Nursing 211: Research Final Versions, Fall, 2007

Disadvantages of Nurses Strategies That Would Assist the Military With Post-Traumatic Stress Disorder (PTSD) In Veterans of Foreign Wars.

2007-12-13T09:58:00.000-08:00

“Among American Vietnam theater veterans 31% of the men and 27% of the women
have had PTSD in their lifetime. Preliminary findings suggest that PTSD will be present in at least 18% of those serving in Iraq and 11% of those serving in Afghanistan,” (National Center for PTSD, 2005, p.4). As troops return from deployments in Iraq and Afghanistan, the need for post-traumatic stress disorder treatment is expected to increase.
Due to the ongoing war in Iraq and conflict in Afghanistan, nurses needs to implement strategies that assist the military with effective screening, identifying tools, and methods to managing and treating post-traumatic stress disorder in the United States military and veterans.
Combat linked trauma has existed as long as humans have made war. In the U.S., the problem was first identified among World War I, World War II, and Korean War vets (National Center for PTSD, 2005, p.4). According to American Journal of Nursing, in World War I it was called “shell shock”; in World War II, “combat fatigue.” Although the difficulties combat veterans experience have long been recognized, it wasn’t until 1980, the year posttraumatic stress disorder (PTSD) was added to the Diagnostic and Statistical Manual of Mental Disorders, third edition ( Kaiman, 2003, ¶ 3). Families welcoming soldiers home encountered profoundly damaged men: chronically tense, clinically paranoid, and often unable to maintain jobs or carry on social relations—some prone to violence (National Center for PTSD, 2006). In today’s era of global conflict, the number of patients with war related trauma has soared. Their wounds are not just physical, but mental. Despite the soaring numbers of war related trauma among veterans returning from Iraq and Afghanistan, there are not near enough programs that effectively identify and treat Post Traumatic Stress Disorder among these veterans after deployment. Such programs are an important part of identifying the mental health burden of the current war and ensuring that there are adequate resources to meet the mental health care needs of veterans returning from Iraq and Afghanistan. Unfortunately, individuals with PTSD are often undiagnosed, which highlights the importance of proper recognition, assessment, and diagnosis. Providers need a quick, readable, accessible reference guide and annual education (Guess, 2006, ¶1).
There is current evidence determining what prerequisites are necessary to provide a firm basis for implementing a military psychological screening program. “Screening programs need to be acceptable: clinically, ethically, and socially, to the soldiers being screened. Screening programs also need to be simple, precise and validated in order to accurately identify psychological problems such as Post Traumatic Stress Disorder. Unlike anonymous surveys, it is likely that current pre-deployment and post-deployment questionnaires under identify psychological problems,” (Rona, 2005, ¶ 7). Nurses can play a critical role in determining that program prerequisites are met by organizing an active committee that will validate current screening programs. Nurses must take into account that surrounding circumstances such as anticipated leave, concerns of confidentiality, and shame influence soldiers that are being screened. Soldiers feel that admitting that they may have Post Traumatic Stress Disorder will ruin their future career prospects in the military, such as being denied promotions, awards or future reenlistments (National Center for PTSD, 2005, p.8). Early recognition of PTSD signs and symptoms are important for the most effective treatment (Guess, 2006).
To be diagnosed with Post Traumatic Stress Disorder, patients must meet four criteria: a history of “reexperiencing” the trauma (with associated panic symptoms such as dyspnea and palpitations) along with chronic social avoidance and withdrawal, emotional numbness, and hyperarousal (amplified startle reflexes or hypervigilance in anticipation of flight or fight) (Hoge, 2006). Although written psychological questionnaires have not been proven to be an effective tool on determining Post Traumatic Stress Disorder, it is the primary tool being used. “The Fort Lewis Soldier’s Wellness Assessment Pilot Program (SWAPP) has been developed to identify the susceptibility of returning troops to mental health ailments through questionnaires and face-to-face on-site interviews with nursing staff. This pilot program is giving nurses the ability to identify soldiers that are at risk of having Post Traumatic Stress disorder. Nurses are scheduling follow-up appointments immediately if a soldier is identified as at risk of having Post Traumatic Stress Disorder. Although this is a test site for such a program, on-site SWAPP assessments have helped improve access to health care and are working to breakdown the fear of soldiers not wanting to ask for help,” (Cantwell, 2006). By nurses having the proper education and access to more programs like SWAPP, nurses can continue to work together with each other, other health care professional and soldiers to deteriorate this fear that soldiers have developed.
Treatment for Post Traumatic Stress Disorder starts with education. Knowledgeable nurses can play a major role in the recognition and treatment of Post Traumatic Stress Disorder while in primary care settings or in such programs as SWAPP. Soldiers and their family members need to be educated by nurses on the development of the disorder, effects that Post Traumatic Stress Disorder has on the soldier and family, and effective treatments available. Nurse can provide patients and their family members with educational materials that help them understand that their effected family member’s feelings are related to the Iraq war and its consequences (Schnurr, P., 2004, p.59). Treatment for PTSD is really very practical and involves common sense. Soldiers have regular conversations with a trained counselor, in order to think about their situation and how the soldier wants to change it (National Center for PTSD, 2005, p.8). Through this form of psychotherapy the soldier learns more about what PTSD is and how it affects them . Although psychotherapy along with medication seems to work best for most, there are many other treatments available. While in a safe environment exposure therapy helps patients confront trauma-related situations, people, objects, memories, or emotions that evoke intense fear. Cognitive therapy helps patients identify and change assumptions, beliefs, and thoughts that lead to disturbing emotions and impaired functioning. Anxiety management, also called stress inoculation training, teaches patients skills they can use to reduce both the distress and the intensity of PTSD symptoms. In hypnotherapy, also know as eye movement desensitize and reprocessing (EMDR), the patient recalls traumatic memories while the therapist elicits eye movements that are similar to those that occur naturally during REM sleep. (Neason, 2006)
As returning PTSD-affected soldiers face their ghosts, RNs across the country will be involved in their struggle to regain their lives. “By recognizing patients with PTSD and other trauma related symptoms nurses can validate patients’ distress, and help them know that their feelings are not unusual” (Schnurr, P., 2004, p.59). Since there seems to be no ending to the current war in Iraq, implementing strategies that will assist the military with effective screening, identifying tools, and methods to managing and treating post-traumatic stress disorder in the United States military and veterans is a crucial need of nurses. If we are lucky, as a nation, we will not lose quite the generation like we have in the past to Post Traumatic Stress Disorder.

“Many soldiers wounded in Afghanistan or Iraq who would have died in prior wars now survive. However, they may sustain lasting injuries resulting in disfigurement or loss of function.
A recent study of combat troops following return from deployment to Afghanistan or Iraq found postwar rates of posttraumatic stress disorder (PTSD) ranging from 12.2% to 12.9% and rates of depression from 7.1% to 7.9%. Higher rates of PTSD were associated with higher levels of direct combat exposure and minor wounds or injury,” (Grieger, 2006). These are the type of statistic that one may come across when researching posttraumatic stress disorder, also known as PTSD. There are studies that show that posttraumatic stress disorder is nothing more than an attempt to medicalize a response to trauma. Further research also debates the usefulness of certain treatments that are meant to help victims of posttraumatic stress disorder.
“The predominant view in psychiatric publications is that post-traumatic stress disorder is a medical disorder, characterized by particular psychobiological dysfunction. Although the question of what constitutes a medical disorder is still debated, the identification of both psychobiological dysfunctions and medical interventions that can reverse dysfunctions, provide an important basis to legitimize the medicalization of a disorder (Stein, 2007). Studies show that post traumatic stress disorder may not be a medical disorder after all but an increasing medicalization of a problem that has been brought into the limelight by recent events such as the terror attacks on 9/11 and the ongoing war in Iraq. A more radical view is that post-traumatic stress disorder is merely a social construction, a label that has been applied to distress, for particular sociopolitical reasons. (Stein, 2007)
“Veterans may resist attempts to participate in treatment because they may associate authority figures with distrust. Angry veterans may also become impatient during the treatment process due to their desire to gain relief from their anger problems and their general heightened level of hostility and frustration. They may become easily frustrated when changes do not immediately occur as a result of therapy, and may become hostile or otherwise resistant to therapy,” (National Center for PTSD, 2005). This is a situation that clinicians might find themselves facing when treating service members returning from a combat zone. This is only a few disadvantages that come up when treating service members with therapy alone. Posttraumatic stress disorder therapies include psychotherapy, cognitive therapy, anxiety management, and hypnotherapy. Surrounding circumstances such as anticipated leave, concerns of confidentiality, and shame influence soldiers that are being screened are other disadvantages that effect a service member’s treatment. Soldiers feel that admitting that they may have Post Traumatic Stress Disorder will ruin their future career prospects in the military, such as being denied promotions, awards or future reenlistments. It has also been discussed that therapy alone may not help victims of posttraumatic stress disorder.
“There is a strong rationale from laboratory research to consider antiadrenergic agents. It is hoped that more extensive testing will establish their usefulness for PTSD patients. Hypotension and sedation needs to be monitored. Patients should not be abruptly discontinued from antiadrenergics. Despite suggestive theoretical considerations and clinical findings, there is only a small amount of evidence to support the use of carbamazepine or valproate with PTSD patients. Further, the complexities of clinical management with these effective anticonvulsants have shifted current attention to newer agents (e.g., gabapentin, lamotrigine, and topirimate), which have yet to be tested systematically with PTSD patients,” (National Center for PTSD, 2005). There have not been enough studies on successful treatment of posttraumatic stress disorder with only pharmaceuticals. There are many disadvantages for the pharmaceutical treatment. Side effects and improper dosage for such a disorder are those that are brought up most often.
Despite the ongoing war in Iraq and service members returning with symptoms of PTSD, there is a lack of studies on posttraumatic stress disorder. Further studies need to be conducted in order to determine whether posttraumatic stress disorder is in fact a medical disorder. Once this is established than proper treatment is than needed to treat service members that are returning from the combat zone that have posttraumatic stress disorder symptoms.

T. Grieger, S. Cozza, R. Ursano, & C. Hoge. (2006). Posttraumatic Stress Disorder and Depression in Battle-Injured Soldiers. The American Journal of Psychiatry, 163(10), 1777-83. Retrieved October 10, 2007, from Platinum Full Text Periodicals database.

D. Stein, S. Seedat, A. Iversen, & S. Wessely. (2007). Post-traumatic stress disorder: medicine and politics. The Lancet, 369(9556), 139-144. Retrieved October 10, 2007, from Platinum Full Text Periodicals database.

National Center for PTSD. (2005). Returning from the War Zone: A guide for Military Personnel. United States Department of Veterans Affairs. Retrieved on May 26, 2007, from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/GuideforMilitary.pdf

Cantwell, M. (2006). Cantwell Calls for Extensive Mental Health Screenings for Soldiers Returning from Iraq. Retrieved on May 01, 2007 from http://cantwell.senate.gov/news/record.cfm?id=262201

Guess, K. (2006). Posttraumatic Stress Disorder: Early Detection is Key. The Nurse Practitioner: The American Journal of Primary Health Care, 31(3), 26-33. Retrieved on May 26 2007 from http://www.nursingcenter.com/pdf.asp

Hoge, C., Authterlonie, J., & Milliken, C. (2006). Mental Health Problems, Use of Mental Health Services, and attrition From Military Service After Returning From Deployment to Iraq or Afghanistan. The Journal of the American Medical Association, 295(9), 1023-. Retrieved on November 7, 2006 from
http://jama.ama-assn.org/cgi/content/full/295/9/1023?eaf

Kaiman, C. (2003) PTSD in the World War II Combat Veteran. American Journal of Nursing, 103(11), 32-40. Retrieved on May 26, 2007 from http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=429109

National Center for PTSD. (2005). Returning from the War Zone: A guide for Military Personnel. United States Department of Veterans Affairs. Retrieved on May 26, 2007, from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/GuideforMilitary.pdf

National Center for PTSD. (2006). Returning from the War Zone: A Guide for Families of Military Members. United States Department of Veterans Affairs. Retrieved on May 26, 2007, from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/GuideforFamilies.pdf

Neason, K. (2006). PTSD: Help patients break free. RN Professional Journal, RN/AHC Media Home Study Program CE CENTER. Retrieved on October 1, 2006, from
http://www.rnweb.com/rnweb/article/articleDetail.jsp?id=375524

Rona, R., Hyams, K., Wessely, S. (2005). Screening for Psychological Illness in Military Personnel. The Journal of American Medical Association, 293(10), 1257-. Retrieved on November 7, 2006 from http://jama.ama-assn.org/cgi/content/full/293/10/1257?eaf

Schnurr, P. & Cuzza, S. (Eds). (2004). Iraq War Clinician Guide (2nd ed.) (pp. 58-61). Retrieved November 7, 2006 from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/iraq_clinician_guide_v2.p

Combating the Nursing Shortage

2007-12-11T10:33:00.000-08:00

Prayer in Nursing

2007-12-09T21:29:00.000-08:00

With spiritual care being a part of holistic care, nurses need to utilize prayer more effectively for spiritual well being, through implementation of guidelines to help nurses utilize this very important role in nursing care. There are many components of holistic care, and all of them should be recognized and implemented in care for the patient.
Nurses seem to be lacking the comfort and usage needed in spiritual care to give total holistic nursing care. Assessment of the patient’s desire for prayer or spiritual care can help solve this problem. Many nurses may not have the time or familiarity with prayer and other forms of spiritual care, therefore implementing guidelines for prayer and spiritual care are necessary to insure that all patients receive the best experience they can get. If the nurse does not have the time or knowledge, then pastoral services are available and a good resource for the patient’s spiritual needs.
Although prayer is a long established nursing intervention, praying with patients is still very controversial. It has been asked if praying with patients is ethical. The answer is that it is, if the nurse is true to the patient and themselves. Evaluation of the nurse’s own spiritual beliefs and comfort in spiritual care is essential to being sincere in providing this form of care. Taylor (2003) suggests that nurses should also seek to understand the relationship between prayer in care giving and patient/family coping. Maintaining integrity in spiritual care is important and essential in maintaining ethical standards. The question according to Wallace (n.d.) is, “Should we pray with their patients”? According to Taylor (2003) a considerable number of studies have identified prayer as a frequent and favored coping strategy among patients. Which answers the question of if nurses should pray, but a personal assessment is still necessary in each individual case. Prayer works. In recent research studies it is indicated that prayer reduces complications in CCU patients (Wallace n.d. para 2&3). According to Maier-Lorentz (2004) “The prayer group (n = 192) patients consisted of Christian born-again individuals who willingly offered prayers from a distance for these individuals whom they had never met, although they were given their names. A second group (n = 201) from the same CCU acted as the control group, and these individuals were not assigned to others to pray for them. Results indicated that patients who were prayed for had significantly less congestive heart failure, used fewer diuretics, had fewer cardiopulmonary arrests and less pneumonia, used fewer antibiotics, and were less intubated than those who did not receive intercessory praying from the born-again Christians” (para. 19). With this in mind prayer as an intervention with patients, fits the broader spectrum of spiritual care (Winslow & Winslow, 2003, para. 4).
One nursing strategy is to assess a patient’s desire for prayer or spiritual care. Assessing the patient’s need is essential for providing true holistic care. Every patient whether they are religious, spiritual, or, agnostic has needs for spiritual or emotional support. “Nurses must conduct a spiritual assessment to be involved in a caring-healing relationship that transcends all other dimensions of the physical world” (DiJoseph & Cavendish, 2005, para. 27). By allowing the patient the opportunity to reveal their beliefs or values, nurses can “understand the patient, meet spiritual needs, and provide appropriate support” (DiJoseph & Cavendish, 2005, para. 27). Using assessment skills to determine the patient’s need for spiritual care is a way to get to know the patient’s understanding and value of prayer. The nurse may try this statement to assess the patient’s desire for prayer as a coping mechanism, ‘It has been shown that prayer is a common way for people to cope with illness and life in general. Does this apply to you?’ Some other questions that may help in the assessment are, “Do you consider yourself spiritual or religious? [...] How might health care providers address any needs in this area?” (Winslow & Winslow, 2003, para. 14). If the patient answers affirmatively about prayer and the desire to receive support from the nurse, these following questions may also be helpful. “How important is prayer to you now?” or “How helpful is prayer for you now?”(Taylor, 2003, Table 1). Spiritual care may be as easy as the "gift of presence" through listening to you patient.
Another nursing strategy to help meet the spiritual needs of a patient is to implement guidelines for prayer in patient care. Suggested are some questions/ guidelines that may be appropriate. When should nurses pray with their patients? “The need for prayer during illness, even for people who do not consider themselves to be particularly religious” (Wallace, S., n.d. para. 5) is much higher and more common than many nurses probably know. Prayer with your patient is a personal choice and should not be taken lightly, but if the patient wants prayer, the nurse needs to address that need. Determining if prayer is an appropriate intervention is the first step to figuring out when to pray with a patient. If the patient suggests that, it is appropriate, asking them if they would like you to pray or for to just be present in silence with them, may be the best course of action. According to Taylor, how will a nurse know whether to pray or even discuss spiritual care with a client is a question that many nurses have asked (2003). First, permission from the patient is crucial before any prayers by the nurse should be said or thought. If the patient grants permission, the best thing to do is follow the patient’s cues as to how to proceed. When the patient specifically asks the nurse to pray for them, the next step would be to find out how they pray and what their beliefs are. An adequate assessment of a patient’s spiritual strength, needs, resources, and preferences will often include some knowledge of his or her religious tradition (Winslow & Winslow, 2003, para. 16). The nurse should focus on the patient’s spiritual needs and not their own. If the nurse does not have the same beliefs, then they should inform the patient that they are available to listen and be present while the patient prays but does not feel qualified to properly pray for them. When this happens, utilizing the hospital’s pastoral resources is an option.
Pastoral services are a good nursing strategy when the nurse is unable to provide for the patient’s religious needs. Whether it is when a nurse does not feel comfortable, they are lacking the knowledge base required for praying with the patient, or if the nurse just does not have the time necessary to address the patient’s spiritual needs, pastoral care is available. Pastoral support services may not be the exact religion or belief system that the patient follows, but they are trained in providing spiritual care. They can provide a more personal and in depth manner of care than the nurse may be able to. If the particular religions supported by the hospital are not sufficient, then they have resources outside of the hospital that can be used. Pastoral care should be able to address the patient’s needs when the nursing staff cannot, whether personally or through other religious avenues.
Praying is one of many ways to be effective in spiritual nursing care. Establishing guidelines for spiritual care and/or prayer is necessary if nurses are going to be able to provide this very important component of holistic nursing care. Assessing the patient’s need for prayer is another key element in providing good care. In the event that a nurse is not knowledgeable, uncomfortable or to busy to provide personal spiritual care and prayer, than hospital pastoral services are available. A nurse should never neglect or ignore a patient’s spiritual needs.

a. Intervention 1 (Assessment of patient’s desire for prayer or spiritual care)
i. Disadvantage 1 (Too many assessments too little time)
Assessments are the registered nurses job and priority. These assessments include respiratory, cardiovascular, skin, gastrointestinal, neurological, and psych/psycho-social to name a few. With all these assessments necessary to maintain proper care of the patient and keep them alive it would seem that assessing spiritual needs might not be prudent to the nurse, although it is definitely taught that spiritual well-being is part of holistic care. Nursing is a very fast paced stressful field of work, and nurses often have more than four patients to care for at any given time and the ongoing needs of the patients should come first. Some patient care events such as assessment, giving medications, and blood sugar checks are time specific and cannot be put off or ignored, while other patient care events can be juggled around to fit the time constraints of the nurse. Prioritization of these events enables the nurse to accomplish the job within the shift, yet emergencies can and do happen. (Navuluri, 2001) With all these patient care events, it is no wonder that spiritual care often takes the back burner in priorities.
ii. Disadvantage 2 (Delivery may discourage patient from verbalizing desire)
According to a national survey in 2004 of over 200 Americans, over one-third prays for good health. Among those who said they pray for specific health problems 69% stated that the prayer was helpful. Researchers say that people who are ill may turn to prayer as a means of coping, but on average 1 in 10 actually verbalize the desire to their nurse.(McCaffrey, et al. 2004) This may be due to the approach or delivery that the nurse uses to assess the patients desire. The delivery or route taken in order to acquire an assessment for the desire of prayer can vary greatly. If the nurse is friendly forthcoming and honestly believes in the assessment then the likelihood is that the patient will cooperate and verbalize the desire to pray if it is there. If on the other hand the nurse is short and seems distracted during the assessment results will more often than not be that the patient will keep their desires to themselves.
b. Intervention 2 (Implementing guidelines for prayer and spiritual care)
i. Disadvantage 1 (Noncompliance)
Implementing guidelines in nursing for prayer is a good idea, but there is a potential problem. While there are many guidelines in nursing, there has never been a specific set of universal guidelines for prayer. This may be due to lack of resources or interest in the subject. Without nurses, pursuing the development of these guidelines there is a huge potential for facilities to not put forth the effort to implement guidelines. With this in mind, it is not too far fetched to think that if guidelines were established but the nurses were not aggressive about implementing them then noncompliance would follow. Guidelines have been established for many different aspects of nursing and some of these are not followed as well as expected. If these guidelines are not being followed then who can expect that prayer guidelines would be, especially since prayer in nursing is not being used to its full potential as it is. Nurses may feel that they have not really used prayer so far in their care of patients so why should they start now even with guidelines.
ii. Disadvantage 2(establishing guidelines that apply to all patients)
Once the idea of guidelines has been established, we then face the problem of creating guidelines that will fit all aspects of prayer and spiritual care. This would be a very time consuming process, especially considering the many different beliefs in this world today. If the guidelines seem to cater more towards one belief than another does, it could cause serious problems with the religions or cultures of those that are not the majority. While this is understandable, it would also be almost impossible to incorporate all cultures, religions, and beliefs into one set of guidelines. This in itself can be a barrier in the implementation of prayer guidelines and then when you add in the reactions from the patients if guidelines were actually implemented but the patient’s beliefs did not fit the mold. Which would cause further issues with establishing guidelines for nurses and prayer?
References
DiJoseph, Josephine, & Cavendish, Roberta. (July-August 2005) Expanding the dialogue on prayer relevant to holistic care. (CONTINUING EDUCATION). In Holistic Nursing Practice, 19, p147(9).Retrieved April 16, 2007, from Expanded Academic ASAP via Thomson Gale
Maier-Lorentz, Madeline M. (July-Sept 2004) The importance of prayer for mind/body healing. In Nursing Forum, 39, p23 (10). Retrieved April 19, 2007, from Expanded Academic ASAP via Thomson Gale
Navuluri, R.B. (2001). Our time management in patient care. Retrieved October 20, 2007, from http://www.graduateresearch.com/NovuTime.htm
Taylor, E.J. (2003). Prayer’s clinical issues and implications. Holistic Nursing Practice, 17 (4), 179-188. Retrieved September 28, 2005, Expanded Academic ASAP database
Wallace, S. (n.d.). Should you pray with your patients?. Retrieved October 29, 2005, from http://nasw.org/users/suewallace/pages/pray_with_patients.html
Winslow, G.R. & Winslow, B.W. (2003). Examining the ethics of praying with patients. Holistic Nursing Practice, 17 (4), 170-178. Retrieved September 28, 2005, from Expanded Academic ASAP database

Controversy of Hand Washing vrs Alcohol Based Hand Rubs

2007-12-05T20:48:00.000-08:00

I thought they were really singing me Happy Birthday.....
The Controversy of Hand Washing vrs Alcohol Based Hand Rubs
How did the hospital staff know that is was almost my birthday? Of course it was on my chart, but I thought they would be more interested in my medical history more than my personal history.
I heard that familiar song being sung over and over with each nurse that came into my room. It wasn't until I said thank you for the 20th time before the nurse told me it was because they use that old familiar tune for the timing of hand washing.
This made me think about my Mother asking me over and over again...”Did you wash your hands?” Who would have known that this training would help me in my future nursing career? There are many agencies with guidelines, the CDC may be the best known, on just how to wash you hands and why. My question was, “Is alcohol based hand rubs better or more efficient than soap and water?” We all know that washing has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms (ie...MRSA: methicillin resistant staphylococcus aureus) and reduce overall infection rates. Alcohol-based hand rubs take less time to use than traditional hand washing, but is one better than the other? Research (2*) shows that in an eight hour shift, an estimated one hour of time will be saved by using an alcohol-based hand rub.
Are hand rubs more effective than washing your hands with running water and soap? According to the Middlesex-London Health Care Unit (2*), the answer is “no”. Traditional hand washing with water and soap is just as effective if done properly.
While hot water may more effectively clean your hands, this is primarily due to its increased capability as a solvent, and not due to hot water actually killing germs. Hot water is more effective at removing dirt, oils and/or chemicals, but contrary to popular belief, it does not kill microorganisms. A temperature that is comfortable for hand washing is about 113 degrees F and it would take more than double that temperature, about 212 degree F, to effectively kill germs. The addition of antiseptic chemical to soap does have a killing action to a hand washing agent. (4*)
The proper washing of hands with water in a medical setting generally consists of use with generous amounts of the antiseptic soap, rubbing each part of ones hands systematically for 15-20 seconds...(3*)which happens to be that old familiar song talked about earlier. Hands should be rubbed together with digits interlocking. If there is debris under fingernails, a bristle brush is used. Finally, rinse well and wipe dry with a paper towel. Lastly turn off water with a dry paper towel. (2*)
Non water based hand hygiene agents, also known as alcohol based hand rubs, antiseptic hand rubs, or hand sanitizers, are based on isopropyl alcohol or ethanol formulated together with a humectant such as glycerin into a gel, liquid, or foam for ease of use and to decrease the drying effect of the alcohol. Their increasing use is based on their ease of use, rapid killing activity against microorganisms, and lower tendency to induce irritant contact dermatitis as compared to soap and water hand washing. Despite their effectiveness, the non water agents do not clean hands of organic material, they simply disinfect them. However, disinfection does prevent transmission of infectious microorganisms.(4*)
Hand sanitizers containing a minumum of 60-95% alcohol are very efficient germ killers. It kills bacteria, multi-drug resisitant bacteria (MRSA & VRE), tuberculosis, and viruses (including HIV<>
Allergic contact dermatitis due to alcohol hand rubs is very uncommon. However, with increasing use, it is reasonable to expect have occasional true allergic reactions to such products. (2*)
In conclusion, Alcohol rubs and combination hand sanitizers are effective at killing germs on your hands, but not effective at removing dirt. Conversely, soap and water are very effective at cleaning dirty or soiled hands, but are not good at killing germs (as discussed above).
References:
1* “Why Do I Really Need to Wash My Hands?”; Mary L. Gavin, MD from Children's Hospital, 13123 E. 16th Ave; Aurora, CO http://www.thechildrenshospital.org/wellness/info/kids/10624.aspx
2* “Hand Hygiene Fact Sheet”; United States Department of Health and Human Services: Center for Disease Control and Prevention Hospital URL:http://www.cdc.gov/od/oc/media/pressrel/fs021025.htm
3* “Alcohol Based Hand Rubs; Questions and Answers”; Local Public Health Program at the Middlesex-London Health Unit, 2007 http://healthunit.com/article.aspx?ID=12684
4* “Hand Washing” from Wikipedia.org; http://en.wikipedia.org/wiki/Hand_washing
A. Interventions #1 Truth about actually killing HIV virus with alcohol based hand rub
Disadvantage #1: There is not enough evidence in the articles researched to confirm this claim of alcohol being absolutely responsible to kill the AIDS virus through proper hand sanitizing techniques. The reference sited as its source: Hand Hygiene for Healthcare Workers. LearnWell Resources, Inc, a California nonprofit public benefit 501(c)(3) corporation. Retrieved on 2007-04-27,
Disadvantage #2 Even though microorganisms are killed on your hands after washing or alcohol base hand rub, there are still other areas in the room that can be picked up after gloving and transferred to patients wound sites or to their body. ( 1*)
B. Intervention #2 Hand washing must be done every time a nurse, Dr., other personnel staff or visitors enter the room.
Disadvantage #1: Due to the hurry staff or visitors are in, the assurance that hand washing or alcohol based hand rub is used every time is questionable and therefore puts the patient in greater risk for infections or contamination. (CDC.gov on their Fact Sheet on Hand Washing)
Disadvantage #2: Constant hand washing or use of alcohol based hand rub dries skin and may cause allergic reactions to occur on personnel while caring for patients. (Wikipedia web site under “Hand Washing”)

Best Practices for Nurses in Maintaining Safe Medication Administration by Practicing the "5 rights" of Medication Administration.

2007-12-05T11:36:00.000-08:00

A medical mistake made at a Methodist hospital in Indianapolis was reported again in California at the Cedars Sinai Medical Center. In the California pediatric unit, the three infants got an adult dose of Heparin, a blood thinner.

That's 10,000 units instead of the infant dose of ten. “It's the same mistake that led to the death of three young patients in the NICU at Methodist hospital last year (Tiernon, 2007)”
Ongoing research shows that medication errors are happening frequently and that adverse drug events, or injuries due to drugs, occur more often than necessary. According to Kaufman (2006), at least 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications (para.1). Mistakes in giving drugs are so prevalent in hospitals that, on average, a patient will be subjected to a medication error each day as he or she occupies a hospital bed (Kaufman, 2006, para.2). Medication administration errors are not only harmful and widespread but also very costly. "The extra expense of treating drug-related injuries occurring in hospitals alone was estimated conservatively to be 3.5 billion a year” (Kaufman, 2006, para.4). The errors indicate a breakdown in the system. Nurses should carefully practice the “5 rights” of medication administration in order to provide safe medication administration. The “5 rights” of medication administration are: Right patient, right route, right time, right drug, and right dose.

Meadows (2003) noted that the National Coordinating Council on Medication Error Reporting and Prevention defines a medication error as “any preventable event which may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health-care professional, patient, or consumer" (para.4).According to Stoppler (2006), a study by the Food and Drug Administration evaluated reports of fatal medication errors from 1993-1998, “the most common error involving medications was related to administration of an improper dose of medicine, accounting to 41% of fatal medication errors. Giving the wrong drug and using the wrong route of administration each accounted for 16% of the errors. Almost half of the fatal medication errors occurred in people over the age of 60. Older people may be at greatest risk for medication errors because they often take multiple prescription medications.”In addition, many medication names look or sound like other medication names, which may lead to potentially harmful errors. Examples of medications that look and sound alike include: Amaryl and Reminyl, Clonidine and Klonopin, Depakote and Depakote ER, Famitidine and Furosemide, Xanax and Tenex. "An 8-year old died, it was suspected, after receiving methadone instead of methylphenidate, a drug used to treat attention deficit disorders.A 19-year-old man showed signs of potentially fatal complications after he was given clozapine instead of olanzapine two drugs used to treat schizophrenia. And a 50-year-old woman was hospitalized after taking flomax, used to treat symptoms of an enlarged prostate, instead ofvolmax, used to treat bronchospasm. In each of these cases reported to the Food and Drug Administration, the names of the dispensed drugs looked or sounded like those that were prescribed” (Rados, 2005).
To provide safe medication administration, the nurse should carefully practice the “5 rights” of medication administration. First, the nurse should ensure that the medication is given to the right client by checking the client’s identification bracelet and having the client state his or her name. The nurse should never go by room and bed number alone. “Some clients answer to any name or are unable to respond, so their identification should be verified each time a medication is administered. The nurse should verify the client by checking the identification bracelet. Some facilities put the client’s photo on his or her health record. The nurse should distinguish between two clients with the same last name” (Kee & Hayes, p.24)."Children are not totally reliable in giving correct names on request. Infants are unable to give their names, a toddler or preschooler may admit to any name, and school age children may deny their identification in an attempt to avoid the medication. Children sometimes exchange beds during play. Parents may be present to identify their child, but the only safe method for identifying children is to check their hospital identification band with the labeled medication or medication card" (Wong & Perry, 2002,p.1156). According to Kee & Hayes, in settings such as schools, physician’s office, and outpatient departments where clients do not wear identification bands, it is the nurse’s responsibility to identify accurately the individual when administering medications.
Second, the nurse should ensure that the medication is administered via the prescribed route. “The common routes of absorption are oral (by mouth), sublingual (under the tongue), inhalation (aerosol spray), suppository, (rectal, vaginal), buccal (between gum and cheek), via feeing tube, instillation (in nose, eye, ear), topical (applied to skin), intramuscular (IM), subcutaneous (SC), intradermal, and intravenous (IV)” (Kee & Haye, 2006, p.26).The oral route is preferred for administration of medication to clients whenever possible because of the ease of administration of oral medications. However, whichever route is prescribed, the nurse needs to make sure that the route is accessible. For example, if a medication is to be given by mouth, can the patient swallow? If not, can the medication be crushed? Third, the nurse should administer the medication at the time the prescribed dose should be administered. “Daily drug dosages are given at specified times during the day, such as twice a day, three times a day, four times a day or every 6 hours, so that the plasma level of the drug is maintained” (Kee & Hayes, 2003, p.26). Drugs with a long half-life are given once a day whereas drugs with a short half-life are given several times a day at specified intervals. In addition, drugs that are prescribed in association with meals need to be given with meals.In addition, the nurse should administer the right drug. This means the client receives the drug that was prescribed. To do this effectively, the nurse should check the medication order against the medication. If the order is illegible or some components of the order are missing, such as signatures, the nurse should contact the health care provider.
Furthermore, the nurse should administer the right dose prescribed for a particular client. The nurse should check the order and the medication label and look up any medication which he or she is not familiar with. The nurse should calculate each dose accurately, and ensure that each dose is within the recommended dose for the particular drug. Mayor (2004) states that “training and assessment of competence in pediatric drug therapy- including calculations of doses and infusion rates should be introduced to reduce the risk of drug errors in children.”
In conclusion, medication errors are surprisingly common and costly to the nation. They can lead to prolonged hospital stay, unnecessary diagnostic tests, unnecessary treatments, and death. Nurses can help to decrease the prevalence of medication errors by carefully practicing the “5 rights” of medication administration. Nurses can maintain patient safety by administering the right medication, in the right dosage, to the right client, by the right route, and at the right time.

References:
Kaufman, M. (2006, July 21). Medication Errors Harming Millions. The Washington Post. p. A08. Retrieved February 19, 2007 from http://www.washingtonpost.com/wp-dyn/content/article/2006/07/20/AR2006072000754.
Kee, L.J., & Hayes, R.E. (2003). Pharmacology. A Nursing Process Approach (4th Ed.). Philadelphia, PA: W.B.Saunders Company.
Mayor, S. (2004). Report Calls for Strategies to Reduce Medication Errors.British Medical Journal 328:248 .7434.248-b . Retrived May 20, 2007 from http://www.bmj.com/cgi/content/full/328/7434/248-b
Meadows, M. (2003).Strategies to reduce medication errors. FDA Consumer Magazine. Retrieved, February 14, 2007 from http://www.fda.gov/fdac/features/2003/303. Rados, C. (2005). Drug Name Confusion: Preventing Medication Errors. Retrieved, May 20,2007 from .http://www.medicinet.com/script.
Stoppler, C.M. (2006). The Most Common Medication Errors. Retrieved, May 20, 2007 from http://www.medicinenet.com/script/main.
Tiernon M.A (2007). Families upset over new Heparin overdose cases. Retrieved, December 3, 2007 from http://www.msnbc.msn.com/id/21920910.
Wong, D., Perry,S. & Hockenberry, M.J. (2002). Maternal Child Nursing Care. (2nd Ed.) St. Loius, MO. Mosby-Year Book, Inc.

A: Intervention # 1: Incomplete and illegible orders

Disadvantage # 1: Sometimes physicians write incomplete orders with either the drug, dose, route, and frequency missing from the order. All of these components must be present for a physician order to be considered complete. It is not a good practice to accept orders when the dosage is written as "1 tablet." "A complete order includes specific numerical dosages. For example, Acetaminophen 2 tablets po prn should now be written as Acetaminophen 650 mg. po prn. It is also no longer safe practice to administer vague orders such as "Laxative of choice." Drugs ordered need to be specific and the dose explicit (Cook, 2007)."

Disadvantage # 2: At times physicians write illegibly making it difficult for the nurses to read and transcribe orders correctly. Some facilities such as The Massachusetts Hospital Coalition recommends physicians use computers to directly order medications. "However, such costly systems may take years to implement.Cefoxitan and Cefotetan may look alike when hand written but confusing one drug for the other results in the patient receiving the wrong medication (Cook, 2007)."

B: Intervention # 2: Knowledge deficit

Disadvantage # 1: "Due to the large number of medications available and the large body of information required for appropriate drug administration, it is important to have access to a current medication reference such as the Physician's Desk Reference or other reference handbooks about medication." However, not every family, nursing facility or clinic have drug guides. The package insert that comes with every medication is also a good resource but yet due to language barrier, inability to read and comprehend medical terminology, some patients or nurses may not be in a position to give the right dose, of the right drug, at the right time. Pharmacists are knowledgeable resources and can answer many questions regarding medication but this may not be the case for over-the-counter medications (Hauswirth, 2002).

Disadvantage # 2: At times nurses have minimal or no knowlege of calculations leading to the right dosages. "Calculations may need to be performed to ascertain the correct dose. For example, a scored tablet, or one that is designed and intended for dividing, may need to be halved or quartered in order to administer the correct oral dose. This requires simple division. Common situations requiring calculation include calculation of intravenous infusion rates and the conversion of measurement units, for example, determining how many milliliters (mL) are required to give the ordered number of milligrams (Hauswrith, 2002).

References:

Cook C. Michelle (2007). Nurses' Six Rights for Safe Medication Administration. Retrieved November, 7 2007 from http://www.massnurses.org/nurse_practice/sixrights.htm Katherine Hauswirth (2002). Administration of medication. Gale Encyclopedia of Nursing and Allied Health, 2002. Retrieved November 7, 2007 from http://www.healthline.com/galecontent/administration-of-medication

Preventing Child Abuse and Neglect

2007-12-04T23:59:00.000-08:00

Child abuse and neglect (CAN) is a serious problem that results in devastating and long lasting damage to the individual affected, and to the community at large. Abuse and neglect in childhood can destroy self-esteem, self-concept, relationships, and the ability to trust (Valente, 2005).

