Table 1. Mean Scores on Body Cathexis Scale and Self Cathexis Scale
Body Cathexis StaTe* Healthy subjects Moderate COPD subjects Severe COPD subjects Self Cathexis Scale** Healthy Moderate Severe
to guide nurses toward discovering the most effective nursing interventions.
Special acknowledgmentis extended to Cheryl Stetler, PhD, RN, FAAN for her assistance with this project.
49 37 50
207.71 182.24 154.58
33.15 32.01 36.00
95-274 117-230 95-221
Diekmann, J.M. (1988). Measuring body image. In: M.F. Stromberg (Ed.), Instruments for Clinical Nursing Research (pp. 185-203). Norwalk, CT: Appleton & Lange. Secord, P., & Jourard, S. (1953). The appraisal of body cathexis: Body cathexis and self. Journal of ~onsulting and Clinical P~ychology, 17, 343-347.
° F = 15.02; d f = 2,130; p < .000t. ** F = 12.70; d f = 2,130; p < .0001.
highest mean scores on both the BCS and the SCS followed by individuals with moderate COPD. Subjects with severe COPD had the lowest mean scores on both the BCS and the SCS. The correlation coefficient for the BCS and the SCS was .83 in the sample (N = 136). Males and females did not differ significantly on BCS or SCS scores. The results of this study illustrate the negative impact of the chronic disease process of COPD on body image. Individuals with more severe COPD had a lower self-perception of body image, as measured by the BCS and SCS, than individuals in whom the disease was less severe. COPD is a major health problem for patients and health care providers. To provide quality care, nurses must be knowledgeable about the implications of chronic illnesses such as COPD. It is important to carefully assess the patient with COPD, knowing that the functional limitations that occur as a result of COPD will require adaptation on the part of the patient. This period of adjustment could potentially be negative and may require interventions to facilitate positive alterations for the patient. Strategies to promote positive alterations may include providing the patient with reliable, clear information regarding the illness and concomitant body image changes; and membership in a support group may provide the opportunity to share one's experience with other individuals with COPD. Changes in body image related to COPD must be recognized before nursing interventions are tailored to patients with this chronic illness. Validation of the nursing diagnosis of body image disturbance with this patient population would support the use of this nursing diagnosis and would serve
From the MGH Institute of Health Professions, Boston, MA. Patrice Kenneally Nicholas, DNSc, RN, CS: Assistant Professor, MGH Institute of Health Professions; Jean D'Meza Leuner, MS, RN: Assistant Professor, MGH Institute of Health Professions. Address reprint requests to Patrice Kenneally Nicholas, DNSc, RN, CS, Assistant Professor, MGH Institute of Health Professions, 15 River St, Boston. MA 02108. Copyright © 1992 by W.B. Saunders Company 0897-1897192/0502-000355.00/0
Effect of N i t r o p a s t e A d m i n i s t r a t i o n Times on Sleep and N o c t u r n a l Angina
M a r t h a Ryan, S u s a n G a l l a g h e r , a n d Jane Corrigan Wandel
OSPITALIZED PATIENTS with coronary artery disease (CAD) are frequently administered nitroglycerin paste (NTP) in doses that are titrated to systolic blood pressure (SBP). At our institution, physicians commonly prescribe NTP every 4 hours around the clock. Based on routine medication administration schedules used on our unit, NTP is administered on the night shift at midnight and 4 AM. Clinical nurses on our 30-bed medical cardiology floor frequently noted that when they woke a patient for a scheduled 4 AM dose, the patient's SBP was too low to permit the administration of the NTP. Such patients often reported difficulty in falling back to sleep. Early moming interruption of sleep results in
decreased rapid eye movement (REM) sleep and subsequent REM rebound which can be associated with irregular heart rate and rhythm and variable blood pressure (Snyder, Hobson, Morrison, & Goldfarb, 1964). These changes can increase the oxygen demands on the heart which may pose a health risk for patients with CAD (Nowlin et al., 1965; Rosenblatt, Hartmann, & Zwilling, 1973; Sanford, 1983). Our clinical experience with the disruption of cardiac patients' sleep, in addition to our knowledge about the effects of REM rebound, prompted nurses on our unit to question the early morning dosing schedule of NTP. We conducted a pilot study with a convenience sample of 33 CAD patients to examine the influence of the NTP dosing schedule on patients' sleep and nocturnal angina. METHOD
