We believe that Nursing is united by: • A personal commitment to caring • A dynamic search for professional

excellence

• A team spirit of courage, joy and hope in our interaction with mankind

The Key Components Of Our Practice • Caring and Compassionate Environment • Professional excellence • Continuum of Care • Mind, Body and Spirit approach to

Health and Wellness • Evidence-based Practice • Sensitivity for Customer Service,

Outcomes and Cost • Advocacy • Collaboration across disciplines • Autonomy

1.What's Evidence Based Nursing (EBN)? Evidence Based Nursing is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences. Three areas of research competence are: interpreting and using research, evaluating practice, and conducting research. These three competencies are important to EBN.

2.Evidence-based practice (EBP) involves complex and conscientious decision-making which is based not only on the available evidence but also on patient characteristics, situations, and preferences. It recognizes that care is individualized and ever changing and involves uncertainties and probabilities.

The movement of evidence-based healthcare has evolved over time. Dominant themes for the decades of 1970-1980 were "doing things cheaper" (efficiency) and "doing things better" (quality improvement). These two themes together were considered "doing things right." During 1980-1990, "doing the right things" (increasing effectiveness) was the major theme and this, in combination with "doing things right" was considered "doing right things right" in the 21st century (Gray, 1997). These days, practitioners have come to expect evidences for their interventions, some to the point of saying, "In God we trust: All others bring data" (Cornelia Beck, as cited in Tanner, 1999). The history of evidence-based nursing is closely related to the evolution of evidence-based health practice and evidence-based medicine.

(Florence Nightingale 1860/1969)

- the Mother who gave birth to Professional Nursing -by publishing her Notes on Nursing

-demonstrating evidence of its efficacy by statistics

- recognized the potential of combining sound logical reflection and empirical research in the development of scientific knowledge about nursing and the application of its principles in professional nursing.

Virginia Henderson(1960) Second Pragmatic Visionary Nurse Defined the function of nursing Because of its conceptual clarity, this

description of nursing was accepted by the ICN.

This description structured Henderson's meticulous search for empirical evidence already generated by the physical, biological, and social sciences foundational to nursing

(Henderson & Nite, 1978), collected the wealth of empirical evidence

in Principles and Practice of Nursing . This description also structured her

identification of research questions with great relevance for professional nursing practice.

last 40 years – efforts to generate evidence-based practice have intensified and expanded.

Nurse theorists - Orem, Rogers, Leininger, Roy, King, Parse, Newman, and Benner in the US Roper, Juchi, Bienstein, van der Bruggen, and Norberg in Europe

• Nursing research began to focus on clinical issues in the mid 80's (Stevens & Cassidy, 1999). • The National Institute for Nursing Research (NINR) was formed in 1986, greatly increasing the visibility and funding opportunities for nursing research. • Many new journals emphasize nursing research • In recent years the International Society for Nursing Research, Sigma Theta Tau, has greatly increased its capacity to support and disseminate nursing scholarships • McMaster University in Ontario, Canada has developed extensive resources in teaching and implementing evidence-based practice in nursing and other disciplines

Factors to be considered to carry out EBN -sufficient research must have been published on the specific topic -the nurse must have skill in accessing and critically analyzing research -the nurse's practice must allow her/him to implement changes based on EBN

DEFINITIONSSackett (1996) Evidence Based Medicine • "Integrating clinical expertise and the best available evidence from systematic researchStetler (1998) Evidence Based Nursing • "De-emphasizes ritual and isolated unsystematic clinical experience, ungrounded opinions and traditions• "Emphasizes research, findings from QI data and other operational and evaluation data, consensus of experts, affirmed experiences.Evidence-based practice refers to a decision-making approach based on integrating clinical expertise with the best available evidence from systematic research. This is in contrast to opinion-based decision-making that is based primarily on values and resources (Gray, 1997).Ingersoll (2000) proposed the following definition. "Evidence-based nursing practice is the conscientious, explicit and judicious use of theory-derived, research based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences“

Evidence-based Nursing Practice: solves problems encountered by nurses by carrying out four steps:

I. Clearly identify the issue or problem based on accurate analysis of current nursing knowledge and practice

II. Search the literature for relevant research

III. Evaluate the research evidence using established criteria regarding scientific merit

IV. Choose interventions and justify the selection with the most valid evidence

(1) The Conduct and Utilization of Research in Nursing (CURN) project.The CURN Project was designed to develop and test a model for using research-based knowledge in clinical practice settings. Research utilization is viewed as an organizational process. Planned change is integrated throughout the research utilization process. Systems change is essential to establishing research-based practice on a large scale.