Because nurses are on the frontline of assessment, they must be trained to recognize child abuse and neglect, and they must be trained in the proper response to positive screening results. Nurses must also be educated in methods of support for affected victims, and in ways to prevent abuse and neglect.
Children who are abused and neglected often come to believe that they do not deserve loving treatment. Abuse teaches those who suffer from it that others can not be trusted. Neglect and abuse of children is far from rare: The American Humane Association (2003) cites statistics that indicate that 17% of college students experienced abuse before the age of 18. The effects of abuse and neglect persist throughout the lifetime of the affected child. Society is affected as well, because those whose belief in themselves is shattered may turn to criminal enterprises, are more likely to engage in substance abuse, and are more likely to be sexually promiscuous (Overstolz, 2001).
Nurses are well trained to recognize the indicators of physical disease. Screening for problems with hearing and vision is a common nurse's role in primary schools. Because nurses routinely conduct screenings and assessments, they are ideally placed to also screen for the indicators of CAN. However, even nurses who have been practicing for many years may often believe that they have had little or no experience with abused or neglected children. To remedy this problem, programs are being developed to educate nurses in identification of the at-risk or victimized child (Young, Jackson, 2007). Studies have shown that nurses are interested in learning to screen for CAN, and that they feel confident in their ability to effectively do so (Waibel-Duncan, 2006). Once the nurse has identified a child who is at risk for or experiencing CAN, he or she needs to respond properly. Education of nurses in the identification of CAN must therefore include training in the appropriate response to positive screens. This response may include notification of legal authorities or supportive interventions for the family, depending on the severity of the indicators observed and the parties involved. Just as protocols are developed to achieve high standards of physical care, so too should nurses act to develop protocols for response to danger signs in the dynamics of the families that they care for.
Nurses develop therapeutic relationships in order to support those suffering physical and psychological disease. It is vital that nurses also be trained in the specifics of properly supporting victims of CAN. Recovery from CAN is often a life-long process. Recovery is facilitated when those afflicted receive appropriate and caring support and guidance. Well meaning but poorly trained attempts to help victims can actually slow recovery, as when the affected child is advised to "just put it out of (his or her) mind" or "just get over it." This illustrates the importance of education in the proper methods for supporting and facilitating victim's recovery. Nurses may encounter CAN victims in the hospital, or may discover that they have identified a child at risk for or suffering CAN during school screenings or at a doctor's office visit. In these situations, nurses can begin the process of recovery of CAN victims by taking steps to build the affected child's self esteem. Ensuring that the child has a safe environment where his or her needs are met in a loving manner is a major priority. Nurses may also work with CAN victims in mental health units. Abused children often believe they are damaged, unlovable, and worthless (Valente, 2005). Nurses must constantly reinforce the idea that an affected child is worthwhile, lovable, valuable and deserving of loving care. It is crucial that nurses allow those suffering from CAN to speak openly about their experiences, and that when a victim reports abuse, they must be believed (American Humane Association, 2003).
Supporting recovery of victims is very important, but few would dispute that it is far better to prevent a situation that causes serious harm to a child from happening in the first place. This is especially true in CAN. No means of therapy exists that is superior to avoiding the experience of abuse trauma or neglect entirely. There are many ways to reduce the chance that children will suffer abuse or neglect. Preventative measures include the following: At schools, health fairs, or clinics, nurses can provide age appropriate educational materials on CAN to children. Children can be trained in problem solving techniques, taught to identify troublesome occurrences, and conditioned to believe in themselves. Parents can be educated in finding safe child care arrangements. The public at large can be taught that a child abuser is most often some one who is known to the child. For too long, efforts at avoiding CAN have centered on alerting children to "stranger danger," when in fact the danger most often comes from relatives or acquaintances (American Humane Association, 2003).
Child abuse and neglect is a significant and pervasive problem which causes devastating and long lasting damage to those affected. In their roles as patient advocates, nurses can make a real difference in the lives of children, through training in CAN recognition, and in the appropriate response to positive CAN screening results. Nurses can effectively support the recovery of those who are damaged by CAN, and can take meaningful action to stem the tide of CAN. As compassionate professionals who dedicate their lives to serving their patients, nurses are ideally suited to make the world of childhood brighter and safer for all children.
There are potential disadvantages to these interventions:
a- "Because nurses are on the forefront of assessment, they must be trained to recognize child abuse and neglect, and trained in the proper response to positive screening results".
i- Disadvantage 1: Inadequate Insurance. The cost of training nurses is already high. Health care receivers ultimately shoulder the burden of the education of heath care providers, either through insurance payments, or through direct payment for services. Every item that is added to a nursing school curriculum adds costs to that program, in terms of time and money. Insurance is already unaffordable for many people. Adding to the costs of healthcare would put insurance out of the reach of even more people. A survey of 1,712 college students revealed a 17% rate of occurrence of sexual abuse before age 18 (Epstein & Bottoms, 1998). Ending abuse for 17% of the population would involve a huge increase in insurance rates.
ii- Disadvantage 2: Discrimination. The poor have long had a saying: "Justice means 'just us'", meaning that fairness is only available to those who are prosperous and mainstream. Disenfranchised minorities would be vulnerable to any attempt to screen for abuse as they lack the money and power to appeal an inaccurate finding. According to Douglas Besharov in The Future of Children (1994), “Potential reporters are not expected to determine the truth of a child’s statements. As a general rule, therefore, all doubts should be resolved in favor of making a report.” This implies that every time a child made a statement indicating potential abuse, the parents of that child would inevitably face a removal process, and the costs of an appeal. Poor and minorities by definition do not have excess funding and power, therefore their children would be removed at rates much greater than prosperous members of mainstream culture.
b- "Nurses must be educated in methods of support for affected victims and in ways to prevent child abuse and neglect".
i- Disadvantage 1: Knowledge Deficit. Most nurses would not know where to begin in repairing the shattered psyche of an abused child. A knowledge deficit exists in the nursing community at large regarding what child abuse is and how to respond to it. To remedy this problem, programs are being developed to educate nurses in identification of the at-risk or victimized child (Young, Jackson, 2007), however these programs are still in development. ii- Disadvantage ii: Religion. Preventing child and abuse means that some of the power over decisions about a child is taken away from parents and given to government. Religions vary in their views on the roles of child and parent, however most religions advocate for submission of the child to the will of the parent. The Bible tells the story of Abraham, who was preparing to sacrifice the life of his son to God (Genesis 22:1-12 ). This action would not be condoned by a society that educates its nurses in preventing abuse, however that occurrence is a cornerstone of the Christian faith. The religious right believes that there is one ultimate authority for all things, and that authority is God. It would be expected that they would oppose the transfer of power from God to the government.
Child abuse and neglect is a complex problem. Finding solutions to this problem requires evaluation of the benefits and the drawbacks of potential interventions.

References
Besharov, D. J. (1994). Responding to child sexual abuse: The need for a balanced approach. In R .E. Behrman (Ed.), The future of children (Vols. 3 and 4) (pp. 135-155). Los Altos, CA: The Center for the Future of Children, The David and Lucile Packard Foundation.
Epstein, M., & Bottoms, B. (1998). Memories of childhood sexual abuse: A survey of young adults. Child Abuse & Neglect, 22(12), 1217-1238.
Genesis 22:1-12 , (1952). Holy Bible. Dallas, Texas: The Melton Book Company.
Young, C, & Jackson, E (2007). Innovative Learning Opportunity. Journal of Nursing Education, 46, Retrieved May 1, 2007, from http://proquest.umi.com/pqdweb? index=0&did= 1245472821&SrchMode=1&sid=2&Fmt=6&VInst= PROD&VType= PQD&RQ T=309&VName=PQD&TS=1180685630&clientId=3236.

Nurse's Role in Palliative Care

2007-12-04T20:36:00.000-08:00

Research indicates that professional education and knowledge on end-of-life or palliative care has been limited or nonexistent in both nursing and medicine (LaPorte-Matzo & Sherman, 2001; Foley, 2005). Competent and compassionate end-of-life care is a responsibility of all health care professionals. Nurses consume the health care profession, and thus, have a tremendous potential to effect change in the care of the dying and their families.

(LaPorte, Matzo & Sherman, 2001). Armed with an understanding of the goals of palliative treatment,
nurses can play a leading role in palliative care by creating and implementing a plan of care.
The World Health Organization published its first definition of “palliative care” in 1986
and a revised version in 2002 (Foley, 2005). The revised definition the WHO provides states:
“Palliative care is an approach which improves quality of life of patientsand their families facing life-threatening illness, through the preventionand relief of suffering by means of early identification and impeccableassessment and treatment of pain and other problems, physical,psychosocial, and spiritual.”
By definition, palliative care now addresses the continuum of a patient’s illness and
preventing suffering rather than simply treating it (Foley, 2005). Caring for the whole person is
a key concept in palliative care (Seery, 2004). An easy way for nurses to accomplish this is by
considering the domains of holistic care, that is, the physical, psychological, social, and spiritual
needs of a patient.
Dying patients asked to rank their basic needs have said that they wished to be free of
pain, anxiety and shortness of breath; to be kept clean; and to be touched (Seery, 2004). For
many patients, the diagnosis of a chronic or terminal disease means the immediate end of a
“good life.” This is why palliative care today seeks to integrate curing with caring, to improve
quality of life and support the patient’s view of a “good death.” ( Rushton, Spencer & Johanson,
2004). The goals of palliative treatment are concrete: relief from suffering, treatment of pain
and other distressing symptoms, psychological and spiritual care, a support system to help the
individual live as actively as possible, and a support system to sustain the individual’s family
(Kuebler, Davis, & Moore, 2005).
Comfort measures should be included in the physical component of care which involve
frequent repositioning and padding of bony prominences (Seery, 2004). Attention should also
be taken to skin care to prevent the development of pressure ulcers. Additional physical
symptoms include nausea and fatigue. Nurses should focus care of the tired patient on
promoting adequate, restful, and restorative sleep when possible (Kuebler, Davis, & Moore,
2005). This can be done by preventing or reducing the factors that are disturbing the patient’s
sleep or that have the potential to do so and by providing bedtime routines, comfort measures
and a setting that accommodates sleep.
Palliative care can relieve most, but not all of terminal suffering for the patient. While
most experts agree that 95% of pain can be relieved by treatment that is acceptable to the
patient, the fact still remains that 5% of the palliative care population must cope with
unrelieved pain (Quill, 2001). The goals of palliative treatment become less concrete for these
patients. Nurses must acknowledge the fear for patients and families regarding unrelieved
pain. Also, it becomes paramount for the nurse to understand the therapeutic and institutional
barriers to effective pain management. The palliative care nurse may need to rely on non-
pharmacological alternatives to complement pain management (LaPorte, Matzo & Sherman,
2001).
Nurses can face an ethical dilemma when treating patient suffering. The most
commonly cited reason for requesting physician-assisted death is not pain, but rather
increasing weakness, debility, fatigue and dependence (Quill, 2001). Some end-of-life patients
experience terminal delirium and lose the capacity to make decisions for themselves toward
the end (Quill). This can lead to patient agitation and the decision to sedate such a patient who
can now no longer consent to such treatment. The palliative care nurse needs a plan for
handling such tough symptoms especially if they threaten the patient’s integrity during the
dying process. Inevitably, nurses may struggle with morally and ethically compromising
decisions such as these.
When addressing psychological, social and spiritual needs of the patient, an effective
way to determine his or her needs is to ask open-ended questions designed to elicit thoughts,
feelings, hopes and values. Utilizing therapeutic communication and empathy tends to not only
help the patient feel better, but also improves the patient and family’s perception of care
during the last days (Seery, 2004). Thus, care planning with the palliative patient should include
more than discussion of treatment preferences. Nurses should also address patient values,
beliefs, and goals. Patient values are the foundation for treatment preferences and medical
decision making (Kuebler, Davis, & Moore, 2005). Nurses can assess values and goals by asking
open-ended questions such as: What is most important to you as you think about the future
(Kuebler, Davis, & Moore, 2005)?
Nurses must also be aware that they bring their own spiritual and cultural beliefs and
values, as well as their own personal and professional experiences regarding death and dying to
palliative care nursing (LaPorte, Matzo & Sherman, 2001). Without this awareness and coming
to terms with it beforehand, the potential for biased care exists. This is why some professionals
have argued against using the method of open-ended questions during palliative care (Quill,
2001).
As nurses make every effort to ensure the psychological and spiritual component of
palliative care and help to create valuable support systems, they place themselves at risk of
becoming emotionally and physically drained (Laporte, Matzo, & Sherman, 2001). Nurses often
spend many hours in the supportive role and can suffer from caregiver strain. Efforts should be
made by the palliative care nurse to seek their own emotional outlets and plan care
accordingly.
Nursing’s history reveals compassionate care for the dying and that care exists beyond
cure. Presently, nurses must take the lead in integrating palliative care into the daily practice of
every nurse, making it a core competency for all nurses who care for people with actual or
potentially life-limiting illnesses (Rushton, Spencer & Johanson, 2004). In summary, nurses are
responsible for educating themselves on the goals of palliative treatment. With this
accomplished, nurses can most effectively create and implementa plan of care, thus becoming
the best advocate for the palliative care patient and their families.

REFERENCES
Foley, K. M. (2005). The past and future of palliative care. The Hastings Center Report,
35, (6), 42-. Retrieved February 20, 2006 from ProQuest database.
Johanson, W; Rushton, C. H.; & Spencer, K. L. (2004). Bringing end-of-life care out of the
shadows. Nursing Management, 35, (3), 34-. Retrieved February 20, 2006 from Infotrac
database.
Kuebler, K.K.; Davis, M.P.; & Moore, C.D. (2005). Palliative Practices: An Interdisciplinary
Approach. (63-396). Elsevier Mosby, Philadelphia, PA.

LaPorte-Matzo, M., Sherman, D. W. (2001). Palliative Care Nursing: Quality Care to the
End of Life. (xvii – 278). Springer Publishing Company, New York, NY.

Quill, T. (2001). Caring for Patients at the End of Life: Facing an Uncertain Future
Together. (115-154). Oxford, University Press.
Seery, D. H. (2003). Shifting gears: from cure to comfort: hundreds of thousands of
patients die in ICU’s each year, but few receive palliative care. Nurses play a central role in
transitioning from aggressive treatment to comfort care. RN, 67, (11), 52-. Retrieved February
20, 2006 from ProQuest database.

Pressure ulcers Know How to Stop the Pain

2007-12-04T20:21:00.000-08:00

To the untrained eye, a pressure ulcer may appear to be an open scab; although a pressure ulcer is more serious. According to Black and Hawks (2005), a pressure ulcer is, “any lesion on the skin caused by unrelieved pressure and resulting in damage to the underlying tissue” (p. 1403).

People who most commonly get pressure ulcers are those that are immobile or paralyzed. The reason for this is because sitting or laying down for extended periods of time increases pressure points by collapsing blood vessels and restricting the flow of blood to these areas. This may eventually lead to the death of the cells in these areas. By studying the causes of pressure ulcers and knowing the proper treatment procedures, nurses should be able to reduce the number of pressure ulcer cases in high risk groups.
Educating patients and nurses is one of the most important strategies to prevent and reduce pressure ulcer occurrences. Continuing education programs should be periodically conducted for nurses to reinforce and update their training. This will help to make sure the patient teaching that the nurses are doing is accurate and reliable. Pressure ulcers can affect anyone who is either paralyzed or immobile for an extended period of time, although these types of ulcers are most commonly seen in elderly people. Pressure ulcers develop when soft tissues are compressed between a bony prominence and a firm surface for a long period of time. Elderly people have the highest occurrences due to their limited mobility in conjunction with their thinner fragile skin. Given that this group has the greatest risk for pressure ulcers evaluating what causes them to appear and how to prevent them is the next step.
There is a scale that can be used in order to determine risk for pressure ulcers called a Braden or Norton tool. This tool gives a numerical score to six different areas in order to better determine risk factors for skin breakdown. According to Frantz (2004), “a patient in any setting with a score of eighteen or below should be considered at risk” (p. 5).Using this tool while doing daily skin checks could dramatically influence the number and severity of cases seen. Risk assessments should be completed on admission and 48 hours later. One cause, which could affect how fast a pressure ulcer is detected, is the lack of pain perception related to a loss of sensation. The Mayo Clinic staff state that , “in some cases, the pressure that cuts off circulation comes from unlikely sources: the rivets and thick seams in jeans, wrinkled clothing or sheets, a chair whose tilt is slightly off- even perspiration, which can soften skin making it more vulnerable to injury”(2007, para. 3). This is usually due to spinal cord injuries or disease. Smoking, malnutrition, incontinence, and medical conditions such as diabetes or cardiovascular disease can also affect the chances of getting pressure ulcers.
Once the patient is admitted with pressure ulcers the focus needs to shift to treatment and to prevent them from getting worse. One way to reduce the ulcers is to change the patient’s support surfaces, such as switching to an air mattress or water mattress, in order to limit the number of pressure points and increase movement. Another very important part of the treatment plan is turning the patients. The outdated recommendation for moving a patient to help with relieving pressure used to be every two hours. The new recommendation is dependent on the patient and their illness. When caring for a client who already has a pressure ulcer it is essential to know the different stages involved in order to give the proper treatment depending on the stage.
Stage 1- Skin has redness that does not turn white with pressure. It may hurt, itch or fell warm and spongy. If pressure is relieved quickly stage 1 will go away shortly after.
Stage 2- The top layer of the skin and the skin just below it are damaged. The ulcer can look like a shallow blister or abrasion. The surrounding tissue may have a red or purple discoloration.
Stage 3- This stage can have damage down to the muscle by causing damage or necrosis of the subcutaneous tissue.
Stage 4- A deep crater with extensive destruction or damage to muscle, bone or supporting structures. It is very difficult to heal and can lead to deadly infections.
It is crucial to identify pressure ulcers as early as possible to increase the chance of saving the skin from any further damage.
The skin can be protected using several methods; movement is the most effective for patients that are in bed. Movement at least every two hours is very important because it relieves pressure on the blood vessels and allows unrestricted blood to flow to those areas. Frantz (2004) states, “when patients are sitting in chairs and are unable to reposition themselves, their weight should be shifted every fifteen minutes to relieve pressure on the ischial tuberosities” (p. 7). Another method is to inspect the skin at least once a day, looking for warm reddened areas mostly around bony prominences, for example: the hips, heels, shoulders and back of the head. As detailed by the figure below from, Aging in the Know (2007).
Using pillows can help to avoid reddened areas or areas of increased pressure. Using a systematic schedule for turning and repositioning will help to ensure repositioning is being done consistently and in the right time frame. When repositioning a patient, lifting devices such as a trapeze or lifting sheet are helpful to make turning and repositioning easier. An important thing to remember is to be careful not to cause shearing or breaking of dry cracked skin. Dry cracked skin can be avoided by washing with warm water and a mild cleaning agent and treated with moisturizers to minimize irritation and dryness. It is also imperative to protect the skin from excess dampness, caused by sweat, wound drainage, and urinary or fecal incontinence.
Knowing the causes of pressure ulcers and who is at the greatest risk will make it easier for nurses to reduce the number of cases in high risk groups. As stated by, Courtney, Ruppman, and Cooper (2006), ”nearly 60,000 U.S. hospital patients are estimated to die each year from complications due to hospital acquired pressure ulcers” (p. 36). That is a very high number for a condition that is so preventable with daily skin checks and regular repositioning.
a. Intervention 1 Education and Prevention
i. Disadvantage 1 Anxiety and Interpretation of the material.
The material may be misinterpreted because English may not be the patient’s primary language which may cause the important issues and points to not be communicated properly. The patient may also not understand everything the nurse is saying due to an increased anxiety level from being in the hospital. According to (Quinn, 2007, p. 451). Some disadvantages are that the patient may feel under the spotlight. They may also miss the support of other patients. Along with the fact the patient may feel embarrassed they are not learning the information quickly and the teaching is going to fast.
ii. Disadvantage 2 Nurses misconception of the patient and patient’s reluctance.
The nurse may be taking for granted that the patient understands everything the nurse is saying due to the patient’s not wanting to ask questions. The nurse also knows the information much more than the patient and it comes easy to them so the nurse may skip over something they feel is not as crucial to cover. The nurse may go too fast thinking the patient can keep up also which may make the patient more apprehensive to asking questions. Because of this the patient may feel rushed and unimportant.
b. Intervention 2 Treatments
i. Disadvantage 1 Support surfaces
Disadvantages to having an air mattress can be that it may be punctured. Without proper inflation the bed is easier to puncture which is not beneficial to the patient. A water mattress may also be used but some disadvantages to this are that it must have a heater for the water to keep the patient’s body temperature at a comfortable level. Maintenance of a water mattress is difficult because the water has to be conditioned to prevent bacteria from growing. Procedures may also be more complicated when trying to perform them on a water mattress, such as a thoracentesis. Getting out of bed or changing a patient’s dressings may be more difficult for the patient as well. There are other support surfaces available to patients all having their own disadvantages. According to (Popescu and Salcido, 2006, section 8). The other available options are gel, foam, low air loss, dynamic overlays and air fluidized. Nurses should include this as part of the risk assessment that is performed when patients arrive at their facility to ensure patients are getting the proper support surfaces.
ii. Disadvantage 2 Dressings and Nutrition
Dressings are a very important part of the treatment process. Although dressings are not effective unless the wound is kept moist while the skin around it is dry. If the wound is not cleaned and the dressing not changed daily the wound will not heal. The disadvantage to this is the fact the patient may not be able to change the dressing on the wound by without assistance. Nutrition also plays a vital role in wound healing because if proper nutrition is not maintained the wound will heal slower. When discussing nutrition the nurse must make sure the patient does not have any GI dysfunction or can not swallow without aspirating. As stated in Black and Hawks (2005). Nutritionally compromised clients need to have a plan for nutritional support or supplementation implemented. Implementing a plan could be difficult for older patients that have definite food preferences and expectations. If adequate nutrition is not met alternative methods are put into action such as enteral or parenteral feedings.

References

American Geriatric Society, (2005). Pressure sores (bed sores). In Aging in the Know (ch 30). Retrieved January 31, 2007, from
http://www.healthinaging.org/aging intheknow/chapters_ch_trial.asp?ch=30
Black, J.M., & Hawks, J.H. (2005). Pressure Sores. Medical Surgical Nursing Clinical Management for Positive Outcomes, 7, 1403-1411.
Courtney, B.A., Ruppman, J.B., & Cooper, H.M. (2006). Initiative cuts pressure ulcer incidence in half. Nursing Management, 37, 36-45.
Frantz, R.A., (2004). Prevention of Pressure Ulcers. Journal of Gerontological Nursing For Nursing Care of Older Adults. 30, 4-9
Mayo Clinic Staff, (2007). Bed sores. Retrieved January 31, 2007, from http://mayoclinic.com/health/bedsores/DS00570
The Medical Journal of Australia, (2004). Preventing Pressure Ulcers. Retrieved October 28, 2007, from http://www.mja.com.au/public/issues/180_07_050404/sta10029_fm.html
NSW Department of Health, (2003). Prevention of Pressure Ulcers Rehabilitation and Residential Settings. Retrieved October 20, 2007, from http://www.health.nsw.gov.au/quality/pdf/pressure_ulcers_rehab.pdf
Propescu, A., Salcido, R. (2006) Pressure Ulcers and Wound Care Retrieved October 15, 2007, from http://www.emedicine.com/pmr/topic179.htm
Quinn, F. (ND). The Principles and Practice of Nurse Education. Retrieved October 15, 2007, from http://books.google.com/books?id=r0bqU8lgSXgC&pg=RA1-PA451&lpg=RA1-PA451&dq=patient+teaching+disadvantages&source=web&ots=5jGbU94u21&sig=OjBf02Rpm6fI1h54EPkxkd-5oDE#PRA1-PA451,M1

The Role of the Nurse in Incorporating Spirituality within the Healthcare Field

2007-12-04T16:19:00.000-08:00

Thesis: Nurses, as caretakers, are in the position to offer spiritual health care through education in recognizing spiritual distress w/in their patients, developing or utilizing an preexisting spiritual assessment tool to measure the level of spirituality in each client and providing unique interventions to attend to their spiritual needs.

Patients that now come into health care facilities seeking care are inflicted with many multiple acute or chronic diseases that are not curable but, perhaps, manageable. Despite how manageable these diseases are, they are debilitating to the patient physically and psychologically. Many clients spend the majority of their time in rehabilitative care, slowly progressing to some level of self-sufficiency. Although long term care facilities have advanced to a more humane caring environment than before, it can be a lonely, depressing, isolating experience for clients previously independent or involved. This is a time that clients are endowed with plenty of time to think about their lives in retrospect and their lives to be. Many develop/enhance their spirituality as means of coping and emotional support. Methods of spiritual engagement, such as prayer, have been associated with benefits to physical health. Nurses, as caretakers and a client’s most frequent visitor, are in the position to offer spiritual health care by allowing themselves to be educated in recognizing spiritual distress w/in their patients, develop or utilize an preexisting spiritual assessment tool to measure the level of spirituality in each client and provide unique interventions to attend to their spiritual needs.

Many patients in hospitals do not perceive their nurses at spiritual caretakers. According to a study in the New York Metropolitan area of hospitalized adults, the participants in the study perceived that nurses were not having enough time to provide spiritual care because of short staffing and heavy work loads, were not comfortable discussing another's spirituality, and were not well prepared to provide spiritual care (Cavendish, Konecny, Naradovy, Luise, Kraynya, June & et al., 2006). They believed the nurses were kind and caring but didn’t attend to their spiritual care. However, many nurses feel that spirituality can promote the health of their patients but do not engage confidently in the responsibility of assessing and implementing spirituality into the care plan. In a nationwide study, Piles (1990) found that although 96% of nurses believed spiritual care is a component of holistic care, almost two thirds of them felt inadequate to perform spiritual interventions. Between 75-90% (of 299 nurses providing care in one of the largest hospitals in the southwest) believed spirituality could reduce bodily pain, provide an experience of God’s forgiveness and assurance of eternal life, produce physical healing through the powers of the mind, and half patients discover the deeper meaning of their illness. (Grant, 2004).

One nursing strategy is for nurses in training and nurses in the field to be educated to recognize manifestations of spirituality. The focus of this strategy mostly targets nursing education programs to prepare students to identify spiritual distress and provide spiritual care. Since 2004, the National Council of State Boards of Nursing have been moving towards this goal by requiring students (RNs and LPNs)( in their most recent test plan) to be knowledgeable of religious and spiritual influences of health (as cited by Lantz, 2007, ¶ 29). The education provided should include teaching of different etiologies of spiritual distress (acute, chronic, and terminal illness, and near-death experience), the variety of concepts in spiritual health, assessment of, interventions, and applying appropriate nursing diagnoses. Nurses can also gain knowledge by examining their own spirituality. Friedemann, Mouch, and Racey (2002) believed it is important that nurses experience a self-exploration through reading, religious involvement, or activities such as meditation to understand their own beliefs and values (as cited in Potter & Perry, 2005, p. 549) . The critical thinking knowledge and skills learned from examining one’s own biases and spiritual concept as well as recognizing others will help the nurse to enhance the client’s spiritual well-being and health.

Because spirituality is a very subjective concept, nurses in health care facilities should develop different assessment strategies in defining the client’s spiritual well-being. According to Lantz (2007), JCAHO enforces the standard through a requirement that every patient be assessed for spiritual needs on admission and resultant spiritual care interventions be provided by a team of caregivers (¶ 31). One approach is the JAREL spiritual well-being scale which provides nurses with a simple tool comprised of three key dimensions (faith/belief, life/self-responsibility, and life-satisfaction/self-actualization) for assessing a client’s health (Potter & Perry, 2005, p. 551). Another assessment is called the two step approach suggested by Catterall and others (1998). Identification of the client’s religious beliefs, preferences, affiliations, and practices are documented in the initial assessment. The second step includes an ongoing in-depth assessment of the client spiritual well-being over the course of their stay. During the assessment, the nurse becomes more acquainted to the client’s behaviors and emotions enough to identify if the client is at risk for spiritual distress. Both assessments provide nurses with excellent strategies to gather subjective and objective data from their clients.

After gathering information about the client’s faith, religion, rituals, and beliefs, reviewing the client’s view of life, life satisfaction, and meaning, and developing appropriate nursing diagnoses, the nurse can provide effective collaborative management and/or nursing management. Many health care facilities have chaplains on staff to provide spiritual counseling and provide information about community support resources for the patient. Nursing management includes providing different coping methods for care receivers and offering “support to the patient’s religion by encouraging prayer and church attendance, readings, music, and other religious activities” (Baila, Biordi, Coeling, Nalepka, & Theis, 2003, ¶ ). According to Gorman, Raines, & Sultan, 2002), some nursing interventions include seeking assistance of or referrals to hospital chaplain or other resources, promoting the use of prayer and scripture when appropriate if within the patient’s belief systems, allowing patient to ventilate thoughts and feelings, allow family to participate in religious rituals, and being open to the patient’s expression of spiritual concern (p. 326). The use of support systems, diet therapies, supporting rituals, prayer, meditation, and supporting grief work can be incorporated into the plan of care.

Because many clients faced with multiple diagnosis and end-stage diseases spend the majority of their remaining time in health care facilities without receiving satisfactory spiritual support, it is the nurse’s responsibility to be educated in providing spiritual care and implementing care plans that support the client’s spiritual needs appropriately in order to reverse this problem. By recognizing their own aptitude and knowledge of spirituality, nurses can become aware of the client’s spiritual climate. By following a devised spiritual assessment tool for every admitting client, nurses will gather subjective and objective data for measurement or to diagnose a patient in danger of spiritual distress or ineffective coping methods. Afterwards, can nurses implement a nursing care plan unique to the client and apply appropriate nursing interventions such as prayer, chaplain assistance, and meditation. The client’s perception of the attempts of spiritual support made by the nurse would change for the better after these interventions, allowing comfortable and receptive communication between the patient and nurse about spiritual concerns and, in return, enable quality spiritual care to be implemented.

1. Intervention 1: One nursing strategy is for nurses in training and nurses in the field to be educated to recognize manifestations of spirituality. The focus of this strategy mostly targets nursing education programs to prepare students to identify spiritual distress and provide spiritual care

a. Disadvantage 1. Proper educator training of spirituality remains a problem that impedes the student’s spiritual education. Greenstreet (1999) postulated that nurse educators do not teach this content well and have a poor record in preparing nursing students for the delivery of spiritual care (as cited by Lantz, 2007, ¶37). As cited by Lantz (2007), Clark (2005) “acknowledged problems with traditional nursing education based on Western medical methods and suggested a shift to a partnership model that includes holistic and intuitive approaches to nursing” (¶5). According to Meyer (2003), less than 6% of classroom topics and less than 10% of clinical discussions were related to spirituality (as cited by Bennett, Manfrin-Ledet, Mitchell, 2006, ¶7). These problems are manifested in nursing students whom are ill prepared to handle spiritual crises during clinicals and many nurses, today, that do not take the time and energy to conduct a thorough spiritual assessment of their patients. As cited by McEwen (2004), Highfield et al. (2000) found that only “approximately half of the nurses reported receiving formal education in spiritual care through academic work and/or continuing education and that a majority of the nurses stated they were inadequately prepared to provide spiritual care” (¶8). In addition, research remains inadequate and nursing textbooks lack much information to provide nursing educators guidelines to proper delivery of spiritual content. McSherry and Ross (2002) agreed that there is indeed little “research about the assessment of client spirituality and delivery of spiritual care” (as cited by Lantz, 2007, ¶39).

b. Disadvantage 2: Besides nursing educators not being properly equipped and trained for proper teaching of spirituality in nursing care, legal complications, alone, set limitations upon the educator’s depth of teaching. According to Lebold and Douglas (1998), "although nursing is widely known as a caring profession, little is known about how to teach and enhance caring practices" (as cited by Lantz, 2007, ¶18). Besides adequate training, nursing educators in publicly funded colleges are face with legal roadblocks to their curriculum and undefined intricacies relating to separation of church and state. Lantz (2007) states that nursing education textbooks such as Bilings and Halstead test Teaching in Nursing: A Guide for Faculty, did not address the legal implications of teaching spiritual care content (¶ 7). According to Lantz (2007), “inability to engage in prayer, avoidance of religious discussions between students and faculty, cautious display of religious symbols, and sensitivity to the use of the Bible and other religious literature in public education” makes it very “difficult for nurse educators in publicly funded institutions of higher education to teach spirituality principles and spiritual care intervention” (¶ 26).

2. Intervention 2: Because spirituality is a very subjective concept, nurses in health care facilities should develop different assessment strategies in defining the client’s spiritual well-being.

a. Disadvantage 1: Assessments that are created by healthcare facilities are often conducted towards the population of patients in oncology, hospice, with AIDS, and/or with compromised mental health. Patients in other health settings are given little consideration regarding their spiritual health. This occurs because many current spirituality assessments are cumbersome, irrelevant, and time consuming in situations in which physiological care takes priority. According to Bennett, Manfrin-Ledet, and Mitchell (2006), “spirituality is often the last in a long series of assessments for patients” (¶14). If the nurse continues to perceives it as being low priority, the result will be little or no focus upon developing and implementing spiritual care plans, In a study conducted by Narayanasamy in 1993, it was found that the majority of nurses viewed spirituality as a religious matter and rarely offered spiritual care (as cited in McEwen, 2004, ¶7). According to Wakefield, Gerdner, and Tripp-Reimer (2002), there appears to be "collective amnesia of scientists regarding the significance of spiritual issues and religion for health" (as cited by McEwen, 2004, ¶4). Even if health care policies require spiritual assessment with admittance, will there be proper implementation of nursing interventions to alleviate spiritual distress and support the patient’s spirituality?

b. Disadvantage 2: Spiritual assessments, currently, appear to be more focused on information related to specific religious backgrounds and practices. Biases from the nurse with controversial religions may unintentionally instill their own values in assessing and providing care. O’Reilly (2004) states that “in a society characterized by religious pluralism, preconceived notions of clients' religious affiliations or spiritual beliefs must be set aside, and assessment must be guided by cues provided by clients” ¶14). Anandarajah and Hight (2001) proposed that “health care providers assess their own spiritual beliefs, values, and biases before initiating spiritual assessment with clients, in order to remain client centered and nonjudgmental” (as cited by O’Reilly, 2004, ¶ 13). Assessments created for identifying spiritual and religious elements of each patient should include spiritual and religious components that can be easily defined by nurses. As cited by Mohr (2006), Richards and Bergin (1997) differentiate religious interventions as “more structured, denominational, external, cognitive, ritualistic, and public, whereas spiritual interventions are more ecumenical, cross-cultural, internal, affective, transcendent, and experiential” (¶ 32).

References

Baila, M., Biordi, D. L, Coeling, H., Nalepka, C., & Theis, S. (2003). Spirituality in caregiving and care receiving. Holistic Nursing Practice, p48(8). Retrieved November 4, 2006 from Expanded Academic ASAP database.

Bennett, M.J., Manfrin-Ledet L., Mitchell, D.L. (2006). Spiritual Development of Nursing Students: Developing Competence to Provide Spiritual Care to Patients at the End of Life. Journal of Nursing Education, 45(9), 365-70. Retrieved November 2, 2007, from Platinum Full Text Periodicals database. (Document ID: 1121916271).

Cavendish, R., Konecny, L., Naradovy, L., Luise, B., Kraynyak, C., June, O., et al. (2006). Patients' perceptions of spirituality and the nurse as a spiritual care provider. Holistic Health. Retrieved October 21, 2006, from Expanded Academic ASAP via Thomson Gale.

Lantz, C. M, (2007). Teaching spiritual care in public institution: Legal implications, standards of practice, and ethical obligations. Journal of Nursing Education, 46(1). Retrieved February 18, 2007, from Expanded Academic ASAP database.

McEwen, M. (2004). Analysis of Spirituality Content in Nursing Textbooks. Journal of Nursing Education, 43(1), 20-30. Retrieved November 2, 2007, from Platinum Full Text Periodicals database. (Document ID: 523561021).

Mohr, W.K. (2006). Spiritual Issues in Psychiatric Care. Perspectives in Psychiatric Care, 42(3), 174-83. Retrieved November 2, 2007, from Research Library database. (Document ID: 1157381211).

O'Reilly, M.L. (2004). Spirituality and Mental Health Clients. Journal of Psychosocial Nursing & Mental Health Services, 42(7), 44-53. Retrieved November 2, 2007, from Research Library database. (Document ID: 670735571).

Perry, A. G., & Potter, P. A. (2005). Fundamentals of nursing (6th ed). St Louis, Missouri: Mosby.

Gorman, L. M., Raines, M. L., Sultan, D. F. (2002) Psychosocial Nursing for general patient care (2nd Ed). Philadelphia, PA: F.A. Davis Company.

Impacting Childhood Obesity

2007-12-04T11:37:00.000-08:00

Obesity has become the largest health problem in the world surpassing AIDS and malnutrition. The World Health Organization (WHO) designated obesity as a global epidemic affecting adults and children (WHO, 2007).