With the agreement of the prescribing physicians, we devised an NTP administration schedule of every 4 hours on one night and every 6 hours the following night. No other changes in medication regimens were made. Clinical nurses recorded the presence of environmental stimuli and physical discomforts that could potentially affect the subjects' sleep. They also noted the occurrence of nocturnal angina. The 33 subjects (18 males, 15 females) ranged in age from 46 to 84 years with an average age of 68 years. All subjects were alert and oriented, English speaking, and had documented CAD. Using the St. Mary's Hospital Sleep Questionnaire (Ellis et al., 1981), a 14-item selfreport scale, the subjects rated the quality (maximum score = 45) and quantity of their sleep on the two consecutive nights. In reliability tests of the tool with medical and surgical patients, correlation coefficients (Kendall's tau) ranged from .70 to .96 (Ellis et al., 1981). Validity of the instrument has not been evaluated. RESULTS AND DISCUSSION
Subjects' reports of quality and quantity of sleep on the two study nights were compared using t tests for paired scores. Sleep with the 6-hour (M = 6.48 h) schedule was more than 1 hour longer than with the 4-hour (M = 5.24) time (p < .025). Based on the St. Mary's Hospital Sleep Questionnaire, sleep quality was significantly (p < .005) better when NTP was administered every 6 hours (M = 38.30) than every 4 hours (M = 31.33). Nocturnal angina did not occur for any of the sub-
jects on either night. Sedative administration and the occurrence of environmental and physiological factors were not significantly different between the two study nights. Patients slept better and longer without nocturnal angina on the 6-hour schedule. The findings indicate that the 4-hour dose schedule for NTP interferes with patients' sleep. None of the patients in this study experienced nocturnal angina. Because sleep interference can potentially increase myocardial oxygen demands, the risk of sleep disruption in .patients with CAD should not be ruled out from the findings of this pilot study. It has been shown that continuous exposure to nitrates in CAD patients results in the development of tolerance (Parker, 1987; Parker & Fung, 1984; Reichek, Priest, Zimrin, Chandler, & Sutton, 1984; Thadani et al., 1986). In patients using nitroglycerin patches, it has been shown that a 10hour nitrate-free period overnight prevents nitrate tolerance without provoking withdrawal angina (Cowan, Bourke, Reid, & Julian, 1987; DeMots & Glasser, 1989; Schaer, Buff, & Katz, 1988). Nitropaste administered every 6 hours rather than every 4 hours would similarly increase the nitratefree interval and may reduce the development of nitrate tolerance. Further study of the timing of NTP administration is warranted to determine schedules that will minimize the risk of angina without inducing nitrate tolerance and disrupting sleep. More precise information will be yielded from studies that include patients with varying degrees of CAD severity and patients who have and have not developed nitrate tolerance. Because this study was conducted over a period of 2 days, examining the effect of chronic sleep disruption in CAD patients also is indicated. ACKNOWLEDGMENTS
The authorsacknowledgeRichard P. Shannon, MD, for his assistancein elicitingphysiciansupportfor the studyand Peggy Reiley, MS, MPH, RN, for her help with data analysis. REFERENCES
Cowan, J., Bourke,J., Reid, D., & Julian, D. (1987). Prevention of tolerance to nitroglycerinpatches by overnight removal. American Journal of Cardiology, 60, 271-275. DeMots, H., & Glasser, S. (1989). Intermittenttransdermal nitroglycerintherapyin the treatmentof chronicstable angina. Journal of the American College of Cardiology, 13, 786-793. Ellis, B.W., Johns, M.W., Lancaster,R., Rappopoulos,P., Angelopoulos,N., & Priest, R.G. (1981). The St. Mary'sHospital sleepquestionnaire:A studyof reliability.Sleep, 4, 93-97.
