The Plan

Neuroscience Nursing Nursing Assessment in Acute Neurologic Injury Correlational Neuroanatomy Neuroscience Nursing Research Evidence-based practice and neuroscience application of nursing research to the practice of neuroscience Examples of nursing research in Neuroscience

DaiWai M. Olson PhD RN CCRN Assistant Professor of Medicine/Neurology

Disclosures
Research Grant Recipient
Aspect Medical Systems Alsius Medical Amer. Assoc. Crit. Care American Heart Assoc. Bristol-Meyers Squibb Edwards Lifesciences Hospira LiDCO Corporation Medicines Company Medtronic Corp. Nat. Inst. Health (NIH) Neuro. Nursing Foundation Sanofi Aventis

Speakers Bureau

Abbott Laboratories Aspect Medical Systems Alsius Medical Barbara Clark-Mims Assoc. Hospira Medivance Corp USB Pharma Zoll Medical Stock/Financial interest None

A B C D E FGHIJKLMNO
C Airculation irway
A Breathing irway B Creathing irculation Disability Expose

Evidence
Circulation Airway - Breathing
Editorial Board

2010 AHA Guidelines for CPR and Emergency care Science

2010

Circulation
Vol. 122 S640-S656

ABCDEF

G H I JKLMNO

Fahrenheit (temperature)
Gadgets (your call) History (1st assessment)
Head - to Toe (every time)

I.V. s (your call)

ABCDEFGHIJ

KLMNO

Jackson-Pratt (all drains)

Keep family informed

Labs (due, done, & to treat)

Medications (due, done & followup)

New orders

ABCDEFGHIJKLMNO
Okay
Okay, move on Overview On top of it Other patients Other projects (chart)

The great divide

Upper motor neuron lesion
Lower motor neuron lesion

What is a lesion anyway ?

Non-specific term refers to any abnormal tissue

Evidence
Nurses differentiate UMN vs LMN
K. Clarke & T. Levine

Clinical Recognition and Management of Amyotropic Lateral Sclerosis: The Nurses Role
2011

Journal of Neuroscience Nursing

Vol. 43 (4) pp 205-214

Upper or Lower ?
Lower motor neurons are:

From the SPINAL CORD to the MUSCLE

Upper or Lower ?
Upper motor neurons are:

From the BRAIN to the SPINAL CORD

NICE to KNOW Efferent-----Afferent------

Upper or Lower Motor Neuron

Upper Motor We F A
Weakness Fasciculations

Lower Motor
Present Yes Yes Down Down

Present No No Up Up

R T

Atrophy
Reflexes Tone

The Case of J. P.
Primary lesson is Nursing assessment

Highlighting
Nursing Assessment

Evidence
for telling stories
M. Sandelowski

We are the stories we tell

1994

Journal of Holistic Nursing

Vol. 12 (1) pp 23-33

What happened to J.P.?

We need to understand 3 things
1. 2. 3.

Cerebral artery circulation Cranial nerves Do your damn job

Please

J.P.
20 year old G.I. return from Iraq
Prior to formation c/o dizzy and thirsty Went for gatorade tell everyone I went back

Found unresponsive minutes later, minimal

respiratory effort, EMS called by C.O. Transfer to Duke Glasgow Coma Score = 3

Complete Basilar Artery Thrombosis

MERCI
Merci retrieval
Returned to ICU

ICU
Day 1 32 C for 24 hours

Day 2 wean paralytics passive rewarm on

Day 3 he returned to baseline temp, wean pressors Day 4 ventric inserted (ICP =36) = GCS 4 , extensor posturing, pupils sluggish, irreg shape, no dolls eyes, weak gag, good cough Day 5 See video on next slide for NIHSS exam

 Day 5 = GCS from 3 8

ICU

Day 6 = GCS from 8 -10

Hmmm???

Thalamus

Midbrain

Appearance GCS / NIH Cranial Nerves Motor Aphasia

Pons

Medulla

Cranial Nerves
12 pairs
Of Cranial

Nerves
In The Brain Stem
Teaching Tip Lets Play GOD

Cranial Nerves Playing GOD

What is this? Midbrain

Pons

Medulla

Cranial Nerves Playing GOD

Where will you nerves ? What would youput call12 these 12 nerves? How about 12 nerves - - - 3 places ? ? ? 1

2
Midbrain

3 4 5

Appearance

Pons
GCS / NIH Cranial Nerves

6 7 8

9
10

Medulla Motor
Aphasia

11 12

Cranial Nerves Playing GOD

BONUS Question for GOD Where would you put #1, #2 . . . Etc?

Midbrain

I II III IV

Appearance

Pons
GCS / NIH Cranial Nerves

V VI VII VIII

Medulla Motor
Aphasia

IX X XI XII

Cranial Nerves
I II III IV V VI VII VIII IX Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Smell Vision Eye movement Eye movement Face/mouth Eye movement expressions

Auditory hearing/balance
Glossopharyngeal

Taste

X
XI XII

Vagus
Spinal Accessory

HR / BP
swallowing tongue movement

Hypoglossal

On Old Olympus Towering Top A Friendly Viking Grew Vines And Hops

Some Say Marry Money But My Brother Says Bad Business My Man

There Are Others ! ! !

Evidence
for Cranial Nerve Assessment
T. Latha, R. Prakash, L.D. Josphine

Effectiveness of two Teaching Methods for Cranial Nerve Assessment

2011

International Journal of Nursing Education

Vol. 3 (2) pp 65-69

CN I - Olfactory
Characteristics: Sensory
Sense of smell

Clinical Correlate
Injury will result in a loss of

smell

CN II - Optic
Characteristics: Sensory
Vision Pupillary light reflex

Clinical Correlate
Injury will result in a loss of

vision Injury will cause a loss of pupil constriction to light (direct)

CN III

CN III - Oculomotor
Characteristics: Motor
Motor of the oculo Upward movement of the

Clinical Correlate
Patients with CN III injury

eyeball Raising the eyelid Pupillary constriction with accomodation

look down and out. Injury causes diplopia BLOWN PUPIL from CN III compression secondary to elevated ICP

III

Pupil = little doll (latin pupilla)