The incidence of obese children continues to rise in all ages and ethnic groups, equally affecting both sexes, leading to an increased urgency for health care providers to identify and treat children who are obese or are at risk of becoming obese. In order to combat this problem nurses need to identify these children and use a holistic approach in treating and preventing childhood obesity by promoting family involvement in nutrition, positive lifestyle changes and client education regarding physical education.
Currently obesity is defined as having a body mass index (BMI) greater than 30 and a BMI over 25 is considered overweight: BMI equals kg/[height (m)]² (CDC, 2007). “In the United States, the most recent estimates of obesity prevalence are based on data from the 1999-2000 National Health and Nutrition Examination Survey 20.6% of 2- to 5-year-old children in the United States were overweight. In older children, this prevalence was even higher, with 30.3% of 6- to 11-year-old children and 30.4% of adolescents (12-19 years of age) being overweight” (Velasquez-Mieyer, Perez-Faustinelli, Cowan, 2005). Being overweight in childhood also leads to an increased risk of becoming an obese adult. Children and adolescents who have a BMI greater than the 95th percentile have a 62-98% chance of becoming obese adults (Guo SS, Wu W, Chumlea WC, Roche AF, 2002). Childhood and adult obesity lead to increased incidences of type-2 diabetes and cardiovascular disease (Drohan, 2002). Furthermore, over 50% of overweight children suffer from hypertension (Velasquez-Mieyer et. al., 2005). Genetics and parental influence also have a strong influence in determining a child’s predisposition to obesity: As stated by Velasquez-Mieyer , 2005 “biological relatives exhibit similarities in maintenance of body weight, and that heredity contributes between five and 40 percent of the risk for obesity”.
Early detection of overweight and obese children is essential in order for nurses to make a positive impact on the obesity epidemic. Routine assessments include obtaining the child’s height and weight is all that is needed to calculate BMI (kg/m²) and determine if the child is overweight. Identification can be performed during routine clinical visits, at health fairs, or during school health screening. Assessing the child’s parents is also very helpful in identifying a child who is at risk of becoming obese. “If one parent is obese the child is 4-5 times more likely to become obese” (Guo, 2002). This number increased to 13 times in children under 5 years of age if both parents are obese (Velasquez-Mieyer et al., 2005). Nurses need to recognize the importance of identifying overweight children and plan interventions as early as possible. “Interventions should be started when the child reaches the 75th percentile, not the 95th for their age. At this point the child has an adult equivalent BMI of 30” (obese), thus compounding complications and requiring a greater level of intervention. (Hoolihan L, 2005). Interventions should include education regarding health risks and nutrition, as well as promoting physical activity.
Once a child is identified as being overweight and at risk of becoming obese, education regarding obesity is of utmost importance. A nurse should take every opportunity possible to educate children and their parents. This could be during clinical visits, at school, or during health fairs. Education should include nutrition, physical activity, and the multiple health risks associated with obesity including diabetes, cardiovascular disease, and hypertension. Educating the child and particularly the parents can make a substantial impact on a child’s nutritional intake and lifelong habits. Parental influence is a strong determinant in a child’s behavior and nutritional habits. If parents consume high fat, high sugar diet without meeting daily requirements for fruit and vegetable intake, their children will likely follow this example (Hoolihan, 2005). Nutritional education should focus on foods that contain necessary nutrient requirements. A wide range of foods should be listed for sources of each nutrient as well as appropriate serving size. A nurse may also provide the family with a copy of the United States Food and Drug Administration’s food pyramid which lists serving recommendations of each food group and portion sizes. Informing parents of a healthy weight is an important step of education. Many people do not perceive their children as being overweight due to being “accustomed to seeing overweight youth”. “In fact, in certain ethnic and racial groups, overweight is increasingly accepted, almost expected.” (Hoolihan, 2005). Along with nutrition children must also maintain an active lifestyle to treat and prevent obesity.
Physical activity is an important step in preventing obesity. The amount of physical activity varies greatly among children and adolescents; however there is a direct correlation between the amount of regular physical activity and a child’s weight (United States Department of Health and Human Services, 2005). Watching television, video games and computer usage are activities that require an insignificant amount of physical activity. Estimates suggest that the average child in the United States spends 25% of their waking hours watching television (USDHHS, 2005), and “even more hours are spent watching television if the set is in the child's room” (Holcomb, 2004). Often children are consuming high calorie snacks while engaging in sedentary behaviors, further increasing the correlation between lack of physical activity and obesity. A recent examination of the Department of Education’s Early Childhood Longitudinal Survey (ECLS-K) found that a one-hour increase in physical education per week resulted in a 0.31 point drop (approximately 1.8%) in body mass index among overweight and at-risk first grade girls. There was a smaller decrease for boys (USDHHS, 2005). Nurses should stress the importance of physical activity and recommend various activities while educating patients regarding obesity. Examples of activities to recommend include a daily walk with the family, a YMCA membership, enrolling in school or county sponsored organized sports, or at last resort an interactive video game that requires dancing or other intense physical movement. A brief explanation of the benefits of being physically fit will also enhance a patient’s willingness to engage in physical activities. This should include physical changes such as weight loss, improved muscle tone and endurance, body image and self esteem, as well as how it benefits the metabolic and cardiac systems. Again promoting physical activity with the child’s family would help strengthen the family’s commitment to treat and prevent obesity.
Early identification, nutritional education and promoting physical activity are essential components of treating and preventing childhood obesity. Nurses often spend more time with clients than other heath care providers during clinical visits and health promotion activities, or illness prevention functions. Therefore, nurses have multiple opportunities to initiate and facilitate identification, education and physical activity that will have a positive impact on childhood obesity.
References:
Drohan, S.H. (2002) Managing early childhood obesity in the primary care setting: A behavior modification approach. Pediatric Nursing, 28, 599-611. Retrieved October 27, 2006, from ProQuest database. (277433901).
Guo SS, Wu W, Chumlea WC, Roche AF (2002) Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. American Journal of Clinical Nutrition. 76:653-658.
Holcomb S.S., (2004). Obesity in children and adolescents: Guidelines for prevention and management. Nurse Practitioner. 29(8), 9-13. Retrieved October 26, 2006, from ProQuest database (683132191).
Hoolihan, L. (2005) The role of education and tailored intervention in preventing and treating overweight. Nutrition Today 40.5: 224(10). Retrieved Feb 16, 2007, from Expanded Academic ASAP. A138397561
World Health Organization (WHO). (2006). Overweight and obesity. Fact sheet N-311. Retrived January 9, 2007, from: http://www.who.int/mediacentre/factsheets/fs311/en/index.html
United States Department of Health & Human Services. (2005). Childhood Obesity. Washington, DC. Retrieved January 9, 2007, from: http://aspe.hhs.gov/health/reports/child_obesity/
Velasquez-Mieyer, P., Perez-Faustinelli, S., & Cowan, P. A. (2005). Identifying children at risk for obesity, type 2 diabetes, and Cardiovascular Disease. Diabetes spectrum. 18(4), 213-221. Retrieved January 20, 2007 from ProQuest database (933878111).

Type rest of the post here
Impacting Childhood Obesity.
Early detection and identifying overweight and obese children.
Insufficient Parental knowledge regarding obesity and Body Mass Index.
Basic assessment of height and weight and calculating a BMI are part of every complete physical assessment. While this information provides valuable data for health care providers, parents are often unaware of what BMI indicates. A lack of information and teaching leads parents to disregard the significance and negative health consequences of a BMI above 25. Health care providers may not emphasize the importance of an elevated BMI assuming the parents are aware that their child is overweight and they understand the importance of such information. Culture may also effect the how a parent views their child’s weight and BMI, obesity is not stigmatized in some cultures as it is in others (Davis). This leads to increased boundaries regarding patient education and receptiveness to teaching.
Legal considerations preventing widespread Health screening and reporting for Children.
A majority of public grade schools institute annual health screening programs. From state to state a these programs are required to assess immunization compliance (50 states), vision (36 states), hearing (35 states), scoliosis (27 states), and dental (9 states). However few schools obtain BMI information, according to Center for Disease Control report (2006) only 11 states have policies that require height and weight to be obtained during health screening. Furthermore only 60% of schools sent information home regarding each component of the health screening, but less than 30% offered any health education to families (CDC, 2006). Broad Federal Government legislation covering school health screening is currently lacking. States are allowed choose what screening is performed and what information and teaching is offered to families. State to state legislation mandating minimum health screening also fails identify overweight children. To compound the problem only 3 states require schools to have at least 1 full time nurse (CDC, 2006). This leads to a lack of professional health assessment capability as well as planning and recording information from health screening activities.
2. Boundaries to successful interventions through education.
1. Socioeconomic status may prevent may prevent families from obtaining appropriate nutrition required to treat and prevent obesity.
Education aimed at providing nutritional information for overweight and obese children often emphasizes low fat foods, fresh fruit and vegetables, low fat dairy products and an avoidance of highly processed foods. Many processed and prepared foods are inexpensive, high in fat content, calories, and poor in nutrients. With an overwhelming availability of poor cheap food choices it is difficult for families to follow a nutritional diet. Fresh foods require preparation time and cost significantly more than pre-packaged and processed foods. Ounce for ounce potato chips cost less than apples, as does prepared fried chicken (loaded with saturated fats and oil) vs. fresh skinless chicken breast (98% fat free). The cost alone will prevent many families from obtaining nutritious foods. Convenience also plays a major role in nutritional decisions. Over 61 of all two parent families with children under 18 have two incomes, this leads to increased time away from home and less time for obtaining and preparing nutritional foods. Forty two percent of food dollars are spent on food consumed outside of the home.(Savage).
2. Poor feasibility in changing parental eating habits.
Obese children have learned to eat what their parents provide and aquire tastes and preferences similar to their parents beginning at birth. Educating a parent regarding proper food choices and encouraging them to follow the recommendations will not have a beneficial effect on the child’s weight if the parents do not concurrently change how and what they eat. Combating childhood obesity is compounded three fold by educating and promoting change in the child, the parent, and the entire family. To further complicate this 31% of children are cared for during mealtime by a caretaker or grandparent and 41% are enrolled in an organized day care center (Savage). This limits the parents influence on nutrition and relies on someone else to follow proper nutrition guidelines.

Best Practices in the Management and Treatment of Irritable Bowel Syndrome

2007-12-03T23:58:00.000-08:00

THESIS: Best practices in the management and treatment of Irritable Bowel Syndrome includes treatment combinations tailored to each individual and their proven efficacy.

INTRODUCTION
Irritable bowel syndrome (IBS) is a common gastrointestinal condition characterized by abdominal pain, discomfort, and altered bowel patterns. The pathophysiology of IBS is not explicit. Approximately 10 to 15 percent of the U.S. population is affected by IBS, and women are more likely to have symptoms than are men (Hadley & Gaarder, 2005, p. 2501). No one pharmacological treatment is effective for all symptoms of IBS, and not all clients are in need of drug treatments. The absence of acquired facts regarding the cause and origin of the ambiguous symptoms of IBS impedes research for a cure and effective management.
DIAGNOSIS
The diagnosis of IBS cannot be made by laboratory tests. A focused assessment and patient history should be conducted, noting the intensity of symptoms and their impact on quality of life. Diagnosis is based on clinical signs and symptoms that include abdominal pain, bloating, constipation, and diarrhea (Hadley& Gaarder, 2005, p. 2501). The diagnostic criteria in Table 1 were developed to assist in the diagnosis of IBS.
"The diseases that need to be considered when evaluating gastrointestinal complaints include Irritable Bowel Disease (IBD), which is a condition of inflammation of the intestinal tract, celiac sprue, gallbladder inflammation, infection, including parasites, dietary intolerances, and colon cancer, among others” (Meisler, 2001, p.224).

TABLE 1
Diagnostic Criteria for IBS
Abdominal discomfort or pain, for at least 12 weeks (which need not be consecutive) in the preceding 12 months, with two or more of the following features:
Relief with defecation
Onset associated with a change in stool frequency
Onset associated with a change in form or appearance of stool
These additional symptoms cumulatively support the diagnosis of IBS:
Abnormal stool form (loose and watery or lumpy and hard)
Abnormal stool passage (urgency, frequency, feeling of incomplete evacuation)
Passage of mucus (white material)
Bloating or sensation of abdominal distention
IBS= irritable bowel syndrome
Note: The diagnostic criteria for IBS is adapted from “Treatment of Irritable Bowel Syndrome” [Electronic Version], by S.K. Hadley & S. Gaarder, 2005, American Family Physician, 72(12), pp.2501-2506.

TREATMENT
Management of IBS should begin by initiating a therapeutic provider-client relationship.
Education regarding the nature of the illness and long-term prognosis should be addressed, as well as any concerns the client has. The diagnosis is common and there is no special risk of serious complications may comfort many (Thompson, 2002, p. 1398).
Initial suggestions are related to modification of the client's diet that may reduce symptoms. Frequent exercise, allotting sufficient time to eat and defecate, and consuming a balanced diet can be addressed. "Reported dietary triggers of IBS include caffeine, citrus, corn, dairy lactose, wheat, and wheat gluten, with lactose and caffeine being associated with diarrhea-predominant IBS" (Hadley & Gaarder, 2005, p. 2502).
Increasing fiber in the diet has been recommended as a treatment for IBS, because of its action on the stool. Fiber enhances the stool's water-holding properties, provides lubrication, aids to bulk the stool, and enhances the binding of agents such as bile (Hadley & Gaarder, 2005, p. 2503). Because fiber is inexpensive and easily accessible, it may be a good starting point, especially for those who experience constipation-predominant IBS. There are a variety of fibers available, including synthetic fibers and natural fibers. The synthetic fibers are more soluble, but may generate gas discomfort. Psyllium seed and linseed are bulking agents with lubrication properties and both contain mucilages that contribute to this (Hadley & Gaarder, 2005, p. 2503).
Sweeteners, such as sorbitol and fructose are added to gum, jams, and soda, for example, and are laxatives that may be upsetting to the bowels. Some medications may provoke IBS, such as opiates, calcium channel blockers, and non-steroidal anti-inflammatory drugs, which may cause constipation. While some antacids, antibiotics, and occult laxatives may induce diarrhea (Thompson, 2002, p. 1399).
Eating stimulates the gut to move and secrete, and an exaggerated gastrocolic response experienced by those with IBS can lead them to believe foods in their diet are the cause. The impact of this response may be relieved by avoiding meals high in fat content (Thompson, 2002, p. 1399). It may be useful for the client to keep a food diary containing foods eaten, bowel habits, and exercise, and their response to those activities.

No drug treatment is efficacious for all symptoms of IBS, and many clients do not need any drugs at all. Drugs should be prescribed based on the predominant symptom, constipation or diarrhea (Thompson, 2002, p. 1395).
Antispasmodics (anticholinergics) temporarily block nerve impulses to the gut, thereby reducing smooth muscle contractions. Dicyclomine (Bentyl) and hyoscyamine (Levsin) act to relax smooth muscle 1. These drugs can offer relief from the cramping of constipation. If used habitually, they may induce constipation (O'Hare, 2001, p. 132).
Loperamide is an opioid agonist and works by inhibiting intestinal secretions and increasing fluid and electrolyte absorption due to increased intestinal transit time (Talley, 2003, p. 364). Loperamide does not cross the blood-brain barrier, therefore side effects are minimal (Hadley & Gaarder, 2005, p. 2503).
5-HT3 receptor antagonists slow colonic transit, relaxes the descending colon, and results in decreased perception of volume in diarrhea-predominant irritable bowel syndrome (Talley, 2003, p. 365). Alosetron (Lotronex), an IBS-specific medication, is available again after being pulled from the market following cases of ischemic colitis and five deaths. It is available for women only with severe diarrhea-predominant symptoms, but with strict prescribing guidelines. Alosetron should only be prescribed after other conventional treatments have failed (Hadley & Gaarder, 2005, p. 2505).
5-HT4 receptor agonists, such as tegaserod (Zelnorm) stimulate the release of neurotransmitters and increases colonic motility. Zelnorm is safe for up to 12 weeks of use, but long-term safety has not been proven. Zelnorm improves general symptoms of IBS in women, although it is minimally advantageous (Hadley & Gaarder, 2005, p. 2505).
Antibiotics may be prescribed for refractory diarrhea due to a bacterial infection, for short-term use. Long-term use of antibiotics can increase diarrhea by changing the normal flora in the bowel (Hadley & Gaarder, 2005, p. 2505).
Peppermint acts as an antispasmodic and may improve digestion. It also acts by anesthetizing, decreasing nausea, and relaxing smooth muscle. It is inadvisable in clients with gastroesophageal reflux disease (Hadley & Gaarder, 2005, p. 2505).
CONCLUSION
The treatment and management of Irritable bowel syndrome has proven to be difficult due to the lack of understanding about the pathophysiology. IBS presents differently in each client, and treatment should be comprehensive and approached by the provider and client. While many treatment options exist, each client should be treated individually and holistically.

Intervention 1: Patient Education
An important component in treating patients with Irritable Bowel Syndrome is the provision of patient information, including an explanation of the syndrome and reassurance.
Disadvantage 1: Knowledge Deficit
Irritable bowel syndrome remains undiagnosed in many individuals mainly because of failure to seek medical attention for symptoms and lack of recognition of the syndrome (Spinelli, 2007). Manifestations of IBS include constipation, diarrhea, and abdominal pain, which may be interpreted as a "stomach flu" or food allergy. Fear of cancer and malignant disorders may keep the individual from seeking medical care (Mearin, 2006). This may result from an ineffective patient-physician relationship that lacks communication and trust. Therefore, a confident diagnosis and avoidance of repeated or unnecessary tests is important.
Disadvantage 2: Lack of Resources
Irritable bowel syndrome is a disease of unclear, complex pathophysiology (Spinelli, 2007) and research shows healthcare professionals still have limited knowledge of the disorder
(Boyd-Carson, 2004). Providers in busy outpatient practices may have difficulty providing detailed information, advice and support about the disorder, the precipitating factors and treatment options. Studies demonstrate that less than thirty percent of IBS patients under the care of a primary care physician are referred to a specialist (Faresjo et aI, 2006).
Intervention 2: Dietary Modifications
Dietary modifications are frequently recommended as a first step in the management of Irritable bowel syndrome. Although no specific diet can be recommended to all patients with IBS, many will report an improvement in symptoms with the identification and avoidance of specific trigger foods and the inclusion of dietary fiber (Boyd-Carson, 2004).

Disadvantage 1: Exacerbation of Symptoms
Fiber must be introduced gradually, as an increase in fiber initially may worsen symptoms such as bloating and pain ((Boyd-Carson, 2004). Fiber therapy may aggravate symptoms by decreasing pain threshold secondary to distention and by inducing colon distention through the formation of gas from bacterial fermentation (Mearin, 2006).
Disadvantage 2: Altered Nutrition
Limitations on dietary habits may further impair the patient's quality of life (Mearin, 2006). Avoidance of nutrients that induce symptoms may require supplementation, such as calcium supplements (Boyd-Carson, 2004). Insufficient intake of nutrients can have an effect on the metabolic system, as evidenced by weight loss, poor muscle tone, muscle weakness and abnormal lab studies (iron deficiency, electrolyte imbalances).

REFERENCES
Boyd-Carson, W. (2004). Irritable bowel syndrome: assessment and management. Nursing Standard, 18(52), 47-52. Retrieved October 29, 2007, from Academic Search Premier Database.
Hadley, S.K., S., Gaarder. (2005). Treatment of Irritable Bowel Syndrome. American Family
Physician, 72(12), 2501-2506. Retrieved July19, 2007, from Academic Search Premier
Database.
Faresjo, A., Grodzinsky, E., Foldevi, M., Johansson, S., Wallanders, M.A. (2006). Patients with Irritable bowel syndrome in primary care appear not to be heavy healthcare utilizers. Alimentary Pharmacology & Therapeutics, 23,807-815. Retrieved October 29, 2007, from Academic Search Premier Database.
Mearin, F. (2006). Pharmacological Treatment of the Irritable Bowel Syndrome and Other Functional Bowel Disorders. Digestion, 73(suppl1), 28-37. Retrieved October 29, 2007, from Academic Search Premier Database.
Meisler, J.G. (2001). The Experts Discuss Irritable Bowel Syndrome.
Journal of Women's Health & Gender-Based Medicine, 10(3), 223-228. Retrieved July 19, 2007, from Academic Search Premier Database.
O'Hare, L. (2001). The Irritable Bowel Syndrome. New York:
McGraw-HilI.
Spinelli, A. (2007). Irritable Bowel Syndrome. Clinical Drug Investment, 27(1), 15-33. Retrieved October 29, 2007, from Academic Search Premier Database.
Talley, N.J. (2003). Evaluation of Drug Treatment in Irritable Bowel Syndrome. British Journal of Clinical Pharmacology, 56(4), 362-369. Retrieved July 19, 2007, from Academic Search Premier Database.
Thompson, W.G. (2002). Review Article: The Treatment of Irritable Bowel Syndrome. Alimentary Pharmacology &Therapeutics, 16, 1395-1406.

Best Practices in Nursing: Elderly Wellness and Restraint Alternatives

2007-12-03T23:40:00.001-08:00

The use of restraints in health care settings has been a long debated topic. Restraints are used in every arena of patient care, including acute care settings, long-term care, pediatrics, and especially geriatrics. Although the use of restraints is ordered by a physician, nurses are often the caregivers who apply the restraints and care for the patient, while the restraints are in place.

Nurses have an ethical and professional responsibility to their patients during their care. Often their own beliefs relating to restraints will shape their decision making and actions regarding their patient’s care. Further education on the use of restraints and possible alternatives to their use has proven to influence nurses in their care practices. By minimizing the use of physical restraints, overall patient wellness has improved in elderly populations and their care settings.
Physical restraints have been defined as limiting a person’s freedom of movement by specific devices such as wheelchairs, safety vests, a room with closed doors and bed rails (Hantikainen, 1998, p. 331). The Health Care Financing Administration further defines a physical restraint as “any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body” (Janelli, Stamps, & Delles, 2006, p. 163). Medications such as tranquilizers and sedatives are used as chemical restraints, which will treat behavioral symptoms by altering their mental state (NCCNHR, para. 1). Physical restraints are the most often used.
In 1987, Congress passed the Nursing Home Reform Act. The Act was prompted by prior studies that found nursing home residents to be abused and neglected. This act aims to provide quality care which in turn will lead residents to live at their optimal physical and mental state. To ensure these rights, the Act contains a Resident’s Bill of Rights, which specifically states residents have the right from freedom of physical restraints. States have a certification process which monitors homes and holds them to the standards set forth by this act. If standards are met, the homes will receive government funding (Klauber & Wright, 2001, para. 1-7)
In response to neglect, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) also has a set of standards for restraint use. JCAHO is one of the primary organizations that aim to constantly provide quality care while safely protecting the patient. JCAHO is asking hospitals to implement interventions to decrease patient restraint use. Also, if restraints are warranted under their standards, they are requesting an increase in patient monitoring (Janelli et al., 2006, p. 163).
The utilization of restraints in the elderly population often receives the most attention, as they require extensive care for a wide variety of conditions and diseases. Due to their reduced independent capacity to care for and protect themselves, elderly choose to move into long-term care settings. The responsibilities of the patient’s health and security have now shifted to their nurses, whom have become their primary caregivers (Hantikainen, 1998, p. 343). Nurses care for the elderly in nursing homes for lengthy periods and also in acute care settings, when their medical needs exceed what the nursing home can provide.
In order to protect the elderly from potential harm to themselves, numerous types of restraints are used. Myers et al. (2001) states types of restraints used during their study were numerous, and the most common restraints used in the past year were jacket restraints, wrist/hand restraints, belt restraints, and secured table (30-31). Bed rails, wheelchairs, and waist restraints were other frequently used devices (Hantikainen, 1998, p. 332, & Liukkonen & Laitinen, 1994, p.1084).
The reasons these restraints were used on patients were widespread. Myers et al. (2001) stated patients were restrained in acute care settings primarily for preventing falls, limiting wandering, controlling disruptive behavior and to avoid interfering with medical devices (p. 29). In long-term care settings, often the reduced physical and cognitive state of residents is the reason for restraint. This must be done in order to protect the resident, to allow the nurse to complete basic care, and for time management of all nursing duties (Liukkonen & Laitinen, 1994, p.1083).
Outcomes of restraint use are rarely positive. While the nurse is capable of accomplishing more tasks, this is often at the detriment of the patient. The National Citizens’ Coalition for Nursing Home Reform [NCCNHR], (2007) cited that restrained individuals experience physical changes that include, decreased circulation, skin breakdown, ulcer formation, incontinence, constipation, muscle atrophy, weakened bones, increased risk of urinary tract infections and pneumonia (para. 5) Risk for falls and death by strangulation are also possible physical risks (Myers, 29). Of equal importance, the quality of the patient’s life is diminished by being physically restrained. The patient will experience depression, sleep disturbances, increased anxiety, and loss of independence and will become socially withdrawn from their environment (NCCNHR, 2007, para. 5)
Nursing response on the ethics of restraints is ambiguous. While Myers et al. (2001) cited nurses had a slightly positive attitude toward the elderly on all three scales of measurement, they indicated restraint use was acceptable in circumstances in which they were protecting their patients from harm and preventing injury (p. 31-32). Liukkonen & Laitinen (1994) also points out that physical restraints create a perpetual ethical dilemma for nurses. Restraints directly interfere with the nursing objective of patient autonomy. While trying to support their independence, nurses find the effect of restraints as “dehumanizing” to the patient and themselves (p. 1082). Hantikainen (1998) reported that nurses felt “ambiguity, frustration, sadness, powerlessness, strain and dissatisfaction” related to restraint use (p. 341). Liukkonen & Laitinen (1994) noted that the nursing staff in each research group was “considering the use of restraint as a difficult ethical problem which needed to be brought into open discussion on the wards.” While restraints were still applied to patients, their use is often questioned, leaving the use of alternatives more prevalent (p. 1085).
Janelli et al. (2006) stated 77% of the nurses in their study indicated they would attempt to use alternative measures before applying restraints to a patient (p. 165). Alternatives most attempted by the nurses were one-on-one observation, sedation, diversional activities and bed/chair alarms (p. 166). Both Hantikainen (1998) and Liukkonen & Laitinen (1994) stated the staff in their studies most frequently tried to comprehend patient behavior, used therapeutic touch and listening, and complied with resident’s requests that deviated from their daily schedule as substitutes for restraint use (p. 338 & p. 1082).
In their literature review, Evans, Wood, & Lambert (2002) found
a common restraint minimization technique to be staff teaching in conjunction with expert clinical consultation (p. 616). Different studies, conducted in acute and long-term settings, proved a decrease in restraint of patients using nursing education in conjunction with “multiple restraint-minimization activities” (pg. 619). Education topics included resident’s rights, risk and results of physical restraint, myths of restraint use, law based on restraint use, behaviors that are predictors of restraint and alternatives to restraint (p. 621). Evans et al. (2002) identified the best results occurred with gradual change that involved an interdisciplinary approach (p. 622).
When education and consultation are implemented in long-term care, overall results were successful. Residents restrained dropped from 41% to 4.05% when education was introduced (p. 619). Restraint use in long-term care was reduced without a rise in resident falls and major injury (p. 619). Nursing attitudes after alternative measures were not reported in any study. Additional studies must be conducted to explore nurses’ attitudes toward the implementation of restraint alternatives. As the debate over restraints continues, more research and education is needed to improve nursing practice.

Intervention 1 - Knowledge Deficit
i. Disadvantage 1 – Emphasis on Prior Experience
In several studies, when nurses were questioned on the use of restraints, nurses found restraint use to be an integral part of patient care. Many nurses did not feel restraints were a violation of patient rights, rather a means of patient safety. Nurses admitted that they often restrained residents of their long-term care facility for unclear reasons and without physicians’ orders. Restraints were used more often as routine practice rather than a reaction to a specific situation. Over one half of these nurses had more than six years of nursing experience (Hantikainen, 1998, p. 331-6). Concern for patient protection and safety was the prevailing primary reason nurses used restraints on their patients. (Liukkonen & Laitinen, 1994, p. 1084, Hantikainen, 1998, p.338). In a study by Myers, Nikoletti, & Hill (2001), nurses with an average of fifteen years experience were in agreement that restraints were used to protect patients from falls and injuries from interfering with therapeutic devices (p. 32).
ii. Disadvantage 2 – Lack of Training
As care facilities differ in their focus of care, staff for each type of facility varies. Acute care settings generally require nursing staff with more professional licensure (RNs, LPNs, and CNAs), many long-term care facilities have more unlicensed assistive personnel (Hantikainen, 1998, p.334). Uncertified staff are often uneducated in specific aspects of care, like restraint use. Without proper teaching, correct implementation of patient restraint use cannot be expected, even for licensed personnel. Liukkonen & Laitinen (1994) stated that more than 60% of nurses in one study stated they had received no instruction at all on the use of physical restraint while working in a geriatric ward (p. 1085). Furthermore, Evans, Wood, & Lambert (2002) found little evidence of the minimization of restraint use after an educational program was implemented. Over a year after restraint intervention and alternatives had been taught in an acute care setting, restraint use was over fifty percent, which was twenty percent higher than the pre-intervention level (p. 618).
Intervention 2 - Discrimination
Disadvantage 1 – Dislike for the elderly
Negative feeling regarding the elderly has been a theory as to the widespread use of restraints in this aged population. A study that examined the relationship between attitudes toward the elderly and attitudes toward restraint use did find a significant relationship between these negative attitudes toward older people and positive attitudes toward restraint use. (Myers, Nikoletti, & Hill, 2001, p. 29-30). This correlation may explain why up to eighty-five percent of elderly nursing home residents have been restrained at least once while living in the facility (Hantikainen, 1998, p. 331).
Disadvantage 2 – Dislike for the Mentally Ill
Caring for patients with mental illness results in may challenges, in addition to a nurse’s regular duties. With mentally ill patients, nurses face problems with “verbal and non-verbal communication, nutrition, physical functioning, safety, perceptual and motor difficulty, memory loss, and social isolation, “all in addition to other disease processes. With the addition of these factors to the nurses’ duties, some nurses grow to dislike their patients and treat them with less respect. Decreased understanding of demented patient’s behavior may contribute to nurses’ negative reactions in difficult care situations. (Liukkonen, 1994, p. 1086).

References

Evans, D., Wood, J., & Lambert, L. (2002). A review of physical restraint
Minimization in the acute and residential care settings. Journal of Advanced Nursing, 40(6), 616-625. Retrieved July 5, 2007 from
Academic Search Premier Database.
Hantikainen, V. (1998). Physical restraint: a descriptive study in Swiss
nursing homes. Nursing Ethics, 5(4), 330-346. Retrieved July 12, 2007 from Academic Search Premier Database.
Janelli, L. M., Stamps, D., & Delles, L. (2006). Physical restraint: a
nursing perspective. MEDSURG Nursing, 15(3), 163-167. Retrieved July 12, 2007 from Academic Search Premier Database.
Klauber, M. & Wright, B. (2001, February). The 1987 Nursing Home
Reform Act. AARP. Retrieved August 7, 2007 from
http://www.aarp.org/research/longtermcare/nursinghomes/aresearch
-import-686-FS83.html
Liukkonen, A. & Laitinen, P. (1994). Reasons for uses of physical restraint
and alternatives to them in geriatric nursing: a questionnaire study among nursing staff. Journal of Advanced Nursing, 19, 1082-1087. Retrieved July 12, 2007 from Academic Search Premier Database.
Myers, H., Nikoletti, S., & Hill, A. (2001). Nurses’ use of restraints and
their attitudes toward restraint use and the elderly in an acute care setting. Nursing and Health Sciences, 3, 29-34. Retrieved July 15, 2007 from Academic Search Premier Database.
National Citizens’ Coalition for Nursing Home Reform. (2007). Fact sheets: restraint use. Retrieved August 7, 2007 from
http://www.nccnhr.org/public/50_156_451.cfm

Addressing the Shortage of Nurses: From a Nursing Perspective

2007-12-03T20:35:00.000-08:00

A posting by Nathan Ho about the the nursing shortage and what nurses can do to combat it.
Nursing has always had a shortage, but with the upcoming generation of Baby Boomers (those born from 1946 to 1964) reaching the social security age of 65, the need for additional healthcare workers increases.
Whether Baby Boomers find themselves in hospitals or long term care centers, registered nurses will need to be there to ensure proper care.

However, many factors such as a deficit of teaching faculty, a negative work environment, and the fact that women now have broader career options, have placed a severe shortage on the amount of current nurses. The nursing shortage leads to a decreased quality of care in patients which is further perpetuated by an increase of those needing care, the Baby Boomers. This dilemma is best solved through nurses forming committees to find and address concerns they may have, advertising the benefits of nursing through job fairs or school visits, and encouraging retiring nurses to become faculty.
Born right after World War II.and around the Vietnam War, thanks to soldiers returning to their wives, Baby Boomers created a sharp increase in the population. As this large age group matures, requires more care as they grow older, and lives longer due to advanced medicine, a problem arises. By 2020 there will be at least 400,000 less nurses than in 2006, right when Baby Boomers are around their seventies or eighties (Hassmiller, 2006). The Service Employees International Union Nurse Alliance reports that nurses already work eight and a half weeks of overtime a year (as cited in Hassmiler, 2006) and a study done by Curtin and Rogers reports that, “Taking care of too many patients and working overtime…are associated with errors and poorer quality of care” (as cited in Hassmiler, 2006, para.8). As the Baby Boomers age and begin to seek more health care, the ratio between patient and nurse will only increase, further increasing the stress of nurses still in the field and decreasing quality of care.
According to a 2002 and 2004 United States national nursing survey reviewed by Buerhaus, Donelan, Ulrich, Norman, and Dittus (2006), four of the top reasons for the nursing shortage were inadequate benefits and salary, more career options for women, objectionable hours, and a negative work environment. Though the 2004 survey showed an increased satisfaction in these areas compared to the 2002 survey, both surveys stated the change most desired was an improved working environment. The surveys reported that nurses who felt they had a very good or excellent relationship with their fellow nurses had increased from 53% in 2002 to 72% in 2004. However, few Registered Nurses reported having very good or excellent relationships with the physicians or hospital managers. While individual hospitals can survey nurses to determine how they feel about their work environment a more aggressive action would be for nurses to come together and form committees to agree on what needs to be changed at work and how it should be done. It has been suggested by Buerhaus et al (2006) that the government establish an independent board within the Department of the Health and Human Services which would be responsible for essentially “grading” the quality of care hospitals provide. If there is a quantifiable quality of care difference between facilities which incorporate the nursing committee’s ideas and facilities that do not, then in the future the status of nurse’s opinions would increase.
According to Buerhaus et al (2006), 83% of nurses in both the 2002 and 2004 surveys reported being either somewhat, moderately, or very satisfied with their profession and 70% of nurses would recommend nursing to qualified students. If this is the case, nurses should take the time to voice how they feel about their career to the public. Exposing the community to nurses through free blood pressure readings, presentations at local schools, or a booth at job fairs would increase public interest in nursing. In addition, having male nurses present during these exposures could open interest to a whole new group of people to nursing, the males. Though the amount of male nurses has increased from 57,000 in 1983 to 164,000 in 2002, men made up only 5.9% of the nurses in 2003 (Cantrell, 2004). A lot of room for potential growth exists for this population, especially since Auerbach, Buerhaus, and Staiger state that “recently published projections indicate large, demographically driven shortages [are] developing in the next decade” (as cited in Buerhaus, Donelan, Ulrich, Norman, DesRoches, Dittus, & Wfcthan, 2007, para. 4).
Exposure of nursing to the public however is not enough to quell the shortage. Nursing school enrollment has gone from a 3.7% increase in 2001 to a 13% increase four years later, yet in 2005 over 147,000 qualified applicants were rejected from nursing schools due to a lack of faculty to teach them (Larson, 2006). In addition there has been a 72% percent growth in faculty who desire to teach only part time. Coupled with the fact that the influx of about 180,000 new RN’s between 2002 to 2004 were over the age of 50 and that almost a third of them plan to retire within three years, recruiting seems to have little benefit (Buerhaus et al, 2006). However, what if the retiring nurses were to become faculty? Even if they desired to teach part time, enough part time faculty members could make up for the lack of full time members. Retiring nurses could enjoy a less demanding schedule with a chance to impart the wisdom they gathered throughout their nursing career. If they require further education before being able to teach, the government is currently debating on two programs to assist potential faculty in financing their education, the Nurse Faculty Education Act and the Nurse Education, Expansion and Development Act which might prove convincing for those interested in returning to school to increase their education but are deterred by the cost (Larson 2006).
Though the burden of more patients looms ever closer to nurses, strategies exist to help cope with this challenge. By forming committees committed to alleviating any concerns nurses may have about their work environment, the number one desired change by nurses may be addressed and improve work morale. This in turn helps keep nurses from leaving the field. Exposing the community to nurses through public health fairs, free blood pressure tests, or simply by word of mouth is also an excellent way to attract new nurses. Finally, nurses who have had enough of the business environment of health care, but would still like to be involved in helping people, have the chance to spread their knowledge and experience by becoming teachers. Government programs even exist to assist in financing nurses who need further education. The journey ahead may be difficult, but nurses are by no means without the power to do something about it.
a. Intervention 1- Retiring Registered Nurses further their Education and become Teachers
i. Disadvantage 1- Difficulties with Distant Education
In order to maximize productivity of time, RN’s with a desire to continue their education while still working have the opportunity to do so via distant learning (otherwise known as fully online classes). Though benefits of online classes include elimination of distance between student and classrooms and a more flexible schedule, a study of students done by Sit, Chung, Chow and Wong revealed some learning hindrances to be “inadequate opportunity to study with others, lack of confidence, difficulty applying concepts taught, and inadequate opportunities for discussion with faculty and to establish peer support” (as cited in Murphy, 2007, para. 16). Murphy (2007) states that technical expertise is important when taking an online class which might be difficult for retiring nurses with little computer experience. Also, a survey done by Atack and Rankin which evaluated RN’s who took online classes at home and at work showed general dissatisfaction when classes were performed at the workplace (as cited in Murphy, 2007).
ii. Disadvantage 2- Funding
Though scholarships and programs exist to help finance RN’s with desires to continue their education, there are not a whole lot of them. According to Livsey, Campbell, and Green, the Nurse Training Act passed in 1964 puts Title VIII in the Public Health Service Act which is responsible for funding nursing education. However, less than 3% of resources from Title VIII were directed towards faculty development and many Title VIII programs expired in 2002 (2007). Due to a lack of sufficient scholarships most RN students who pursue a doctorate are part timers which in turn decrease the graduation rate. Also, to make matters worse, not all nursing doctorates decide to become faculty with a 23% reporting that they will take a practice related position due to the better financial reimbursement (Livsey, Campbell, and Green, 2007). Thus limited capital for continuing nursing education in the hopes of producing teachers is wasted.
b. Intervention 2- Increased Exposure of Public to Nursing
i. Disadvantage 1- High School Student’s Perceptions on Nursing
With students in high school graduating and deciding what career to pursue, exposing them to the nurse’s role is critical to provide an accurate idea of what the vocation entails. Unfortunately though, high school student perception of nursing is somewhat negative and a vast majority has little interest in pursing a career in nursing. A study done by Steven and Walkers showed that of 642 high school students only 7.7% (about 49) considered nursing as a future career. This lack of interest also extends to other cultures as another study done by Tang et al. with 789 non English speaking students from 36 different high schools had a majority state that they did not view nursing as a potential career due to their impressions of it being non influential and poor paying (as cited in Catz, 2007, para 26). This impression was verified by Warda who found that negative impressions of nursing included the facts that nurses were powerless, poorly paid, and worked in poor conditions (as cited in Catz, 2007, para 27). Those working to expose high school students to nursing have a bit of an uphill battle to fight.
Ii. Disadvantage 2- Males in Nursing
While recruitment of men into nursing represents a huge potential work force, the public perception of male nurses has generally been negative. An informal survey of the public by Rallis stated that men disapproved of male nurses and often they were mistaken for doctors (as cited in LaRocco, 2007, para 4). Some male RN’s stated it was difficult to establish themselves in a female work group (LaRocco, 2007). Male RN students recollecting some perceived barriers during nursing school included no mentorship programs for male students, a pressure to prove themselves because people expected women to be nurses, no opportunity to work with male nurses during clinical settings, fear of accusation of sexual inappropriateness when providing intimate care and no guidance provided on the appropriate use of touch (O’lynn, 2007). Males interested in pursuing nursing have the difficulties of social expectations and then barriers present during RN education.
References
Buerhaus, P. I., Donelan, K., Ulrich, B. T., Norman, L., & Dittus, R. (2006). State of the
registered nurse workforce in the United States. Nursing Economics, 24, (1) 6.
Retrieved February 4, 2007, from ProQuest database.
Cantrell, M. (2004, December 13). Male Call. Nurse Week. Retrieved January 7, 2007
from http://www.nurseweek.com/news/Features/04-12/MenInNursing.asp
Doheny, K. (2006). Treating the nursing shortage. Workforce Management, 85, (19) 1.
Retrieved February 4, 2007, from ProQuest database.
Fulcher, R. (2007). Nursing in Crisis. Community College Journal, 77 (5) 38-43.
Retrieved November 2, 2007 from ProQuest database.
Hassmiller, S. B. & Cozine, M., (2006). Essay: Addressing the nurse shortage to improve
the quality of care. Health Affairs, 25, (1) 268. Retrieved February 4, 2007, from
ProQuest database.
Katz, J. (2007). Native American High School Student’s Perception of Nursing. Journal
of Nursing Education, 46 (1) 282-287. Retrieved November 2, 2007 from ProQuest
database.
Larson, L. (2006). Who will teach the nurses we need. Hospital and Health Networks, 80,
(12) 52. Retrieved February 4, 2007, from ProQuest database.
LaRocco, S. (2007). A Grounded Theory Study of Socializing Men into Nursing. Journal of Men’s Studies, 15 (2). Retrieved November 2, 2007 from ProQuest database.
Mead, J. (2006). On the east end, a nursing shortage is felt more deeply. The New York
Times, p 14L1.) Retrieved February 4, 2007, from ProQuest database.
Murphy, J. (2007). Distance Education in Nursing: An Integrated Review of Online
Nursing Students' Experiences with Technology-Delivered Instruction. Journal of
Nursing Education, 46 (6) 252-261. Retrieved November 2, 2007 from ProQuest
Database.
O’lynn, C. (2004). Gender Based Barriers for Male Students in Nursing Education
Programs: Prevalence and Perceived Importance. Journal of Nursing Education, 45
(1) 229-237. Retrieved November 2, 2007 from ProQuest database.