(2) The Stetler Model of Research UtilizationThe Stetler Model of Research Utilization applies research findings at the individual practitioner level. The model has six phases: (1) preparation, (2) validation, (3) comparative evaluation, (4) decision making, (5) translation and application, and (6) evaluation. Critical thinking and decision making are emphasized.

(3) Iowa Model for Research in Practice The Iowa Model of Research in Practice infuses research into practice to improve the quality of care , and is an outgrowth of the Quality Assurance Model Using Research (QAMUR). Research utilization is seen as an organizational process. Planned change principles are used to integrate research and practice. The model integrates evidence-based healthcare acknowledges and uses a multidisciplinary team approach.

The Star Model of Knowledge Transformation is a model for understanding the cycles, nature, and characteristics of knowledge that are utilized in various aspects of evidence-based practice (EBP). The Star Model organizes both old and new concepts of improving care into a whole and provides a framework with which to organize EBP processes and approaches.

The Star Model depicts various forms of knowledge in a relative sequence, as research evidence is moved through several cycles, combined with other knowledge and integrated into practice. The ACE Star Model provides a framework for systematically putting evidence-based practice processes into operation.

Definition of Knowledge Transformation--the conversion of research findings from primary research results, through a series of stages and forms, to impact on health outcomes by way of EB care.

STAGES OF KNOWLEDGE TRANSFORMATION 1. Discovery 2 . Evidence Summary

3. Translation 4. Integration5. Evaluation

1. Discovery

This is a knowledge generating stage. In this stage, new knowledge is discovered through the traditional research methodologies and scientific inquiry. Research results are generated through the conduct of a single study. This may be called a primary research study and research designs range from descriptive to correlational to causal; and from randomized control trials to qualitative. This stage builds the corpus of research about clinical actions.

2. Evidence Summary

Evidence summary is the first unique step in EBP—the task is to synthesize the corpus of research knowledge into a single, meaningful statement of the state of the knowledge

This stage is also considered a knowledge generating stage, which occurs simultaneously with the summarization. Evidence summary produces new knowledge by combining findings from all studies to identify bias and limit chance effects in the conclusions. The systematic methodology also increases reliability and reproducibility of results

3.Translation

The transformation of evidence summaries into actual practice requires two stages: translation of evidence into practice recommendations and integration into practice.

The aim of translation is to provide a useful and relevant package of summarized evidence to clinicians and clients in a form that suits the time, cost, and care standard. Recommendations are generically termed clinical practice guidelines (CPGs) and may be represented or embedded in care standards, clinical pathways, protocols, and algorithms.Summarized research evidence is interpreted and combined with other sources of knowledge (such as clinical expertise and theoretical guides) and then contextualized to the specific client population and setting. Evidence-based CPGs explicitly articulate the link between the clinical recommendation and the strength of supporting evidence and/or strength of recommendation.

4. Integration

Integration is perhaps the most familiar stage in healthcare because of society’s long-standing expectation that healthcare be based on most current knowledge, thus, requiring implementation of innovations. This step involves changing both individual and organizational practices through formal and informal channels. Major factors addressed in this stage are those that affect individual and organizational rate of adoption of innovation and integration of the change into sustainable systems.

5. Evaluation

The final stage in knowledge transformation is evaluation. In EBP, a broad array of endpoints and outcomes are evaluated. These include evaluation of the impact of EBP on patient health outcomes, provider and patient satisfaction, efficacy, efficiency, economic analysis, and health status impact.As new knowledge is transformed through the five stages, the final outcome is evidence-based quality improvement of health care.