Swinging Flashlight - Test

Normal Reaction

Swinging Flashlight - Test

Marcus Gunn

CN IV - Trochlear
Characteristics: Motor
Rotation and adduction of

Clinical Correlate
Lazy downward gaze

the eye

CN V - Trigeminal
Characteristics: Both
Sensation (touch) face, scalp,

Tri

Clinical Correlate
Injury results in loss of facial

cornea Motor for chewing

sensation, decreased direct corneal reflex Partial facial paralysis

= three

CN VI - Abducens
Characteristics: Motor
Lateral movement of the eye

Clinical Correlate
The patient can not look to

the side with the affected eye (maintains peripheral vision)

The six cardinal fields of gaze

The Visual Exam

Vision (CN II)
How many fingers do you see

Pupillary reflex (CN III)

Direct response to light

EOMs (CN IV and CN VI)

Follow my fingers as I make the letter N

Swinging flashlight

CN VII - Facial
Characteristics: Both
Sensory is taste on the front

Clinical Correlate
Injury leads to crocodile tears Decreased taste sensation Poor closure of the eye

2/3 of the tongue Motor is for facial expression, eyelid closure and for both the lacrimal & salivary glands

CN VIII - Vestibulocochlear
Characteristics: Sensory
Hearing Equilibrium Balance Some feedback to

Clinical Correlate
Wobbly Vertigo Loss of hearing Patients flip upside down in

compensatory eye movement (dolls eyes)

bed

G CN IX - Glossopharyngeal
Characteristics: Both
Sensory taste on posterior

Clinical Correlate
Injury will result in a loss of

portion of tongue Motor parotid gland

taste Loss of Gag reflex

= Gag

CN X - Vagal
Characteristics: Both
Sensory sensation of the

Clinical Correlate
Loss of gag & cough reflex Bradycardia

pharynx & larynx & Carina Motor swallowing, cardiac & GI

CN XI - Accessory
Characteristics: Motor
SCM and Trapezius

Clinical Correlate
Injury will result in an inability to turn head or droopy shoulders

Accessorize !

CN XII - Hypoglossal
Characteristics: Motor Clinical Correlate
Injury will result in tongue

deviation. The tongue points to the weak side

This test may not be as clinically relevant as we want it to seem

Im gonna go pretty fast!

but trust me. . . Its gonna end up alright !

The Case of Delia Washington

Highlighting

Aneurysms

Cerebral Arteries

Miss Delia
While at church c/o WHOL & DFO Family rushed her to OSH

Transfer to Duke as probably an SAH

GCS = 6 (E2, V1, M3[flexion])
DFO she got all swimmy headed and done fell out

Emergency Department
Rapid assessment A B C D
Stroke Code Imaging (?WHY? Is imaging important)

Imaging to rule out/in bleeding

Stroke
Ischemic >24 hours = Acute ischemic Stroke (AIS) <24 hours = Transient ischemic attack (TIA)
Hemorrhagic Subarachnoid Hemorrhage (SAH) Intracerebral Hemorrhage (ICH)

Evidence
Nursing Role in Emergence Stroke care
DM Olson, M Constable, G Britz, CB Lin, L Zimmer, LH Schwamm, GC Fonarow, ED Peterson

A Qualitative Assessment of Practices Associated with Shorter Door-to-Needle Time of Thrombolytic Therapy in Acute Ischemic Stroke
2011

Journal of Neuroscience Nursing

Vol. 43 (6) pp 329-336

Cerebral Aneurysm
Nearly 20 million Americans harbor an aneurysm
Annually 30,000 of these rupture resulting in

subarachnoid hemorrhage (SAH)

Women affected more than men Typically present between 35-60 years of age

Aneurysms

A bubble in an artery caused by a weakening of the vessel wall.

Delia
CT shows diffuse blood Suspicious for aneurysm Transfer to NeuroCritical Care Unit (NCCU) Develops continually falling level of consciousness Progression in weakness of her left arm.
Prep for ANGIOGRAM

Delia
Stabilize & prep for A-gram
Why A-gram and not O.R.

Aneurysm treatment option

Coiling
Insertion of tiny platinum

coils into the aneurysm, blocking blood flow to the aneurysm. If the aneurysm has a wide neck, a stent can be deployed across the neck to keep the coils in place.
http://www.brainaneurysm.com/aneurysmtreatment.html

Wide Neck Aneurysms cant be coiled - - -yet (sorta)

Hunt and Hess Score

Hunt & Hess Grade 1 2 Description Asymptomatic, mild headache, slight nuchal rigidity Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy Drowsiness or confusion, mild focal neurologic deficit Stupor, moderate to severe hemiparesis Coma, decerebrate posturing

3 4 5

Fisher Scale
Presence of Subarachnoid Blood No blood on CT scan Diffuse blood, < 1 mm thick Localized clot or think layer, >1 mm thick Diffuse or none, with intracerebral or intraventricular blood Fisher Grade I II III IV

WFNS SAH Grading Scale

Grade I II GCS 15 13 14 Motor Deficit None None

III
IV V

13 14
7 12 3-6

Present
None / Present None / Present

World Federation of Neurological Societies

Delia
A-gram shows large right MCA aneurysm
Not amenable to coiling Surgical ligation NOW

Surgery

Case study - Delia

Back from Surgery NOW WHAT ? ? ? ? What do we expect and why?

Vascular Anatomy
There are two very common representations of the cerebral arteries. I find they are both confusing. Well look at them briefly and then . . . . .

ACA MCA ACommA PCA Basilar

We are going to look at a series of slides that I created to look at circulation. Try to focus on the ONE artery that I highlight in each slide

Vertebral Arteries

Basilar Artery

Internal Carotid Arteries

Anterior Communicating

Posterior communicating

Anterior Cerebral Arteries

Middle Cerebral Arteries

Posterior Cerebral Arteries

S.A.H.
ICP Perfusion (PbtO2) Neuro exam Multi-modal monitoring ICP

T.B.I.
Perfusion (PbtO2) Neuro exam Multi-modal monitoring

Secondary Brain Injury Secondary What are we concerned with? Brain Injury

Respond to changes
Blood in subarachnoid space

Respond to changes
Direct trauma to the skull/brain

causes primary brain injury which through a variety of neurochemical changes causes a risk of secondary brain injury

causes primary brain injury which through a variety of neurochemical changes causes a risk of secondary brain injury

* More alike then different

Case study - Delia

Day 14 transfer to step down

Transition

The Case of Phineas Gage

Highlighting Functional Neuroanatomy

* * * Classic Case * * *

Phineas Gage (b. 1823 d.1860)

Year 1848 (age 25) The Foreman - Hard working, energetic, driven Setting explosives in Vermont for Rutland and

Burlington Railroad

Phineas Gage (b. 1823 d.1860)

1848
Wyatt Earp born Wisconsin becomes the 30th state
The tamping iron for the explosives reversed

direction (caused by a spark) and shot through his skull and his frontal lobe.
Family prepared a coffin upon hearing of a fungal

infection following surgery.