Nursing Best Practices on Barriers of Preventing Medication Errors

2007-12-03T20:30:00.000-08:00

Gladys Ng’ethe
More than 2 years after the first Institute of Medicine (IOM) report, reducing medication errors and enhancing patient safety remain among the most compelling issues in health care. The 1999 IOM report To Err is Human: Building a Safer Health System elevated the level of urgency needed to focus on how medical errors are killing thousands of people in the United States annually, and adding billions of dollars to the cost of health care.
Medication-related errors alone kill 7,000 people or more each year, and the rate of deaths for inpatients has dramatically increased in the past 15 years (Phillips, Christenfeld, & Glynn, 1998). Beyond medication errors themselves, there are also serious and potential adverse drug events (ADEs) that have a significant human and financial cost.
THE RIGHT REPORTING SYSTEMS.
Miscommunication/ Knowledge deficit:
Collaborative communication among healthcare providers is a prerequisite for safe and effective patient care. The Joint Commission suggests that communication is a key contributor to sentinel events and medication errors. Kirkpatrick (2003) stressed people in organizations typically spend over 75% of their time in an interpersonal situation; thus it is no surprise to find that at the root of a large number of directorial problems is poor information exchanges. Nurses are required to read back any verbal of telephone orders given. Noisy transmission (unreliable messages, inconsistency), receiver distortion: selective hearing, ignoring non-verbal cues are contributing factors erroneous messages.
Prescribers should avoid using abbreviations, including those for drug names because they can be misunderstood. Indecipherable handwritten prescriptions, metric vs apothecary systems, look alike- sound alike drug names, drug miscalculations, ambiguous or incomplete orders.
Identifying Vulnerabilities:
You cannot begin to correct a problem or susceptibility until you know that it exists. You cannot fix what you do not know about. Reporting systems appropriately used for self-reported information such as incident reports and many kinds of administrative data sets. Unfortunately, many organizations view the data in reporting systems as a true reflection of what is really happening in their organization according to Patient Safety(2007). This is in no way a reliable assumption. As far as patient safety is concerned, the reporting system should be looked at as a vulnerability detector, not as a measurement of incidence or prevalence. Realizing that clear communication and credibility are crucial to leading change, NCPS established a goal that people would accept: preventing harm to the patient (VA 2002).
SOCIO-ECONOMIC STATUS.
Insurance policies:
The relentless, decades-long rise in the cost of health care has left many Americans struggling to pay their medical bills. Workers complain that they cannot afford high premiums for health insurance. Patients forgo recommended care rather than pay the out-of-pocket costs. Employers are cutting back or eliminating health benefits, forcing millions more people into the ranks of the uninsured. And state and federal governments strain to meet the expanding costs of public programs like Medicaid and Medicare. A closer look at the people who admit to having prescription-filling problems shows that they come from all socio-economic strata, but are more likely to report low income or no insurance coverage. This suggests that financial burden rather than personal preference may be the culprit. Cohen (1997) found that elderly persons living below the poverty level were six times more likely to go without a necessary prescription than those with higher incomes.
Lack of unexpendable resources:
Kozer et al propose a few widely advocated potential systems improvements. For example, computerized physician order entry (CPOE) has been shown to be an effective technology for reducing prescribing errors. CPOE clearly has enormous potential for improving patient safety. At the most basic level, CPOE ensures that orders are complete, legible, and in a standardized format. When decision support is incorporated, CPOE can guide drug dosage, frequency, and choice of route or administration, as well as perform checks for drug allergy and drug-drug interactions. Handheld devices have considerable promise in hectic environments such as EDs and clinics, where it may be difficult to access a computer terminal while providing care. Robots have promise in reducing errors in drug dispensing; smart intravenous pumps may reduce administration errors, and bar coding can improve the reliability of the entire medication system.
The availability and quality of supervision is particularly important for preventing and catching mistakes by trainees. Prompt, direct faculty supervision is available in most EDs, and close supervision of trainees is fast becoming the expected standard of care. Real or perceived authority gradients (eg, seniority-based, gender-specific, cultural) are particularly problematic because they inhibit trainees from seeking help and dampen enthusiasm for open dialogue and feedback.
Nursing education must look beyond the finite skill of medication calculation and acknowledge system issues that plague most medication errors. Nursing must be experts in evaluating systems embedded within the medication administration process, and educators need to assume leadership with this daunting task. Risk factors could be proactively addressed and ultimately reduce the factors surrounding with medication errors. Hence, nursing faculty must foster critical thinking in risk reduction factors when administering medications and examine the entire continuum of the medication process with students.

BIBLIOGRAPHY
Phillips, D.P., Christenfeld, IV., Glynn, L.M. (1998). Increase in US medication-error deaths between 1983 and 1993. Lancet, 351, 643-644.
Joint Commission on the Accreditation of Healthcare Organizations. The measurement mandate. Oakbrook Terrace, IL: JCAHO; 1993.
Kirkpatrick, C. (2003) Safety first: The JCAHO introduces new patient goals. Nurses Week, 4(2), 23.
National Center for Patient Safety. 2005. "Safety Assessment Code Matrix." [Online information; retrieved 9/24/07.] http://www.patientsafety.gov /matrix.html.
Veterans Health Administration (VA). 2002. VHA National Patient Safety Improvement Handbook. [Online document created 1/30/02; retrieved 10/23/07.] VHA Handbook 1050.1. http://www.patientsafety.gov/NEWS/Pubs/NCPShb.pdf.
Cohen RA, Bloom B, Simpson G, et al. Access to Health Care. Part 3: Older Adults. National Center for Health Statistics. Vital Health Stat 19(198),1997.
Kozer E, Scolnik D, Macpherson A, et al. Variables associated with medication errors in pediatric emergency medicine. Pediatrics.2002; 110; 737 –742

Reducing litigation risks related to Obstetrics and Nursing:

2007-12-03T19:48:00.000-08:00

Increasing demands society has placed on obstetric nursing, especially through issues of malpractice, has put our nation’s pregnant mothers at risk for a national crisis due to a lack of care to meet the demands of childbirth. Ultimately, OB nurses need to decrease the risk factors that are increasing malpractice claims.
Some nursing strategies that will help to do this include preventative measures within the workplace to minimize errors in patient care; insisting that there be a designated support person in every woman’s laboring process; and implementing some of the strategies of care in midwifery because midwives have been found to have better outcomes in delivery even with the inclusion of “risky” patients.

In numerous counties across the nation pregnant mothers must drive anywhere from 45 to 80 miles for prenatal care (Moninger, 2007). The doctors can no longer afford to deliver babies; they are being charged malpractice insurance premiums into the six figures. Many maternity wards have closed across the nation due to a lack of obstetricians; this even affects the midwives in those areas considering they often have to work in collaboration with obstetricians (Moninger, 2007). Liability insurance for certified nurse midwives has increased as well. Neonatal/obstetric nursing can often be at the forefront of a malpractice suit when an injury to a neonate happens in the hospital’s care (Verklan, 2004). The author, Verklan (2004), goes on to give an example of a perinatal nurse who questioned a physician’s orders in the care of an induced mother, the nurse followed all orders regardless of her questions and the child ended up with severe retardation. Here, the doctor misinterpreted the electronic fetal monitor, and ordered the continuation of Oxytocin. The nurse’s questionable administration of Oxytocin is what placed her at fault and in the courtroom. According to the authors the misinterpretation of the electronic fetal monitor often leads to suit. Another major factor that comes into play in medical malpractice hearings is insufficient documentation (Greenwald & Mondor, 2003). With all of the possibilities for malpractice suit in the obstetric setting, a plan to reduce errors and increase positive outcomes is the only option for obstetric nurses.
OB nurses must decrease risk factors in labor and deliver through a prophylactic approach, starting with transitioning teamwork innovation from other industries into healthcare, resulting in better safety. Implementation of the MedTeams Training Program to enhance overall performance on the Labor & Delivery floor it is a strategy that could decrease the risk of error and the inevitable litigation that accompanies malpractice (Harris, et al, 2006). MedTeams Training is something the registered nurse will have to justify to hospitals management. It addresses management of distractions, changing coping mechanisms, behaviors, and attitudes; improving communication and teamwork; and evaluation of information related to operational dangers. “In a closed case review of civilian emergency department risk management cases, Dynamics Research Corporation suggested that 43% of errors were due to a lack of team behaviors (Harris, et al, 2006).” A retrospect review of closed claim L&D files by two separate pairs of physician-nurse experts suggested that 40% or more of L&D malpractice events could have been prevented by a formal team approach (Harris et al, 2006).
A lack of adequate teamwork between obstetrical nurses is as big a problem as a lack of physical or emotional support for the patient. Having a support person during labor and childbirth has been associated with decreased rates of cesarean births and lengthy labor (Cragin, & Kennedy, 2006). Therefore, suggesting that patients choose a person to be their birth partner as added support through the four stages of the laboring process will lessen the complications that often are associated with malpractice cases. Added support provides a positive presence to the situation which potentially can improve the patients’ labor and delivery.
Certified Nurse Midwives have been found to have better outcomes in delivery even with the inclusion of “risky” patients. According to a study done to examine optimality in women at equally moderate risk, “those cared for by midwives achieved a higher optimality score (less use of technology and equal or better health outcomes) than those cared for by physicians, with equally positive neonatal outcomes (Cragin & Kennedy, 2006).” This would be a wonderful research opportunity for the Registered Labor and Delivery nurse. If implementing some of the strategies of the CNM in hospital care will decrease adverse outcomes in the hospital setting than in turn malpractice litigation will also be decreased. Collaboration between CNM and OB RN will also decrease the stress that the patient feels just by being in the hospital.
Increased adverse outcomes in obstetric nursing have led to increases in malpractice cases, and therefore a lack of care due to doctors and nurse midwives leaving practice. With the demands society has placed on obstetric nursing, especially through issues of litigation, our nation’s pregnant mothers are at risk for a national crisis of not being able to meet the demands of childbirth. Ultimately, OB nurses need to decrease the risk factors that are increasing malpractice claims. In order to do this first RNs will implement team strategies and coordination, which in turn will reduce risk through a decreased work load and open communication. Next, the RNs will suggest a system that designates a person of support to help ob patients through their labor; this will decrease mom’s anxiety resulting in fewer complications during birth. The last strategy the RN will do is through taking on some of the qualities of care that nurse midwives are using, as in less technology, which will also lead to better outcomes for mom’s meaning better outcomes for babies.
A. Intervention 1: implementing some of the strategies of care in midwifery.
i. Disadvantage 1: Knowledge deficit related to midwifery.
Midwifery has been proven to be as effective as or even more effective than hospitals with good outcomes related to childbirth. Yet, the findings are not being recognized by hospitals nor insurance companies making it very hard for certified midwives to practice and for patients to find coverage if they decide to go with a midwife rather than an obstetrician. “Many insurers discourage giving birth at home, a practice usually attended by a midwife, arguing that it is not as safe as going to a hospital” (Perez-pena 2004). For example, “Aetna (a health insurance company) will not contract with some birthing centers because it considers them inadequate for emergencies or too far from hospitals, and it will not cover any home births unless required to by state law . . . Midwives argue that they actually save health insurers money, because their care results in fewer Caesareans and other expensive procedures” (Perez-pena 2004). Without the practice of midwifery taken seriously hospitals and insurance companies continue to utilize too many machines, too many drugs, and end up causing more problems using this whole medicalized, institutionalized way of birth that doctors do (Perez-pena 2004).
ii. Disadvantage 2: Lack of insurance related to midwifery practice.
Patients across the nation are turning to midwifery for childbirth practices often being stopped in their tracks by the insurance companies denying coverage. On another note midwives across the nation are being stopped in their tracks by increased malpractice insurance rates and decreased Medicare coverage sending them out of business. “Certified Nurse Midwives receive only 65% of the physician reimbursement rate for comparable services” (Health Insurance Week 2005). Many patients are being forced to pay larger shares of their bills with a CNM than if they would’ve gone to a doctor (Perez-pena 2004). The obstacles of both patient and midwife in regards to insurance have driven many birthing centers out of business. “The Elizabeth Seton Childbearing Center in Greenwich Village, shut it’s doors, driven out of business by rising medical malpractice insurance premiums . . . when Seton needed a new malpractice policy last summer, the best quote it could find was a 400% premium increase” (Perez-pena 2004). “ Midwives face fast-rising malpractice insurance premiums, and new limitations imposed on their practices by many hospitals and health insurance companies” (Perez-pena 2004).
B. Intervention 2: Transitioning teamwork innovation from other industries into healthcare.
i. Disadvantage 1: Knowledge deficit related to strategies for teamwork.
Strategies for teamwork innovation are not being looked at seriously. Hospitals are not realizing the benefits of spending money on such quality assurance programs to decrease the risk of malpractice and lower malpractice rates in the long run. “The MedTeams training program, a nationally funded research project, provided the framework for team training in several labor and delivery units in the United States. Many challenges were confronted when team training was implemented” (Harris; et al 2006). The article goes on the state, “little has been written about how to implement teamwork initiatives to ensure success” (Harris, et al 2006). However, formal teamwork training was almost nonexistent in obstetric care settings until the development of the MedTeams training program leaders (managers, directors, clinical nurse specialists, chiefs of obstetrics and anesthesiology) attended several days of training. Staff did not attend. As a result, they perceived that their input did not matter and that the project was simply another change they did not control (Harris, et al 2006). Therefore, the MedTeams training program dedicated to providing a framework for team training in labor and delivery units confronted many challenges.
ii. Disadvantage 2: Malpractice insurance rates shut down OB units.
Malpractice rates are launching our country into national crisis due to a lack of childbirth care. There are numerous OB units and birthing centers that have already been shut down without ever giving teamwork innovation a chance. Teamwork innovation programs, such as Medteams Training or other quality assurance programs are not being implemented prior to shut down, and the power that they hold in decreasing risk will never be known in those locations. “Jeanes Hospital in Philadelphia closed its obstetrics ward in May, it became the 33rd Pennsylvania hospital, and the 14th in the Philadelphia area, to stop delivering babies in the last decade” (Thrall 2007). Only one hospital in Rhode Island has taken steps to prevent this trend, the hospital, with a captive insurance plan, offers discounts of up to 30% for doctors who participate in quality assurance training (Thrall 2007).
References New Stuff:
1. Bush, H. (2007). Perfect storm forces hospitals to shut down obstetrics services. Hospitals & Health Networks, 81(9), 20.
2. Harris, K. T., Treanor, C. M., & Salisbury, M. L. (2006). Improving patient safety with team coordination: challenges and strategies of implementation. Journal of Obstetrics and Gynecology Neonatal Nursing, 35(4), 557-566.
3. Health Insurance Week (2005). Obstetrics; Midwives to lobby U.S. congress for Medicare reimbursement equity. http://proquest.umi.com/pdqweb?did=860911461&Fmt=3&clientid=3236&RQT=309&VName=PQD
4. Perez-pena, R. (2004). Use of midwives, a childbirth phenomenon, fades in city. New York Times, B.1.
Reference List Original:

1. Cragin, L., & Kennedy, H. P. (2006). Linking obstetric and midwifery practice with optimal outcomes. Journal of Obstetrics and Gynecology Neonatal Nursing, 35(6), 779-785.

2. Greenwald, L. M., & Mondor, M. (2003). Malpractice and the perinatal nurse. Journal of Perinatal & Neonatal Nursing, 17, 101-109. Retrieved January 7, 2007, from Proquest online database.

3. Harris, K. T., Treanor, C. M., & Salisbury, M. L. (2006). Improving patient safety with team coordination: challenges and strategies of implementation. Journal of Obstetrics and Gynecology Neonatal Nursing, 35(4), 557-566.

4. Moninger, J. (2007, January). The doctor drought: skyrocketing insurance premiums are forcing thousands of ob-gyns out of the baby business. And your doctor could be the next to go. Parents, 62-65, 116-117.

5. Verklan, M. T. (2004). Malpractice and the neonatal intensive-care nurse. Journal of Obstetrics and Gynecology Neonatal Nursing, 33(1), 116-123.

Methicillin Resistant Staphylococcus aureus

2007-12-03T18:55:00.000-08:00

Shannon Rutz
An a opposable thumb, four fingers, and a palm, that some say, ‘carries your future.’ As nurses, we are trained that by our own hand, we can convey compassion, empathy, and trust. Unfortunately, nurses can infect patients, too.
Methicillin Resistant Staphylococcus aureus(MRSA) is one of the most common causes of community and health care associated infection (Graham lll, P. 2006). Hands of health care workers are the most prevalent form of transmission from patient to patient (Public Health 2007). There can be a large dichotomy between what nurses are trying to accomplish and what they may actually be doing. With increasing incidence of cross transmission among patients in clinical care settings and hospitals, education and protocol should take the highest priority in preventative nursing practices.
In 1940, the discovery of penicillin helped to cure bacterial infections around the world. Revered as the answer to all bacterial infections, the medical pioneers were unaware of what was to come. In 1961 the first strain of Methicillin Resistant Staphalococcus aureus was identified (Capriotti, T 2003). A bacterium that developed the ability to destroy penicillin by producing an enzyme called beta-lactamase (Capriottti, T 2003). The impact of this “super bug” resonated among the medical community. In 2002 a study found that approximately 84 million and two million noninstitutionalized
persons in the U.S. population are colonized with MRSA, respectively (Graham lll, P. 2006). It caused severe morbidity and mortality worldwide, with death rates in patients
with MRSA infection ranging from 20% to 50% (Capriotti, T 2003). Clinical manifestations of MRSA include but are not limited to: abscesses, endocarditis, osteomyelitis, postoperative pneumonia, and surgical/skin infections, or death (Ott, Shen, Sherwood. 2005).
As nurses, it is our responsibility to first do no harm. Yet, after receiving education and following strict guidelines, MRSA seems to be increasingly more prevalent in care settings. Where is the breakdown in nursing practices?
In 1860, Florence Nightingale wrote, “the greater part of nursing consists in preserving cleanliness” (Practices 2004). That is a great start to an integral part of nursing practices. With hands being the major transport system for MRSA infections, it seems that the first step to reduction in cross contamination would be to educate nurses about preventing infection. Education that must include teaching proper hand washing techniques, standard precautions, aseptic practices, facility isolations procedure, and maintaining good personal hygiene (Spaulding, L 2006). Studies show that under routine hospital practices, compliance with hand washing protocol between patients is less than 50%. The technique and duration of the hand washing was also inadequate (Capriotti, T 2003). Reasons given for non-compliance ranged from lack of sufficient facilities, lack of time, high patient load, urgency of care for patients, and dermal irritation (Capriotti, T
2003). Artificial nails have also been found to carry greater bacterial counts than natural nails, thus increasing bacterial contamination (Capriotti, T 2003). Hand washing is the single most important infection control practice (Ott, Shen, Sherwwod. 2005).
A recent study compared the effectiveness of three modes of different hand hygiene practice among health care workers:
• hand wash using chlorhexidine gluconate; water-based, antiseptic had washing soap used for one minute
• hand rub using ethanol; waterless, alcohol-based, antiseptic hand rub solution used for 30 seconds
• waterless, alcohol-based antiseptic gel hand rub for 30 seconds
The study showed that repeated hand rubbing for 30 seconds with ethanol was better tolerated than repeated hand washing with antiseptic soap (Capriotti, T 2003). There was greater compliance with the practice of using the ethanol for 30 seconds than with the one-minute of washing with soap (Capriotti, T 2003). Compliance with hand washing is also very hard on health care workers’ hands. The Centers of Disease Control, CDC, recommends use of hand lotions and creams during non-patient contact, such as breaks or before and after work (Capriotti, T 2003).
While hand washing is the first line of defense in prevention of the spread of MRSA, the CDC recommends patients who are colonized or infected should be placed in isolation (Ott, Shen, Sherwood. 2005). Isolation is beneficial because it can help
minimize close contact, which increases risk of contamination, and nurses tend to wash their hands more when caring for patients in separate rooms (Ott, Shen, Sherwood. 2005).
Even with the best nursing practices, if procedures are not followed the benefits of MRSA prevention fails to accomplish its goal. Standard precautions to control the spread of MRSA:
• Wash hands after contact with patient fluids and contaminated items, whether gloves are worn or not
• Wash hands immediately after gloves are removed between patient contacts
• Use gloves when touching pt mucous membranes and non-intact skin
• Wear a gown if splashes or sprays may happen during procedures
• Use single-use disposable equipment
• Clean pt environment with antiseptic solution daily
• Dedicated medical equipment for patients in isolation
The complete list is available through the Centers of Disease Control who have provided a standard guideline (Capriotti, T 2003). Special care should be given to those that are at high risk for MRSA. Those included are: invasive dwelling devices, nursing home pts, critically ill pts, presence of a wound or decubitus ulcer, and proximity to a patient with MRSA (Capriotti, T. 2003). These procedures and guidelines are set forth to protect the
patient along with the nursing community. Many nurses not only have passed MRSA between patients, they have contracted the infection themselves. By protecting ourselves
as nurses, we can perform safely for our patient, giving them the protection that they need to have productive and infection-free hospital or clinic stays.
The incidence of antibiotic-resistant infective agents such as MRSA is increasing among health care settings. Those that are sent to heal sometimes harm without knowledge of what they are doing. The invisible microbe can be a mighty force. The air that we breath, the touch of a friend, the sneeze of a child; all things that we take for granted in our daily lives, but which can potentially bring illness to one another. As nurses it is our ethical duty to provide a safe environment for our patients. The rise of MRSA has put infection control as one of our highest priorities in nursing practices.

References
Capriotti, T. (2003, December). Preventing Nosocomial Spread of MRSA is in Your
Hands. Dermatology Nursing,15(6),Retrieved July 19,2007,from Academic Search
Premier database.
Graham lll, P., Lin, S., & Larson, E. (2006, March 7). A U.S. Population-Based Survey
Of Staphylococcus aureus Colonization. Annals of Internal Medicine, 144(5),318-
w-58. Retrieved July 19, 2007, from Academic Search Premier database.
MRSA Super course, ( July 22, 2007). Public Health of Pittsburg College.
Http://www.publichealth.pitt.edu
Ott, M,. Shen, J,. Sherwood, S,. (2005). Evidence Based Practice for Control of
Methicillin Resistant Staphlococcus aureus. Association of Operating Room Nurses
AORN Journal, 81(2), 361-364,367,369-378. Retrieved July 12, 2007, from Research
Library database.
Practices of Keeping Clean (2004) The Lancet, 364(94,31)304. Retrieved August 3, 2007,
From Platinum fulltext periodicals.
Spaulding, Linda L. (2006, May) The Changing Role of Infection-control Programs in
Longterm Care Management. Nursing Homes, 55(5), 95-96. Retrieved Aug 3, 2007
From Platnium full text Periodicals.
Annotated Bibliography
Capriotti, T. (2003, December). Preventing Nosocomial Spread of MRSA is in Your
Hands. Dermatology Nursing,15(6),Retrieved July 19,2007,from Academic Search
Premier database.
The reason I used this source was because it was very informative. I had also seen other articles in the database by this author. The article contained lots of information on MRSA and its history. It also contained information on the epididomology and treatment and prevetion of MRSA. Capriotti is a DO, MSN, CRNP and the assistant Clinical Professor at the College of Nursing.
Practices of Keeping Clean (2004) The Lancet, 364(94,31)304. Retrieved August 3, 2007,
From Platinum fulltext periodicals.
I used this article only once in my paper. It was a very small article and no author was listed on the paper. The only reason I used it was I liked a quote from Florence Nightengale. I also went ahead and used the quote because I figured that it could be verified very easily if I had to.
MRSA Super course, ( July 22, 2007). Public Health of Pittsburg College.
Http://www.publichealth.pitt.edu
I found this power point on the web just browsing. I searched for epidimology of MRSA. It had lots of good information and since it was an edu site I figured it was pretty safe to use. I only used tidbits of information that I knew would be easily confirmed.
Spaulding, Linda L. (2006, May) The Changing Role of Infection-control Programs in
Longterm Care Management. Nursing Homes, 55(5), 95-96. Retrieved Aug 3, 2007
From Platnium full text Periodicals
I used this article the second most in my paper. I found it by using Boolean search terms and thought it had a lot of the information I needed to make this paper less dry. I also liked it because it came from a magazine that deals with long term care facilities which is the highest rate of MRSA cross contamination.
Intervention 1: Manditory testing for high risk patients entering a hospital setting or
long term care facilities. There are rapid screening tests available for the medical community that can quickly give results. MRSA cultures can take up to 2-3 days to process and receive results(Stone1998). By instilling a rapid screening process that is mandatory for all high risk patients, it can potentially eliminate many of the cross contamination infections.
Disadvantage: As with many rapid screen tests, the cost of testing is enormous. MRSA rapid screen test is relatively new on the market which makes it rather difficult to make it economically beneficial for patients and health care organizations(Stone 1998). In addition to the cost of the testing, it is expensive to employ the workers qualified to read and perform the testing. It also is rather expensive to educate existing staff to be qualified to read and run the test.
Disadvantage: Because of MRSA’s virulent nature and its high potentiallity for cross contamination, the rapid screening creates an avenue to break patients confidentiality. A patient, upon entering a rehab facility tests positive for MRSA, is then put in isolation and on droplet precautions and is now flagged for having the infection. Any one entering that room whether it is staff or family are now aware of the infections this pt carries.
Intervention 2: Improving handwashing technique and compliance will help to eliminate the cross contamination that happens in health care facilites. It has been documented that the compliance of handwashing and the type of alcohol based cleanser has reduced the incidince of MRSA cross over(Capriotti).
Disadvantage: Increasing compliance can be a relatively hard task to complete. Most healthcare workers state reasons for non compliance are lack of places to wash hands, time between pts, and effects of soap on hands(Capriotti). Many facilites are not up to standards with the number of sinks, disinfectant stations, or ability to don protective equipment. Many nurses are bogged down with numerous pt’s that take away from time to wash between pts. Frequent handwashing also takes a toll on health care workers hands.
Disadvantage: While it is difficult to obtain compliance among healthcare workers it is even harder to gain the general populations compliance with proper handwashing techniques. The general population has a signifigant knowledge deficit at this time in regards to MRSA. With socioeconomic status being a major effector in many countries the knowledge of handwashing and cross contamination is very difficult in communicating to the masses.
Sheldon P Stone, Virka Beric, Anne Quick. (1998). The effect of an enhanced infection-control policy on the incidence of methicillin-resistant staphylococcus aureus conlinization in acute elderly medicare pt. Age and Ageing, 27(5), 561-568. Retrieved 10/28/07 from Platinum Full Text periodicals database.

Obstacles to Nursing Interventions to Reduce Perinatal HIV Transmission

2007-12-03T17:59:00.000-08:00

Catherine Hill
HIV infection and its subsequent diagnosis of AIDS have changed in status from a certain death sentence to a chronic disease able to be lived with. As a result of this change, many people are able to live relatively normal lives with this disease. This normalcy includes pregnancy and childrearing. The risk remains at the forefront for transmission of HIV from an infected mother to her baby. The majority of HIV infected women are of childbearing age. It is vital that nurses play a role in the education and care of these women to reduce the incidence of mother to baby HIV transmission.
The AIDS epidemic has a major effect on women’s health. About one half of the almost 40 million people living with AIDS globally are women, with more than 2 million pregnancies occurring annually to HIV positive women. (McIntyre, 2005) Groups of women at increased risk of HIV infection and subsequent transmission to their infants include adolescents, uneducated, undereducated and the uninsured. The global infection rate among pregnant women is highly variable with ranges between 1% to over 40%. Successful strategies to reduce the risk of mother- to- child transmission of HIV have almost eliminated pediatric HIV infections in developed countries and these strategies are beginning to have an impact in countries where HIV infections are still at epidemic proportions. The World Health Organization recommends a “four-pronged strategy” for prevention of mother-to-child HIV transmission that focuses on prevention of new infections and the prevention of unintended pregnancies in HIV positive women as well as interventions to reduce the risk of transmission to infants with appropriate care and support. (WHO, 2002).
The human immunosuppressant virus is spread by exposure to HIV infected blood or body fluids. The exact mechanism of perinatal transmission is unknown but exposure can occur at any one or all of three instances: before birth by micro transmission of maternal blood through the placenta, during labor and delivery by exposure to vaginal secretions and blood, and after birth through breastfeeding. The risk percentages are 5-10% during pregnancy, 10-20% during childbirth, and 10-20% through breastfeeding. (Kriebs, 2006). Studies have shown that 40-80% of the perinatal transmissions occur during the last two months of pregnancy or during labor and delivery. (Cibulka, 2006). The rate of HIV transmission to an infant through breastfeeding is estimated to be 14%. This rate can increase to as much as 29% among women who are in the acute stage of HIV infection; that is they have a high viral load. The incidence of HIV transmission increases with the length of time breastfeeding. Treating HIV infected mothers with HAART (highly active antiretroviral therapy) does not negate the possibility of HIV transmission, but it has been shown to significantly reduce it. The reported rates of mother-to -child transmission are less than 2% for women who begin treatment early in pregnancy, 12-13% for women who do not initiate treatment until labor, delivery or after birth, and 25% among women who do not receive any preventative care. (Kirshenbaum, 2004) Studies have shown that women who have not taken antiviral therapy during pregnancy have an increased risk of transmission by vaginal delivery and prolonged rupture of amniotic membranes. Elective cesarean section has been shown to reduce transmission rates among these groups. Use of illicit drugs, smoking, and the presence of sexually transmitted infections are all factors that increase the risk of mother-to-child HIV transmission as well as other obstetric risks.
Nurses involved with the care and treatment of pregnant women can play a very important role in reducing the incidence of mother- to- child HIV transmission. Although testing is a voluntary decision, counseling all pregnant women to be tested for HIV is a basic step. According to the CDC, HIV testing should be routine for all pregnancies with the option to op-out if desired. With this method HIV testing becomes a part of basic prenatal care. Those women who test positive should be further evaluated to determine their viral load. Reduction in viral load during pregnancy is achievable using HAART, (highly active antiretroviral therapy). According to Cibulka, (p2), HAART significantly reduces the likelihood of prenatal HIV transmission when combined with good perinatal care of both mother and child. Reducing an HIV mother’s viral load to less than 1000 copies/ml significantly reduces the likelihood of transmission. Studies have shown that HAART is safe to use after completion of the first trimester. Nurses must be knowledgeable about HIV infections and treatment options so they can offer counseling to pregnant HIV mothers regarding the risks and benefits of HAART treatment during pregnancy. Nurses are particularly important in their role as a preserver of patient confidentiality, support for the mother’s choice in route of delivery, and encouragement for maintaining healthcare and treatment after birth. General counseling and education about safe sex practices, lifestyle habits including smoking and illicit drug use, and the fundamental need for the pregnant women to tell the truth about lifestyle and habits is an important task of the prenatal nurse.
The role of the nurse in reduction of HIV transmission from mother to child can start well before a woman ever becomes pregnant. A nurse can be an advocate for all unborn fetuses by educating and counseling at risk populations in a public health setting. It is not necessary to wait until a woman seeks treatment. “Every perinatal HIV infection represents a sentinel health event, often indicating a woman who had undiagnosed HIV infection before pregnancy or did not receive appropriate interventions to prevent transmission of the virus to her infant. Therefore, to strengthen and sustain measures to maximally reduce preinatal transmission, public health activities should give priority to collection of data to identify where missed opportunities occur and target prevention efforts accordingly.”(Mofenson, et.al. 2006, p2). Public health nurses can reach out to adolescents and at risk populations through educational programs, school visits and public health clinics. Of the new AIDS cases reported in 2004, 27% were women over the age of 13. “ Enhanced primary HIV prevention strategies are needed to prevent new infections in women, which will, in turn, prevent perinatal HIV infections”(Mofenson, et.al.,2006, p4). Safe sex practices, education on condom usage, free condoms, and basic knowledge of how HIV is transmitted are fundamental elements in the fight against HIV transmission. It is imperative for the public health nurse to seek information from her clients rather than wait for those clients to offer information regarding habits and lifestyle. This can be a scary and delicate subject. If the nurse does not initiate a dialogue there is a good chance the topic could be ignored. Studies have shown that adolescents, especially males, underprivileged, and uninsured groups have limited exposure to preventative health care services and counseling on sexual behaviors. These services must be brought to these groups. Catching and educating the adolescent population before they become sexually active can significantly reduce the sequelae associated with risky sexual behaviors, which include teen pregnancy, HIV infection and transmission to the next generation.
Globally, HIV continues to be at epidemic proportions. According to Kriebs, approximately 40 million people are infected with HIV; of that 40 million 40-48% are women. The infection rate of children continues to rise. Nurses can have a far reaching effect on this global problem by actively participating in programs to test, treat and educate at risk groups in foreign countries.” Current studies show that too few women benefit from programs for preventing mother to child transmission of HIV” (Bassett, 2002, p3). Nurses can be trained to provide testing and counseling. A major obstacle to providing this service is funding. Also the stigma associated with HIV infection continues to be a deterrent to seeking treatment even in countries where the infection is rampant. These issues are hard to overcome. Nurses should advocate for universal testing of pregnant women and subsequent treatment for HIV infected mothers and their children. The World Health Organization is a natural partner for the nurse. The WHO has outlined a comprehensive program to prevent mother to child transmission that incorporates primary prevention of HIV among adults and prevention of unwanted pregnancy among women with HIV, as well as direct prevention of mother to child transmission. This programs success requires the willingness of rich countries to contribute financially, drug manufactures to provide medications at low cost, and a basic establishment of an infrastructure to provide clinical treatment and laboratory testing. This is surely a tall order to fill. Nurses must be a vital part of initiating this program.
As the number of HIV infections continues to rise worldwide, the number of opportunities to curb the spread of this infection also rises. Nurses can have a significant effect in the reduction of transmission of HIV infections to subsequent generations by being proactive in their care of the current reproducing population, especially those currently infected with HIV and those at greater risk for becoming infected. The task of nurses involves education and prevention of HIV infection, comprehensive treatment of pregnant women infected with HIV to reduce transmission of the virus to their offspring, and globally to increase knowledge of HIV prevention and treatments. Each opportunity seized will assist in the fight to curb the rise in HIV infections and lower the incidences of mother-to-child transmission.

Stopping or slowing the transmission of HIV from mother to child is a very significant task. Currently almost 40 million people are infected with HIV worldwide; of this group over 40% are women. The role of nurses in preventing the spread of HIV from mother to child is a very important one, but it is also a very difficult task with many obstacles.
Intervention 1: Nurses caring for pregnant women need to counsel and treat for HIV and
it’s transmission.
Disadvantage 1: Testing of pregnant women is not occurring at a consistent rate.
The CDC has recommended that HIV testing be conducted routinely on all pregnant women as part of their basic laboratory tests, however the testing rates vary greatly in the United States and worldwide. According to the CDC “ studies found that HIV testing rates for pregnant women vary widely and that a relatively high proportion of women of childbearing age were unaware that treatment is available to reduce the risk of perinatal transmission.” Bindman further states that “current HIV prevention efforts, such as HIV testing programs, are not reaching enough people with enough strength, and are not keeping pace with achievements of treatment programs for people already infected with HIV. For every one person who began antiretroviral therapy in 2006, six people were newly infected.” These inconsistencies in testing and treatment delivery can only be overcome if they become the standard of practice in all prenatal assessments.
Disadvantage 2: Certain subgroups are not receiving adequate prenatal care.
There are racial and socioeconomic subgroups within the population who continue to receive substandard or no prenatal care. These groups include lower socioeconomic classes including those who are already receiving protective and social services, adolescents, and Latinos. In one study these women identified substance use, the need for private and thorough communication with medical and Child and Family services personnel, and the need for positive social relationships as issuesto address to enable HIV positive mothers to engage in care. (Lindau, 2006) Studies continue to show that underprivileged, uninsured and adolescents have limited exposure to preventative health care services and counseling. These groups are also those that have a greater risk of acquiring HIV. This remains as a significant hindrance in the fight to stop the spread of HIV to subsequent generations.
Intervention2: Nurses in the global fight against HIV must be proactive.
Disadvantage 1: Political barriers
Nurses in the global fight against HIV must become advocates for their patients. Political obstacles are a significant barrier to this goal. Nurses trying to promote the prevention and treatment of infected women must be able to counteract the sometimes overpowering political attitude toward HIV and AIDS. “Public health professionals must become skilled at combating the substitution of politics for true science.” (Quinn, 2006) In Africa, where HIV and AIDS infect the greatest percentage of the population, the political impact of the AIDS epidemic has been relatively minimal. “AIDS occupies a commensurately marginal place in African political life. AIDS is never at the top of the list of issues of concerns for the population, according to polls taken in many African countries.” (De Waal, 2007) There is a great deal of personal denial by the individual and collective denial among the political forces about the impact AIDS and HIV transmission has on the society. Attempts to overcome this attitude have been largely state-controlled media based public education, which has been ineffective due to the oppressive nature of the political powers. (De Waal, 2007)
Disadvantage 2: Funding and its distribution
Financial concerns over how the funds are distributed in the fight against HIV transmission is also an obstacle. According to Bindman,” globally, resources should be distributed according to the scientifically proven needs of HIV patient populations, and not the ideology of the donors. Treatment efforts are difficult to integrate into prevention programs because marginalized populations are often denied equitable access to care and lack nutrition and transportation services.” The Global HIV Prevention Working Group reports that HIV prevention and education programs could prevent approximately 30 million of the expected 60 million global HIV infections expected by 2015. The funds must be allocated where they are needed most. Nurses can help by remaining active, outspoken and participatory in organizations responsible for distribution of funds and services.
Bibliography
Quinn,Sandra Crouse. ( 2006, OCT.) We must fight HIV/AIDS with science, not politics,
American Journal of Public Health 96. 10 (1). Retreived 22 October,2007 Proquest
Thompson Gale. Tacoma Community College. Proquest ID:1142876391.
De Waal, Alex,(2007, Spring) The politics of a health crisis, Harvard International Review
29.1(5). Retreived 22, October, Proquest Thompson Gale, Tacoma Community
College, Proquest ID: 1276899311.
Lindau, S.T., Jerome,J., Miller,K., Monk,E.,et al. (2006, January) Mothers on the
margins:Implications for eradicating perinatal HIV, Social Science and Medicine 62.1(1) Retreived 22 October, Proquest Thompson Gale, Tacoma Community College. Proquest ID:940087201.

