American Association of Neuroscience Nurses, Society of Pediatric Nurses & American Pediatric Surgical Nurses Association, Inc.

Eight Things Nurses and Patients Should Question

Released December 1, 2022

  1. 1

    Don’t routinely order a head CT to assess for shunt failure in children with hydrocephalus.

    Computerized tomography (CT) scans have been used for diagnostic imaging for more than 40 years, but it should not be assumed that a head CT is always needed in an evaluation for shunt failure. Because CT is the usual mode of imaging for children with hydrocephalus, these patients have a much higher cumulative radiation exposure than the average population. Children have an increased risk of cancer with exposure to higher cumulative radiation doses. CT scans should be performed only when warranted to reduce exposure to radiation and decrease the risk for radiation induced cancer. Consider using head ultrasounds when there is an open fontanel, or a rapid sequence magnetic resonance imaging (MRI) scan to reduce the amount of ionizing radiation exposure to pediatric patients with a ventricular shunt. A rapid sequence MRI is less expensive than a formal MRI and comparable in costs to CT scan. Because the rapid sequence MRI is quick, sedation is not needed, further reducing costs and medical risks of sedation. A CT scan can be used for emergencies and if the child has implanted metal or a device that is not compatible with an MRI.

  2. 2

    Don’t routinely order an EEG on neurologically healthy children who have a simple febrile seizure.

    Febrile seizures are the most commonly occurring seizures in the first 60 months of life. Caregiver anxiety can often lead to requests for neurodiagnostic testing. Attention should be directed at finding the cause of fever and treating it. Electroencephalogram (EEG) tests are costly and can increase caregiver and child anxiety without changing the outcome or course of treatment. EEG has not been shown to predict recurrence of febrile seizures or future epilepsy in patients with simple febrile seizures. EEG can be ordered for children that present with afebrile seizures, complex febrile seizures and in children with neurological insult.

  3. 3

    Don’t administer diazepam for muscle spasm following spine surgery in the elderly.

    Classic spine surgical treatment involves bilateral dissection of paraspinal muscles to expose the involved levels. Spasms of these muscles are common postoperatively. Treatment of these spasms should include both pharmacologic and non-pharmacologic interventions. Age-related changes in adults can affect both metabolism and drug elimination in the body, resulting in a prolonged half-life for medications. Among the benzodiazepines, diazepam is particularly problematic due to its long half-life and many active metabolites. Benzodiazepines can lead to over-sedation, potential for respiratory depression, increased risk of delirium, and extended in-hospital recovery time. Benzodiazepines have consistently been associated with falls in the aging population and should be avoided. Effective non-pharmacological interventions for use include heat, cold, repositioning, and massage.

  4. 4

    Don’t use lumbar puncture (LP) opening pressure as a reliable measure of intracranial pressure in children with severe chronic headache.

    There are many limitations with LP pressure measurement as it varies with patient position and level of the manometer. As a “snapshot in time,” it cannot be correlated with symptoms over time, and anesthetic agents can cause false readings. An intracranial monitor (bolt) measures intracranial pressure (ICP) over time as the patient goes about daily activities. Medical and surgical treatment decisions are based on relieving intracranial pressure. Inaccurate pressure readings can lead to unnecessary surgeries such as cranial vault expansion, shunt revisions and placement of lumbar-peritoneal shunts as well as unnecessary medical treatments.

  5. 5

    Don’t order “formal” swallow evaluation in stroke patients unless they fail their initial swallow screen.

    Dysphagia (difficulty swallowing) is a common disorder in patients who have suffered a stroke, occurring in 50–60% of acute stroke patients. It is associated with an increased risk of aspiration, pneumonia, prolonged hospital stay, disability, and death. Swallow screening is critical in the rapid identification of risk of aspiration in patients presenting with acute stroke symptoms. Because formal swallowing evaluation is not warranted in all patients with acute stroke, the purpose of a swallowing screen is to identify those who do not need a formal evaluation and who can safely take food and medication by mouth. Formal swallowing evaluations can be done in patients who don’t pass the initial screening.

  6. 6

    Don’t apply continuous cardiac-respiratory or pulse oximetry monitoring to children and adolescents admitted to the hospital unless condition warrants continuous monitoring based on objectively scored cardiovascular, respiratory, and behavior parameters.

    Nurses use continuous electrocardiography (ECG), respiratory, and pulse oximetry monitoring to track patient vital signs and trends, and to help identify signs of patient status deterioration. However, when pulse oximetry and physiologic monitoring are used inappropriately, significant cost burdens can affect the entire healthcare system. In addition, the high number of alarm alerts and level of noise created by these alarms leads to alarm fatigue. When high levels of false alarms occur in the work environment, clinically significant alarms may be masked by being silenced or unrecognized when clinicians become desensitized. In addition to alarm fatigue, continuous bedside monitoring of pediatric patients can provide a false sense of security that the patient is “safer” and that the nurse will note status changes in a patient more easily when a bedside monitor is used. Continuous bedside monitoring should not be used in place of hourly safety checks. Focused nursing assessments using a standardized early warning tool should be used to monitor changes in a pediatric patient’s status to identify deteriorations.