Phineas was fine as reported in 1949. But . . .

Friends of gage, now state that . . .

Gage is no longer Gage

Harlow, J.M. (1868) Bulletin of Mass. Med. Society

His contractors, who regarded him as the most efficient and capable foreman in their employ previous to his injury, considered the change in his mind so marked that they could not give him his place again. He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint of advice when it conflicts with his desires, at times pertinaciously obstinent, yet capricious and vacillating, devising many plans of future operation, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. In this regard, his mind was radically changed, so decidedly that his friends and acquaintances said he was no longer Gage.

There are rumors about what happened to Gage.

We know he did not get his job back. He is rumored to have traveled about with the tamping iron and sold himself (Barnums Circus) as a novelty. In 1860, living with his mother, he died of complications (aspiration) from an epileptic fit.
His body was exhumed in 1867 and his skull and the tamping iron are now at Harvard.

The Frontal Lobe

Extends back to the central sulcus executive functions

thought Emotion voluntary motor control

Contains the MOTOR STRIP

Start drawing your brain

no too much yet

Frontal Lobe

Drawing class !

Central Sulcus

Drawing class !

Inferior Temporal Gyrus

Central Sulcus

Superior Frontal Gyrus

Higher cognitive functions We are able to deduce and infer and plan Working memory (later)

Higher cognitive function

Is it always a good thing? I am going to start the movie play close attention.

Middle Frontal Gyrus

We are not sure yet
Maybe in decoding/encoding and arbitration

Your middle frontal gyrus tells you this is the letter . . . .?

Inferior Frontal Gyrus

The go / no-go area
Response inhibition Why we stop walking when we hear a snake rattle

Homunculus

Motor homunculus

Frontal Lobe motor strip

Premotor Cortex - Anatomy

Location
Within the frontal lobe Anterior to the motor strip

Premotor cortex - Function

Lateral Premotor Cortex
Intentional movements (preparation) Triggered by visual cues

Baby claps when you clap catch a ball

Premotor cortex - Function

Medial Premotor Cortex
Mediates movements Triggered by internal cues

Your hand comes up to your mouth before you cough

Executive Function
Controls other functions. My intact executive function

will tell my motor cortex to lift my hand of the hot stove, or will see a wall in front of me and tell my legs to stop moving.

The Case of Tan Tan

Highlighting Functional Neuroanatomy

* * * Classic Case * * *

Who was Dr. Paul Broca?

Physician
(b. 1824 d.1880)

Asylum
Bicetre Hospital (Paris)

Most famous resident

the Marquis de Sade

speech pattern recognized in Tan Tan

th 19

Century BB

(before Broca)

The gyri of the brain were drawn resembling intestines

Thought the gyri kept the brain warm

Focus on ventricles brainstem internal capsule Late 1700 some thought that back of skull = vision 1861 Paul Broca performed an autopsy on Tan Tan 1865 Broca published a paper that there are many patients who

have lost speech and have left frontal lesions

First called non-fluent aphasia

Brocas Aphasia
Patient can not name items (anomia) Show objects fingernail wedding ring
There is no fluency to the speech pattern Do the words flow together? You can understand the patient Often only 1 or 2 unrelated wordstan Unable to repeat phrases Five Purple Monkeys

Wernickes Aphasia
Patient can not name items (anomia) Show objects fingernail wedding ring There is a fluency to the speech Although it does not make sense, the speech the patient produces is fluent You can not comprehend the speech May be some recognizable words, but communication is not understood Unable to repeat phrases Five Purple Monkeys

Bill
65 y.o. male with over 50 caths and 3 dozen stents
Admit s/p tussive syncope and Left MCA acute

ischemic stroke with tPA NIHSS = 2 (R. Foot numbness & mild anomia)

The scan

Tan Tan - Aphasia

Naming Brocas
(expressive)

Fluency ---

Comprehension Yes --Yes Yes Yes

Repetition ----Yes Yes --Yes

---

Wernickes
(sensory receptive)

Aphasia ---Receptive Yes

----Maybe ---

Transcortical Motor
Transcortical Sensory Conduction Anomic Aphasia

Expressive Aphasia --Global Aphasia

Yes Yes Yes

Speech
Most often but not always left hemisphere Pars triangularis through pars opercularis

This leads us to think about a new problem . . . Overlapping function

So What ?
If one location deals with one function then other

locations may similarly deal with separate functions.

Hint: in the 21st century, we are reversing our thinking away from the one-to-one relationship

Transition ! ! !

The Case of Yoel

Highlighting Visual Cortex

Yoel
During World War I, Yoel was a first lieutenant in the British Army. As was common during WWI, he was hit with very small bore lead

shot. The bullet penetrated the back of his

head. In the excitement of the battle he did not at first realize he had been hit, but he did immediately note that he had visual field changes.

Yoel
The Bullets used in WWI were considerably smaller than those used today, and also had a lower spread
(we had not learned how to be as deadly).

The brain injuries were highly localized.

Drawing class !
Drawing Class ! ! !

The Occipital Lobe

Line from parieto-occipital sulcus to pre-occipital notch (like
that helps!)

Important for Vision

Interpreting visual input Visual reflex

Anatomy of the EYE

Word

Lesion location determines deficit

Drawing Class - - -use your handouts

The Visual Exam

Visual acuity Visual fields

Transition

transition

Thanks !
DaiWai Olson Olson006@mc.duke.edu

The Case of H.M.

Highlighting Memory

* * * Classic Case * * *

H. M.
27 y.o. male

H.M.
intractable seizures 1953 = surgical resection (bitemporal lobectomy)

No more seizures !
BUT
No more memory Thibodaux LA & Mom is Irish

December 2nd 2008 HM dies Henry Molaison

H.M.
Throughout his life, H.M. was extensively studied. Probably in more studies than any other human. His memory was reduced to less than 5 minutes. No short term memory. No long term memory. Hippocampus Surgical removal of the hippocampi. Every day is alone by itself

The Limbic System

A.K.A. emotional system Olfactory cortex

Smell memory Emotion Homeostasis: the quaalude of the limbic system

Hippocampus

Amygdala

Hypothalamus

Coronal slice of the Amygdala

In the next slide (animated) try to focus on structures around the amygdala

Amygdala

Hippocampus
Required for making new memories but not storing new memories. H.M. could not develop new Spatial relationship. memories but he could develop new skills. One such example is where he could draw objects in the mirror.