CDC.(2007, October) Mother-to-child (perinatal) HIV transmission and prevention.
Retreived 22, October, 2007 from http://www.cdc.gov/hiv/topics/perinatal/resources/factsheets/print/p...

CDC.(2003).Advancing HIV prevention: new strategies for a changing epidemic-United States,2003. MMWR 2003:52 329(3). Retreived 21 April,2007 ProQuest Thomson Gale. Tacoma Community College. ProQuest ID:978250191.

Global HIV Prevention Working Group(2007,June). HIV prevention: The access and
funding gap. Retreived 22, October from http://www.globalhivprevention.org/reports.html
Bindman, Alyssa,(2007,Sept.) HIV prevention, treatment not reaching those in need.
The Nation’s Health.37.7(1). Retreived 22 October Proquest Thompson Gale,
Tacoma Community College. Proquest ID:1331897761.

Bibliography
Kirshenbaum,S.B., Hirky E., Correale J.,Goldstein R., et.al (2004, May-June) Throwing the dice: pregnancy decision-making among HIV-positive women in
four U.S. cities, Perspectives on Sexual and Reproductive Health 36.3 ,106(8).
Retreived 21 April,2007 Expanded Academic ASAP. Thompson Gale. Tacoma
Community College. Thomson Gale Document Number:A119656685
Burstein,G.R.,Lowry R. Klein,J.D.,Santelli,J.S.(2003,May)Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics 111.5,996(6). Retreived 21 April,2007 Expanded Academic ASAP. Thomson Gale. Tacoma Community College. Thomson Gale Document Number:A101860491
Intyre,James (2005,May).Maternal health and HIV.Reproductive Health Matters,13.25.129(7). Retreived 21 April,2007 Expanded Academic ASAP. Thomson Gale. Tacoma Community College. Thomson Gale Document Number:A134313001
ebs,Jan M.(2006,January-March).Changing the paradigm: HIV in pregnancy.(III. Reviews on the State of the Science and Practice in Perinatal and Neonatal Care). Journal of Perinatal & Neonatal Nursing. 20.1.71(3). Retreived 21 April,2007 Expanded Academic ASAP. Thomson Gale. Tacoma Community College. Thomson Gale Document Number:A143241111
ulka,Nancy J.,(2006,July). Mother-to-child transmission of HIV in the United States. American Journal of Nursing.106.7.56(8)
ebs,Jan M.,(2002,December).The global reach of HIV: preventing mother-to-child transmission. Journal of Perinatal & Neonatal Nursing. 16.3.1(10). Retreived 21 April,2007 Expanded Academic ASAP. Thomson Gale. Tacoma Community College. Thomson Gale Document Number:A94982607
Mofenson,L.,Taylor,A.W.,Rogers,M.,Campsmith,M.,et al.(2006,June).Reduction in perinatal transmission of HIV infection – United States, 1985-2005. Morbidity and Mortality Weekly Report.55.21.592(6). Retreived 21 April,2007 ProQuest Thomson Gale. Tacoma Community College. ProQuest Document ID:1065646691
CDC.(2003).Advancing HIV prevention: new strategies for a changing epidemic-United States,2003. MMWR 2003:52 329(3). Retreived 21 April,2007 ProQuest Thomson Gale. Tacoma Community College. ProQuest Document ID:978250191.

Childhood Obesity: What can be done?

2007-12-03T17:00:00.000-08:00

The growing epidemic of childhood obesity has become a recent public health crisis for our country. Because childhood obesity can lead to adverse health outcomes such as increased blood pressure, type two diabetes, and orthopedic complications, nurses must come together to find a solution. Nurses can aid in combating this concern by implementing early identification measures, assessing parental perception, and providing family education.
Over the last ten years the incidence of childhood obesity has greatly increased for all ages and ethnicities. The primary cause for this increase is the imbalance between energy intake and energy expenditure (Nicholas & Livingston, 2002). America’s sedentary lifestyle and poor nutritional habits have contributed to this energy imbalance. Many obese children will suffer from social isolation, poor body image, and depression if proper intervention does not occur (Berry, Galasson, Melkus, & Grey, 2004). It is imperative that nurses identify children at risk and take action to assist them in living a healthier lifestyle.
A complete assessment needs to be taken by the registered nurse (RN) before planning interventions for an obese child. Well child check-ups and yearly child physicals at a family or pediatric office presents an optimal time for assessment. It should consist of a family history (heart disease, diabetes, obesity, hypertension, hyperlipidemia, pancreatic disorders, and musculoskeletal disorders), a review of the child’s body systems, weight/height measurements, daily nutritional intake, daily activity, and previous attempts to manage weight (Nicholas & Livingston, 2002). Following the evaluation of data, a body mass index (BMI) should be calculated. The BMI is based on the child’s height/weight and is considered the most accurate measurement (Hodges, 2003). Based on a standardized growth chart a child with a BMI greater than 30 is considered obese (Nicholas & Livingston, 2002). Once the nurse has identified the child as being obese or at risk for becoming obese, he/she must evaluate parental perception.
It is critical for the RN to carefully evaluate the parental perception of their child’s health and their willingness to take part in a change. The primary concern with poor dietary practices lies between the parent and child. In one study, 79% of mothers failed to recognize their child as being overweight (Hodges, 2003). To be successful in combating this growing epidemic, it is vital for parents to recognize and accept their child’s need for interventions. Well child check-ups present an optimal opportunity for nurses to address these concerns. Key points the RN should assess with families include: exposure and accessibility of food to the child, modeling appropriate eating behaviors, providing food that leads to positive or negative physiological consequences, and feeding practices utilized (Hodges, 2003). After properly assessing an obese child and evaluating parental perceptions, family education on improving nutrition and physical activity can begin.
Children must receive proper nutrition and adequate physical activity to promote a healthy lifestyle. An individual’s body changes significantly during the ages of two and twenty. Each person’s required nutritional intake is based on their height, built, gender, and activity level. The appetite of children goes through peaks and troughs that correspond with their rate of growth. It is important for parents to understand that children may eat well one day and show minimal interest in food the next. Toddlers have high energy expenditure and small stomachs. They may need several small meals throughout the day. As children grow into teenagers they often develop erratic eating habits. This frequently includes skipping meals and snacking throughout the day (Readers Digest, 2007). It should not be of concern so long as nutritional snacks are provided. Physical expenditure for children has decreased over the years and sedentary activities such as television viewing, and hand-held video games have increased (Domrose, 2007). These behaviors have greatly contributed in the rise of obese children. To promote proper nutrition, physical activity, and assist the family in establishing healthy eating habits, the nurse must educate the parents. Education should consist of eating a balanced diet that includes appropriate portions of grains, fruits, vegetables, dairy, and meat, creative methods to encourage children to eat, and an environment that nurtures physical activity (Hodges, 2003). Following education, families can then take action and improve their quality of life.
A multidimensional approach is the best method in combating childhood obesity. Proper identification, parental assessment, and family education all need to be considered prior to interventions. The focus of care should be living a healthier lifestyle rather than reaching a target weight. Children will be more successful and compliant if they are not held to a restrictive regimen. It is the nurses’ responsibility to provide creative and encouraging methods to assist all children in becoming successful.

New Paper
A. Parental Contribution
Denial
In a study, 79% of mothers failed to recognize their child as being overweight. Many parents associate a heavy child as a healthy child. Parents will often base their competency as a father or mother on their child’s growth percentile. They fear a change in eating habits and daily lifestyle will deprive their child from the things they have come accustomed to. Parent education needs to be available to alleviate some of these concerns. This should include possible health risks their child could encounter if the current behavior continues. The nurse needs to teach the parents that there is a fine balance between introducing new habits as well as modifying old practices. Parental recognition and acceptance that their child is overweight is a vital component if the interventions are to be initiated and successful (Hodges, 2003).
Poor Role Modeling
Parents of obese children are often obese themselves. It would be counterproductive to implement healthy lifestyle interventions for a child if the parents are not willing to become an active participant. Children learn and mimic the behaviors that are exhibited in their environment. It is imperative that parent’s understand their influence with food selection and the level of physical activity that their children take part in. To implement a positive change and obtain optimal success in this ever growing epidemic the family unit as a whole needs to commit to a new way of living (Lindsay, Sussner, Kim, & Gortmaker, 2006).

B. Implementation of proper nutrition and physical activity
1. Nutrition
Nutrition is an important component when establishing a healthier lifestyle for overweight or obese children. This can create an obstacle for many families. With today’s fast paced society parents often resort to quick and convenient meals. These meals are often high and low in nutritional value. Parents need to be educated on how to make and plan nutritious meals that can fit into their day to day life. This can include meals at home, school, and/or dining out. Resources and information need to be provided to families prior to beginning a lifestyle change to ensure their success (Hodges, 2003).
2. Physical Activity
It is imperative that children participate in regular physical activity. Sports programs are an excellent way for children to receive adequate exercise while building relationships and forming valuable team work skills. For many families financial restraints prevent them from taking part in organized activities. These individuals have to seek other options when sports programs are unavailable to them. Research has shown that the more time children spend outdoors the more active they will become. This seems like a reasonable assumption and resolution for the families who can not afford to take part in organized activities. Many low-income families question the safety of this solution. They are concerned with traffic, drug dealers, crime, and violence that might be present in their neighborhoods. When working with families of obese children information and resources needs to be presented that overcomes this obstacle. Children will have a difficult time becoming healthy if they can not find a safe and accessible location to be active (Sallis & Glantz, 2006).

References

Berry, D., Galasson, P., Melkus, G., & Grey, M. (2004). Obesity in youth: Implications for the advanced practice nurse in primary care. Journal of the American Academy of Nurse Practitioners, 16, (8) 326. Retrieved Feb. 2, 2007 from ProQuest database.

Domrose, C. (2007, March 26). Small steps: Nurses take on childhood obesity. Nurseweek, mountain west edition, 10.

Hodges, E. A. (2003). A primer on early childhood obesity and parental influences. Pediatric Nursing, 29, (1) 13. Retrieved Jan. 19, 2007 from Expanded Academic ASAP database.

Lindsay, A.C., Sussner, K.M., Kim, J., & Gortmaker, S. (2006). The role of parents in preventing childhood obesity. Childhood Obesity: The Future of Children, 16 (1) 169-186. Retrieved Oct. 25, 2007 from http://www.futureofchildren.org/information2826/information_show.htm?doc_id=355732.

Nicholas, M. R. & Livingston, D. (2002). Preventing pediatric obesity: Assessment and management in the primary care setting. Journal of the American Academy of Nurse Practitioners, 14, (2) 55. Retrieved Feb. 2, 2007 from ProQuest database.

Readers Digest. (2006, March). Childhood nutrition: Food for the growing years. Retrieved Feb. 2, 2007, from http://www.rd.com/content/openContent.do?contentId=26202

Sallis, J.F. & Glanz, K. (2006). The role of built environments in physical activity, eating, and obesity in childhood. Childhood Obesity: The Future of Children, 16 (1) 89-108. Retrieved Oct. 25, 2007 from http://www.futureofchildren.org/information2826/information_show.htm?doc_id=355433.

Increasing rates of autism diagnosis; A nurse's role

2007-12-03T16:33:00.000-08:00

Sara Salamonsen
Over the last decade, diagnosis of autism has greatly increased. This has concerned the scientific and medical communities, leading to many research studies to determine not only the cause of the condition itself, but also to determine the reason for the sudden increase in its diagnosis. These findings range from biological causes such as multiple gene involvement or environmental exposure, to education of physicians and other practitioners who may not have the knowledge of and accessibility to screening and diagnostic criteria. With this increase in diagnosis, pediatric and family practitioners need to be knowledgeable and informed of the potential causes, signs, symptoms, and subsequent interventions for autism and other Autistic Spectral Disorders (ASD).
What is an ASD? The term Autistic Spectral Disorder encompasses a wide variety of neurobehavioral and cognitive disorders. The nurse’s first strategy for caring for these children is recognition of signs and symptoms of ASD. Some of the cardinal signs include difficulties with socialization, impairment of verbal and non-verbal communication, and repetitive and restricted behavioral patterns. Autism is the second most common disorder of childhood, estimated to occur in one in 166 to 500 children (CDC, 2000). Despite its prevalence, it often is not diagnosed until the child reaches school age (Filipek, Accardo, Ashwal, Baranek, et al. 2000). A recent study found that the average age for a child to be diagnosed with autism was six years old, though parents usually had concerns starting around 18 months. These parents most often sought medical care by age two (Howlin, Moore, 1997). At initial presentation, fewer than ten percent of patients were diagnosed with autism. In a study of nearly 2000 pediatricians, 71% stated that they believed that the most significant reason for delayed diagnosis of ASDs was that diagnostic criteria and treatment has changed in the last decade (Dosreis, et al. 2006).
Among the barriers to ASD diagnosis that practitioners encounter is that parents may not recognize or acknowledge when developmental and behavioral milestones have not been reached. The belief that every child develops at a slightly different rate and may “grow out of” behavioral delays often hinders an early diagnosis. Educating parents regarding signs and symptoms of ASD can assist them in recognizing abnormal behaviors and missed developmental milestones, thus aiding in early diagnosis and initiation of treatment. It was found that approximately ten percent of patients’ parents were told “not to worry” or that their child would “grow out of” these behaviors by their practitioner upon initial evaluation (Howlin, 1997). This desire to not make a premature diagnosis can delay subsequent timely interventions.
A child’s first three years are very important in their physical and cognitive development. During early childhood, frequent routine wellness checks are scheduled. These visits allow for physicians and nurses to regularly evaluate a child’s physical, emotional, and communication development. Pediatric practitioners must be familiar with regular developmental milestones and be able to recognize when there is a deviation from the normal range of development. Some serious variations that warrant medical investigation include displaying no big smiles or joyful expressions by six months; no verbal back and forth interaction or sharing of smiles by nine months; no gesture exchanges (such as pointing, reaching, waving) by 12 months; no words by 16 months; no use of two-word meaningful phrases by 24 months; or any loss or change of speech or social skills at any age (Filipeck, et al. 2000). Recognizing such problems can assist the practitioner in beginning interventions for the child as soon as possible.
The pediatric nurse must be able to recognize the need for and understand the various forms of diagnostic and testing procedures for the child suspected to have an autistic disorder. The nurse must ensure that proper avenues are taken for accurate diagnoses. This often means becoming familiar with varying diagnostic methods. Testing for developmental delays or ASDs can be easily integrated into the child’s regular wellness checks. Depending on the patient’s age and severity of symptoms, these vary from formal testing to providing history and correlations with behavior. Upon initial presentation for concerns of autistic behavior, approximately 40% of patients were referred to a specialty provider, however less than half of those patients were given a formal diagnosis at that time. These patients were often referred to a third or fourth specialist prior to the assignment of a diagnosis of ASD. This process can cause financial and emotional stress on both patient and family, as insurance companies often will not cover or require extensive documentation for reimbursement for diagnosis and treatment of developmental disorders (Howlin, 1997).
The exact cause of autism is not known. There are many environmental factors, biological predispositions and disorders that research has associated with ASDs. Some of the environmental concerns include exposure to heavy metals such as lead and mercury. Some of the disorders associated with increased rates of autism include the rare genetic conditions involving a variant of the MET gene such as Rett’s Disorder and Fragile X (Carmichael, 2006). The MET gene is involved in brain development. Researchers have begun to widen the scope of research in ASD study, and have identified hundreds of different factors that can be associated to various aspects of autistic spectral disorders (Carmichael, 2006).

Diagnosis of ASDs is usually started in a child’s pediatrician or general practitioner’s office when children present for well-child visits. If there is a concern raised by the parent or any observation made by the physician or nurse, a written developmental delay data sheet can be filled out. This usually takes no more than ten minutes, and can often be requested before and completed by the caregiver prior to the visit. This form may also be filled out in the office with or without the assistance of the nurse. If the developmental delay data form reveals any cause for concern, the child is referred to an autism specialist, often a Pediatric Neurologist, child Psychologist, child Psychiatrist or Developmental Pediatrician (Filipeck, et al. 2000).
The most significant role of a nurse in autism recognition and diagnosis is education. The nurse, the family, and the patient (within developmental and age-appropriate levels) must all be educated on various aspects of autism and autistic disorders. Important areas for the nurse to include are symptoms, treatment options, expected and potential outcomes, available support resources, and his or her own willingness to listen and be supportive. Much of this education is done within the primary care or specialty care clinical setting. One study found that only ten percent of parents had their child’s condition explained to them (Howlin, 1997) in a clinical setting. Because so few families are being adequately informed, the nurse’s role as an educator becomes much more integral to positive patient outcomes.
The increase in diagnosis of autism places nurses at a critical juncture, where nurses must be increasingly knowledgeable, understanding and supportive of the parents and children afflicted with this condition. The nurse’s level of understanding of autistic spectral disorders can have a great impact on the patient outcome. The nurse must be able to provide assistance with personalized education plans and referrals to support services and specialty medical providers (such as developmental or pediatric neurologists, speech and auditory therapists, and counseling services) in addition to being available and open to the parents or caregivers of these children. Being readily available and knowledgeable as an educator and advocate is often the most important role that the nurse can play in the care and treatment of a patient with an autistic disorder.
A. Intervention 1: Increasing parental knowledge of signs and symptoms of ASD
i. Disadvantage 1: Knowledge deficit
Because the exact cause of autism is unknown, there is a lot of speculation and misinformation available to the public. Due to the recent increased media and medical attention that ASDs have received, there is an increase in the number of parents who seek formal screening for their children. This is in contrast to the relatively low rate for screenings of other developmental delays. A study conducted in 2004 by the state of Pennsylvania found that certain cardinal behaviors of ASD can lead to earlier recognition and diagnosis of the disorder. “Children with severe language deficits, hand flapping, toe walking and sustained odd play received a diagnosis earlier… Physicians may be more familiar with these symptoms from portrayals of ASD in the popular media, or they may be more disturbing to parents and physicians alike, prompting additional evaluation” (Mandell, et al., 2005). If parents are unable to recognize these signs and symptoms as problematic, they are unable to report them to a physician or seek medical attention for them.
ii. Disadvantage 2: Socioeconomic status/Inadequate insurance
Many factors affect potential delays in diagnosis or possibility for missed diagnosis. Several familial-based causes are considered. Socioecomonic status was evaluated in relationship with ethnic background. “In a Study of Medicaid-eligible children, black children with ASD received a diagnosis an average of 1.5 years later than white children… Research suggests that differences by ethnicity may be associated with poverty, differences in clinical presentation, difference in parental behaviors, and differential treatment by physicians” (Mandell, et al., 2005). For these reasons it is extremely important to provide care with using culturally-appropriate care. The providers must understand the differences in cultural beliefs and practices and provide care and teaching cooperatively to ensure that efficient and age-appropriate interventions are made.

B. Intervention 2: Increasing professional training and knowledge of ASD, s/s, treatment of disorder
i. Disadvantage 1: Knowledge deficit
The most highly reported reasons for primary care providers to not screen for autistic spectral disorders are lack of familiarity with tools and a basic lack of time during office appointments. “Most pediatricians (71%) believe that ASD incidence has increased, and nearly all attributed this to changes in diagnostic criteria and treatment. Service system limitations must be overcome to increase awareness and familiarity with screening tools, provide sufficient time and resources, improve screening, and enhance provider education” (Dosreis, et al., 2006). Another survey found that “many physicians have limited knowledge of the presentation, prognosis and treatment of ASD or other developmental disorders with polymorphous phenotypes” (Mandell, et al., 2005).
ii. Disadvantage 2: Inadequate insurance (reimbursement) / Inadequate resources
Not using formal and/or standardized evaluation tools and techniques can also cause discrepancy in evaluations and accuracy or reporting. In a survey conducted in 2002 by the American Academy of Pediatrics, it was found that, “only half of responders used formal developmental screening tools during routine preventative care visits with 2-year-old children, with approximately two thirds indicating that they did not have adequate time to screen patients and 90% indicating that reimbursement for such services was insufficient” (Dosreis, et al., 2006).

References:
Boyle, C.A., Decoufle, P., Yeargin-Allsopp, M. (1994). Prevalence and health impact of developmental disabilities in US children. Pediatrics. 9, 399-403.
Carmichael, M. (2006). A terrible mystery; new clues and new questions in the hunt for a cause (autism). Newsweek (Nov 27, 2006), p 52.
Centers for Disease Control and Prevention (CDC). (April 2000). Prevalence of Autism in Brick Township, New Jersey, 1998 Community Report
Dosreis, S., Weiner, C.L., Johnson, L., Newshaffer, C.J. (2006). Autism spectrum screening and management practices among general pediatric providers. Journal of Developmental & Behavioral Pediatrics 27.2 (April 2006).
Filipek, P.A., Accardo, P.J., Baranek, G.T, et al. (1999). The screening and diagnosis of autistic spectrum disorders. Journal of Autism Developmental Disorders 1999; 29: 437-482.
Howlin, P., Moore, A. (1997). Diagnosis of autism. A survey of over 1200 patients in the UK. Autism 1997; 1:135-162
Mandell, D.S., Noyak, M.M., Zubritsky, C.D. (2005). Factors associated with age of diagnosis among children with autism spectrum disorders. Pediatrics 2005; 116.6: 1480-1487.

Aromatherapy and Its Potential Downfalls

2007-12-03T16:24:00.000-08:00

Studies have proven aromatherapy to be beneficial in treating several illnesses, but there are also problems related to its use. It is the nurse’s job as a patient advocate to ensure that patients have the right resources available to make the best decision for their health regarding aromatherapy

Nurses can do this with the following strategies: encourage the patient to consult their primary care provider regarding the use of aromatherapy, nurses should seek education on proper use of aromatherapy and direct patients to someone specializing in this field, and nurses can ensure that patients are aware of potential side effects of aromatherapy.
“Aromatherapy is one of the fastest growing therapies in the world today” (Thomas, 2002, pg. 1). Aromatherapy is the use of essential oils to stimulate certain brain structures through smell, massage, and ingestion of oils. A few examples of oils are lavender which promotes relaxation, and peppermint oil relieves nausea and vomiting and promotes digestion (Alternative Medicine, 2004). Aromatherapy is used for pain relief in chronic illnesses, mood enhancement, and to promote relaxation. The problems related to aromatherapy occur when patients do not consult their primary care provider before undergoing procedures. “Researchers find that patients often do not consult their physician or healthcare providers before starting complimentary alternative therapy” (Fowler & Newton, 2006 pg. 5). The second problem is when patients have not properly researched aromatherapy, they risk going to someone who does not specialize in alternative therapies. Another problem that occurs from lack of research by patients and nurses is adverse side effects of essential oils.
Nurses can ensure that patients benefit from aromatherapy by encouraging them to consult their primary care provider before undergoing treatment. According to Scrace, “the need for a more collaborative approach between professionals and the patient and family is a big issue when exploring complimentary alternative therapy (2003). The primary care provider is the best source of information about treatments that could be beneficial or hazardous because they know the patient’s health history. This intervention can prevent patients with serious illnesses from subjecting themselves to potentially fatal complications. If patients do no communicate with their primary care provider, it could result in one monitored treatment for their illness, and one unmonitored treatment such as the aromatherapy with no supervision of how they interact (Scrace, 2003).
To address the problem of improper administration of aromatherapy nurses should seek education on the proper aromatherapy use and refer patients to a specialist. Patients with chronic or terminal illnesses may not have the physical or emotional strength to do the research themselves. This is where the nurse steps in as a patient advocate. “Many professionals are members of organizations that strive to improve public awareness of aromatherapy and increase the standards of aromatherapy education and practice” (Alternative Medicine, 2004 pg 3). Nurses can also direct patients or their family members to websites and toll free numbers that give them information on aromatherapy. The Australian Nursing Journal states, “Nurses are also considered more likely than doctors to discuss the use of and give advice about complementary therapies to patients (2004, pg 1). Nurses with proper credentials can organize health fairs throughout the community that focus on alternative medicine. This would reduce the risk of patients receiving therapy without the proper knowledge. Once the patient is informed and knowledgeable about aromatherapy it is especially important for nurses practicing aromatherapy to have the right credential before administering treatments. Studies show that nurses have offered or used alternative medicine on patients without hospital permission (Scrace, 2003). Nurses wanting to practice alternative treatment need to seek the approval of the National Association of Holistic Therapy and their employer’s approval. Nursing schools are now incorporating alternative medicine into their curriculum, and graduate certificates are being offered. For nurses wanting to prescribe essential oils, a prescribing training would be necessary (Buckle, 2003). This can help prevent the problem of improper administration.
To keep patients healthy and safe, nurses can inform them of the potential side effects of aromatherapy some of which can be life threatening. According to Alternative Medicine, “rare side effects include allergic reaction including rash, headache, liver and nerve damage, as well as harm to fetus” (2004, pg 3). Nurses should know exactly what type of therapy the patient is receiving and which essential oil is being used. For example oils high in phenols cause skin irritation, and eucalyptus increases metabolic rates of meds such as pentobarbital and amphetamines (Alternative Medicine, 2004). Continuous monitoring of patients over the course of the treatment can alert the nurse to any adverse changes. Patients should also be advised to continue their primary treatment protocol to manage their illness.
Aromatherapy with proper knowledge and use could make a lot of diseases more manageable, and be very beneficial to the healthcare profession. The problems, such as patients not consulting their primary care provider before undergoing procedures, patients’ not properly researching aromatherapy, and adverse side effects can be resolved with three interventions. The three interventions are encouraging patients to consult their primary care provider before undergoing procedures, nurses seeking proper education on aromatherapy and referring patients to the proper specialists, and nurses informing patients of the potential side effects of aromatherapy.
Intervention #1: Ensuring that patients benefit from aromatherapy by encouraging them to consult their primary care provider.
Disadvantage #1: Although nurses would like to see patients consulting their primary care provider, there are healthcare professionals unwilling to embrace alternative therapies. This makes patients’ less likely to inform them of their use of aromatherapy for fear of rejection by their provider. According to Smith there are those who contend that alternative therapy and traditional medicine should remain separate (2005). It is believed that nurses are more likely to discuss and give advice about the use of alternative therapies with patients (Australian Nursing Journal, 2004). It is important for the nurses to discuss this, but the doctor is the most knowledgeable resource about the patient’s health history. If the doctor is not willing to discuss the topic of aromatherapy then patients proceed to endure treatments without the permission of their provider. The doctor should provide an environment where the patient feels safe discussing holistic approaches (Parkman, 2001).
Disadvantage #2: Ensuring that patients consult their primary care provider before treatments becomes a problem when patients do not have a primary car provider due to financial costs or lack of insurance. Research shows that when compared “complimentary therapies are generally less expensive than traditional medicine” (Smith, 2005). For the patient with financial issues the use of aromatherapy may seem beneficial, and this makes patients more likely to try to treat their own illnesses due to the rising costs of healthcare. In a study done by the European Journal of Epidemiology patients with breast cancers used alternative therapies before visiting a physician mainly because of economic factors (Malik, 2003).
Intervention #2: To keep patients healthy and safe nurses can inform them of the potential side effects of aromatherapy, some of which can be life threatening.
Disadvantage #1: Nurses who aren’t familiar with alternative therapies and their risks can’t educate and inform patients about adverse effects. It is the nurses’ professional responsibility to be knowledgeable about complimentary therapy. “Alternative therapies require staff competency, patient assessment, and patient-focused care (Parkman, 2001). One study showed that patients who use alternative therapy believe there are no risks associated with it. When the patient and the nurse are both uninformed adverse effects are likely to occur (Calogiuri, 2006).
Disadvantage #2: It is the nurse’s job to inform patients’ of the risks and potential life threatening side effects of aromatherapy, but studies has proven there is not sufficient research for every type of patient and their condition. For example, there is little research on aromatherapy specific to pregnant patients (King, 2004). “Advocates of complimentary alternative therapy (CAM) highlight their benefits and often point to the safety of natural, soft, or holistic approaches, but little is known about their possible side effects”. Most studies of alternative therapies are considered difficult to interpret or inconclusive, and most remedies are not under strict regulation of health officials (Calogiuri, 2006).
References

Buckle, S. (2003). Aromatherapy and massage: the evidence: Sandra Buckle considers the safety and efficacy of the use of aromatherapy and massage by children’s nurses. Pediatric Nursing, 15(6), 24-28. Retrieved January 21, 2007 from Expanded Academic ASAP database.
Calogiuri, G., Gaeta, F., Pesole, O., Romano, A., Ventura, M., & Viola, M. (Sept, 2006). Hypersensitivity reactions to complimentary and alternative medicine products. Current Pharmaceutical Design, 12(26) pg. 3393-3399. Retrieved November 1, 2007 from Academic Search Premier.
Fowler, S., & Newton, L. (2006). Complimentary and alternative therapies. Journal of Neuroscience Nursing 38(4), 261-265. Retrieved January 7, 2007 from Expanded Academic ASAP database.
King, M., McGhee, K., Pettigew, A., & Rudolph, C. (2004). Complimentary therapy use by women’s health clinic patients. Alternative Therapies in Health and Medicine, 10(6), 50-55. Retrieved October 28, 2007 from Proquest.
Learning about complementary therapies. (Complementary Therapy/Education). (2004). Australian Nursing Journal 12(4), 28-29. Retrieved from Expanded Academic ASAP on April 18, 2007.
Malik, I. (2003). Use of cam results in delay in seeking medical advice for breast cancer. European Journal of Epidemiology, 18(8), 817. Retrieved November 1, 2007 from Proquest.
Modalities-Aromatherapy (2004). Alternative Medicine. Retrieved January 7, 2007 from http://www.Alternativemedicine.com.
Parkman, C. (2001). Alternative therapies are here to stay. Nursing Management, 32(2), 36-39. Retrieved November 1, 2007 from Proquest.
Scrace, J. (2003). Complementary therapies in palliative care of children with cancer: a literature review. Pediatric Nursing 15(3), 36-40. Retrieved January 7, 2007 from Expanded Academic ASAP.
Smith, Y. (2005). Independent Study: Complimentary therapies from a nursing perspective. Journal ISNA Bulletin, 31(2). Retrieved October 28, 2007 from Academic Search Premier (CINAHL).
Thomas, D. (2002). Aromatherapy: mythical, magical, or medicinal? Holistic Nursing Practice, 16(5), 8-17. Retrieved April 18, 2007 from Expanded Academic ASAP.

Nursing Hospitalized Children: Barriers to Care

2007-12-03T15:42:00.000-08:00

Hospitalized children often experience pain and anxiety, which can dramatically affect their well-being and often delay healing. This can result in long term effects such as post-traumatic stress disorder, often causing decreased intellectual and social capacities and decreased immune function (Zengerle-Levy, 2006).

Because hospitalization can cause substantial long term negative effect in children, both physically and psychologically, it is important for nurses to be knowledgeable of these effects, and be educated on techniques they can utilize to help ease the pain and anxiety children feel during hospitalization. Strategies nurses can use include teaching the child guided imagery techniques, establishing and maintaining a sense of trust with the child, and using specific therapeutic techniques to provide comfort and spiritual support to the child.
Acute pain causes a release of “fight or flight" stress hormones. These stress hormones cause a breakdown of body tissues, as well as an increase in heart rate and blood pressure. The end result is a strain on the immune system, which can complicate the effects of injury and slow down recovery (Zengerle-Levy, 2006). Most children do not become used to repeated painful procedures over time. In fact, their anxiety can increase and they may respond with much more negative behavior when faced with a repeated painful event. If procedural pain is not well managed during the first instance of a procedure, children can develop increased anxiety about the next time they face this or similar procedures. Such increased anxiety leads to greater pain intensity, which may make the management of pain relief medications more challenging (Zengerle-Levy, 2006).
Several studies have shown how nurses can utilize different techniques to improve a child’s experience while hospitalized. Guided imagery is a technique where the imagination is used to focus on an object or a scene in order to help relieve stress of pain, and promote relaxation. It is a way of communicating with the autonomic nervous system, the part of the nervous system that regulates many involuntary body functions, such as heart rate, blood pressure and digestion. A study conducted at Cincinnati Children’s Hospital Medical Center found that nurses who taught guided imagery techniques to hospitalized children significantly reduced postoperative pain and anxiety in children (Childers, 2004). Children can be very imaginative, which allows for this technique to be very successful. According to several of the nursing staff, the use of guided imagery with children increased the effectiveness of pain medications, elevated immune functioning and lessened anxiety and depression they were experiencing (Childers, 2004).
Another method nurses can use to help hospitalized children was discovered as the result of over 112 hours of interviews and 134 hours of observation with sixteen nurses in a pediatric burn intensive care unit (Zengerle-Levy, 2006). This data was grouped into four distinct categories. The first category involves being a “parent-minded nurse” (Zengerle-Levy, 2006). Nurses would care for the hospitalized child in the same way they would want their own child to be cared for. This involved providing unconditional love to the children and using storytelling techniques to explain procedures or answer questions. Another category was described as “sustaining human connections,” which involved establishing a relationship with the child (Zengerle-Levy, 2006). The nurses would use the power of touch, play music or videos to soothe the children. They would also talk to children that were unconscious to help them feel comforted and safe. The third category nurses used when caring for hospitalized children was described as “receiving the patient as a child” (Zengerle-Levy, 2006). Nurses would make sure to incorporate play and humor when interacting with children, which would lift their spirits and give them a way to express fear (Dowling, 2002). They also expressed the importance of realistic expectations when it came to caring for the children. The final category nurses described was “renewing the spirit of the child” (Zengerle-Levy, 2006). This involved providing spiritual support for the children who felt that God had abandoned them. The nurses would talk to the children and help them to find meaning or purpose in life, which would establish hope in their minds
A third strategy nurses can use when caring for hospitalized children involves establishing trust in a series of four distinct phases. Research conducted by the Tasmanian School of Nursing in Australia examined these phases and how they impacted the nurse-child relationship (Crole & Smith, 2002). The first phase is described as “the introduction phase” (Crole & Smith, 2002). This involves establishing initial contact with the child and his/her family by talking about favorite toys or television shows, which allowed the child to talk with the nurse about something other than their illness. The second phase is defined as “the building trusting relationships phase” (Crole & Smith, 2002). This is achieved by using child appropriate language and preparation for procedures. The nurses would also use games and play to help reduce stress the child may be feeling. The third phase is “the decision-making phase” (Crole & Smith, 2002). Nurses gave children some control over their care by allowing them to participate in making certain decisions. This is critical to maintaining trust between the nurse and child. The final phase is “the comfort and reassurance phase” (Crole & Smith, 2002). Children can often hold nurses responsible for pain and trauma they may be feeling. It is important for the nurse to re-establish trust with the child by praising and comforting him or her after a painful procedure. Providing comfort to the child has also been shown to improve health seeking behaviors and positive outcomes overall (Kolcaba & DiMarco, 2005).
In conclusion, pain and anxiety can cause many problems in hospitalized children, both short and long term. Acute pain can affect how quickly tissues heal, as well as impact a child’s long-term psychological health. Providing care to hospitalized children involves more than just implementing the medical aspect of nursing. It requires the nurse to play an active role in the psychological and emotional needs of the child, in order to promote holistic well-being and healing. Strategies such as guided imagery, establishing and maintaining trust and using specific therapeutic techniques to comfort and spiritually support the child have been shown to positively impact the outcome of the child’s experience, both physically and psychologically.
Childers, L. (2004, November 24). Escape artists: Nurses help children relieve their pain, anxiety through guided imagery. Nurseweek. Retrieved April 10, 2007 from http://www.nurseweek.com/news/features/04-11/PediatricPain.asp
Crole, N. & Smith, L., (2002). Examining the phases of nursing care of the hospitalized child. Australian Nursing Journal, 9, 30-31. Retrieved March 26 from Proquest database.
Dowling, J. (2002). Humor: A coping strategy for pediatric patients. Pediatric Nursing, 28(9), 123. Retrieved April 14, 2007 from Expanded Academic ASAP database.
Kolcaba, K. & DiMarco, A. (2005). Comfort theory and its application to pediatric nursing. Pediatric Nursing, 31(3), 187-194. Retrieved May 2, 2007 from Proquest database.
Zengerle-Levy, K. (2005). Nursing the child who is alone in the hospital. Pediatric Nursing, 32(3), 226-231. Retrieved April 4, 2007 from Proquest database.
Intervention 1: Guided Imagery
Disadvantage 1: Knowledge Deficit
Although the use of guided imagery has been proven to decrease pain in hospitalized children, many nurses do not use it as a form of pain management because they are unaware of the technique or have not been educated in its use. According to a study recently published in Pediatric Nursing, only 14.3% of nurses routinely use guided imagery in addition to typical pharmacological methods for pain relief (Ely, 2001.) Because of the lack of knowledge in this form of therapy, there is often resistance in the nursing community on whether or not the technique works. Typically, nurses who have been in the profession for many years are most hesitant to try guided imagery, and often rely on medical management for pain relief. It is important for nurses to be open minded when considering all of the options for pediatric pain relief, whether it involves the use of medications or an alternative technique.
Disadvantage 2: Inadequate Insurance
Despite the vast and rising interest in this field, guided imagery and other alternative medical care remains untapped by hospitals. A major reason is the refusal of insurance companies to reimburse hospitals or physicians for the service. Hospitals want assurance that complementary medical services will be reimbursed. However, a crucial problem in reimbursement is the inconsistency in terminology usage among practitioners, sponsors, and consumers. Insurers or managed care providers that want to provide alternative medical coverage often do not because no “Current Procedure Terminology” codes represent alternative therapies on billing claims. Without uniform coding, insurers face the problem of providers misusing procedure codes to get reimbursed for alternative services; thus, widely implementing complementary alternative medicine such as guided imagery into hospital settings will be difficult.
Intervention 2: Spiritual Support for the Hospitalized Child
Disadvantage 1: Religion
Hospitalization can have many negative effects on a child. When children experience long term hospital stays as the result of a traumatic injury or chronic illness, they can often just “give up” and lose the will to live. Loss of their former self and excruciating pain could potentiate feelings of abandonment or punishment by God, which will ultimately affect their healing and outcome. A study conducted in a pediatric burn intensive care unit stated that nurses who nourished the spirit of the child helped them to find meaning and purpose in life in spite of their injuries (Zengerle-Levy, 2006.) Unfortunately, many nurses are uncomfortable incorporating spirituality in their nursing care. This lack of a spiritual component may be due to nurses' anxiety or confusion about introducing spirituality into what traditionally has been considered science-based nursing practice. Nurses may feel uncomfortable discussing spiritual issues with patients and may worry about boundaries or seeming "inappropriate." They also may feel ill equipped to implement spiritual aspects of care because they have not been formally trained or educated in this area. After all, asking patients about their spirituality and how they find meaning in their lives is very different from performing a physical assessment (Ameling & Povilinis, 2001.)
Disadvantage 2: Knowledge Deficit
Even though studies have shown that incorporating spirituality into nursing, it is not being included as part of the curriculum in many nursing programs. One hundred thirty-two randomly selected baccalaureate nursing programs in the United States responded to a survey exploring how the spiritual dimension of nursing care currently is being taught. The majority of programs included the concept of the spiritual dimension in curricula, but few programs had definitions of spirituality or spiritual nursing care. There appeared to be a lack of clarity in the understanding of the concept of spirituality, as well as uncertainty about levels of faculty knowledge and comfort with teaching this topic (Lemmer, 2002.) One factor that may affect the teaching of spiritual care is that faculty may be uncomfortable addressing the topic due to either their own lack of knowledge or discomfort.
Ameling, Ann & Povilions, Margaret. (2001). Spirituality, Meaning, Mental Health and Nursing. Journal of Psychosocial Nursing and Mental Health, 39(4) 14-20. Retrieved November 1, 2007 from Proquest database.
Lemmer, Corinne. (2002). Teaching the spiritual Dimension of Nursing Care: A Survey of U.S. Baccalaureate Nursing Programs. Journal of Nursing Education, 41(11), 482-491. Retrieved October 31, 2007 from Proquest database.
McEwan, William. (2004). Spirituality in Nursing: What are the Issues? Orthopaedic Nursing, 23(5), 321-322. Retrieved October 31, 2007 from Proquest database.
Santa Ana, Coleen F. (2001). The Adoption of Complementary and Alternative Medicine by Hospitals: A Framework for Decision Making. Journal of Healthcare Management, 46(4), 250-251. Retrieved October 25, 2007 from Proquest database.