86 Luke, R., Sharpe, N., & Coxon, R. (1987). Transdermal nitroglycerin angina pectoris: Efficacy of intermittent application. Journal of the American College of Cardiology, I0, 642-646. Nowlin, J., Troyer, W., Collins, W., Silverman, G., Nichols, C., Mclntosh, H., Estes, E., & Bagdonoff, M. (1965). The association of nocturnal angina pectoris with dreaming. Annals of lnternal Medicine, 63, 1040-1046. Parker, J. (1987). Nitrate therapy in stable angina pectoris. New England Journal of Medicine, 316, 1635-1642. Parker, J., & Fung, H. (1984). Transdermal nitroglycerin in angina pectoris. American Journal of Cardiology, 54, 471-476. Reichek, N., Priest, C., Zimrin, D., Chandler, T., & Sutton, M.S.J. (1984). Antianginal effects of nitroglycerin patches. American Journal of Cardiology, 54, I-7. Rosenblatt, G., Hartmann, E., & Zwilling, G. (1973). Cardiac irritability during sleep and dreaming. Journal of Psychosomatic Research, 17, 129-134. Sanford, S. (1983). Sleep in the cardiac patient. Cardiovascular Nursing, 19, 19-24. Schaer, D., Buff, L., & Katz, R. (1988). Sustained antianginal efficacy of transdermal nitroglycerin patches using an overnight ten hour nitrate-free interval. American Journal of Cardiology, 61, 46-50. Snyder, F., Hobson, J., Morrison, D., & Goldfarb, F. (1964). Changes in respiration, heart rate and systolic blood pressure in human sleep. Journal of Applied Physiology, 19, 417-422. Thadani, U., Hamilton, S., Olson, E., Anderson, J., Voyles, W., Prasad, R., & Teague, S. (1986). Transdermal nitroglycerin patches in angina pectoris. Annals of Internal Medicine, 105, 485-492.
From the Intermediate Cardiac Care Unit, the Berenson Emergency Unit, and the Center for the Advancement of Nursing Practice, Beth Israel Hospital, Boston, MA. Martha Ryan, BSN, RN: Intermediate Cardiac Care Unit; Susan Gallagher, MSN, RN: Cardiovascular Nurse Specialist, Intermediate Cardiac Care Unit; and Jane Corrigan Wandel, MS, RN: Nurse Specialist, Berenson Emergency Unit and the Center for the Advancement of Nursing Practice. Address reprint requests to Martha Ryan, BSN, RN, Beth Israel Hospital, 330 Brookline Ave, Boston, MA 02215. Copyright © 1992 by W.B. Saunders Company 0897-1897192/0502-000455.00/0
Nurses' P e r c e p t i o n s of Reportable Medication Errors and Factors That C o n t r i b u t e to Their O c c u r r e n c e Jean A. Waiters
EDICATION errors are a universal concern of hospitals. Jessee (1981) reported that error rates cited in several hospital studies ranged from 13% to 18% of all doses administered and
that only 25% of medication errors are actually reported. According to Wolf (1989), "Unreported errors constitute those errors about which nurses deliberate and choose not to report" (p. 11). Wolf (1989) also stated that nurses feel guilty when they make a medication error and believe they have not upheld their duty to protect the patient and do no harm. Weiland, Cohen, and Wieman (1987) reported that unfamiliarity with a nursing unit contributes to increased medication errors. Fuqua and Stevens (1988) indicated that medication errors decreased with nui'sing experience and increased with number of distractions. These investigators found that increased stress on a unit leads to increased medication errors and that peak activity times and nursing shortages also were causes of error. The purpose o f this study was to describe nurses' perceptions of the causes and types of reportable medication errors and to examine the influence of nurses' age, years of practice, and years of employment at our institution on the occurrence and reporting of medication errors.
METHOD Questionnaire A 33-item questionnaire was developed to obtain information on registered nurse (RN) characteristics and perceived causes of medication errors. The questionnaire was divided into (a) demographic information; (b) organization of work regarding medication administration; (c) number of errors made and number reported; (d) perceptions of major causes of medication errors; and (e) practice of reporting medication errors. The questionnaire was favorably reviewed by 10 RNs from the Nursing Care Evaluation Committee for content validity, and two pairs of parallel questions in the section on reporting practices yielded 75% and 100% agreement of responses.
Setting and Sample The study was conducted in a large Midwestern tertiary care hospital that used a 7/70 nurse staffing pattern (7 10-hour days on and 7 days off). The medication administration system was based on a computer generated list of medications referred to as the Medication Administration Record (MAR). RNs use the MAR as the primary document for checking and charting medication.