Try it some time !

Memory organization along temporal lobe

Subjects were asked questions & shown pictures that made them think about people, animals, and tools . . . . *considerable overlap* think of your first pet could elicit, Dog Heidi leash pet store mother etc.

Memory

Long Term

Short Term

Declarative

NonDeclarative

Sensory

Working

What is the basic difference between Events Procedural short term and long term memory?
Specific Personal experiences Skills

Long Term Memory Schema theory Perceptual Facts Representation Chunking Memories from S.T.M. World, object Are moved Language to L.T.M. Perceptual priming knowledge And sorted into Where they fit best and Classic Added to existing Conditioning Chunks of data Conditioned To become Response SCHEMA
Nonassociative Learning

Short Term Memory Humans can have About 7 +/- 2 chunks Of information At any given One point In time

153

Chunking and memory

Key concepts in MEMORY

Perceptual priming prior recent exposure affects the next action.

look at my new watch. I bought this watch at the watch store. Fill in the blanks: W A T __ __
Conditioned response think Pavlovs Dog Habituation the more you do somethingthe lesser the response

Sensitization each stimulus brings a greater response

(shes touching me ! ! !)

Memory

Long Term

Short Term

Declarative

NonDeclarative

Sensory

Working

Events

Procedural

***Short term memory is your desktop***

Sensory = sensory information is registered briefly. We selectively attend to this
(and shift to working) or ignore. World, object Perceptual Language something, but dont attend to it until your spouse Example: you hear priming knowledge asks, what was that? then you suddenly remember it. Working = command and control Example: I say something that reminds you of your shopping list. You put Conditioned this idea in short-term working, get your list, add that item, Response remember to put the pen and paper back.
Nonassociative Learning Classic Conditioning Facts Perceptual Representation

Specific Personal experiences

Skills

156 This is ONE model of short term memory . . . there are others

Nemo
Dory

No short-term

memory No what area?

Short term memory prefrontal Lobe

Is there photographic memory?

The Savant Syndrome
Males > females
1 in 10 autistics have some savant syndrome Most have very narrow skill set The skills almost always are linked to
(aka idiot savant)

phenomenal memory
We still dont have theory as to how this works.

The savant syndrome: an extraordinary condition. A synopsis: past, present, future Darold A. Treffert. Phil. Trans. R. Soc. B 2009. 364, 1351-1357

Blind Tom
Born May 25th, 1849 Thomas Green

Bethune was born blind a slave in Georgia.

Spoke early, and in

perfect tone and pitch but inappropriately. Mother taught him like you would a horse Played several instruments having heard a song only once.

Memory

Long Term

Short Term

Declarative

NonDeclarative

Sensory

Working

Events

Procedural

Specific Personal experiences

Skills

Facts

Perceptual Representation

World, object Language knowledge

Lets put this all back together

Perceptual priming Classic Conditioning Conditioned Response

Nonassociative Learning

161

Temporal lobe

Anatomy hint: think Sylvian Fissure

Transition : The Ponzo illusion

The lines are actually the same length. It becomes hard because you can only activate one visual pathway at once and that gets stored in short-term memory.

Correlative Neuroanatomy
Left vs Right A. Motor & Sensory B. Logic vs. Emotion 2. Key locations A. Occipital vision B. Frontal motor & premotor C. Motor STRIP D. Speech & Language 3. Neuroanatomist have ZERO imagination
1.

End of Part 1

Neuroscience Nursing Research

?
Systematic Review Randomized Clinical Trial

Non-experimental research
Clinical Reports

Nursing Experience
Textbooks The Religion of Science beliefs opinions &

Belief Textbook - Experience

Turning the patient from side to side Talking to patients when giving a bath Giving pills with a break in between Sit on the edge of the bed before standing up Skin care Vitals every hour (or 2-hours, or 15-minutes) Making assignments Monitor on/off at end-of-life CSF drainage Etc. etc. etc.

Tradition

Tradition

Just because youve always done it that way Doesnt mean it is not incredibly stupid

 Belief is usually something we develop before we start nursing school Textbooks are most often at least 3 years out of date (closer to 5+) Experience can be good or bad
Nursing Experience
Textbooks The Religion of Science beliefs opinions &

Experience is really the foundation

Not a bad startbut

Is this EVIDENCE

?
Systematic Review Randomized Clinical Trial

Non-experimental research
Clinical Reports Nursing Experience Textbooks The Religion of Science beliefs opinions &

Evidence Based Practice

A shift in the culture of healthcare provision away from basing decisions on opinion, past practice and precedent toward making more use of science, research and evidence to guide clinical decision making
(Appleby et al, 1995)

NOT
Practice Based on Evidence

Evidence Based Practice

The process of disseminating & using research-generated information to make an impact on or change in existing health care practices

Evidence Based Health Care

an approach to health care that promotes the collection, interpretation and integration of valid, important and applicable patient-reported, clinician-observed and research-derived evidence
(McKibbon et al, 1995)

Evidence Based Practice

the conscientious, explicit and judicious use of current best evidence about the care of individual patients
(Sackett et al, 1996)

Evidence-Based Practice Evidence-Based Nursing

Process by which nurses make
clinical decisions using the best

available research evidence, their

clinical expertise and patient

preferences

?
Systematic Review Randomized Clinical Trial

Non-experimental research
Clinical Reports Nursing Experience Textbooks The Religion of Science beliefs opinions &

In real life . .. The answer is not always so easy !

Her own horse Small group
This story just does not make sense

~42 y.o. female - Experienced rider

Neither does her CT Scan

CT Scan reveals diffuse edema & small left frontal SDH

When the Scan does not match the story . . . . . .. . . . One of them is probably wrong . . . . .

ICP
N
Before CPT During After CPT

MAP
95%CI

s.d.

91.82 91.73 90.08

s.d.