Preterm Birth; A Growing Threat to Our Children

2007-12-03T15:33:00.001-08:00

Karen Schobert
Premature infants have higher health risks and face more social challenges than do infants born at full-term. Physiological causes such as low maternal weight gain and pregnancy-induced hypertension (PIH) as well as psychosocial issues including domestic violence and stress are correlated with preterm birth. The consequences of prematurity include stillborn births, infant mortality, lower academic achievement and increased rates of emotional, cognitive and physical health problems. Nurses play an essential role in providing resources, support and prevention strategies to patients at-risk for preterm birth. In order to reduce the incidence of preterm birth, it is imperative that nurses identify the risk factors associated with prematurity and educate patients and their families accordingly.
Prematurity is defined as birth occurring before 37 weeks gestation according to Rosenberg, Garbers, Lipkind & Chiasson (2005). There are various methods used to determine gestational age. The most common include using the date of the woman’s last menstrual period or by visualization of the fetus using ultrasound technology. Preterm birth is a growing problem. The March of Dimes reports that since 1981, the rate of preterm births has risen by 30%. Dr. Jennifer Howse, president of the March of Dimes, stated:
“These numbers underscore the need to address premature birth in our country with the same urgency and focus that has been brought to other threats to children’s health including secondhand tobacco smoke and rising rates of obesity”
There are multiple risk factors leading to preterm birth, many of which can be identified by nurses. Pregnancy spacing has an impact on birth outcomes. According to Gellene (2006), women who become pregnant sooner than 18 months after giving birth to an older child are at increased risk for delivering prematurely. Ricketts, Murray & Schwalberg (2005) suggest that psychosocial factors such as pregnancy-related anxiety, homelessness, domestic violence, unemployment and level of education are associated with preterm births. Women who smoke, engage in substance abuse or gain an inadequate amount of weight during pregnancy are also at risk (Ricketts, et all, 2005). Rosenberg, Garbers, Lipkind & Chiasson (2005) have found that obese women run a higher risk of delivering a premature infant due to the positive correlation with diabetes mellitus. Mothers who suffer from PIH may have to deliver before 40 weeks gestation as stated by Rosenberg, et. all, (2005), and various infections such as HIV and periodontitis, as well as the premature rupture of membranes account for a substantial number of premature births according to Ricketts, et. all, (2005). Nurses who are familiar with these various risk factors will be able to recognize a patient who has a higher probability of delivering preterm, and will be better equipped to implement early interventions.
The effects of prematurity can be seen from before birth, to well into adulthood. Gellene (2006), points out that prematurity is linked to stillborn birth as well as to a higher rate of infant mortality. Studies done by Hollo, Rautava, Kornhonen, Helenius & Sillanpaa (2002) show those children born too early tend to obtain lower academic achievement than their cohorts who were born at term. Adolescents and adults who were premature as infants have increased rates of emotional, cognitive and physical health problems according to Patton, Coffey, Carlin, Olsson & Morley (2004). Many high-risk expectant mothers and their families may not fully understand the consequences of prematurity and therefore may fail to take necessary steps toward the prevention of preterm birth. Nurses, in collaboration with other health care professionals can provide education to those at risk in order to facilitate as healthy a pregnancy as possible.
Once nurses have identified high-risk populations, such as teenagers, smokers, substance abusers, obese and underweight women and low income patients, they can provide these women and their families’ with strategies to avoid complications leading to preterm birth. Education related to smoking cessation, appropriate caloric intake, physical activity during pregnancy and early warning signs of preterm labor can benefit patients. Nurses can also provide patients with resources to turn to for help, such as support groups for adolescent mothers, rehabilitation for drug or alcohol dependencies and counseling for psychosocial issues.
Since many premature infants have health problems and face lifelong developmental challenges, it is imperative for health care providers to educate patients and their families about the risk factors and health effects associated with preterm birth. Nurses play an important role in providing resources, support and preventions strategies to patients at risk for preterm birth. By identifying specific risk factors leading to preterm birth, providing patients with information related to the effects of prematurity and by collaborating with women to create strategies to avoid preterm birth, nurses can have a positive impact on pregnancy outcomes and help to safeguard the health and well-being of generations to come.
Intervention 1: There are multiple risk factors leading to preterm birth, many of which can be identified by nurses.
Disadvantage 1: However, certain situations such as a patient’s income level and subsequent lack of insurance can inhibit women from seeking prenatal care and this eliminates the opportunity for nurses to intervene in the clinical setting. According to Klitsch (2000), many low-income women initiate prenatal care late or do not receive it at all. Lack of insurance puts both nurses and pregnant women at a significant disadvantage. Ciro Scalera, executive director of the Association for Children of New Jersey points out that in order to identify the women at risk who are not receiving prenatal care,
“you need some kind of much targeted outreach effort at a community level with community people”.
Disadvantage 2: A patient’s socioeconomic status presents additional challenges to nurses who are working to identify women at risk for preterm birth. For patients who do seek prenatal care, some may choose not to disclose information pertaining to problems such as homelessness, unemployment, substance abuse or domestic violence. While anxiety related to socioeconomic problems puts women at a higher risk for preterm birth (Dole, et. All, 2004) many women will elect to withhold anxiety-related issues from their health-care providers for reasons including differences in gender-related social norms, social support structures, and experience with discrimination (Perreira & Cortes, 2006)
Intervention 2: Nurses can provide education, resources and prevention strategies to help women avoid preterm birth.
Disadvantage 1: One barrier to this intervention is the patient’s knowledge deficit relating to the seriousness of the problem. For example, Leiner, Villa, Singh, Medina & Shirsat (2007), conducted a study on the knowledge levels of teenage mothers and pregnant teens regarding the risks of tobacco use during and after pregnancy. The results of the study indicated that the messages about the risks of exposure to cigarette smoke during and after pregnancy are not well understood by teenage mothers and pregnant teenagers. Ninety-four percent of the study group declared that they were informed about the risks of smoking during and after pregnancy. Their information came from doctors, books, television, school-specific programs, relatives, teachers, health education programs outside of the school and on the internet. Despite the information received, a knowledge deficit remained. Health care workers and nurses in particular need to look for alternatives to improving communication among high-risk groups.
Disadvantage 2: A second barrier that nurses face when attempting to provide education, resources and prevention strategies can be found in both environmental racism and racial discrimination. New Jersey Governor Christie Whitman released a report on infant mortality in 1997 which theorized that the stress from racism could cause women to have health problems that lead to premature births. Dr. Diane Rowley of the Centers for Disease Control and Prevention states that
“Environmental racism puts many Blacks in neighborhoods where there are high levels of toxins: and many Blacks live in high crime areas that create stress in their lives” (Sun Reporter, 1999).
Moreover, Governor Whitman’s report stated that black women, whose infant mortality rate is over 2.5 times higher than whites (Sun Reporter, 1999)
“have also watched their mothers, sisters, aunts and friends lose their babies. They figure there is little they can do about it” (Sentinel, 1997).
The logistical complications and resigned thought process that this example illustrates presents a unique challenge to nurses.
References:
Ricketts, S. A., Murray, E. K., & Schwalberg, R. (2005). Reducing low birth weight by resolving risks: Results from Colorado’s Prenatal Plus Program. American Journal of Public Health. 95(11), 1952-1957. Retrieved April 28, 2006 from Proquest Platinum Full Text Periodicals database.
Rosenberg, T., Garbers, S., Lipkind, H., & Chiasson, M. A. (2005). Maternal obesity and diabetes as risk factors for adverse pregnancy outcomes: Differences among 4 racial/ethnic groups. American Journal of Public Health. 95(9), 1545-1551. Retrieved April 13, 2006 from Proquest Platinum Full Text Periodicals database.
Little, M., Shah, R., Vermeulen, M.J., & Gorman, A. (2005). Adverse perinatal outcomes associated with homelessness and substance use in pregnancy. Canadian Medical Association Journal. 173(6), 615-618. Retrieved April 28, 2006 from Proquest Platinum Full Text Periodicals database.
Dole N., Savitz D., Siega-Riz A.M., Hertz-Picciotto I., Buekens P. & McMahon, M.J. (2004). Psychosocial factors and preterm birth among African American and white women in central North Carolina. American Journal of Public Health. 94(8), 1358-1365. Retrieved April 13, 2006 from Proquest Platinum Full Text Periodicals database.
Medina, T.M. & Hill, D. A. (2006). Preterm premature rupture of membranes: Diagnosis and management. American Family Physician. 73(4), 659-665. Retrieved April 28, 2006 from Proquest Platinum Full Text Periodicals database.
Hollo, O., Rautava, P., Korhonen, T., Helenius, H., Kero, P. & Sillanpää, M. (2002). Academic Achievement of Small-for-Gestational-Age Children at Age 10 Years. Archives of Pediatric and Adolescent Medicine. 156(2), 179-187. Retrieved May 5, 2007 from Proquest Platinum Full Text Periodicals Database.
Patton, G.C., Coffey, C., Carlin, J.B., Olsson, C.A., & Morley, R. (2004). Prematurity at birth and adolescent depressive disorder. British Journal of Psychiatry. 184, 446-447. Retrieved May 4, 2007 from Proquest Platinum Full Text Periodicals Database.
Government Data Confirms Rise In Preterm Birth Rate. (Oct. 3, 2006). Retrieved May 18, 2007 from http://www.medicalnewstoday.com/medicalnews.php?newsid=53199
Perreira, K. M. & Cortes, K. E. (2006). Race/Ethnicity and Nativity Differences in Alcohol and Tobacco Use During Pregnancy. American Journal of Public Health. 96(9), 1629-1636. Retrieved October 22, 2007 from Proquest Platinum Full Text Periodicals database.
Leiner, M., Villa, H., Singh, N., Medina, I. & Shirsat, P. (2007). Pregnant Teenagers and Teenage Mothers: How Much They really Know About the Risks to Children’s Health Associated With Smoking During and After Pregnancy? The Journal of School Health. 77(3), 101-102. Retrieved October 22, 2007 from Proquest Platinum Full Text Periodicals database.
Klitsch, M. (2000). Preexisting Factors, But Not Logistical Barriers, Inhibit Timely Use of Prenatal Care. Family Planning Perspectives. 32(5), 262-263. Retrieved October 22, 2007 from Proquest Platinum Full Text Periodicals database.
Racism, Resignation Contribute To Black Infant Mortality Rate (1997, October 1). Sentinel. 63(27). pg. A10. Retrieved October 22, 2007 from http://proquest.umi.com/pqdweb?did=490597111&Fmt=3&clientId=3236&RQT=309&VName=PQD
Black Doctors to Address Racial Disparities. (1999, March 25). Sun Reporter. 56(12) pg. 1. Retrieved October 22, 2007 from http://proquest.umi.com/pqd

Nurses Promoting Breastfeeding

2007-12-03T15:03:00.000-08:00

Lynn Jodoin
Due to the increasing number of young mothers and mothers who work outside the home, many new mothers are choosing to bottle feed rather than breastfeed because of lack of knowledge and the convenience of a bottle. Nurses can promote breastfeeding through education, demonstration and support.
According to Spatz (2004), the Department of Health and Human Services deducted that many Americans were not knowledgeable on the length of breastfeeding nor the negative consequences of not breastfeeding. Dobson & Murtaugh (2001), suggests that infants should be breastfeed only for six months and then for at least twelve months of breast milk and complementary foods. The benefits of breast milk are vast and numerous. Advantages are breast milk is the most optimal for the infant due to its unique composition and the right balance of nutrients and it is easily digested (Dobson & Murtaugh, 2001). The infant also profit immunologically because breast milk decreases the incidence of a variety of diseases such as bacterial meningitis and necrotizing enterocolitis because of the ingestion of the antibodies found in breast milk (Gartner & Eidleman, 2005). The mother also gains from breastfeeding. Maternal benefits according to Dobson & Murtaugh (2001), include amenorrhea while lactating, weight or fat loss, less risks of premenopausal breast and ovarian cancer, higher levels of bone remineralization than prelactation and a more optimal blood glucose level in women with gestational diabetes. There are also economic benefits to breastfeeding such as decreased absenteeism from work, savings in healthcare from the reduced incidents of infant illness and since breast milk is a natural resource, there is a reduction in the purchase of infant formula (Dobson & Murtaugh, 2001). Finally, breast milk can also improve the environment since there is no need of packaging and disposal of packages (Dobson & Murtaugh, 2001).
Many hospitals are aware of the numerous benefits of breast milk and are using that knowledge to promote breastfeeding to new mothers by becoming Baby Friendly Hospitals. A program first initiated by UNICEF and WHO in 1991, provides hospitals with guidelines for a best of practice protocol for breastfeeding (Hunt, 2006). The Baby Friendly Initiative not only has guidelines for the hospital and nurses to follow; it also has suggestions that the mother is encouraged to practice. The recommendations include: having a hospital policy regarding breastfeeding and having it accessible to all health care staff, providing training to nurses and staff to implement the written policy; demonstrating to mothers how to breastfeed and to maintain milk supply even if the mother and infant are unable to room together, the encouragement of breastfeeding on demand and to acknowledge breastfeeding support groups and to refer mothers to them if needed at discharge (Spatz, 2004). Nurses can further their own education by becoming more knowledgeable in the physiology of breastfeeding and also by becoming more skilled in the clinical management of breastfeeding (Gartner, 2005). Many hospitals whose nurses have additional training and certifications in breastfeeding are considered lactation consultants and can be an additional resource to both the nurse and new mother (Frick, 2004). Nurse’s can promote breastfeeding in the hospital by promoting and implementing hospital policies and procedures that encourage breastfeeding (Gartner, 2005). Since new mothers rely on the expertise and support of nurses, nurses have an important role in providing education and support to new mothers about breastfeeding. With continued nursing education and skills, nurses can ensure a successful breastfeeding program.
With the training provided by many Baby Friendly Hospitals, nurses can implement those policies by educating and supporting new mothers to breastfeed. Nurses assume many different roles when promoting breastfeeding. Nurses are educators and supporters of breastfeeding (Frick, 2005). According to Gartner (2005), nurses should enthusiastically promote, support and protect breastfeeding due to the numerous benefits of breastfeeding for the infant and mother. Nurses can educate mothers by various methods such as written material, video and demonstrations. For the education to be effective, Wellberry (2006), suggests that all interventions from counseling and early problem solving, should be face to face because interventions that were not in person or too brief proved to be ineffective. Also any problems encountered should be dealt with at that time when the mother has access to nurses and other resources. Gartner & Eidleman (2005), also suggests that an evaluation of breastfeeding including positioning, latching and milk transfer should be conducted by trained nurses at least twice daily and documented. Along with education, nurses also provide emotional support through positive verbal and nonverbal communication (Spatz, 2004). Nurses not only have a responsibility to promote hospital policies of breastfeeding, educating and supporting new mothers about breastfeeding during their hospital stay but also responsible to provide community resources and referrals should the new mother need any additional help.
With so many new mothers being discharged from the hospital in a relatively short amount of time and perhaps unable to retain the many new information given to them, the mother may benefit from additional education and support given to her outside community resources and support groups. Nurses can provide additional education through the use of her familiarity of local breastfeeding resources such as WIC clinics, lactation educators and consultants and support groups (Gartner, 2005). When utilizing home visits, it is more beneficial when a nurse trained in assessment and management of lactation conducts the visit (Dobson& Murtaugh, 2001).
For various reasons, many new mothers are not choosing to breastfeed or are not breastfeeding for an adequate length of time. To increase awareness of the many benefits of breastfeeding, nurses can educate new mothers about the benefits of breastfeeding, demonstrate many techniques to achieve successful breastfeeding and support the new mother so she may attain a successful and lasting breastfeeding regimen. To promote breastfeeding, many hospitals are undertaking the Baby Friendly Initiatives such as having policies regarding breastfeeding and providing educations and training regarding breastfeeding practices to nurses. Many hospitals are now utilizing lactation consultants who are nurses with additional training and certifications in breastfeeding. These practices and nurses are an important resource for new mothers who need support and education about the benefits of breastfeeding. New mothers may be overwhelmed from childbirth to retain any information given by nurses and hospital personnel. To help retain information, nurses can provide written materials, videos and other take home education materials so that the mother can read or watch later after she is settled at home. Nurses can demonstrate various positions and latching techniques and have the mother return demonstrate all the while providing positive support and encouragement. Due to the relative short hospital stays that are common to new mothers, it is important to offer community resources and support groups so that the mother can receive continuing education, guidance and support to continue her success with breastfeeding.

Intervention 1: During the hospital stay, it is a crucial time for the nurse and new mother to develop and implement the importance of successful breastfeeding techniques.

Disadvantage 1: Dobson & Murtaugh, 2001, states that many new mothers seek the advice of nurses so it is crucial that the nurses be knowledgeable about breastfeeding. Nurses can negatively impact breastfeeding behaviors due to the lack of knowledge and inaccurate or inconsistent advice given to new mothers (Mann, et al, 2003). According to Dobson & Murtaugh, 2001, many nurses are willing to support breastfeeding, but many nurses are not adequately trained in breastfeeding, such as being able to recognize problems and the interventions to alleviate the problems. Mann, et al, 2003, states that nurses contribute to ineffective breastfeeding by providing misinformation, lack of prenatal breastfeeding education, inconsistent hospital policies, interrupting the mother and baby during feeding and by promoting and distributing formula at discharge.

Disadvantage 2: The result of inadequate training of nurses on breastfeeding can result in the promotion of using human milk substitutes when a problem with breastfeeding happens (Dobson & Murtaugh, 2001). Many new mothers are told to exclusively breastfeed their infants for the first six months, but this left many new mothers feeling frustrated and panicked that the infant was not getting enough to eat so the mother quits nursing before the recommended six months (Kam, 2006). According to Cropley & Herwehe, 2002, institutions that distribute formula can negatively affect breastfeeding. Many low-income mothers choose formula to breast milk due to personal beliefs such as thinking that breastfeeding is painful, the convenience of formula, a lack of professional and social support and the need to return to work soon (Mann & et al, 2003). According to Mann, et al, 2003, many women who receive advice and assistance from WIC were less likely to breastfeed and more likely to use formula.

Intervention 2: Nurses can promote breastfeeding by being supportive to new mothers. Nurses can also refer unsure mothers to local community resources and support groups to help further success with breastfeeding.

Disadvantage 1: According to Cropley & Herwehe, 2002, breastfeeding rates can be related to demographic factors. The factors include the age of the mother, the education level of the mother, family type and income and the working status (Dubois & Girard, 2003). Mothers who were less likely to breastfeed have been identified as being African-American or Hispanic, aged 25 years or less, average income of less than $10,000 a year, having a grade school education, being a mother for the first time, live in the region of the South Atlantic, have low birth weight babies, are employed full time, enrolled in WIC, have negative attitudes about breastfeeding and have little confidence in their ability to breastfeed (Mann, et al, 2003). In today’s society, breastfeeding is not a cultural norm. According to Kam, 2006, 57% of Americans frown upon seeing mothers’ breastfeed in public. A baby being bottle fed in public is more readily acceptable than seeing a baby being breast fed (Hunt, 2006). A lack of support from family and peers or partners, beliefs and expectations and an absence of peer role models are all barriers to successful breastfeeding practices (Cropley & Herwehe, 2002). Kam, 2006, states that a new mother’s energy and morale is quickly vanquished if she does not feel supported.

Disadvantage 2: Many mothers have difficulty with trying to maintain breastfeeding while working outside the home. 90% of mothers who work outside the home quit breastfeeding before the recommended six months (Kam, 2006). Many low-income jobs do not offer the time or the privacy for mothers to pump at work (Hurst, 2007). In many places, employers are not required to accommodate new mothers with an area of privacy to pump (Kam, 2006). According to Johnson, 2006, a survey conducted by the Society for Human Resource Management concluded that 23% of the companies in the United States offer new mothers a lactation program or an area to breastfeed. Inflexible work hours, lack of breastfeeding or time to pump make it difficult for the mother to maintain a good supply of milk (Dobson & Murtaugh, 2001).

References

Cropley, Lorelei & Herwehe, Jane Casey. “Evolution of institutional support for breastfeeding among low-income women in the metropolitan New Orleans area.” American Dietetic Association. Journal of the American Dietetic Association. 102 (1) (Jan 2002). Expanded Academic ASAP. Thompson Gale. Tacoma Community College. 27 Oct 2007.
Dobson, Brenda & Murtaugh, Maureen. “Position of the American Dietetic Association: Breaking the barriers to breastfeeding.” American Dietetic Association. Journal of the American Dietetic Association. 101(10) (Oct 2001). Expanded Academic ASAP. Thompson Gale. Tacoma Community College. 24 May 2006.
Dubois, Lise & Girard, Manon. “Social determinants of initiation, duration and exclusivity of breastfeeding at the population level; The Results of the Longitudinal Study of Child Development in Quebec (ELDEQ 1998-2002).” Canadian Journal of Public Health. 94(4) (Jul/Aug 2003). Expanded Academic ASAP. Thompson Gale. Tacoma Community College. 27 Oct 2007.
Frick, Kevin D., Milligan, Renee A., White, Kathleen M., Serwint, Janet R., & Pugh, Linda C., “Nurse-supported breastfeeding promotion: a framework for economic evaluation.” Nursing Economics. 23.4 (July-August 2005): 165(9). Expanded Academic ASAP. Thomson Gale. Tacoma Community College. 22 Apr. 2007.
Gartner, Lawrence M. & Eidleman, Arthur I. “Breastfeeding and the use of human milk.” (policy statement). Pediatrics (Feb 2005): v115 p496(11). Expanded Academic ASAP. Thompson Gale. Tacoma Community College. 22 Apr. 2006.
Hunt, Felicity. “Breastfeeding & Society. (policy).” Pediatric Nursing. 18.8 (Oct. 2006): 24(3). Expanded Academic ASAP. Thomson Gale. Tacoma Community College. 22 Apr. 2007.
Hurst, Carol Grace. “Addressing Breastfeeding Disparities in Social Work.” Health & Social Work. 32(3). (Aug 2007). Expanded Academic ASAP. Thompson Gale. Tacoma Community College. 27 Oct 2007.
Johnson, Heather Moors. “Working and Breastfeeding.” Working Mother. 29(6). (Jul/Aug 2006). Expanded Academic ASAP. Thompson Gale. Tacoma Community College. 27 Oct 2007.
Kam, Katherine. “Why Don’t Women Nurse Longer?”. Baby Talk. 71(6) (Aug 2006). Expanded Academic ASAP. Thompson Gale. Tacoma Community College. 27 Oct 2007.
Mann, Angela R., Reifsnider, Elizabeth, Gill, Sara L., & Ritsema, Melanie. “Health Disparities in Breastfeeding Among Low-Income and Hispanic Women.” Journal of Multicultural Nursing Health. 9 (3) (2003). Expanded Academic ASAP. Thompson Gale. Tacoma Community College. 27 Oct 2007.
Spatz, Diane Z. “Ten Steps for promoting and protecting breastfeeding for vulnerable infants.” Journal of Perinatal & Neonatal Nursing. 18.4 (Oct.-Dec. 2004): 385(12). Expanded Academic ASAP. Thomson Gale. Tacoma Community College. 22 Apr. 2006.
Wellbery, Caroline. “Intervention to increase breastfeeding rates.” American Family Physician. 73.11 (June 1, 2006): 2047. Expanded Academic ASAP. Thomson Gale. Tacoma Community College. 22 Apr. 2007.

Postoperative nursing care and complications related to gastric bypass

2007-12-03T14:43:00.000-08:00

As the number of morbidly obese people increases with each year, bariatric (weight loss) surgery is becoming more popular. Bariatric surgery is a relatively new type of treatment for obesity that has been evolving since the 1950s (Gallagher, 2004, p. 60). Although a lot of research has been done on the surgical management of morbid obesity, a big controversy regarding success and mortality rates of gastric bypass still exists. Studies have shown that operative mortality (thirty days postoperative or more) is 0.5% for gastric bypass surgery (M. Grindel & C. Grindel, 2006, p. 133). On the other hand, surgeon M.S. Srikanth from St. Francis Hospital, Federal Way, WA states that gastric bypass mortality rate varies from 0.5 to 1.9% (personal communication, June 18, 2007). Although a person’s overall health condition can lead to his or her post procedural deterioration, nursing care remains a direct link between a gastric bypass and its outcome. A patient’s success rate can be improved by understanding the nature of gastric bypass, using preventive measures in the immediate postoperative period, and providing the patient with adequate discharge instructions.
Gastric bypass is designed to reduce excess body weight by limitation of food intake and altering digestion (Grindel M. & Grindel C., 2006, p.131). In other words, the weight loss effect is reached by malabsorption. Gastric bypass is defined as a Roux-en-Y gastroenterostomy that is done by making a one to two ounce pouch in the proximal part of the stomach, which normally can hold thirty to fifty ounces (Nettina, 2006, p. 731). It can be performed as an open procedure or laparoscopically, by horizontal stapling of the smaller proximal part, which is separated from the larger distal stomach. The proximal jejunum is anastomosed to the distal jejunum, while the distal jejunum is connected to the proximal pouch, bypassing the inferior part of the stomach (et al, p. 731). As a result of the procedure, the small gastric pouch serves as food storage. Whereas, the distal part (90 % of the stomach) remains functional. Because of the narrowed outlet of the proximal pouch, its empting is delayed. Consequently, the patient is feeling sated for longer period of time (Grindel, M. & Grindel, C., 2006, p.130-131). Although gastric bypass is one of the most commonly used bariatric surgeries, it can’t be performed on any morbidly obese person.
Weight loss surgery can be an option for the clinically severely obese with a body mass index (BMI) >40 or BMI >35 with co-morbid conditions (American Nurse Association, 2000, p. 48). Despite the fact that patients who are about to have their weight loss surgery are undergoing comprehensive health evaluation, mostly all of the bariatric patients present with a coexisting disease. The research data by Snow, Barry, Fitterman, Qaseem, and Weiss (2005) states that bariatric surgery is the first choice of treatment, for the patients who have not had any success with other methods of therapy and are presenting with co-existing conditions such as hypertension, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea, OSA (Harrington, 2006, p. 357). For instance, 193 patients, who had undergone bariatric surgery, were studied. They found out that more than 50% of the patients had hypertension, a third had OSA, and 25 % had diabetes (McGlinch, Que, Nelson, Wrobleski, Grant & Collazo-Clavell, 2006, p. S25). Therefore, nursing care of the bariatric patient should not only focus on monitoring for immediate postoperative complication but should also be meticulous in evaluating a patient for other potential complications related to the patient’s health history.
As the nature of the gastric bypass and the co-morbidity related to obesity offer quite a big challenge for nurses, the nursing care requires deep knowledge of in pathophysiology of bariatric patient. Unfortunately, the data reveals a relatively big complication incidence among these patients. According to the Centers for Disease Control and Prevention, between 1998 and 2003, 10% of gastric bypass patients developed a complication during a hospital stay (CDC, 2006). Moreover, about one fifth of the patients are readmitted to the hospital within the first year of their procedure, some of them are experiencing serious complications such as wound infection, bowel obstruction, and hernia. Since the nurses are responsible for complications monitoring and infection control, they can be accountable for inappropriate postoperative care. In fact, most of the life threatening complications can be detected, and action can be taken for its avoidance, in the early postoperative period (Srikanth, personal communication, June 18, 2007).
Nurses that are giving postoperative care to a bariatric patient should consider a few major concerns the person may be at risk for. They may be inclusive but not exclusive to anastamotic leak, thrombotic disorders, dumping syndrome, and pulmonary system complications (Grindel, M. & Grindel, C., 2006, p.137).
The research data by Podnos, Jimenez, Wilson, Stevens, and Nguyen states that the number one cause of death following bariatric surgery is intra-abdominal infection, which is a result of an anastamotic leak at the site. The most common symptoms of the leak are unexplained tachycardia, dyspnea, and restlessness (Harrington et al, 2006, p. 359). Unexplained tachycardia is the only symptom that can be indicative of the anastamotic leak for the first 24 hours after the procedure (McGlinch, et al. 2006, p. S28). So, the frequent monitoring of the heart rate and blood pressure is required in the immediate postoperative period, because changes in those values can point toward anastamotic leak or hemorrhage (Grindel, M. & Grindel, C., 2006, p. 137). However, if the patient presents with low hemogram, high serum potassium, metabolic acidosis upon arterial blood gas examination, complaining of non-incisional abdominal pain, it should alert the nurse to anastamotic leak as well (Gallagher, 2004, p. 62). In this case the surgeon should be notified immediately, so that computed tomography scans and upper gastrointestinal series with gastrographin can be performed to rule out the leak (Harrington, 2006, p. 361).
Bariatric patients are also at risk for thrombotic disorders such as deep vein thrombosis and pulmonary embolism. Therefore, heparin therapy and sequential compression devices (SCD) or antiembolic stockings should be used as the preventative measures in the immediate postoperative period. Furthermore, it is essential to do frequent checks for positive Holman’s sign, change in the pulse pattern, redness, unilateral edema, or pain to the extremities. If any of the above symptoms present, the physician should be notified immediately (M. Grindel and C. Grindel, 2006, p. 137). Finally, early and frequent ambulation is the most effective method of prevention of the deep vein thrombosis (McGlinch et al., 2006, p. S29).
Dumping syndrome is another common complication that can affect patient following gastric bypass surgery, because the pylorus sphincter is bypassed and stomach contents can rapidly pass into intestine. An increased amount of water is forced down to the intestine, which increases intestinal peristalsis as it propels food down the lower gastrointestinal tract. As the result of increased peristalsis, a patient may exhibit tachycardia, sweating, dizziness, diarrhea, and abdominal pain (Grindel, M. & Grindel, C., 2006, p. 142). On the other hand, consumption of the simple sugars can lead to dumping syndrome as well (Gallagher, 2004, p.63). Therefore, it is highly recommended for the patient to have sugar free popsicles, gelatin, and non-carbonated beverages starting on the first postoperative day and up to discharge (Grindel et al., 2006, p. 139).
The pulmonary system is one the greatest postoperative concerns in caring for a bariatric client due to the fact that a heavy weight of fatty tissue on the rib cage prevents the chest wall from full expansion (Gallagher, 2004, p.62). Moreover, anesthesia adds stress on the respiratory system, which makes the patient more vulnerable to hypoxia. Therefore, nursing care should also be focused on encouraging the patient to use incentive spirometry at least ten times every hour and keeping record of all of the readings. Oxygen saturation should be monitored frequently including a night time for those with history of OSA (M. Grindel and C. Grindel, 2006, p.137). Patients with OSA, should also continue using the continuous positive airway pressure (CPAP) machine (if they have one) as the preventative measure of apnea in the times when they are about to fall asleep. A 25° reverse Trendelenburg position of the bed is highly recommended as well since this position is associated with greater lung volumes and a reduced tendency for atelectasis (McGlinch et al., 2006, p. S26). Dr. Srikanth is simply explaining the importance of mandatory 14° reverse Trendelenburg position by the need of the obese patients to get “weight off their lungs” (personal communication, June 18, 2007). Finally, nursing care should be meticulous regarding monitoring patient’s breath sounds and frequent ambulation in order to reduce his or her risk for any pulmonary complication. In fact, M. Grindel and C. Grindel (2006) alone with other researchers suggest that the patient should be ambulating as early as two to twenty-four hours after surgery (p. 137).
Although it is essential for the client to receive the best possible nursing care, the discharge instructions are becoming more important because stays are getting shorter. Adequate postoperative teaching is a one more step towards the patient’s success following gastric bypass surgery. When teaching bariatric patient, it is essential to cover the great risks for wound infection, dehiscence, nutritional balance, and the need in life long supplementation.
Obesity itself predisposes patient to the wound infection because of the poor blood supply to the skin and large subcutaneous spaces (McGlinch et al., 2006, p. S28). Also, the wound that is hiding within a skin fold may harbor more bacteria due to excess moisture and may heal slowly (Gallagher, 2004, p. 62). However, if a gastric bypass is done laparoscopically, it has a 3% incidence of incisional infection; whereas, if it is done as an open procedure, it has a 7% incidence (McGlinch et al. 2006, p. S28). Nevertheless the prevalence of infection depends on the type of a surgical incision; nurses remain responsible for educating a bariatric patient about the infection prevention. The person may be taught about the normal drainage characteristics, its reasonable amount, and about signs and symptoms of infection. For instance, he or she should be informed that serosanguineous drainage from the noninfected wound may be indicative of dehiscence not infection (McGlinch et al., 2006, p. S28). When giving the discharge instruction on infection control, the nurse should remember that it is negligent to assume that patient knows something. In other words, a repetition will not hurt but benefit the patient later on.
Another important topic, to be covered in the patient teaching, is life long need in the supplementation. Because of the nature of gastric bypass surgery, people following the procedure have decreased absorption of vitamin B 12, iron and calcium (Grindel, 2006, p. 131). Therefore, a multiple vitamin and mineral supplementation alone with a low calorie diet (800-1000 cal/day) is essential in order to avoid deficiencies (Nettina, 2006, p. 731). Furthermore, gastric bypass patients are at risk for secondary hyperthyroidism due to the sufficient calcium levels. Although non-compliant clients usually are more prone to this complication since it can be easily corrected by vitamin D intake, it is highly recommended that the patients have their bone density monitored closely (Srikanth, personal communication, June 18, 2007).
As a final point, it is important to stress that the diet regimen slowly progresses from clear liquids on the first postoperative day, to regular diet starting the sixth week following the procedure (Grindel, 2006, p.139-141). So, the patient should be instructed how to transition to the regular diet correctly. First of all, the nurse should let the client know that the paced fluid intake with one to two ounce sip at a time can alleviate discomfort and prevent complications. Secondly, it should be emphasized that daily fluid intake is gradually increased to 48 ounces to keep self well hydrated. Finally, it is highly recommended that the patient drinks his or her fluids from 30 ounce medicinal cup in order to learn the right intake in the small amounts (Grindel, 2006, p.137).
Taking care of morbidly obese patients that are undergoing weight loss surgery can be quite a challenge. Especially with increased popularity of bariatric procedures, nurses have a greater need in understanding of the nature of gastric bypass in order to use preventive measures and providing patient with adequate postoperative teaching. As the result of continuing nursing education, the operative mortality rates can be reduced, with a significant increase in a patient’s success rate.
a. Intervention 1 (Utilization of CPAP machine in the immediate postoperative period).
I. Disadvantage 1 (A one strap mask also called a nuisance mask can’t protect a patient in the postoperative period from Farmer’s Lung disease).
Utilization of continuous positive airway pressure (CPAP) is highly recommended for bariatric clients with obstructive sleep apnea (OSA) (Harrington, 2006, p. 360). According, to Centers for Disease Control and Prevention (2002), these masks that can be seen on some CPAP machines are helpful for very large particles, whereas tiny particles that cause Farmer’s Lung still can invade the patient.
Farmer’s Lung is caused by the invasion of microscopic sized particles into the body’s natural filtering mechanisms (nose, hair and throat mucous). As they accumulate in lungs, an allergic type of pneumonia can result (Farm Safety Association, 2002). Manifestations can be similar to severe cases of flu in the early period. However, as the disease progresses, it affects ability to breathe, laboring inspirations as well as expirations. Consequently, in about five years patient will have permanent scarring of lung tissue that is irreversible (CDC, 2002).
Therefore, in order for CPAP machine to be safe and effective, the mask should have two straps, which are meeting NIOSH standards. Although one strap masks are relatively inexpensive and remain popular among general public, they predispose patients to Farmer’s Lung disease. Thus, they should not be used due to the inadequate protection against the microscopic particles (CDC, 2002). Moreover, only two strap mask can properly fit the nose in order to promote adequate ventilation. In fact, Farm Safety Association (2002) states that it is important to improve air circulation within the mask in order to prevent the growth of mold spores or limit the damage that they can cause. Failure to adjust mask can labor breathing, hit the air inside of the mask, and decrease protection (CDC, 2002).
II. Disadvantage 2 (The cost of the CPAP machine is one of the greatest obstacles for patients to begin such treatment).
For instance, the machine’s cost ranges somewhere from $ 239.99 to $ 579.99 depending on brand and retailer (CPAP Auction, 2007). Moreover, American Academy of Sleep Medicine (2007) is offering sleep education series from S 125.00 to 200.00. As the result, a lot of people remain not educated about OSA, are not yet diagnosed, or not sure how to use CPAP machine properly. American medical news have reported that medicare premiums for outpatient services (which include OSA studies) will rise 3.1% in 2008 due to the fact that that physician rates are set to be cut by 10% in January 2008 (October 22/29, 2007). Therefore, it will decrease a chance of been diagnosed and treated for OSA in people who are using this type of insurance.
b. Intervention 2 (Patient’s education regarding new diet regimen).
I. Disadvantage 1 (Mortality incidence still existing even if people are closely following the diet in the postoperative period).
As the clear liquid diet progresses to regular diet starting sixth week following the procedure, bariatric patients require more personalize attention and teaching (Grindel, 2006, p.139-141). On November 1, 2005 Swedish obese subjects were studied. Among 1338 cases, which were followed for at least ten years, the frequencies of re-operations or conversion surgeries not including the surgeries caused by postoperative complications was 17 % for gastric bypass The study have found that the most common cardiovascular causes of death were myocardial infarction, sudden death, and cerebrovascular damage. Cancer was listed as the most common cause of death from non-cardiovascular causes. (Sgostrom, L., Narbro, C., el al, 2007, p. 748).
II. Disadvantage 2 (Because of the nature of gastric bypass surgery, people following the procedure are on life long multiple vitamin and mineral supplementation).
The Rounx-en-Y gastric bypass (the most common type) causes iron, vitamin B-12, and calcium deficiencies as a result of bypassing a large portion of jejunum (Grindel, 2006, p. 131). Therefore, a multiple vitamin and mineral supplementation alone with a low calorie diet (800-1000 cal/day) is essential in order to avoid deficiencies (Nettina, 2006, p. 731). Furthermore, gastric bypass patients are at risk for secondary hyperthyroidism due to the sufficient calcium levels. So, it is very important for patients to have their bone density monitored closely (Srikanth, personal communication, June 18, 2007).
References:
American Academy of Sleep Medicine. (2007). Sleep Education Series. Retrieved November 2, 2007, from http://www.aasmnet.org/store/products.aspx?depid=19
Centers for Disease Control and Prevention. (2002). Farmer's Lung - Physical Simulation, University of Kentuky. Retrieved November 1, 2007, 2007, from http://www.cdc.gov/nasd/docs/d000101-d000200/d000153/lung3.html
Centers for Disease Control and Prevention. (2006). Women’s Health. Hyattsville, MD: National Center for Health Statistics. Retrieved July 5, 2007,from http://www.cdc.gov/nchs/products/pubs/pubd/hus/women.htm
CPAP Auction. (2007). Retrieved November 2, 2007, from http://www.cpap.com/?gclid=CKX61I3jvo8CFSFaagodmiHgYw
Farm Safety Association (2002). Farmer’s Lung. Retrieved December 2, 2007, from http://www.cdc.gov/nasd/docs/d001601-d001700/d001609/d001609.pdf
Grendinning, D. (2007). Medicare 2008 premium hike low, but doctor’s pay remains
unresolved. Retrieved November 2, 2007 http://www.ama-assn.org/amednews/2007/10/22/gvl11022.htm
Grindel, E.G., & Grindel, C.G. (2006). Nursing Care of the Person Having Bariatric Surgery. MedSurg Nursing, 15(3), 129-143. Retrieved July 5, 2007, from Academic Search Premier database (AN 21110332).
Harrington L. (2006). Postoperative Care of Patients Undergoing Bariatric Surgery. MedSurg Nursing, 15(6), 357-363. Retrieved June 23, 2007, from Academic Search Premier database (AN26359832).
Nettina, S. M. (2006). The Lippincott manual of nursing practice. (8th ed.). Ambler, PA: Lippincott Williams and Wilkins.h vice
Sjostrom, L., Narbo, K, Sjorstrom, D, Karason, K., Larsson, S., Bengtsson, C., Dahlgren, S., Gummeson, A., Jacobson, P., Karlsson, J., Lindroos, A., Lonroth, H., Naslund, I., Olbers, T., Stenlof, K., Torgerson J., agren, G., and Carlsson, L. (2007). Effects of bariatric surgery on mortality in swedish obese subjects. The New England Journal of Medicine. August 23, 1007. 357 (8), pp. 741-751.

