الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Nurse driven protocols are an approach of utilization of EBP research findings into practical area. A nurse driven protocol is one in which the nurse initiate the detailed plan of collaborative care according to a set plan. They have been shown to improve patient care outcomes through the provision of high quality care. They are increasingly being used in the critical care setting and have been associated with improved outcomes such as a reduction in mortality and more efficient use of resources. In addition, nurse driven protocols create a healthy work environment of increased retention rate, nursing empowerment, nursing and patient satisfaction.
Implementation of nurses driven electrolytes repletion protocols may help critical care team members to drive their patients to the way of positive clinical outcomes as less length of ICU stay, days of mechanical ventilation and less mortality rates through control of their electrolytes disturbances that are widely common. These protocols have been tested in the ICU environment in other health problems as sedation management, weaning from mechanical ventilation and insulin therapy. They demonstrate positive clinical outcomes and become widely adopted by critical care team members.
Materials & Method
A Quasi experimental research design was used to determine the effect of applying nurses driven electrolytes repletion protocol on electrolytes disturbance control among critically ill patients. The study was carried out at the ICUs of the Alexandria Main University Hospital (AMUH), namely: casualty care unit (unit I) and the general ICUs; Unit II and unit III.
A convenience sample of 62 newly admitted critically ill adult patients who have electrolytes disturbances were included in this study. Patients who have (renal disorder, on any type of renal replacement therapy and patient with diabetic ketoacidosis) were excluded from the study. Patients who have met the inclusion criteria were randomly and equally assigned to either of the two groups (31 patients in each); group “A” the control group were managed by unit routine replacement interventions and group “B” the study group were managed by nurses driven electrolytes repletion protocol.
One tool was used to collect the data of this study namely “Electrolytes repletion assessment record”. This tool was developed by the researcher after reviewing the relevant literature. It consists of two parts: critically ill patient clinical profile that was used to assess the patients’ clinical status such as health history, diagnosis of admission, severity of illness and length of ICU stay. And electrolytes monitoring record that was designed to record patients’ electrolytes levels during their stay in the ICU to monitor the target electrolytes range and the episodes of electrolytes disturbances, and any electrolytes disturbance related adverse events.
All episodes of hypokalemia, hypophosphatemia and hypomagnesaemia experienced by each patient were evaluated using part II of the study tool and daily check of serum electrolytes (potassium, magnesium and phosphorus) and serum creatinine were done from admission to the intensive care unit up to seven days of ICU admission for both groups. Repletion of electrolytes disturbances was done according to the routine followed interventions in the units for the control group and repletion of electrolytes disturbances was done according to the nurses driven electrolytes repletion protocol for the study group.
Adherence to target electrolytes levels, episodes of hypo and hyperelectrolytemia and other related adverse events were evaluated and documented in electrolytes monitoring record (part ΙΙ) for both groups. Comparison between the two groups was done as regard effectiveness and timeliness of electrolytes repletion approaches in each group. Effectiveness of electrolytes repletion approaches was evaluated by assessment of post replacement electrolytes levels, electrolytes replacement doses to achieve target electrolytes level, number of replacement doses indicated but not given, prevalence of electrolytes loss after replacement and electrolytes loss associated adverse events. Timeliness of electrolytes repletion approaches was evaluated by determining the time between laboratory reporting of low serum electrolytes levels and administration of the replacement doses.
Results
Neurological disorders represent the most encountered diagnosis among both groups. The most common cause of hypokalemia, hypomagnesaemia and hypophosphatemia in both groups was the use of diuretics.
Furthermore, there was a highly statistical difference between the two groups throughout sixth consecutive days after admission as regard electrolytes levels and timing of replacement. Moreover, patients in the study group have achieved the target electrolytes levels with fewer doses from the second day of the study in contrary with patients in the control group who have not achieved this target level throughout the seven consecutive days except for phosphorus that was achieved on the third day with a DROP in the fourth day.
Regarding adverse events associated with electrolytes disturbances, in relation to potassium, magnesium and phosphorus, the most common adverse events in both groups was dysrhythmia, hypokalemia and hypomagnesaemia respectively.
Conclusion
from the present study it could be concluded that the implementation of nurses driven electrolytes repletion protocol among CIPs resulted in improvements in the effectiveness and timeliness of electrolyte replacement.
Recommendations
Based on the findings of this study, the following recommendations are suggested:
Recommendations regarding clinical practice:
• Develop a multidisciplinary critical care team to be responsible for the development and sustaining the protocolized directed therapies in the ICU especially nurse driven protocols.
• Adoption and implementation of nurses driven electrolytes repletion protocol.
Recommendations regarding education:
• Provide training program to upgrade nurses’ knowledge and practices as regard protocolized directed therapies in the ICU especially nurse driven protocols.
• Pre-service training for intern nurses to minimize the gap between their limited skills/experience and expected performance.
• Highlighting and signifying the concept of protocolized directed therapies in managing CIPs health problems in the undergraduate’s courses.
Recommendations regarding administration:
• Develop policies to develop, implement, promote and sustain protocolized directed therapies in the ICU.
• Include magnesium and phosphorus in the daily lab plan.
• Simplify the charting and documentation system as regard electrolytes repletion.
Recommendations regarding research:
• Consider further researches about nurses driven electrolytes repletion in ICU such as:
Barriers to implementation of nurses driven electrolytes protocols among the CIPs
Assessment of the effect of implementing nurse driven computerized electrolytes repletion protocol among the CIPs.
• Replicate this study on a larger sample size and multiple centers for generalization of results.