95%CI

46 25.6 48 23.0 50 17.3

8.4 9.57 7.15

2.49 2.77 2.03

12.26 10.48 9.95

3.48 3.04 2.83

Steady decrease in ICP associated with a NURSING intervention.

?
Systematic Review Randomized Clinical Trial

Non-experimental research
Clinical Reports Nursing Experience Textbooks The Religion of Science beliefs opinions &

Two Kinds of Statistics

Descriptive Statistics

Organizing summarizing and describing a batch of data

means, standard deviations, frequencies, percents charts and graphs

Inferential Statistics

Methods of drawing conclusions about a population based on a sample from that population using a statement of probability

Both involve SAMPLING . . .

Hypothesis Testing
Typical steps

1.

Design the study & state the hypothesis

2. Collect data 3. Determine the test statistic

4. State the distribution when Ho is true

5. State the decision rule 6. Calculate the test statistic 7. Reject or fail to reject Ho 8. Interpret the results (power, error)

Hypothesis Testing
We wish to draw a conclusion about some population based on some sample.

Who will be likely to graduate on time?

We wish to make a decision about a hypothesis.

Does being married lead to longer life span?

Hypothesis Testing
We test the null hypothesis (HO) against the alternative

hypothesis (HA)
We either reject HO or we fail to reject HO. We sort of end

up accepting HA because we dont have any ALTERNATIVE.

Its all about evaluating the evidence

Hypothesis Testing
Criminal trial - Presumed innocent. Declared guilty

when the evidence leading towards being guilty is beyond a reasonable doubt
H0: Defendant is not guilty versus

HA: Defendant is guilty

Hypothesis Testing
Criminal trial - Presumed similar. Declared different

when the evidence leading towards difference is beyond a reasonable doubt

H0: Not enough evidence to declare a difference versus

HA: The evidence is overwhelming and I am forced to reject the idea that there is no difference

Hypothesis Testing
The Decision Rule

Typically something like we will reject the null hypothesis if the observed Z score is so unusual that it just doesnt make sense to keep believing that the null hypothesis represents reality A fancier way to express this is . . . If Zobs > 1.96 reject Ho

Hypothesis Testing
Truth
Not Guilty H0 is true

H0 Guilty is false
Correct decision (1 - ) = Power Type II error

Decision

Reject H0 Go to Jail Fail to Go Free reject H0

Type I error (sig. level) Correct decision (1-)

A Type I error is like convicting an Innocent man

But, the jury has the POWER to make the right decision

?
Systematic Review Randomized Clinical Trial

Non-experimental research

The Key factor here is that we are still doing Nursing RESEARCH Experience But it is Textbooks research Non-experimental
The Religion of Science opinions & beliefs We are generating NEW knowledge

Clinical Reports

DaiWai M. Olson PhD RN CCRN Ananda R. Gurram MD Brad Kolls MD Julie Eckstrand Carmelo Graffagnino MD

High Glucose is Bad in Critical Illness

Van Den Berghe et al1 1548 patients in a surgical ICU

randomized to intensive glucose control (80-120 mg/dL) vs. standard control (180-200 mg/dL).
Mortality reduced from 8% to 4.6% (P<0.04) If in ICU >5 days mortality reduced from 20.2% to 10.6%

(P<0.005).
Overall hospital mortality reduced by 34%, bloodstream

infections by 46%, renal failure by 41%, transfusions by 41%, neuropathy by 44%.

Most of the patients were post op cardiac surgery
Tight glucose control was a miracle treatment!
1. Van Den Berghe et al. NEJM. 2001;345:1359-67

Very Low Glucose is Bad in Critical Illness

NICE-SUGAR Study1- 6104 pts in ICU randomized to

intensive glucose control (81-108 mg/dL) vs. standard glucose control (180 mg/dL).
Mortality was worse in the intensive group was 27.5%

vs. 24.9% (OR for death, 1.14; 95 %CI, 1.02 to 1.28)

Severe hypoglycemia (40 mg/dL) in 6.8% of intensive

group vs. 0.5% in conventional group (P<0.001)

No difference in LOS (ICU or hospital), ventilator days or

renal-replacement therapy.
1. NICE-SUGAR Study Investigators.NEJM.2009;360:1283-97

Intensive Insulin Therapy is bad Following Cardiac Arrest

Study randomized 90 patients with V Fib arrest and

post anoxic coma to intensive insulin therapy (glucose 72-108 mg/dL) vs standard therapy (108144 mg/dL)
No differences in mortality however, intensive insulin therapy was associated with hypoglycemia 18% of the time compared to 2% for standard therapy (P=.008)

Intensive Insulin Therapy is bad Following Traumatic Brain Injury

Vespa et al1 assigned 14 patients with TBI to intensive

insulin therapy (glucose target 90-120 mg/dL) and compared them to 33 pts treated with standard approach (glucose target 120-150 mg/dL).
Microdialysis glucose reduced by 70% in intensive group

compared to 15% in standard group

Glutamate increased in intensive group compared to

standard group (3837% vs 1017%, P<.01)

Lactate/pyruvate ratio elevated (3837% vs. 1115%,

P<.05) and glucose levels lower

1. Vespa et al . Crit Care Med. 2006;34:850-56)

Duke NICU Glucose Control Study

NICU is a 16 bed neurological, neurosurgical semi-closed ICU All neurosurgical patients are co-cared by NICU team and neurosurgical team

All other patients admitted to NICU service

NICU team made up of one of 6 attendings, ACNPs, house-staff, unit pharmacist. Insulin therapy based on written protocols

Duke NICU Glucose Control Study

Sept 2006 - glucose protocol changed to an

intensive insulin therapy (iiT) protocol target glucose of 80 120 mg/dL.

Spring of 2008 we conducted a QA project to

evaluate our experience with iiT.

Duke NICU Glucose Control Study

Retrospective, before and after, historical cohort study

Data extracted from, electronic health record and

exported into Microsoft AccessTM.

Results approved for publication by IRB Compared 1885 patients admitted to our NICU between

2/1/2005 and 8/30/2006 (SIT) to 1871 patients admitted between 9/1/2006 and 3/30/2008 (IIT)

Standard
Total Subjects Female : N (%) Mean Age Intracerebral Hemorrhage 1885 51% 53.66 147

iiT Group
1871 50.5% 54.68 192

P value

0.07 0.06 0.007

Subarrachnoid Hemorrhage Ischemic Stroke

Traumatic Brain Injury Other

120
94 49 1497

142
99 82 1378

0.125
0.620 0.002 <0.01

Distribution of Glucose scores for the two groups.