Pediatric Palliative Care: Considerations for Pediatric Nurses

2007-12-03T14:36:00.000-08:00

Culturally, it is widely believed that children should not die. Yet each year in the United States of America, 55,000 children under the age of twenty die, many experiencing long-term illnesses. Previous research has highlighted the myriad of concerns pediatric nurses face in palliative care. Pediatric nurses are confronted with complex issues involving physical, psychological, legal, ethical, social and spiritual dilemmas (Malloy, Ferrell, Virani, Wilson & Uman, 2006). While great strides have been made recently by the End-of-Life Nursing Education Consortium of Pediatric Palliative Care (ELNEC-PPC) in training, research indicates nurses are not fully equipped to deal with many of these difficult issues. Given the connection between training and quality of care in nursing more emphasis should be placed on ethics, communication, documentation, and continuity of care of the palliative pediatric patient.
Palliative care in pediatric patients is not solely focused on dying but also on helping children and family live to their fullest while facing complex medical conditions (Himmelstein, 2006). Unfortunately, the philosophy of palliative care is often in direct conflict with physicians, parents, and families who extend the child’s life at any cost. Identifying patients for palliative care often goes overlooked. On any given day, 15,000 infants, children, adolescents and young adults do not receive supportive care services while they die from conditions (Himmelstein, 2006). Even after identification of patients for palliative care supportive services such as pastoral care, social work, behavioral health or child life services were used in a minimal number of cases in a study of the circumstances surrounding the death of children (Carter, Howenstein, Gilmer, Throop, France & Whitlock, 2004). The Medicare Hospice Benefit was created by Congress in 1982 to meet the needs of patients nearing end of life. Children under 17 years of age make up only 0.4% of all hospice admissions and many hospices are ill equipped to meet their needs (Himmelstein, 2006).
While accessing palliative care is difficult, there are also ethical concerns facing providers and nurses. A recent study of 456 nurses and 781 physicians, from all parts of the United States, measured concerns of conscience, knowledge and beliefs, awareness of published palliative care guidelines and agreement or disagreement with those guidelines. Fifty-four percent of nurses and physicians reported, “At times, I have acted against my conscience in providing treatment to children in my care.” In order to alter the culture of pediatric palliative care, attention to the beliefs and values of pediatric health care professionals, who care for children with end of life issues, is the first step in creating meaningful change (Rushton & Catlin, 2002).
Beyond the culture of palliative care, the quality of care provided is often inconsistent. Carter et al. assessed the treatment of symptoms during end-of-life care (EOL). Results indicated inconsistencies in the quality and application of care. Although 90% of the patients studied received pain medication in the last 72 hours of life, only 34% of the medical staff, including nurses, documented the pain assessment and management.
Treatment for symptoms has been inconsistently documented for the pediatric population. Specific symptoms such as fatigue, shortness of breath, dyspnea and prolonged crying often went completely undocumented. Prolonged crying occurred at a rate of 10% in pediatric patients (Carter et al., 2004). Documentation of specific interventions focused on the child’s spiritual and emotional needs was uncommon. Whether the distinction for improvement lies in documentation or actual care, necessary revisions and improvement of standards is needed.
In order to respond to the child’s emotional needs, proper communication with the child receiving palliative care and the family unit must also be addressed. Children communicate in verbal and non-verbal ways. To attend to communication child life specialists, psychologists and art therapist may be required (Himmelstein, 2006).Wolfe et al. performed a study surveying parents whose child died of cancer. The goal of the study was to identify the timing for parental understanding that the child had no for cure compared to the timing of the physicians understanding of no cure as represented in documentation. The results showed that the physician recognized no cure 100 days earlier than the parents (106 versus 206 days). The inability to communicate with children and the family can drastically impair their emotional and spiritual growth, which is essential in the face of a terminal illness.
A study in Sweden by Kreicbergs et al. focused on whether parents should discuss death with a terminally ill child. The retrospective study of parents showed that of the 147 parents who talked to their kids about death, none regretted it. Of the 258 parents who didn’t talk to their children about death 27% regretted it. Research indicates that nurses can take a more active role, not only in communicating with the interdisciplinary team providing care, but also encouraging the family unit to openly communicate and discuss the child’s terminal condition.
For change to occur in the palliative care of pediatric patients focus on educating nurses is paramount. Only 2% of the content found in 50 reviewed nursing textbooks that were commonly used was directed at palliative care. Three out of the 50 nursing textbooks were pediatric nursing textbooks. Only 1.3% of the content in pediatric nursing textbooks was related to end of life care (Ferrell et al., 2006). When surveyed nursing faculty stated they felt inadequate in teaching end-of-life material (Ferrell et al., 2006). If communication, continuity of care, documentation and ethical considerations are to be improved future research and advancements in education are needed.
However, the basic principles of palliative care must remain constant. The function of palliative care is not directed at shortening life, but rather directed by the beliefs and values of the child and their family unit. The ability to be flexible when defining a family unit is very important when making difficult decisions regarding the child. The necessity to diagnose early and help families with do-not-resuscitate orders aids the palliative care process. Respite care with an interdisciplinary team ready to facilitate, provide and document goal directed care should be available. Most importantly any child who is diagnosed with a chronic terminal disease should receive access to palliative care.

a. Intervention 1 (Promote access to pediatric palliative care)
i. Disadvantage 1 (Access to proper pediatric palliative care is limited due to lack of insurance)
In 1998 10.6 million children were uninsured. Fourteen percent of the population, some 38.9 million Americans of all ages, were without health insurance coverage in 2001 (Wallman, 2007). In order for pediatric palliative care to be an option, the pediatric client must have the opportunity for health care. Carter et. al. suggests that most pediatric palliative care occurs in the critical care unit (56%) followed by the neonatal intensive care unit (31%). With 55,000 children under the age of twenty children receiving end this critical end of life care, no research has been done to unearth the number of children who are turned away without insurance.
Unfortunately in today’s political climate, powers are at work to limit the opportunity for children to receive care. Recently President Bush vetoed a multi-billion dollar bill that would extend the State Children's Health Insurance Program (Walsh and Yellin, 2007). About two-thirds of the 10 million or so children who would be covered by the bill will have no insurance whatsoever without the program. Funding must be allocated to allow for uninsured pediatric patients to receive palliative care.
ii. Disadvantage 2 (Access to pediatric palliative care is limited due to socioeconomic status and ethnicity)
Health care for subgroups of American children is limited based on the ability to maintain health insurance coverage, access to a usual place to go for healthcare, and experiencing unmet needs due to cost. In a study by the Center for Disease Control (CDC) an estimated 3 million hispanic/latino children are without health insurance (Gulnur & Hanyu, 2004). There is a clear distinction between white and non-white access to proper pediatric health care. Hispanic children are less likely than non-Hispanic white children to have health insurance (Wallman, 2007). In 2005 a survey by the Center for Disease Control found that while 93% of non-Hispanic white children were covered by health insurance, only 88% of African American children and 79% of Hispanic children were covered. With a health care system that doesn’t serve subgroups of American society, how can pediatric palliative care be successful?

b. Intervention 2 (Promote nursing education and resources for palliative care)
i. Disadvantage 1 (Access to proper nursing education creates a knowledge deficit in the application of proper pediatric palliative care)
Given the connection between training and quality of patient care, more time and money needs to be invested in nursing education. Wolfe et al. performed a study surveying parents of children who had died of cancer. The major response was that there was a discrepancy between when the parents understood there was no cure and when the health care team understood there was no cure. Earlier recognition of terminal prognosis led to many benefits including higher ratings of patient care, earlier DNR orders, less long-term cancer therapies and an earlier focus on comfort measures. In order to create the possibility for earlier understanding, educating nurses about pediatric palliative care is paramount.
Unfortunately only 1.3% of the content of pediatric textbooks was related to end of life care (Ferrell et al, 2006). In a review of the top 50 pediatric textbooks, 2% of the content four in the texbooks was focused on end of life care (Ferrell et al, 2006). How are nurses able to appropriately educate patients that are knowledge deficient without the proper knowledge to pass on to the client? Professional education addressing end of life care should be a major priority in bridging the knowledge gap.
ii. Disadvantage 2 (Access to proper supportive care services are not received due to deficient knowledge and cost)
On any given day 15,000 infants, children, adolescents and young adults do not receive
supportive care services while they die from conditions (Himmelstein, 2006). Pediatric palliative care involves a multi-disciplinary health care team. With this fragmentation of services, knowledge about all of the resources available to patients is necessary. Any program needs to provide continuity of care with hospice, interventions to support the family, siblings dealing with bereavement, and support for the staff. With these services comes a price tag that is very expensive. Palliative care medications can cost thousands of dollars a day. Without access to proper resources and government funded programs children will continue to go without care.

References
Carter. B. S., Howenstein, M., Gilmer, M.J., France, C., & Whitlock, J.A. (2004).
Circumstances surrounding the deaths of hospitalized children: opportunities for pediatric palliative care. Pediatrics, 114 (3), 848. Retrieved July 7, 2007 from PubMed database.
Gulnur, S., & Hanyu, N. (2004). Acess to healthcare among Hispanic/Latino children:
United States, 1998-2001. Center for Disease Control, 344, 2-7. Retrieved October 31, 2007 from CDC database.
Himelstein, B. P. (2006). Palliative care for infants, children, adolescents, and their families. Journal of Palliative Medicine, 9, 163-181. Retrieved July 5, 2007 from
Academic Search Premier database.
Kreicbergs, U., Valdimarsdottir, U., Onelov, E., Henter, J., & Steineck, G. (2004).
Talking about death with children who have sever malignant diseases. New England Journal of Medicine. 351, 1175-1186. Retrieved August 4, 2007 from New England Journal of Medicine database.
Malloy, P., Ferrell, B., Virani, R., Wilson, K., & Uman, G. (2006). Palliative care
education for pediatric nurses. Pediatric Nursing, 32 (6), 555-561. Retrieved July 12, 2007 from Academic Search Premier database
Rushton, C.H., & Catlin, A. (2002). Pediatric palliative care: the time is now! Pediatric
Nursing, 28 (1), 57-60. Retrieved July 12, 2007 from Academic Search Premier database.
Solomon, M.Z., Heller, K.S., Dokken, D.L., Levetown, M., Rushton, C., Truog,
R.D., & Fleischman, A.R. (2005). New and lingering controversies in pediatric end-of-life care. Pediatrics, 116 (4), 872-883. Retrieved July 12, 2007 from Academic Search Premier database.
Wallman, K. K. (2007). America’s children: key national indicators of well-being.
Federal Interagency Office of Management and Budget. Retrieved October 31,
2007 from Forum for Child and Family Statistics database.
Walsh, D. & Yellin, J. (2007). House fails to override Bush veto of child insurance bill.
CNN. Retrieved October 31, 2007 from CNN database.
Wolfe, J., Klar, N. Grier, H.E., Duncan, J., Salem-Shchatz, S., Emanuel, E.J., & Weeks,
J.C. (2000). Understanding of prognosis among parents of children who dies of cancer: impact on treatment goals and integration of palliative care. Journal of the American Medical Association. 284, 2469-2475. Retrieved on August 4, 2007 from JAMA Archives database.

HOW NURSES CAN STOP THE NURSING SHORTAGE

2007-12-03T10:10:00.001-08:00

An article by HSM Group Ltd. states (as cited in Spetz & Given, 2003, para. 1) “estimates of average nurse vacancy rates at hospitals range from 10.2 percent to 13 percent, with one in seven hospitals reporting more than 20 percent.” The Bureau of Health Professions predicts the nursing shortage to worsen within the next twenty years; by 2020 there will be a projected shortage of 800,000 nurses (as cited in Spetz & Given, 2003, para. 2). Because the nursing shortage has been linked to negative patient outcomes and high rates of nurse burnout, nurses have the responsibility as members within a discipline to partner with other professionals in the health care industry to alleviate the nursing shortage by reaching out to youth to promote a positive image of nursing, increase graduation rates of licensed nurses, and increase job satisfaction.
The need for educated nurses is expanding due to a variety of factors including: increasingly risky and complicated work, an aging workforce, invariable financial benefits, increasing work alternatives, and inadequate new nurses entering the field (Stedmen & Nolan, 2007). In addition, some individuals do not rand nursing as high as other professions and are being discouraged from pursuing nursing by their elders (Cohen et al., 2006). Considering that “up to 50% of the current U.S. nursing workforce will reach retirement age by 2020” ( Cohen et al., 2006, para. 3), it is time to start generating changes in several areas of the nursing continuum.
As role models, nurses need to take action to educate the youth of society about the nursing profession. Several authors have noted that “encouraging children to enter nursing should begin during the pre-school and elementary school years because changing children’s perceptions of nursing has been shown to affect their choices of college and careers” (Cohen et al., 2006, para. 7). Programs specifically designed toward the youth should be established like the “Kids Into Health Careers (KIHC) Initiative”. According to the U.S. Department of Health and Human Services, Health Resources and Services Administration, and Bureau of Health Professions (as cited in Cohen et al., 2006) it was created to convey to youth that job opportunities in health care do exist, qualifying for these jobs is an attainable and gratifying goal, financial aid is available, and health care work fills a critical need in medically underserved communities where people are not receiving health care. These types of programs can be launched at health fairs and career days at the local schools. An increase in knowledge and preparation gained in elementary, junior high, and high school about nursing will increase the likelihood that youth will choose nursing as a major in college.
Once a student has chosen the major of nursing, he or she may run into more tribulations before they obtain a nursing degree. In a study done by Paolucci (as cited in Spetz & Given, 2003, para. 25) it is reported that “numerous nursing programs have been forced to reduce admissions because of lack of faculty, and future faculty retirements are likely to make the problem worse”. The average salary for a staff nurse in the United States for 2007 is $59.061 and the average salary for nursing faculty is $62,734, with a difference of only about $3,600 according to hotjobs.com. This seems unjust due to the fact that staff nurses usually hold an associate’s or bachelor’s degree, while the faculty member holds a master’s or Ph.D. The nursing educators need to demand the salary they deserve with the support of unions or groups that they form independently so that the number of admitted applicants can increase. If the shortage is considered to be a crisis, support from the state and federal governments should be increased to meet the needs of educators. Other organizations could also help finance programs. In an article by Rapaport (as cited in Spetz & Given, 2003, para. 25) it is stated that “hospitals are also funding nursing education slots directly, thus enabling cash-strapped programs to expand.”
While nursing programs need money to expand, the nurses who are already in practice are being recruited with benefits packages that include items such as paid leave, health insurance, retirement plans, education benefits, child care, and more (Spetz & Adams, 2006). However, Spence, Laschinger and Finegan (2005) state recruitment and retention of nurses will benefit most from approaches that generate work atmospheres that manifest justice, trust, and respect and thus will reinforce professional nursing practice. The goal is for the organization to value the nurses enough to allow open communication facilitating a mutual respect. In a study done by Laschinger (as cited in Spence Laschinger & Finegan, 2005, para. 8), she found that “only 38.3% of staff nurses felt they received the respect they deserved from their managers.” This absence of respect will only harbor mistrust and lack of commitment thus leading to job dissatisfaction. A relatively new concept to assist with current dissatisfaction is coaching. Coaching is an anonymous two person communication system to help employees make their concerns known and find means to work through them (Stedman & Nolan, 2007). This conflict resolution system may help solve problems by compromise rather than employees simply quitting because of dissatisfaction. Coaches are registered nurses from human resources who are good listeners, experienced in conflict resolution, and are familiar with the hospital’s benefits and policies; they ensure focus on the future, generate strategies and solutions, create a trusting environment, and are not judgmental (Stedman & Nolan, 2007). If the hospital implements a program directed toward employee satisfaction and it works, the employed nurses will likely have an increased feeling of respect and value that will renew their commitment to the hospital and to nursing as a profession.
The quality and availability of healthcare is a growing problem in recent years as a result of a chronic nursing shortage. As members within this professional community, nurses are responsible for finding a resolution for this dilemma. Educating the youth is crucial because they are the individuals that will be entering the workforce whether it is in nursing or not. Lobbying for more college funding is essential so that the faculty can be compensated justly and the programs can accept as many qualified applicants as possible. The last step is to promote workplace satisfaction by demanding the respect and compromise nurses deserve through programs like coaching so recruiting and retention rates rise. Because the nursing shortage is so complex, it is going to take a collaboration of disciplines and several multifaceted strategies to end it. However, since the deficit is a direct nursing problem, nurses need to be on the forefront of new implementations.

a. Intervention 1- Encouraging children to pursue nursing.
i. Disadvantage 1- Knowledge deficit related to day to day work of the registered nurse.
The choice to pursue nursing can occur at a young age. However, if children do not have correct information about the nursing profession, they will not be able to make a solid choice on which educational path to follow when they choose their major in college. Education programs and job fairs can help close this gap however children need to see nurses actually doing their job. In a study done by Stevens and Walker (as cited in Yeager & Cheever, 2007) they found that high school seniors did not know that nurses engage in high-technology work, direct programs, or held leadership positions even after a nurse came to their career day at school. This is a knowledge deficit that can be altered with the utilization of job shadowing and having hospitals host job fairs and camps for the youth.
ii. Disadvantage 2- Discrimination related to gender of nurses
With just of fraction of the registered nursing work force consisting of men, job fair and career day nurses are no longer targeting girls as their main focus for recruiting nurses; nevertheless the youth of America still think that nursing is a woman’s job. In a recent study, students were most likely to consider that “women are better suited” to a career in nursing by up to 16 percent as compared to other occupations (Seago, J.A. et al., 2006). This is a discrimination and knowledge deficit problem that can be easily addressed. Stevens and Walker found that this sort of discrimination didn’t hold true in children who knew a nurse personally; in fact, knowing a nurse personally was positively associated with pursuing a career in nursing (as cited in Yeager & Cheever, 2007).
b. Intervention 2- Obtain funding to expand nursing programs
ii. Disadvantage 1- Financial deficit among state and federal governments
The nursing shortage has not only hit hospital nursing positions, it has greatly effected the faculty nursing positions at the university and college levels. This is crucial because nursing programs need to increase the number of graduating registered nurses to meet the demand for nurses in each pathway of the profession (Spetz & Given, 2003). Due to most RN education programs being in publicly funded colleges and universities, particularly community colleges, government support is going to be required in order to accomplish the expansion of many programs. However, current state and federal budgets are preventing them from expanding the programs as much as necessary (Spetz & Given, 2003). Spetz and Given state that even with the support of unions and organizations, the budget for nursing will most likely not change (2003).
ii. Disadvantage 2- Knowledge deficit related to “lack of vision”
Hospitals are an important asset to nursing programs. They allow a place for hands on practice and staffing to guide students through the learning process without the school paying for additional faculty. Several hospitals have stepped forward and become active participants with their local colleges according to the article by Henderson and Hassmiller Hospitals and Philanthropy as Partners in Funding Nursing Education (2007). Conversely, others have shown less determination due to lack of vision, lack of funding, and a desire to “go it alone and do it the way they’ve always done” (Henderson & Hassmiller, 2007). With government funding that has nearly vanished hospitals need to be convinced that according to the Robert Wood Johnson Foundation (as cited in Henderson & Hassmiller, 2007, para. 8) “nursing shortage problems are beyond the control of any one institution, so partnerships are the only way we will arrive at solutions.”

REFERENCES
Cohen, R., Burns, K., Frank-Stromborg, M., Flanagan, J., Askins, D.L., & Ehrlich-Jones, L. (2006). The kids into health careers (KIHC) initiative: Innovative approaches to help solve the nursing shortage. Journal of Nursing Education, 45(5), 186-. Retrieved April 13, 2007, from ProQuest database.
Henderson, T.M., & Hassmiller, S.B. (2007). Hospitals and philanthropy in funding nursing education. Nursing Economics, 25(2), 95-. Retrieved October 23, 2007, from ProQuest database.
Seago, J.A., Spetz, J., Alvarado, A., Keane, D., et al. (2006). The nursing shortage: Is it really about image? Journal of Healthcare Management, 51(2), 96-. Retrieved October 23, 2007, from ProQuest database.
Spence Laschinger, H.K., & Finegan, J. (2005). Using empowerment to build trust and respect in the workplace: A strategy for addressing the nursing shortage. Nursing Economics, 23(1), 6-. Retrieved April 13, 2007, from ProQuest database.
Spetz, J., & Adams, S. (2006). How can employment-based benefits help the nursing shortage? Health Affairs, 25(1), 212-. Retrieved April 13, 2007, from ProQuest database.
Spetz, J., & Given, R. (2003). The future of the nursing shortage: Will wage increases close the gap? Health Affairs, 22(6), 199-. Retrieved January 7, 2007, from ProQuest database.
Stedman, M.E., & Nolan, T.L., Jr. (2007). Coaching: A different approach to the nursing dilemma. Nursing Administration Quarterly, 31, 43-49. Retrieved January 19, 2007, from Epanded Academic ASAP.
Yeager, S.T., & Cheever, K.H. (2007). A residential nursing camp program: Effects on adolescent attitudes toward nursing careers. Journal of Nursing Education, 46(10), 452-. Retrieved October 23, 2007, from ProQuest database.

PREVENTING DEHYDRATION IN THE ELDERLY

2007-12-02T19:33:00.000-08:00

Margaret Cramer
Water is the most essential component in the human body. Without water the human body is unable to function and will die. Many infections in the elderly have been linked to dehydration and if not diagnosed early enough the mortality rate can be as high as 50% (Ferry, 2005, p. 1). The nurse may be the only factor that will determine life or death in an elderly patient and that is why it is so important to be able to detect dehydration early as well as teach prevention.
Water is an essential component in the everyday functioning of the human body. Approximately 60% of the total body weight is water (Water, 2007, p. 1). Every system in the body depends on water to function properly. Water is necessary for:
Carrying vital nutrients to the body cells.
Transportation of oxygen to the cells.
Is a major factor in the prevention of constipation.
Helps to regulate the body temperature.
Is vital to the liver and kidneys to flush out waste products.
Provides protection for the bodies major organs and tissues.
A vital component in the lubrication of joints.
Is a major part of the tissues in the eyes, nose, and mouth.
When the body becomes dehydrated, and the fluids are not replaced, there is a decrease in the total blood volume. The sympathetic nervous system will then cause vasoconstriction resulting in an increase in the heart rate to compensate for the decreased tissue perfusion (Black, Hawks, 2005, p. 208). Without sufficient blood the heart is unable to pump efficiently resulting in a decrease in the amount of blood to the brain, liver, and kidneys. Eventually this will result in multiple organ failure and ultimately death. Without water the human body will cease to exist!
What causes the body to become dehydrated? There can be many contributing factors that will cause the loss of fluid such as:
Exercising will cause increased sweating.
If the weather is hot or humid, heated indoor air, or higher altitudes.
Illnesses that cause nausea, vomiting, diarrhea, and fevers.
Medications such as diuretics, laxatives, or even sedatives.
Diseases such as diabetes, draining wounds, or even depression which causes a decrease in appetite.
The elderly are at a greater risk of becoming dehydrated because of numerous factors. As the body ages there are changes in body functions that are directly related to the aging process. According to Levi the major changes are a decrease of 20% in the metabolic rate between the ages of 20 and 90 years of age, a reduction of lean body mass (muscle) accompanied by a decrease in the amount of physical activity, thereby resulting in an increase in body fat (2005, p. 6). Fat is almost completely free of water; whereby muscle can contain 73% water, so with the increase in fat, and the loss of muscle, this also will contribute to the incidence of dehydration in the elderly (Ferry,2005, p. 3). Other factors that increase the incidence of dehydration in the elderly is the aging process that will cause a decrease in the sensation of thirst, the gag reflex weakens, and some elderly will develop swallowing disorders which will greatly impact their intake of fluid. Some may even decrease their intake of fluid because of the fear of incontinence. Because dehydration can occur at a faster rate in the elderly it is vital to know the signs and symptoms.
In order to be able to detect dehydration early it is important to know the causes of dehydration and what to look for when assessing an elderly patient. The following signs and symptoms should be looked for when doing an assessment:
Skin turgor needs to be assessed; but remember because of decreased elasticity with aging you need to check for turgor either on the forehead or the sternum.
The patient may appear disoriented, become easily irritated, or become dizzy or faint with position changes.
Muscle tone or any muscle weakness needs to be assessed.
Postural vital signs need to be taken to evaluate any increase in heart rate or if hypotension is present. According to Black and Hawkins (2005) hypotension is a classic sign of a decrease in fluid volume and is defined as:
"A decrease in systolic blood pressure of more than 25 mm Hg.
A decrease in diastolic pressure of more than 20 mm Hg.
A pulse increase of 30 beats/min or more when the patient stands (p.208) ."
Patient’s may have trouble with constipation, a decrease in urine output with urine that is dark or has a strong odor to it.
Weight should be assessed. A loss of two or more pounds in a few days can amount to a body loss of a liter of fluid.
Jugular veins may appear flat when patient is lying down and capillary refill will be less than 5 seconds.
A decrease in fluid will cause the body temperature to rise.
Labs such as urine specific gravity, blood urea, nitrogen, electrolytes, or hemoglobin values that are abnormal are also useful tools in the dehydration assessment.
The patients current medications also need to be charted. Diuretics will increase the incidence of fluid loss and if accompanied by an illness, dehydration may occur at an even more rapid rate.
What can be done to decrease the incidence of dehydration in the elderly? First of all it is important that the elderly, their caregivers, their nurses, as well as their health care providers make it a top priority to all be aware of the signs, symptoms, as well as the health risks of dehydration. Prevention needs to become a top priority and these nursing interventions should be implemented as well:
Including foods in the diet that have a high water content. Such as fresh fruits, vegetables, watermelon ( which is almost all water), yogurt, or even jello.
Encouragement to increase fluid intake when ill.
Teaching that when exercising fluid consumption needs to be increased.
Teaching that if the temperature increases either indoors or outdoors that the need for increased fluid intake will increase as well.
Patient’s should be educated that even if they don’t feel thirsty they still need to drink.
Caregivers need to make beverages as accessible as possible to those that have decreased mobility, dyspagia problems and offer a wide variety of choices.
Since dehydration has been identified as the most common fluid and electrolyte imbalance in the United States, prevention should be the first and foremost step, followed by the ability to recognize the early signs and symptoms of dehydration (Black, Hawks, 2005, p. 205). With everyone working together the incidence of dehydration can be greatly diminished as well as the risk to an elderly person’s health.
Intervention 1 Patient’s need to be educated to drink even when they don’t feel thirsty.
Disadvatange: Meg Sibal M.D. from the Filipino Reporter states that "according to the January 2007 issue of Health After 50, as individuals age, the thirst response system diminishes so that the elderly may not feel thirsty even as dehydration is setting in"(2007, p. 1). The Journal of Applied Physiology published the results of a 2002 trial that compared the fluid intake of men aged 51-60 with men aged 20-28 after they all completed a strenuous 10 day hill- walking trip(Sibal, 2007, p 1). The hikers aged 20-28 kept rehydrating themselves with plenty of water and fluids, while the older men, with their decreased sense of thirst, became progressively dehydrated.
Disadvantage: Age related diseases and the medications the elderly must take for these diseases may also increase the risk of dehydration (Sibal, 2007, p. 2). Certain diseases that are more common in the eldery, such as kidney, diabetes, and thyroid disorders can all cause the body to excrete more water, which also will increase the risk of dehydration. Medications for hypertension such as diuretics, ACE inhibitiors, antipsychotic drugs and cholinesterase inhibitors that are used to treat Alzheimers’s disease and other dementia related illnesses can also cause increased water loss resulting in dehydration.
Intervention 2 Include foods in the diet that have a high water content. Such as fresh fruits, vegetables, watermelon (which is almost all water), yogurt, or even jello.
Disadvantage 1 According to the Journal of Rehabilitation Research and Development, "swallowing problems (dysphagia) can occur at any age but are most prevalent in elderly individuals and are a growing healthcare concern as the geriatric population expands"(Robbins, 2002 p. 543). If dysphagia is not treated or diagnosed early enough it can lead to dehydration, malnutrition, a reduction in the rehabilitation process after injury or illness.
Disadvatage 2 "Malnutrition, weight loss, and dehydration experienced by nursing home elders constitute a large and silent epidemic in the United States"(Sibal, p. 1). According to the Journal of Nursing Care Quality a elderly person that lives in a nursing home is more likely to suffer from dehydration resulting from inadequate fluid intake (Dyck, 2007, p. 59). Research suggests that the quality of nursing care that the elderly receive is greatly effected by the total number and types of nursing staff available to provide care to the residents (Dyck, 2007, p. 59). Even though federal law requires that facilities employ sufficient nursing staff to ensure the quality care for each resident of a nursing home, "loosely written regulations give nursing home operators great latitude in defining "sufficient staff" for their facilities" (Dyck, 2007, p. 59).
References
Black, J., Hawks, J. (2005). Medical Surgical Nursing: Clinical Management for
Positive Outcomes (7th ed.). Missouri: Elsevier Saunders.
Dyck, M., (2007). Nursing staffing and resident outcomes in nursing homes: weight
loss and dehydration. Journal of Nursing Care Quality, 22(1): 59-65. Retrieved
from the Cinahl Plus data base.
Ferry, M. (2005). Strategies for Ensuring Good Hydration in the Elderly.
Nutrition Reviews, 63(6), S22. Retrieved 27 January from Proquest data base.
Hamilton, S. (2001). Detecting Dehydration & Malnutrition in the Elderly. Nursing,
31,(12). Retrieved 28 January from Proquest data base.
Levi, R. (2006). Nursing Care to Prevent Dehydration in Older Adults. Australian
Nursing Journal, 13(3),21. Retrieved 11 February from Proquest data base.
Robbins, J., Langmore, S., Hind, J., Erlichman, M. Dysphagia research in the 21st century
and beyond: Proceedings from Dysphagia Experts Meeting, August 21, 2001.
Journal of Rehabilitation Research & Development, Jul/Aug 2002, 39,
(4), 543. Retrevied from Ebsco Host Research Databases on October 29, 2007.
Sibal, M. (2007). Elderly may not feel it even if dehydrated. Filipino Reporter, 34,
(10), 33. Retrieved 28 October from Proquest data base
(n.d.). Water: How much should you drink every day? Retrieved 11 February, 2007
from Mayo Clinic web site: http://222.mayoclinc.com/health/water/Nu00283
Wood, D. (2007). Dehydration. Retrieved 11 February, 2007 from U.S. Department
Health & Human Services web site: http://www.healthfinder.gov/hyg/files/?id.

