Scientific underpinnings for evidence based practice

1. Evaluating the outcomes of the practice change: Assessing the impact of the implemented intervention on patient outcomes.

Applying EBP to Reduce PONV in the Medical-Surgical Unit

1. Asking a Well-Defined Clinical Question:

The clinical problem identified is the persistent occurrence of PONV in postoperative patients on our medical-surgical unit despite standard antiemetic prophylaxis. Using the PICO (Population, Intervention, Comparison, Outcome) framework, the focused clinical question is: "In adult postoperative patients in the medical-surgical unit (P), does the addition of acupressure at the P6 point (I) compared to standard antiemetic medication alone (C) reduce the incidence and severity of postoperative nausea and vomiting (O)?"

2. Searching for the Best Evidence:

A brief literature search was conducted using the databases PubMed and CINAHL. Keywords used included "postoperative nausea vomiting," "PONV," "acupressure," "P6," and "nursing." The search was limited to articles published within the last five years.

Two relevant research articles were identified:

• Article 1: Lee, A., & Fan, L. T. (2020). Acupressure and acupuncture for postoperative nausea and vomiting. Cochrane Database of Systematic Reviews, 2020(10), CD003281. (Note: While a Cochrane review, it synthesizes recent high-quality evidence).
• Article 2: Yildiz, F., Kaya, S., Pirbudak, L., & Erdem, D. A. (2021). The effect of P6 acupressure on postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: A randomized controlled trial. Complementary Therapies in Clinical Practice, 42, 101304.

3. Critically Appraising the Evidence:

• Article 1 (Cochrane Systematic Review): This systematic review analyzed multiple randomized controlled trials (RCTs) investigating the effectiveness of acupressure and acupuncture at the P6 point for preventing and treating PONV. Cochrane reviews are considered a high level of evidence due to their rigorous methodology for identifying, appraising, and synthesizing research. The review concluded that stimulation of the P6 acupoint (including acupressure) is likely effective in reducing the incidence and severity of PONV compared to placebo or no treatment in adults. While it included various surgical populations, the findings suggest potential applicability to our medical-surgical patients.
• Article 2 (Randomized Controlled Trial): This RCT specifically examined the effect of P6 acupressure on PONV in patients undergoing laparoscopic cholecystectomy. The study design (randomized and controlled) strengthens the evidence. The results showed a statistically significant reduction in the incidence and severity of PONV in the acupressure group compared to the control group who received standard care. While the surgical population is specific, the physiological mechanisms of PONV can be similar across different surgical procedures, making the findings potentially relevant to our broader medical-surgical population experiencing PONV. The sample size (n=120) provides reasonable statistical power.

4. Integrating the Evidence with Clinical Expertise and Patient Values:

The evidence from both the Cochrane review and the specific RCT suggests that P6 acupressure is a safe and potentially effective adjunct therapy for reducing PONV. My clinical experience indicates that some patients find non-pharmacological interventions appealing and may prefer to try them in addition to or even before escalating antiemetic medications due to concerns about side effects like drowsiness. Acupressure is a non-invasive, low-cost intervention that nurses can easily administer after receiving proper training. Considering patient values regarding comfort and minimizing medication side effects aligns with offering this as an additional option.

5. Proposed Intervention:

Based on the appraised evidence and clinical considerations, I propose the following intervention to reduce PONV in our medical-surgical unit:

• Implement the use of P6 acupressure as an adjunct therapy for adult postoperative patients experiencing PONV despite receiving standard antiemetic medication.
• Protocol: Upon a patient reporting postoperative nausea or vomiting, and after the administration of standard antiemetics, nurses will offer P6 acupressure. This will involve applying firm pressure or using commercially available acupressure wristbands on the P6 point (located on the inner forearm, three finger-widths down from the wrist crease, between the two large tendons). Patients will be instructed on the correct location and application of pressure and can continue to use the wristband for several hours or as needed for symptom relief.
• Education: Nursing staff will receive training on the proper identification of the P6 acupoint and the application of acupressure techniques or wristbands. Patient education materials will be developed to explain the benefits and proper use of P6 acupressure for PONV management.
• Documentation: The use of P6 acupressure, the time of application, and the patient's reported response (including symptom relief or lack thereof) will be documented in the patient's electronic health record.

Reflection on Challenges:

One challenge encountered was the heterogeneity of surgical populations in the available research. While the Cochrane review provided a broad overview, the specific RCT focused on laparoscopic cholecystectomy. Applying these findings to our diverse medical-surgical population requires considering the potential variations in PONV triggers and patient characteristics. To mitigate this, we can implement the intervention as an adjunct therapy and closely monitor its effectiveness in our specific patient population. Another challenge might be ensuring consistent and correct application of acupressure by nursing staff. Comprehensive training and readily available resources will be crucial to overcome this. Patient acceptance and adherence to using the acupressure might also vary, highlighting the importance of thorough patient education and addressing any misconceptions.

Evidence-Based Practice (EBP) and Postoperative Nausea and Vomiting (PONV)

Evidence-Based Practice (EBP) is a systematic approach to clinical decision-making that integrates the best available research evidence with a healthcare professional's clinical expertise and the patient's values and preferences (Sackett et al., 1996). The core principles of EBP include:

1. Asking a well-defined clinical question: Identifying a specific problem or area for improvement in patient care.
2. Searching for the best evidence: Systematically locating relevant and high-quality research studies that address the clinical question.
3. Critically appraising the evidence: Evaluating the validity, reliability, and applicability of the research findings to the specific clinical context.
4. Integrating the appraised evidence with clinical expertise and patient values: Synthesizing the research findings with the clinician's knowledge and experience,