Standard Insulin Therapy Group

Intensive Insulin Therapy Group

Glucose Values
* Note similar distribution of values. Intensive Insulin therapy results in slightly tighter grouping of scores with lower mean glucose value compared to standard insulin group

Y axis = Frequency

Standard Insulin Group N= 1885

Intensive Insulin Group N= 1871

Statistic
P - value OR (95%CI)

Mean glucose level Insulin Given Insulin Infusion Moderate Hypoglycemia <70 mg/dL Severe Hypoglycemia <40 mg/dL Extreme Hypoglycemia <20 mg/dL Mean Length of Stay (days) Death

145 56.1% 9.7% 13.1% .53% 5 .27%

136.7 82.5% 13.3% 21.4% .86% 21 1.12%

<.001 0.0001 0.0006 1.8 (1.5, 2.3) 2.4 (1.5, 3.8) 5.36 (1.55, 18.55)

8.7
8.01 %

9.5
10.5 %

0.046
0.001

Effects of Hypoglycemia on Mortality

Severity of Hypoglycemia Moderate Hypoglycemia (<70 mg/dL) Severe Hypoglycemia (<40 mg/dL) Extreme Hypoglycemia (<20 mg/dL) ODDs of Death (95% CI) 3.26 (2.52, 4.22) 3.65 (2.21, 6.02) 6.25 (2.41, 16.23)

Conclusions
Intensive insulin therapy = more hypoglycemia Hypoglycemia = increased mortality the more severe the hypoglycemia, the higher the likelihood of death

Given the above : iit = increased risk of death

?
Systematic Review Randomized Clinical Trial

Non-experimental research
Clinical Reports Nursing Experience Textbooks

A different level of The Religion of Science opinions & ? Evidence ?

beliefs

Evidence
We consider statistics to provide us some measure of evidence

Evidence
I was in Las Vegas and got to talking with the great and powerful (but homeless) Chaz The Magnificent Chaz wanted me to take him into the casino (he wasnt allowed in unless accompanied by someone who had bathed) and we would bet on roulette. C.t.M. guaranteed me that voices in his head could predict the outcome of any binomial distribution. And therefore he wanted to play roulettebetting on red and black. I told C.t.M. that if he could demonstrate the ability to predict a random binomial event sufficiently such that he was better than chance I would take him gambling.

Evidence
I opted to test C.t.M. outside the casino using the toss of a coin. I toss a coin (not actually randombut close enough for our example)

If C.t.M. guesses (the voices tell him) correctly - - then the answer is yes

Chaz the Magnificent

Y
First Toss of the Coin

So,

What can we say about C.t.M. after 2 Y N Y N tosses of the coin?

I decide to start by tossing the coin twice If the voices in C.t.M.s head are just guessingthen there is an equal chance of one of four outcomes

2nd Toss of the Coin

Y Y

N Y

N N

Chaz the Magnificent

First Toss of the Coin Chance and So, chance alone Y N Gives a 0.25 probability that the voices in 2 Toss of the Coin C.t.M.s head will beabout correct on 2 tosses of What can we say C.t.M. after 2 Y N Y N the tosses ofcoin. the coin?
nd

I decide to start by tossing the coin twice If the voices in C.t.M.s head are just guessingthen there is an equal chance of one of four outcomes

Im not willing to gamble - YET

Y Y

N Y

N N

P(YY) = P(YN) = P(NY) = P(NN) = 0.25

Chaz the Magnificent

What would convince you? How many times would C.t.M. have to toss the coin for you to listen to use your money and gamble at roulette based on input from the voices in his head?
Raise your hand

2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 50, 95

Chaz the Magnificent

Y

How About

5
N Y Y N Y N

Y N Y N Y N Y N Y N Y N Y N Y N

Y N Y N Y N Y N Y N Y N Y N Y N

There are 32 possible outcomes for the voices. P(YYYYY) = 1/sum of all probable outcomes = 1/32 = .0250 = .03 . Therefore the voices are right (p < .05)

Only 1 of the 32 is Y-Y-Y-Y-Y

Why do we care about p ?

What is a SAMPLE ?
Lets conduct a simple experiment.

For some odd reason, I want to know the average number of boxing matches a nursing student watches during each month.
Our population is nursing students . . . So I will SAMPLE this class We will assume that this class is representative of ALL the nursing classes in ALL the nursing schools in ALL the world. Further, this includes past present and future nursing students.
THINK ABOUT THIS - I take a sample of 30 students from this class.

- - - How many samples of 30 are there?

What is a SAMPLE ?
What does a sample of 30 really represent?

30 students = 1 sample

31 students = 30 samples
32 students = 90 samples 33 students = 270 samples 100 students = some crazy number 70
30
This relates to a bell curve (next slide)

Sample and the BELL CURVE

From 100 Students, we draw a sample of 30 and wish to know the average number of matches watched.

Every other student even

Every other student odd

First 30 students

Last 30 students

Bell Curve

The more you sample the better the curve

The standard normal distribution

68% of the area is between -1 and 1 SD

95% of the area is between -2 and 2 SD 99% of the area is between -3 and 3 SD

68%

95%
99%

0.5 %

Standard Normal Curve = 0, = 1

2.5%

2.5%

=0
-1.96 Z-Scores 95% 1.96

?
Systematic Review Randomized Clinical Trial

Non-experimental research
Clinical Reports Nursing Experience Textbooks

A different level of The Religion of Science opinions & ? Evidence ?

beliefs

BIS BISpectral Index

Using microprocessor technology it is now possible to continuously analyze the EEG signal and relay that information in a combination of a digital and analog output.

BIS Range Guidelines

Extubate / Perform Neuro Exam

Duke Neuro ICU (90% of pts) Duke Med & Trauma ICU

During medical paralysis Intra-operative Sedation

Burst / Suppression (death)

2001 Aspect Medical Systems, Inc.

COST Study operationalized

Does: BIS + Ramsay = Sedation
a.k.a.