(Voda et al. 1971) the research-practice gap was the result of 1. Failure to directly involve clinical nurses in research projects; 2. Researchers not directly being involved with patient care and; 3. Nurses failing to read research. 4. (Smith 1986 & Miller et al., 1997) insufficient time for nurses to

participate in research activities. 5. Practicing clinicians do not understand the importance of

research. 6. Cruickshank (1996), Walsh & Ford (1986:2) 'nursing tends to

be in-situation driven rather than research driven and actions have become rituals.‘

7. Akinsanya (1993:174) research as a minute and difficult component" of undergraduate nursing programs

Strategies to reduce the research-practice gap:

1.Further development of leadership skills amongst nurses

2.The development of research teams 3.An increase in the research

components in undergraduate and post graduate courses and an improvement of nursing research skills amongst nursing lecturers.

HYDRATION MANAGEMENT

Nursing Standard of Practice Protocol: Oral Hydration Management

Goal To minimize episodes of dehydration in older adults.Overview Maintaining adequate fluid balance is an essential

component of health across the life span; older adults are more vulnerable to shifts in water balance, both over-hydration and dehydration, because of age-related changes and increased likelihood that they have several medical conditions. Dehydration is the more frequently occurring problem.

A. Definitions 1. Hydration management is the promotion of adequate fluid

balance that prevents complications resulting from abnormal or undesired fluid levels. (See Resources: Dochterman & Bulechek, 2004).

2. Dehydration is depletion in TBW content due to pathologic fluid losses, diminished water intake, or a combination of both. It results in hypernatremia (>145mEq/L) in the extracellular fluid compartment, which draws water from the intracellular fluids. The water loss is shared by all body fluid compartments and relatively little reduction in extracellular fluids occurs. Thus, circulation is not compromised unless the loss is very large. This is also known as intracellular dehydration or hypernatremic dehydration (Na > 145mE/L).

3. Volume depletion is the loss of both sodium and water with greater losses of sodium resulting in extracellular fluid loss and a reduction in intravascular volume, 1 also called hypotonic dehydration.

B. Etiologic factors associated with dehydration

1. Age-related changes in body composition with resulting decrease in TBW.

2. Decreasing renal function.

3. Lack of thirst.

C. Risk Factors 1. Individuals older than 85.

2. Individuals who are institutionalized.

3. Individuals with ADL dependencies, specifically feeding and eating.

4. Individuals with a diagnosis of dementia.

5. Individuals with infections.

6. Individuals who have had prior episodes of dehydration.

A. Health history 1. Specific disease states:

dementia, congestive heart failure, chronic renal disease, malnutrition, and psychiatric disorders such as depression.

2. Presence of co morbidities: more than four chronic health conditions.

3. Prescription drugs: number and types.

4. Past history of dehydration, repeated infections

B. Physical Assessments

1. Vital signs2. Height and weight3. BMI

4. Review of systems5. Indicators of hydration

C. Laboratory Tests 1. Urine specific gravity.

2. Urine color.

3. BUN/creatinine ratio

4. Serum sodium

5. Serum osmolality

D. Individual fluid intake behaviors.

A. Risk Identification 1. Identify acute situations: vomiting, diarrhea, or febrile

episodes

2. Use a tool to evaluate risk: Dehydration Appraisal Checklist

B. Acute Hydration Management 1. Monitor input and output.

2. Provide additional fluids as tolerated.

3. Minimize fasting times for diagnostic and surgical procedures.

C. Ongoing Hydration Management 1. Calculate a daily fluid goal.

2. Compare current intake to fluid goal.

3. Provide fluids consistently throughout the day.

4. Plan for at-risk individuals a. Fluid rounds.

b. Provide two 8-oz. glasses of fluid, one in the morning and the other in the evening.

c. "Happy Hours" to promote increased intake.

d. "Tea time" to increase fluid intake.

e. Offer a variety of fluids throughout the day.

5. Fluid regulation and documentation a. Teach able individuals to use a urine color chart to monitor hydration

status.

b. Document a complete intake recording including hydration habits.

c. now volumes of fluid containers to accurately calculate fluid consumption.

d. Maintenance of body hydration.

Evaluation and Expected Outcomes A. Decreased infections, especially urinary tract infections. B. Improvement in urinary incontinence. C. Normal urinary pH. D. Decreased constipation. E. Decreased acute confusion  

Follow-up Monitoring of Condition A. Urine color chart monitoring in residents with better renal

function. B. Urine specific-gravity checks. C. 24-hour intake recording.  

Relevant Practice Guidelines A. Hydration-Management Evidence-Based Protocol