurses and create an environment in which they can manage patients’ needs successfully. Furthermore, the combination of CMN and NTSE will help in transitioning seamlessly from the traditional set of strategies for tending to the needs of CCU patients to the newly designed guidelines. As a result, the possibility of quality-associated issues, such as the potential for medical errors or information mismanagement, will be minimized. Therefore, the proposed approaches should be seen as a platform for managing the issue.
Research Instrument
In order to prove that the application of capnography will be beneficial for patients undergoing resuscitation in the CCU setting, a measurement tool will be essential. Since the research question involves the comparison of two interventions, a randomized controlled trial (RCT) will include Group A, in which capnography will be performed, and a control group. Thus, a quantitative analysis will be performed. The use of this RCT will allow evaluating the proposed framework by comparing the outcomes among patients in both groups, identifying the effects of the application of capnography on the efficacy of the resuscitation process and the transition to ROSC in CCU patients (Lin et al., 2017). Therefore, the specified instrument will be deployed to determine any connection between observed changes in the recovery dynamics in Groups A and B.
To obtain the results required for the assessment of the suggested strategy and determine whether nurses are capable of using the specified device in the context of the CCU environment, it will be necessary to employ the Nurses’ Knowledge about Capnography Test (NKCT). According to Kiekkas, Stefanopoulos, Konstantinou, Bakalis, and Aretha (2016), the proposed device allows the evaluation of nurses’ ability to perform the required actions during resuscitation of patients in the CCU as well as an assessment of their psychometric skills.
NKCT will reveal the nurses’ progress after the adoption of the specified technique and measure their ability to attain ROSC within a shorter amount of time, thus raising patients’ chances for survival. This tool will also help determine the proficiency of the nursing staff by providing data that will allow comparing the time lapse between the identification of the relevant data provided by capnography in the CCU setting and the time used to manage patients’ needs without capnography. Since the study is aimed at determining the efficacy of capnography as a means of increasing the incidence of ROSC among patients undergoing resuscitation in the CCU environment, the use of microdialysis should also be regarded as essential. The specified device represents not only a method of monitoring the well-being of patients that have suffered a severe brain injury but also an important research instrument that helps determine the threat of a heart attack.
Conclusion
The problem of addressing the needs of patients experiencing cardiac arrest in the CCU setting is not new, yet few viable solutions have been introduced to date. It is assumed that the incorporation of capnography into the specified setting will allow nursing staff to monitor crucial factors, particularly the levels of ETCO2 in patients, to prevent the occurrence of critical situations in which ROSC will become impossible. As a result, resuscitation in the CCU is bound to lead to better patient outcomes, decreasing mortality rates among the target demographic.
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