Does: Physiologic

+ Observational = Sedation

COST Study Methods

Enroll 67 patients in the Neuro ICU
Enroll EVERY nurse in the Neuro ICU Randomly assign at patient to group

Standard of care (aka Ramsay) Standard of care + BIS (aka Ramsay + BIS)

Observer and record Sedative Use for 24 hours

Olson, Thoyre, Graffagnino (in press) Bispectral Index reduces drug use
Hypothesis

HO: BIS = Ramsay HA: BIS Ramsay

RamsayAlone Mean
175.36 ml

Dependent Variable Propofol Volume Propofol Rate

BISAugmentation

F 6.00

p value .0180 .0050

r2 .11 .15

Mean 97.51 ml

15.35 30.19 8.63 mcg/kg/min mcg/kg/min

50% reduction

Dependent Variable Propofol Volume Propofol Rate

BISRamsay-alone augmentation Mean Mean 175.36 ml 30.19 mcg/kg/min 97.51 ml 15.35 mcg/kg/min

F 6.00 8.63

p-value .0180 .0050

r2 value .11 .15

What do I make of this nearly 50% decrease in sedation

Patient variables Nurse variables Physician or APN variables

and this small r2 value ?

Shift variables

Family variables

? variables

Intervention Fidelity

Does the % of time at goal predict the propofol infusion rate ? 50

Infusion Rate mcg/kg/min

0 0 10 20 30 40

Percent of time at goal BIS (60 70)

Is it worth exploring intervention fidelity?

Do group assignment and intervention fidelity (taken together) help to predict sedation use?
Source Model Error Corrected Total DF 2 32 34 Sum of Squares 2533.65683 7341.81185 9875.46869 15.14700 22.87827 66.20694 Mean Square 1266.82842 229.43162 F Value 5.52 Pr > F 0.0087

Root MSE Dependent Mean Coeff Var

R-Square Adj R-Sq

0.2566 0.2101

Variable Intercept pctatgoal group

DF 1 1 1

Parameter Estimate 38.85466 -0.38223 -17.01862

Parameter Estimates Standard Error t Value 5.60518 6.93 0.19735 -1.94 5.43733 -3.13

Pr > |t| <.0001 0.0616 0.0037

Type I SS 18320 285.99486 2247.66198

Type II SS 11025 860.67621 2247.66198

Including intervention fidelity helps to explain a greater percent of the variance (25 vs 11%).

Implementing change
A tale of caution !
The Yir Yoront were an aboriginal tribe relatively isolated until ~1950 and still used stone axes.

The Yir Yoront had little free time and a complex social network. The stone axes (few in number) were prized possession of elder males. However, the entire tribe required and used the axes.

Yir-Yoront
Missionaries noted that everyone used the axes, the stone axes were inefficient, and there were not enough axes to go around. . . And so . . They got new steel axes, which they gave freely to all the members of the tribe.

Young males

Most Females

Elder males

Ancient Past
Axe heads were

Steel Axes
Everyone gets an axe Elder males no

Present
The elder males have lost their monopoly on axes and are no longer vital to communication circles. The need for trading was decreased. Rituals associated with the axes effectively ended.

scarce and traded for over hundreds of miles (foot travel) Axe heads were placed on handles only by the males (so male property) Women and children (younger males) had to BORROW the axe from elders Axes became mythical

longer need to trade for stone axe heads Women & children dont need to ask elder males to borrow axes. The steel axes were not actually better than the stonejust more of them.

Yir-Yoront
The Yir-Yoront accepted the axes, which likely contributed to the breakdown of their society and the loss of their culture.
The Yir-Yoront language is now all but extinct.

Diffusion of Innovations

Diffusion of Innovations
Innovators
I am venturesome. I am the first one to try and to endorse a new innovation.

Diffusion of Innovations
Early Adopters
Although I am not the first to adopt a new innovation, other people seek my opinion or follow my example when it comes to new ideas and new innovations.

Diffusion of Innovations
Early Majority
I am usually in the first half of people to adopt a new innovation.

Diffusion of Innovations
Late Majority
I am skeptical about new ideas and new innovations. I am in the last half of people who adopt a new innovation.

Diffusion of Innovations
Laggards
I am the last one to adopt a new innovation.

?
Systematic Review Randomized Clinical Trial

Non-experimental research
Clinical Reports Nursing Experience Textbooks The Religion of Science beliefs opinions &

Del Zoppo GJ, Saver JL, Jauch EC, Adams HP, Jr. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: A science advisory from the american heart association/american stroke association. Stroke. 2009;40:2945-2948

Transitions: Methods
5,783 citations identified past 2000-2011

4605 excluded based on title/abstract

22 excluded based on not original data 750 articles subjected for FULL READ 668 excluded (534-not transition, not peer, no

data, no comparator, not stroke/MI)

34 studies of 4,146 stroke patients

19 studies of 15,216 MI pts

clumping
Hospital-Initiated Support
Patient and Family education
hospital-based home-based

Community-based Support Chronic Disease management

Hospital-Initiated Support
Intervention Early supported discharge Good 8 measures Death mRS Nottingham HP LOS pt. satisfaction Institutionalizaito n I-ADL ----Equal 10 measures Barthel Index, mRS, NHP, Death, BBS, Timed walk, EADL, GHQ, MADR, FAI, MMSE, AshSS, FIM, SF-36, Timed - up-n-go, Rehosp, MD-follow

Integrated care pathway

Barthel Index Death LOS EQ-5D Caregiver Strain Burden Scale for Family Caregivers

ESD for caregivers

Caregivers strain

Patient and Family education (hospital-based)

Intervention
Computertailored education

Good
1

measures
Pt. Satisfaction

Equal
1

Measures
Dartmouth CO-OP Knowledge self-efficacy HADS (Hospital Anxiety and Depression)

Patient and Family education (home-based)

Intervention Information packet & family counseling Post-discharge education Good 1 measures AAP Barthel Index FAD Equal 1 measures GDS HADS Mastery Scale SF-36 (patient) SF-36 (spouse) Barthel Index HADS patient Satisfaction Caregiver satisfaction

OAD pt. confidence in recovery

AAP Adeline Activities Profile FAD McMaster Family Assessment Device GDS Geriatric Depression Scale OAD Observer-Assessed Disability

Community-based Support
Intervention Post-discharge care management Family Support, Communitybased stroke team Good 2 measures SIP Knowledge Equal 3 measures Barthel, CES-D, Death, Falls, NIHSS, LOS, Timed up-n-go, QOL, FAI, FQM, I-ADL Barthel, COOP-(patient), COOP(caregiver), FAI-caregiver, HADS, LHS, RMI, GHQ, Caregiver Strain, EQ-5D, LOS, SF-36 (MCS), SF-36 (PCS), Timed walk