  7. 7

    Don’t routinely repeat labs hemoglobin and hematocrit in the hemodynamically normal pediatric patients with isolated blunt solid organ injury.

    Preset timed interval measurements of hemoglobin and hematocrit are no longer indicated as early detectors of instability. Clinical instability is defined by physiologic criteria such as age-specific tachycardia or hypotension, tachypnea, low urine output, altered mental status, or any significant clinical deterioration that warrants increased level of care and investigation. Therefore, the routine use of repeat laboratories studies in children with isolated solid organ injury who have physiologically normal vital signs for their age is not necessary.

  8. 8

    Don’t remove hair at the surgical site including the hair on the patient’s head, but if hair must be removed it should be clipped not shaved.

    Removing hair at the surgical site has long been believed to be associated with an increased rate of surgical site infections because of razor-induced microtrauma. Specifically, shaving the patient’s head prior to neurosurgery can disturb the natural protective effects of hair and skin flora, also causing micro-abrasions to the scalp that can increase the risk of infection. Postoperative wound infections increase the costs and the length of hospital stay. In any type of surgery there are times when hair removal should be considered. For example, during emergent craniotomies or any time a surgeon deems hair removal necessary for the surgical procedure. When hair removal is necessary, hair at the surgical site should be removed by clipping or depilatory methods. A razor should not be used. In a landmark nonexperimental study of 23,649 surgical wounds, Cruse (1973) found a 2.3% infection rate for surgical sites shaved with a razor, 1.7% for sites that were clipped, and 0.9% when no hair removal was performed. Yet shaving hair at the surgical site continues to be practiced. In addition, most patients dread the thought of having the hair on their head removed, and hair shaving can negatively affect their body image.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a health professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician or nurse.

About American Association of Neuroscience Nurses

The American Association of Neuroscience Nurses (AANN) is the leading authority in neuroscience nursing. AANN is committed to working for the highest standard of care for neuroscience patients by advancing the science and practice of neuroscience nursing. AANN supports neuroscience nurses and their patients by providing continuing education and certification preparatory materials, disseminating information, setting standards, and advocating on behalf of neuroscience patients, families, and nurses.

About Society of Pediatric Nurses

The Society of Pediatric Nurses (SPN) represents a worldwide network of over 3,500 pediatric nurses across 28 specializations from across the United States and across the world. The society provides educational resources, practice resources, publications, events, seminars, industry data and research and networking opportunities that are developed specifically for those within the pediatric nursing industry and help to support job excellence and success in their practice setting. For more information, please visit www.pedsnurses.org

About American Pediatric Surgical Nurses Association, Inc.

The American Pediatric Surgical Nurses Association, Inc. (APSNA) is a dynamic, vibrant organization of members representing various nursing roles including bedside nurses, perioperative nurses, advanced practice nurses, nurse managers and nurse educators. To that end, APSNA leads the way in providing a variety of resources aimed at meeting your practice needs.

Since 1992, APSNA has grown in scope and numbers. Pediatric surgical nurses work in a team-oriented environment. The broad scope of pediatric nursing practice is what makes this field both challenging and rewarding. To learn more about this organization, visit us at www.apsna.org

How This List Was Created

(1–5 & 8) Members of the American Association of Neuroscience Nurses formed a task force to review evidence and make a recommendation of 5–10 things nurses should tell neuroscience patients to consider. AANN’s Special Focus Groups, which are composed of subject matter experts in various subspecialties of neuroscience, were consulted to help identify topics and provide supporting evidence. The task force reviewed the items for possible inclusion to determine the top recommendations. The top recommendations were presented to the AANN Board for review and approval.

(6) SPN initially reached out to several subject matter experts to learn about topic areas where they were aware of both evidence of overuse of health care resources and evidence-based resources to support addressing that overuse. SPN then chose two experts with research experience within the topic area we identified. One served as the main author while the other served as the reviewer. After the initial review was completed, we shared the content with the SPN Board of Directors for further input. Finally, colleagues at the American Academy of Nursing provided a final review.

(7) Once the American Pediatric Surgical Nurses Association, Inc. (APSNA) received an invitation from the Institute of Pediatric Nursing (IPN) to participate in the initiative, the APSNA Board was queried to identify pediatric nursing practices that should be modified based on evidence. The identified practice was presented to experts from APSNA’s Board of Directors, General Membership and Trauma Special Interest Group (SIG). The preliminary statement was reviewed and revised by content experts from both within and outside of the organization. Subsequently, the statement was submitted to the APSNA Board for final discussion and review. The final statement was reviewed and approved by the American Academy of Nursing.

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