SF-36 energy 3 SF-36 caregiver QOL Pt. Satisfaction

Page 1 of 3

Community-based Support
Intervention Telephone counseling Expert Patient Programme Good 1 measures CGI-I (only @ 3 months) Equal 2 Measures CGI-I (6-months) Barthel Index mRS, HADS, SASC, SF-36 HADS (anxiety) HADS (depression) MIDAS SF-36 (MCS) SF-36 (PCS)

Page 2 of 3

Community-based Support
Intervention Social Worker, psychosocial interventions Goo d 1 measures Self-care compliance GDS SF-36 (motor) Equal 2 measures Barthel Index SF-36 PCS

Home care cognitive Therapy

CSS Death I-ADL Physical Exercise

Page 3 of 3

Chronic Disease management

Intervention Integrated care Good 3 measures Depression (PHQ-9), Activity mRS Quality of Life Equal 2 measures Barthel Depression MMSE

Usual care
Most studies used usual care as their comparator, but few studies actually tell us what usual care really is.

Conclusion
Early Supported Discharge may be

helpful for stroke For stroke no other intervention had sufficient evidence of benefit to be recommended.

We have a long way to go . . .

?
Systematic Review Randomized Clinical Trial

Should We Question Our PAST ?

Clinical Reports Nursing Experience Textbooks The Religion of Science beliefs opinions &

Non-experimental research

Subjective Sedation Assessment

Sedation - Scales
Guessing

Patient movement Increased heart rate Increased blood pressure

too little

too much

? Just Right ?

Subjective Ramsay
1 anxious/agitated, restless or both
2 cooperative, oriented, and tranquil 3 responding to commands only 4 brisk response to light glabellar tap 5 slow response to light glabellar tap

6 no response to light glabellar tap

Subjective RAAS
Richmond Agitation-Sedation Score +4
Combative, violent, danger to staff

+3

Pulls or removes tubes, aggressive

+ 2 Frequent non-purposeful movement, fights ventilator + 1 Anxious, apprehensive, but not aggressive 0 Alert and calm - 1 Awakens to voice > 10 seconds - 2 - 3 - 4 - 5
Light sedation, awakens to voice < 10 seconds Movement or eye opening, no eye contact No response to voice, eye opening to physical contact No response to voice or physical stimulation

Subjective Sedation-Agitation Scale

1 dangerous agitation
2 very agitated 3 agitated 4 calm and cooperative 5 sedated 6 very sedated 7 unarousable

Subjective MAAS
Motor Activity Assessment Scale

0 unresponsive 1 responds to noxious stimuli

2 responds to touch or name

3 calm and cooperative

4 restless and cooperative

5 agitated 6 dangerously agitated

Ramsay started this. But

* Ramsay MA, Aavege TM, Simpson BR, Goodwin R (1974) Controlled Sedation with alphaxalone alphadolone. Br Med J 2(920):656-9

A little background on this paper . . .

. . Six levels of sedation were formulated; three with the patient awake and three with the patient asleep. Awake levels where: 1, patient anxious and agitated or restless or both; 2, patient co operative, oriented and tranquil; 3, patient responds to commands only. Asleep levels where dependent on the patients response to a light glabellar tap or loud auditory stimulus: Level 4, a brisk response; 5, a sluggish response; 6, no response.

The Original Ramsay Paper

Sedation time (% of total)

40 30 20 10
Level of Sedation

N = 30

6
Unsatisfactory 8-9%

Unsatisfactory 4-6%

Satisfactory 86-5%

Time spent at different sedation levels expressed as percentages of total sedation time. (See text for definition of sedation level)

We decided to test the reliability of the Ramsay Scale

What Is Reliability
Inter-Rater Reliability Intra-Rater Reliability

Methods
What did we do?

Phase 1 - - - Make the videos

Expert

scoring

Phase 2 - - - Reliability assessment

Phase 1 - - - Making the videos

Consent the patient

Set up equipment Film for ~ 1 minute Head to the BBL Edit to a 30 second video clip Present video-clips to experts

Present video-clips to experts

Harry Hagrid Dumbledore

Phase 2
Yes

Cho
Fawkes Ron Hermoine Cho Harry Snape McGonagal No

Phase 2 - - - Recruit & Randomize

Phase 2 - - - Scoring the video

241 RNs enrolled

Days (48%) - Nights (28%) - Both (24%)

Female (81%) - Male (19%)

2200 44 RNs
7200 39 RNs

3200 28 RNs
Cath Lab 12 RNs

PACU 11 RNs
8200 45 RNs

4200 60 RNs
ISRP 2 RNs

( 7 critical care areas represented )

Data Analysis - what does Kappa measure ?

Red Red Yellow Orange Green Blue Total 7 1 1 0 0 9 Yellow Orange Green 0 24 1 0 0 25 1 0 17 3 0 21 0 0 2 25 1 28 Blue 0 0 2 1 14 17 Totals 8 25 23 29 15 100

Pobs Pexp 1 Pexp

.87 .2247 K 1 .2247

K .8323

Pobs .87
Pexp .2247

7 24 17 25 14 Pobs 100
Pexp (9 8) (25 25) (21 23) (28 29) (17 15) (100 100)

Data Analysis

Reliability of Ramsay
Score 1 Ramsay Scores By Experts Total 2 3 4 5 6 13 15 28 23 1 1 12

Kappa = .277
Ramsay Scores by Nurse Subjects 2 4 11 3 9 14 3 2 4 6 11 2 3 1 5 8 4 27 33 29 3 104 9 36 54 9 6

Total

39 40 41 39 39 39 237

Conclusion
What does this mean?

Why does this matter?

Managing Managing Propofol Propofol Weaning Weaning Nursing Nursing From From CAM ICU Much of what CAM - ICU Workload Workload Ventilator Ventilator we know and think of as the Documentation Cost Documentation MAAS Cost MAAS What SCIENCE What Standards Studies Standards Studies Drugs of sedation assessment and management Drugs Sedation Cost Sedation Work ? RASS RASS Work ? BIS Agitation BIS Studies Agitation (Richmond) (Richmond) Weaning MAAS Scale Scale From Ventilator The MAAS

Ramsay Scale

DONE

Now, its Your Turn