MRSA Explained: Best nursing practice on educating patients, in the outpatient setting, about community acquired MRSA and decreasing the spread of th

2007-12-02T18:43:00.001-08:00

Community acquired MRSA, methicillin resistant staphylococcus aureus, is bacterial infection that is resistant to many antibiotics and is spreading at an alarming rate. Reduction in the spread of MRSA can be accomplished by educating patients about the bacteria and antibiotic misuse, how to decrease the spread during an active outbreak, and improved hygiene practices for everyday living.
In an outpatient setting where time is limited, an important key strategy when educating patients about MRSA is a short, simple explanation of the bacteria. According to Wingard (2005), ‘the keys to successful patient-focused education are to keep it simple and make it understandable” (p. 2). The following is a brief description of MRSA and it’s relation to antibiotic misuse that can be relayed to patients in an outpatient setting. “Some germs that commonly live on the skin and in the nose are called staphylococcus or “staph” bacteria.” (Group Health Cooperative, Pierce County Health Department & Washington State Department of Health, 2006, p. 2). “Staph” bacteria are harmless, unless they find their way into a break in the skin, like through cut. When the bacteria enter the skin, it can cause an infection. MRSA is a form of a “staph” bacteria except more harmful because it is harder to treat effectively with antibiotics. MRSA is the direct result of misuse and over prescribing of antibiotics. Misuse occurs, according to Plonczynski and Plonczynski (2005), when “a patient is given unnecessary or inappropriate antibiotics, or if antibiotics are discontinued prior to complete eradication of the bacteria”(p. 2-3). This inadequate treatment of bacterial illnesses allows time for the bacteria to mutate and become resistant to the antibiotic(s) given. These behaviors render the antibiotic to become less effective against future infections.
There are two types of MRSA: hospital acquired (infected while hospitalized) and community acquired (infected while out in the general public). This paper will focus on community acquired MRSA in an outpatient setting “because community acquired MRSA infections are more virulent” (Doughton, 2003, p. 2). When an individual is infected with MRSA, they frequently report that it started out as a pimple or blemish that they popped. In one to two days, they will have complaints of a red, hard area that is warm to the touch with a lot of pain, swelling and a rapid increase in size. Pus-like drainage may be noted too. These infections resemble a boil, an abscess or a spider bite. MRSA skin infections are commonly found on the buttocks, groin, legs, abdomen and the back. MRSA can also infect wounds, lungs, kidneys or even blood. An individual should seek medical treatment if they have any of the symptoms listed above. If an individual prolongs seeking medical care, the infection can cause a fever, nausea or tissue death to occur and even spread throughout the body causing death.
Another key strategy, of utmost importance, is to stress to the patients how MRSA is spread. As nurses, we need to emphasize that MRSA is transmitted via person to person contact and at a frightening rate. Dragon (2006) feels “one of the reasons infections may be spreading in the community, is that people have become more mobile…There are a lot more people working and leaving children in daycare. Housekeeping today is not what it used to be years ago; more people are at work” (p. 5). There are two ways to get the bacteria via person to person contact. One way is through contact with an individual that has an active MRSA infection with open sores, wounds or drainage. The other is through contact with an individual that is a carrier. A carrier is a person that harbors the bacteria, usually in their nose, but does not exhibit signs and symptoms of an infection. One may also contract the bacteria from infected objects, for example, using the same towel as an individual that has an active MRSA infection. Again, misuse of antibiotics by an individual may also lead to a MRSA infection.
Relating to patients the methods of preventing the transmission of the MRSA bacteria is an essential strategy in decreasing the rate at which it spreads. Prevention of a MRSA infection can be achieved through improved hygiene practices. The most crucial is increasing the frequency of hand washing. “Hand washing is the single most important infection control practice. Hand washing is essential because personal contact is the primary mode of MRSA transmission. Several research studies have shown that “hand hygiene is an effective method of controlling MRSA infection” (Ott, Shen, & Sherwood, 2005, p. 3). Improvement of regular grooming habits, such as cleaning dirty nails, use of alcohol based gels, no sharing of personal items, bathing on a daily basis, regular use of lotions to keep skin from drying or simply covering one’s mouth when coughing or sneezing, also decrease the spread of MRSA. Improvement of current lifestyle habits by taking nutritional supplements, eating healthier and exercising help to improve one’s own natural defenses against infection. Proper wound care and dressing changes are critical in reducing the spread of MRSA too. In a household affected by MRSA, laundry needs to be washed with hot soapy water with bleach, if possible, and dried at a high temperature to kill any MRSA bacteria. When cleaning household surfaces, any cleaner that states it is a disinfectant is sufficient. A mixture of one tablespoon of bleach to one quart of water is an adequate disinfectant as well. It is important to disinfect surfaces on a regular basis since MRSA bacteria can live on surfaces for days or even weeks. Some practices to use while out in the community to safeguard oneself and others are: Frequent washing of hands, carry alcohol based hand gel when one is not able to wash their hands, keep wounds covered with bandages and appropriate clothing, avoid individuals with compromised immune systems, do not participate in contact sports and clean gym equipment before and after use if gym provides disinfectant.
The points to emphasize when explaining MRSA to patients are the risks related to misuse of antibiotics and increasing the frequency of hand washing. If your facility has any pamphlets or other resources at hand for patient education, pass it along to the patient. In addition, give the patient an opportunity to ask any questions prior to ending the discussion.
We, as nurses, are aware of how critical patient education is and understand the need to decrease the spread of MRSA. Unfortunately, there are several disadvantages we nurses will encounter in regards to each strategy previously mentioned.
The first key strategy discussed was giving the patient a brief, simple explanation of the history of MRSA and preventing its spread. A disadvantage of this strategy is assuming that all of our patients readily understand the information given to them verbally or written. “Most adults read at an eighth-grade level and twenty percent of the population reads at or below a fifth-grade level, most health care materials are written at a tenth-grade level” (Keenan & Safeer, 2005, p. 1). Other factors that are barriers when educating patients include a person’s age, any preexisting, uncorrected sensory deficits (i.e. bad vision, hearing loss), educational background, and patients who know English as a second language. In addition, “when giving information verbally, talking too quickly reduces the chance the patients will understand what is being said” (Keenan & Safeer, 2005, p. 5). This is another disadvantage that is frequently experienced in a clinical setting where interaction between medical staff and patients is limited. When any of the above factors are combined, the end result will ultimately be poor patient education.
Enlightening patients about the misuse of antibiotics was also discussed as a strategy to inhibit the proliferation of MRSA. These efforts are undermined because “physicians routinely prescribe antibiotics for clinical syndromes in which antimicrobials are known to have no effect.” (Low, D & McGeer, A, 1997, p. 3). The reasons for routinely prescribing antibiotics range from patient demand to ease of giving a prescription due to lack of time to discuss why an antibiotic is not needed. This action conveys the wrong message to patients about what illnesses warrant the use of antibiotics. Furthermore, this behavior leads to increased noncompliance for antibiotic use and escalates the spread of MRSA in the community. Low and McGeer (1997) feel that “there is an urgent need both to improve prescribing practices and to provide the tools for physicians to diagnose more accurately those conditions for which an antibiotic is indicated” (p. 3) In relation to antibiotic misuse, is the reality of medical staff lacking education about MRSA. Many medical providers are not aware of the signs and symptoms of an active infection. Countless medical staff is ignorant of proper collection and testing techniques. Numerous physicians still misdiagnose this skin infection as a “spider bite.” “Therapy for infections due to community-acquired MRSA presents additional challenges for the clinician. The first challenge is to recognize these organisms.” (Moellering, 2006, p. 3). Unawareness about MRSA slows proper diagnosing, treatment and indirectly promotes its spread. According to Moellering (2006), “Our knowledge of community-acquired MRSA epidemiology is incomplete, which adds to the challenge of controlling infection by community-acquired MRSA” (p. 2).
In conclusion, community acquired MRSA is on the rise around the world. It is the cause of prolonged hospitalization of patients and increased costs in medical care due to frequent medical visits with several rounds of antibiotic therapy. The first step in controlling the spread of MRSA is to increase awareness of its existence by educating communities about the bacteria and its effects. As nurses, it is our job to stress the importance of this epidemic to our patients and have any information regarding MRSA readily available.

References
Doughton, S. (2003). Resistant Staph, Once confined to hospitals, now a threat to public. Seattle Times. P. A-1. Retrieved January 17, 2007, from Proquest database (409046991).
Dragon, N. (2006). Fighting today’s superbugs: infection control at the forefront. Australian Nursing Journal, 14(2), p. 16-19. Retrieved February 18, 2007, from Proquest database (1096108491).
Group Health Cooperative, Pierce County Health Department, & Washington State Department of Health. (2006) Living with MRSA.
Keenan, J. & Safeer, R. (2005). Health Literacy: The Gap Between Physicians and Patients, 72(3), p. 463-468. Retrieved October 26, 2007 from Proquest database.
Low, G. & McGeer, A. (1997). The Microbes Strike Back. Canadian Medical Association Journal, 15(12), p. 1703-1704. Retrieved October, 26, 2007, from Proquest database.
Moellering, R. (2006) The Growing Menace of Community-Acquired Methicillin-Resistant Staphylococcus aureus. Annals of Internal Medicine, 144(5), p. 368-370. Retrieved October 26, 2007, from Proquest database.
Ott, M, Shen, J., & Sherwood, S. (2005). Evidenced-based practice for control of methicillin-resistant Stapylococcus aureus. Association of Operating Room Nurses Journal, 81(2), pp. 361-364, 367, 369-372, 375-378. Retrieved February 18, 2007, from Proquest database (793987051).
Plonczynski, D. & Plonczynski, K. (2005). Antibiotic resistance: the impact on care of hospitalized patients. MedSurg Nursing, 160(7). Retrieved February 18, 2007, from Expanded Academic ASAP database.
Windgard, R. (2005). Patient Education and the Nursing Process: Meeting the Patient’s Needs. Nephrology Nursing Journal, 32(2), pp. 211-215. Retrieved March 6, 2007, from Proquest database (824946611).

Over-the-Counter Supplement Overdose

2007-12-02T18:31:00.000-08:00

“Vitamins are America's favorite supplements; you may be among the 40% who took at least one within the past month. All told, we spend $1.7 billion a year on those pills and capsules” (Smith, 2000, p. 89). Patients are unaware that vitamin and herbal interactions, with prescribed medication, commonly occur and can have effects similar to drug-drug interactions. Patients are taking over-the-counter vitamin and herbal supplements to live a healthier life style, but are actually harming themselves, by decreasing the effectiveness of prescribed medications, overdosing on the supplement, and increasing their risk for other health problems.
First, patients are harming themselves by taking over-the-counter vitamin and herbal supplements, by decreasing the effectiveness of prescribed medications. Common vitamin and herbals taken by the general population are: Fat soluble vitamins A, D, E and K which need dietary fat to be absorbed (Nix, 2004, p. 89-97). A few examples of water soluble vitamins are: Vitamin C (Ascorbic Acid), B1(Thiamine), B2 (Riboflavin), B3 (Niacin) etc. Water soluble vitamins are absorbed easily and directly into blood circulation from the gastrointestinal tract and do not require a carrier for transport into blood circulation (Nix, 2004, p. 97-122). Common herbal supplements include: St. John’s Wart is used for mild depression; Ginseng is used to improve appetite, memory, and sleep pattern; Ginger can be used for decreased nausea and vomiting related to motion sickness, pregnancy, chemotherapy, and surgery; Garlic is used for high blood pressure, high cholesterol, and prevention of cardiovascular disease; Ginkgo is used for improved peripheral circulation and sexual dysfunction; and Kava used for anxiety, stress, restlessness, insomnia, mild muscle ache and pain, menstrual cramps, and premenstrual syndrome (Delgin, 2005, p.1190-1213). One example of supplements interacting with medications adversely is Warfarin, also known as Coumadin. Warfarin is commonly used for prevention of thromboembolism, pulmonary embolism, atrial fibrillation with embolization, and myocardial infarction. Supplements that decrease the effect of Warfarin, placing the patient at risk for thromboembolism, are St. John’s Wart and Ginseng. Supplements that increase the effects of Warfarin, by thinning the blood and placing the patient at risk for bleeding, are Garlic, Ginger, and Ginkgo (Delgin, 2005, p.1097).
In addition to decreasing the effectiveness of prescribed medications, vitamin and herbal supplements are harmful, because patients are overdosing on the supplements. Patients believe that water soluble vitamins are excreted in your urine, making it impossible to overdose on vitamins. Unfortunately, some water soluble vitamins have Upper Intake Levels. According to the article “Does your supplement provide a nutrient overdose? New recommendations on vitamin A and other nutrients reveal how much is too much.” featured in Tufts University Health & Nutrition Letter in April of 2001, the Upper Intake Level (UL) is the highest amount of a vitamin or mineral that you could take daily without suffering adverse effects. For example, the UL for vitamin C (ascorbic acid) is 2000mg/day and the UL of vitamin B3 (niacin) is 35mg/day. See chart from Tufts University Health & Nutrition Letter for UL on other vitamin and minerals on page 9 of this report. Fat-soluble vitamins can be stored in large amounts in the liver. Patients who are not aware of this will take daily doses of fat-soluble vitamins increasing their risk for overdosing. Another term for vitamin and supplement overdosing is megadosing. Megadosing on vitamins can cause a rebound effect, leading to a deficiency known as “artificial induced deficiency”. A rebound effect is a response in which a sudden withdrawal of stimuli is followed by a physiological effect either positively or negatively affecting the body. The example given in Williams’ Basic Nutrition & Diet Therapy Twelfth Edition, published in 2004, was infants born with scurvy due to mothers taking megadoses of vitamin C during pregnancy. After delivery, the baby was no longer receiving high volumes of vitamin C and in turn had a rebound effect of being deficient in vitamin C. (Nix, 2004, p.145-146).
Not only do vitamin and herbal supplements decrease the effectiveness of prescribed medications, and place the patient at risk for accidental overdose, but they increase the patient’s risk for other health problems. Patients taking an excess amount of vitamin C may experience osmotic diarrhea and gastrointestinal upset (Nix, 2004, p.100). Megadosing on vitamin B6 can lead to lack of muscular coordination and nerve damage (Nix, 2004, p.108). Elevated amounts of fat-soluble vitamins can potentially lead to liver and brain damage. Overdosing on vitamin A can lead to joint pain, thickening of long bones, loss of hair, jaundice, portal hypertension, and ascites (Nix, 2004, p.91). Ingesting an exorbitant amount of vitamin D may lead to calcification of soft tissues, such as kidneys and lungs, as well as fragile bones (Nix, 2004, p.92). Surplus amounts of vitamin E can interfere with bleeding (Smith, 2000, p.89). Profuse doses of herbal Kava can lead to liver damage (Delgin, 2005, p. 1206). The list of risks from overdosing on supplements is vast.
Evidence indicates that vitamin and herbal supplementation are causing harmful effects on patient outcomes, by decreasing the effectiveness of prescribed medications, overdosing on the supplement, and increasing their risk for other health problems. Patients should be informed that vitamins are like drugs, and can be harmful if taken in excess or with certain medications. They should be instructed to read labels carefully, and identify the need versus supplemental use. Most importantly, it is imperative for patients to report all over-the-counter vitamin and herbal supplements with their prescribed medications when asked. Ultimately, food is the best source of nutrients.
hart from Tufts University Health & Nutrition Letter for UL
Legend for Chart:
A - Nutrient
B - Goal for intake[*]
C - Upper intake level

A B C

Vitamin A Women: 2,333 IU 10,000 IU
Men: 3,000 IU

Vitamin K Women: 90 micrograms Not established[A]
Men: 120 micrograms

Boron Not established 20 milligrams

Chromium Women: 20-25 micrograms Not established[A]
Men: 30-35 micrograms

Copper Women: 900 micrograms 10,000 micrograms
Men: 900 micrograms

Iodine Women: 150 micrograms 1,100 micrograms
Men: 150 micrograms

Iron Women (pre-menopausal): 45 milligrams
18 milligrams

Women (post-menopausal):
8 milligrams

Men: 8 milligrams

Manganese Women: 1.8 milligrams 11 milligrams
Men: 2.3 milligrams

Molybdenum Women: 45 micrograms 2,000 micrograms
Men: 45 micrograms

Nickel Not established 1 milligram

Silicon Not established Not established[A]

Vanadium Not established 1.8 milligrams

Zinc Women: 8 milligrams 40 milligrams
Men: 11 milligrams

[*] Values given are for adults ages 19 and up unless
otherwise noted.

[A] There's not enough scientific evidence yet to set a
UL for vitamin K, chromium, or silicon.
Work Cited
Deglin, Judith H., Vallerand, April H., 2005. Davis’s Drug Guide for Nurses Ninth Edition. Philidelphia, PA. F.A. Davis Co.
Does your supplement provide a nutrient overdose? New recommendations on vitamin A and other nutrients reveal how much is too much. Tufts University Health & Nutrition Letter, 2001 April, 19(2), 4-5. Retrieved July29, 2007. from Academic Search Premier. CINAHL Database. http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=2003098206&site=ehost-live
Nix, Stacy. (2004, October). Williams’ Basic Nutrition & Diet Therapy Twelth Edition. p.86-154. Salt Lake City, UT. Mosby
Smith, Ian K. (2000, April 24). Personal time: your health. Vitamin Overdose: New Government Recommendations for C and E suggest that maybe mother was right after all. Time.155 (16), 89-89. Retrieved July 29, 2007, from Academic Search Premier. CINAHL Database. http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=2000052763&site=ehost-live
Willett, W.C., Skerrett, P. (2004, January 19). A Simple Cure for Confusion. Newsweek, 143(3), 55-56, Retrieved July 29, 2007, from Academic Search Premier. CINAHL Database. http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=2004075007&site=ehost-live
Intervention 1: Patients should be informed that vitamins are like drugs, and can be harmful if taken in excess or with certain medications.
Disadvantage 1: Patients often take over-the-counter herbals believing there are no interactions because they do not see a warning on the label. In the article “Herbal Medicine” featured in Kansas Nurse in May 2007, Kathleen Wold, EdD, ANP, BC states, “In 1994 Congress passed the Dietary Supplement Health and Education act (DSHEA) to protect sonsumers. Products are allowed to make health claims such as ‘promotes immune systems health’ but they do not have to have proof of efficacy.” Contraindications with prescribed drugs are not required on the warning label for herbal supplements. This, erroneously, leads patients to believe that the herbal supplement they are taking will not have an interaction with the medication they are prescribed, and is the reasoning behind why patients do not relinquish this information to their healthcare professional. They believe that since they are buying it over-the-counter and there are no warnings for contraindications on the label, there is no reason to report this on their medication list.
Citation
Wold, K. “Herbal Medicine”. Kansas Nurse. May 2007. 82(5): 6-8 (28 ref). Retrieved Oct 31, 2007. Academic Search Premier. CINAHL Database. URL: www.cinahl.com/cgi- bin/refsvc?jid=230&accno=2009600319
Disadvantage 2: The popularity of herbal supplementation has risen. “There are many herbal products on the market that are heavily advertised and are popular with consumers (Wold, 2007, p. 6).” Due to the constant barrage of advertisements regarding the benefits of vitamin and herbal supplements, there is a rising number of patients that are trying to self prescribe. Patients are trying to be healthier and so in the efforts of doing something proactive for their own health, they are overlooking the possible pitfalls of medication interactions. Patients are often on several different supplements making their medications lists as long as 20 or more different types of oral supplements, making it very difficult for health providers to cross reference each and every supplement.
Wold, K. “Herbal Medicine”. Kansas Nurse. May 2007. 82(5): 6-8 (28 ref). Retrieved Oct 31, 2007. Academic Search Premier. CINAHL Database. URL: www.cinahl.com/cgi- bin/refsvc?jid=230&accno=2009600319
Intervention 2: They should be instructed to read labels carefully, and identify the need versus supplemental use.
Disadvantage 1: Even if the patients are reading the labels, vitamins and herbal supplements are not federally regulated. The information listed on the actual bottle may not reflect the actual amount that the tablet or capsule really contains. In the article “Multi-ple Failures”, featured in Environmental Nutrition in April 2007, “a study performed by ConsumerLab.com revealed “11 out of 21 multivitamins tested included significantly more or less of a nutrient than the label claimed, an inability of the multivitamin to disintegrate within 30 minutes which is the amount of time need for the adequate absorption by the body, and contamination with lead.” Without federal regulations and reliable standards, consumers can not trust the labels on the vitamins and herbal supplements they are purchasing. This makes it difficult for patients to make informed decisions regarding the vitamin and herbal supplements they are taking. Patients can do more research on websites that offer more detailed information about the safety & efficacy of nutrition supplementation at the following websites: Quackwatch www.quackwatch.com, National Institute of Health Office of Dietary Supplements http://dietary-supplements.info.nih.gov, Supplement Watch www.supplementwatch.com, and National Center for Complementary and Alternative Medicine http://nccam.nih.gov.
Citation
Multi-ple Failures, Environmental Nutrition. April 2007. 30(4): 3. Retrieved Oct 30, 2007. from Academic Search Premier. CINAHL Database. URL: www.cinahl.com/cgi- bin/refsvc?jid=2777&accno=2009609651
Disadvantage 2: In addition to the lack for federal regulation of dosage amounts on the labels of vitamin and herbal supplements, the FDA recommended daily intake values may be misleading. In the article “Multivitamin/mineral supplements: Needed insurance?” featured in Harvard Women’s Health Watch in January 2007, the writer states, “The FDA’s current recommended daily intake of vitamin A - 5,000 International Units (IU) - is probably overgenerous, and it doesn’t distinguish between the two forms of vitamin A, retinol (listed as vitamin A acetate or palmitate) and beta carotene.” Patients may not be aware that there are different forms or names that vitamins are identified as. This misconception can lead to megadosing on vitamins & herbal supplements that can become harmful or toxic. Patient safety is at risk.
Citation
Multivitamin/mineral supplements: Needed insurance? Harvard Women’s Health Watch. January 2007. 14(5): 6-7. Retrieved Oct 30, 2007. from Academic Search Premier. CINAHL

The Nurses Role in the Prevention of Childhood Obesity

2007-12-02T16:38:00.000-08:00

Obesity is the number one childhood and adolescent nutritional disease in the United States. Currently about 11% of children and adolescents are classified as being overweight with an additional 14% at risk for becoming overweight (Story et al., 2002).

The prevalence of childhood obesity has tripled in the last twenty years. Obesity in children can cause many physical and psychological problems that can be long lasting. Because childhood obesity is a growing problem in the United States and can have lasting effects throughout the child’s life, the nurse must play a key role in preventing childhood obesity by assessing parental perceptions about obesity, educating parents about their influence over their child in regards to proper nutrition and eating habits and teaching parents behavior modification techniques.
There are many ways to measure obesity. Body mass index (BMI) is the best measure of obesity for children ages two through twenty (Hodges, 2003). BMI compares height and weight to help measure fat. A BMI of 25-29 equals overweight and a BMI 30 or greater equals obese (Healy, 2006). Many health problems are linked with obesity, some include hypertension, type 2 diabetes, orthopedic problems, asthma, cardiovascular disease, low self esteem and depression. There are three main risk factors for obesity: prenatal, genetic and environmental. The parents play a key element in controlling and changing the home environment (Regber, Berg-Kelly & Marild, 2007). The nurse has an obligation to help change the environmental risk factors.
An important step in the treatment and prevention of childhood obesity is recognizing the problem. Pediatric nurses have the opportunity to assess children at least twelve times before the age of five (Drohan, 2002). This is the time for nurses to question and assess the parental perceptions of obesity. Studies have shown that some mothers believe that a bigger child is a healthy child and that a child’s size is predestined and therefore it does not matter how much a child eats (Drohan, 2002). Studies have also shown that some parents did not think their obese children were overweight (Hodges, 2003). A WIC study found that some parents believed that the higher their child was on the growth curve, the healthier the child was and in turn meant they were more competent parents (Hodges, 2003). Nurses play a key role in educating parents about what obesity is and how it relates to the growth curve. This education should start when the child is born. Nurses can educate parents at well-child visits, health fairs and parenting classes. “Parental recognition and acceptance that their child is over-weight is vital if interventions are to be initiated and successful.” (Hodges, 2003, para. 12).
While parental recognition and acceptance is the first step in the prevention and treatment of childhood obesity, educating parents about their influences over their child is the second step. Parents play a key role in the development of proper eating habits in their children and should be educated about proper nutrition and serving sizes. A toddler’s portion size should only be 1/8-1/2 the size of an adults and children should eat small, frequent meals (Horodynski & Stommel, 2005). Eating habits and food preferences are learned early in life; therefore children should be exposed to various healthy foods at a young age. Parents should be taught not to use food as punishment or reward as this can lead to negative feelings about particular foods (Drohan, 2002 & Hodges, 2003). Nurses can teach parents to present healthy, nutritious food in a positive way. Studies have found that when food is presented to children in a positive way, the preference for the food increased (Drohan, 2002). Parents must be taught to let their child self-regulate their food intake. This will allow children to become aware of their internal hunger cues. Nurses should remind the parents that the child may not be hungry at the same time as the parents are. Parents should be taught not force the child to eat and this includes making the child clean his/her plate.
Nurses should teach parents of obese children behavior modification techniques because these have been found to make the biggest difference in an obese child’s weight (Drohan, 2002). These techniques include self monitoring, social reinforcement, stimulus control and role modeling. Self monitoring involves keeping a journal of the place, time and quantity of foods eaten as well as noting exercise and physical activity. The next technique requires the nurse to teach parents social reinforcement techniques. Praise should be given to children as soon as a good behavior is noticed and the parents should be very specific in stating what the praise is for. Stimulus control involves confining eating to one specific area of the house such as the kitchen or dining room and not allowing eating in front of the television or other places where overeating and inactivity occur. Modeling involves being a good role model for the child. Parents should not do things in front of their children that they do not want their child to imitate. Nurses should stress that parents and children both play an important role in making the behavior modification techniques successful.
In conclusion, nurses can help change the environmental factors that lead to childhood obesity. The number of obese children is increasing daily. Because childhood obesity is a growing problem in the United States and can have lasting effects throughout the child’s life, the nurse must play a key role in preventing childhood obesity by assessing parental perceptions about obesity, educating parents about their influence over their child in regards to proper nutrition and eating habits and teaching parents behavior modification techniques. With these three interventions, nurses should be able to help put a stop to the growing number of obese children in the United States.

Intervention 1: Assess parental perceptions of obesity
Disadvantage 1: Medical insurance
Well child visits are an important time for educating parents and assessing children. Low-income uninsured children are less likely than low-income insured children to have a usual source of medical care or receive any well child care (Davidoff, Dubay, Kenney, Yemane, 2003). Having an uninsured parent and an insured child is a risk factor also. These low income insured children are less likely to receive any medical visits and are less likely to receive well child care than children of insured parents (Davidoff et al., 2003). Nurses are not able to assess parental perceptions of obesity if parents are not bringing their child in for medical visits. Even when parents and children do go to medical appointments, health care professionals have stated that they do not have enough time to counsel and educate the parents. Although the majority of health care professionals stated they had dieticians who could counsel the families, a lot of insurance would not cover a dietician (Larsen, Mandleco, Williams, Tiedman, 2006).

Disadvantage 2: Culture, ethnicity, socioeconomic status
As Forster-Scott (2007) states, “Different ethnic groups have varying ideas about the meaning of overweight and obesity that may be different from those of mainstream American culture or of medical and science practitioners in the country” (para 13). In some cultures, a girl with a thicker body is a sign of good eating and good health. Nurses should also be aware that people of different cultures may eat a different diet than the typical American diet. Suggestions about diet changes made by the nurse may not include foods these families typically eat and so the nurses teaching may be ineffective. Socioeconomic status is a risk factor of a child becoming obese also. A study done on low income mothers showed that these mothers believed that a bigger child is a healthier child (Drohan, 2002). Another study done by Supplemental Nutrition Program for Women, Infants and Children (WIC) showed that some low-income mothers believed that the higher their child was on the growth curve, the healthier their child was (Hodges, 2003). Children from low income families are at a greater risk of becoming obese than children from higher income families. This is due in part to not having access to healthy food choices (Larsen et al., 2006). Food selection is often based on what is available in the grocery store and what the parents can afford. Healthy foods are usually more expensive and may not be as available in grocery stores in low-income neighborhoods (Forster-Scott, 2007).

Intervention 2: Educating parents of obese children behavior modification techniques.
Disadvantage 1: Lack of parental time.
“For young children, parental involvement in obesity treatment is inevitable and necessary” (Drohan, 2002, para 34). Studies have shown that families with two working parents were often too busy to prepare healthy meals and would turn to fast food instead (Larsen et al., 2006). Children from single-parent families are at even a greater risk than children from two working parent families. These children were found to eat more high fat foods and drink more soda and sweetened fruit drinks (Bowman, Harris, 2003). It is difficult for parents to teach behavior modification when they are not around to witness the type and amount of food their child is eating. Families are spending less time eating together and children are often fed by someone other than their parents (Savage, Fisher, Birch, 2007).
Disadvantage 2: Care provider education
Care providers may not feel they have the proper education to teach parents of obese children behavior modification techniques. Studies have shown that there are few opportunities to learn the most current assessments, counseling strategies and behavioral management techniques (Story et al., 2002). Story states “these topics are seldom covered in medical, nursing or dietetic school curricula, and postgraduate training opportunities are limited” (para 23). Caregivers need to develop greater skills in behavioral management strategies and parenting techniques, so they can support parents of obese children more effectively (Regber, Berg-Kelly, Marild, 2007).

References

Bowman, S.A. & Harris, E.W. (2003). Food security, dietary choices and television-viewing status of preschool aged children living in single-parent or two parent households. Family Economics and Nutrition Review, 15 (2), 29-. Retrieved October 28, 2007 from http://proquest.umi.com

Davidoff, A., Dubay, L., Kenney, G., Yemane, A. (2003). The effect of parents’ insurance coverage on access to care for low-income children. Inquiry – Excellus Health Plan, 40 (3), 254-. Retrieved October, 28, 2007 from http://proquest.umi.com

Drohan, S. H. (2002). Managing early childhood obesity in the primary care setting: A behavior modification approach. Pediatric Nursing, 20 (6). Retrieved January 21, 2007 from http://www.medscape.com/viewarticle/448019_2

Forster-Scott, L., (2007). Sociological factors affecting childhood obesity. Journal of Physical Education, Recreation & Dance, 78 (8), 29-. Retrieved October 28, 2007 from http://proquest.umi.com

Healy, B. (2006). Obesity gets an early start. US News and World Report, 141 (8), 79. Retrieved January 7, 2007 from Expanded Academic ASAP database (A150374028).

Hodges, E.A. (2003). A primer on early childhood obesity and parental influence. Pediatric Nursing, 29 (1), 13-16. Retrieved October 28, 2006 from http://www.medscape.com/viewarticle/448019_3

Horodynski, M.A., & Stommel, M. (2005). Nutrition education aimed at toddlers: An intervention study. Pediatric Nursing, 31 (5), 364-. Retrieved October 20, 2006 from Expanded Academic ASAP database (A137860102).

Larsen, L., Mandleco, B., Williams, M. & Tiedeman, M. (2006). Childhood obesity: Prevention practices of nurse practitioners. Journal of American Academy of Nurse Practitioners, 18. Retrieved October 27, 2007 from Academic Search Premier

Regber, S., Berg-Kelly, K., & Marild, S. (2007). Parenting styles and treatment of adolescents with obesity. Pediatric Nursing, 33 (1), 21-. Retrieved April 18, 2007 from Expanded Academic ASAP database (A160925920).

Savage, J.S., Fisher, J.O., & Birch, L.L. (2007). Parental influence on eating behavior: Conception to Adolescence. The Journal of Law, Medicine & Ethics, 35 (1), 22-. Retrieved October 27, 2007 from http://proquest.umi.com.

Story, M.T., Neumark-Stzainer, D.R., Sherwood, N.E., Holt, K., Sofka, D., Trowbridge, F.L., et al. (2002). Management of child and adolescent obesity: Attitudes, barriers, skills, and training needs among health care professionals. Pediatrics, 110 (1), 210-. Retrieved January 7, 2007 from Expanded Academic ASAP database (A89576246).

Post Traumatic Stress Disorder

2007-12-02T15:59:00.000-08:00

The art of nursing originated with the infamous Florence Nightingale. The services provided by her and her colleagues were on the most basic level of human care-giving to the fallen men during the Crimean War of 1853-1856.

The nursing profession has developed immensely into a vast encompassing role during war time; but the sights, sounds, and smells have changed little. The experience nurses endure during war can cause long-term psychological problems no matter what day and age we are in. Post Traumatic Stress Disorder (PTSD) is a psychiatric disorder that can occur after experiencing or witnessing a life-threatening or overwhelming traumatic event such as military combat (Antai-Otong, 2007). A more specific statistic from the National Center for PTSD reveals 15.2% of Vietnam veterans and 30% of men and women in more recent war zones are likely to develop PTSD (Antai-Otong, 2007). Nurses may have developed PTSD following their war experience due to the lack of preparation for the perils they were faced with, clinical inexperience, and sleep deprivation.
Due to the sheer volume and severity of casualties during war, it is no wonder why many nurses developed psychological issues post war time. As in the Vietnam War, one soldier after another starved for medical attention. The nurse would have to mentally formulate in a matter of seconds who needed what and who is worth expending the limited amount of energy and supplies on with life saving interventions. There was a huge amount of guilt felt by the nurses when soldiers were put in the “expectant” category; expecting to die (Wynd, 2006). These patients were in need of emotional support while they lay to die, and even that was hard to accomplish due to time constraints and lack of nursing staff. In addition, there were only a few medical facilities all injured soldiers were sent to with minimal medical staff on duty. This caused less than desirable patient to nurse ratios. The casualties seen were also nothing short of horrific and the training provided to the nurses did not prepare them for what they would see out in the field.
During the enlistment phase of the Vietnam War, the majority of nurses were sent over straight out of nursing school. The minimum age requirements were 21, but some later reported being younger. The amount of clinical experience had by these nurses included their education at a three-year diploma school and basic training through the military. With this inexperience and immaturity came stress during the high volume and extent of casualties seen. Many nurses describe completing highly technical procedures and interventions without having the training necessary. One such nurse tells of opening a wound herself and clamping off a vessel which was bleeding out (Sorrin, 2006).
Compounding the lack of preparation and experience, nurses were deprived of sleep. Many nurses reported not being able to fall asleep, even if lucky enough to have the opportunity to do so in the first place. To fall asleep you have to be relaxed and in a state of comfort, both of which are lacking during war. One nurse recalls lying down in a dark room after a long period of work and having no room in her head to fall asleep; there was too much going on within her mind that she was unable to relax and fall asleep (Freedman and Rhoads, 1987). In addition, with the numerous amount of admits from the field there was little time to sleep. There are many accounts of working at full patient capacity with 12 hour work days, 6 days per week (Sorrin, 2006). That said, it is easy to see the discrepancy and impact the lack of sleep can have on nurses when it is estimated that 90% of people require 8 hours of sleep per 24 hours (Blachowicz & MariJo, 2006).
Many tools have been integrated by the Department of Defense since the Vietnam War in regards to PTSD. This includes virtual reality software and self assessments of mental status available with on-site computers and health reassessments completed after a tour is completed. This is for the family as well as the veteran (Brewin, 2007). Incorporated in military nurses training are regular drills, emergency response teaching, triage protocols, and having communication “roles and channels” in place (Wynd, 2006).
Treatment of PTSD may include cognitive behavior therapy, group therapy, eye movement desensitization and reprocessing, psychodynamic psychotherapy, and pharmacological management with Selective Serotonin Reuptake Inhibitors (Unknown, 2007).
In summary, PTSD can be caused by any stressful stimuli, specifically the jeopardy of war time. The dearth of mental, emotional, and physical preparation of war, clinical inexperience, and sleep deprivation all have negative compounding effects to a state of well being. This disorder may be relieved with more intense, war-like training before going to the battle field; longer clinical exposure with a preceptor period prior to deployment; and lastly, better nurse to patient ratios to help with the hectic environment (Scannell-Desch, 2005).

Works Cited
Antai-Otong, Deborah (2007).Pharmacologic Management of Posttraumatic Stress Disorder. Perspectives in Psychiatric Care. 43, 55. Retrieved July 5, 2007, from Research Library database. (Document ID: 1218669951).
Blachowicz, Ewa, & Letizia, M. (2006). The Challenges of Shift Work. Retrieved August 6, 2007, from MEDSURG Nursing. 15, 275.
Brewin, B. (2007).PTSD and Me. Federal Computer Week. 21, 26. Retrieved July 5, 2007 from Proquest. http://proquest.umi.com/pqdweb?did=1258999171&sid=2&Fmt=3&clientid=3236&RQT=309&VName=PQD
Freedman, D., & Rhoads, J. (1987). Nurses in Vietnam: The Forgotten Veterans.Austin: Texas Monthly Press, Inc..
Scannell-Desch, E. A. (2005).Lessons learned and advise from Vietnam war nurses: A qualitative study. Journal of Advanced Nursing. 49, 600-607. Retrieved July 5, 2007 from Academic Search Premier, CINAHL. http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=2005081089&site=ehost-live
Sorrin, L. (2006). Military Nurses in Vietnam. Retrieved August 6, 2007, from All about Military Nurses in Vietnam Web site: http://www.illyria.com/vnwnurse.html
Unknown, (2007). National Center for Posttraumatic Stress Disorder. Retrieved August 6, 2007, from Treatment of PTSD Web site: http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_treatmentforptsd.html
Wynd, C. A. (2006, September 30). A Proposed Model for Military Disaster Nursing. OJIN: The Online Journal of Issues in Nursing, 11, Retrieved August 6, 2007, from http://www.nursingworld.org/ojin/topic31/tpc31_4.htm

Intervention 1: PTSD relieved with more intense, war-like training before going to the battle field.
Disadvantage 1: Depending on the level of training and experience each nurse had prior to their military training and combat-seen time makes a difference in how they may see a given situation and how they will manage it psychologically. One study, relating nurses with an undergraduate degree (RN1) with nurses holding the same degree but with an added 6-12 month full-time study within a specialized area (RN2) revealed several differences with the learning approach taken by each group. For example, RN1s placed more emphases on the training facilities used and the real-life scenarios involved than did the RN2s. For example, RN2 nurses desired relevant symptoms they may come across and RN1 nurses needed more concrete holistic scenarios. (A Comparison of Experiences of Training Emergency Care in Military Exercises and Competences among Conscript Nurses with Different Levels of Education, 2007) This can be explained with the fact that experienced nurses draw upon their previous clinical experience and intuition to create a plan of care in a split second. This can help minimize PTSD by simply taking that added stress off decision making at the most basic level of nursing care to wounded soldiers. However, this would also mean that different military training curriculum would have to be created for these two types of nurses to get what each needed for war time. (A Comparison of Experiences of Training Emergency Care in Military Exercises and Competences among Conscript Nurses with Different Levels of Education, 2007)
Disadvantage 2: Another disadvantage or barrier of providing war-like training during many wars in the past was simply not having the time to do so. At the beginning of WWII, medical military personnel were below desired levels and thus a draft was initiated. This was done for the majority of civilian medical personnel though, which meant these individuals were trained for combat situations in an accelerated timeframe. It was noted that approximately two-thirds of all American physicians under the age of 45, that were also physically fit, were enlisted in the armed forces by 1943 (Unknown). So not only were these individuals trained in a short amount of time, but they were also trained in war theory of which they had never experienced.

Intervention 2: PTSD relieved with better nurse to patient ratios to help with the hectic environment.
Disadvantage 1: Although in theory this would be the most desirable situation, there is a slim chance it would physically work. When you look at the numbers of armed forces during the Vietnam War it becomes quite evident that the odds are stacked against the nursing personnel. There were over 250,000 US military personnel wounded and 58,132 military men and women killed. These numbers far outweighed the approximate 7500 US military nurses. This number included Navy nurses on two hospital ships, Air Force flight nurses involved in the evacuation of wounded soldiers, and Army, Navy, and Air Force nurses located at hospitals. (Scannell-Desch, 2004) More nurses would need to be recruited in order to fulfill this intervention, which would lead to more needed military nurse training, and thus more time. Again, if this was something that was initiated prior to an anticipated war, it could possibly work. Assuming, however, that civilian nurses would want to transition into military nurses of course.
Disadvantage 2: Although the nurse-to-patient ratio is an important aspect in order to conduct safe nursing care out on the battle field, there is also the factor of the inability to predict how an individual will react to real war scenarios. Directly before WWII, pre-induction tests were administered to attempt to eliminate psychologically unfit military personnel and thus remove most possibilities of PTSD in the future. These tests could pick out the most frank of behavioral disorders, but it was in no way a perfect solution. (Unknown). Everyone, without a doubt, will have a different reaction to stressful situations and this will only be evident in those stressful combat situations themselves. This involves the unknown reaction a highly experienced civilian nurse may experience as well as a recently graduated nurse.

Works Cited

A Comparison of Experiences of Training Emergency Care in Military Exercises and Competences among Conscript Nurses with Different Levels of Education. (2007, October). Military Medicine .
Scannell-Desch, S. (2004, April). Lessons learned and advice from Vietnam war nurses: a qualitative study. Journal of Advanced Nursing , 600.
Unknown. (n.d.). Military Medicine During The Twentieth Century. Retrieved October 25, 2007, from http://www.au.af.mil/au/awc/awcgate/milmedhist/chapter3.htm

Addressing the End-of-Life Spiritual Care

2007-12-02T12:01:00.000-08:00

The spiritual aspect of nursing care is neglected at the present time in the health care field. The focus seems to be more on the physical aspect of client care since hospitals and other facilities work on the systematic healing of the body.

Therefore, it is important to understand that studying the mind or the body alone in terms of health and illness is not enough but nurses should also recognize the spirit in order to fully understand the patient in context. Because of the lack of recognition of end-of-life spiritual care in the domain of nursing, nurses should acknowledge immediate innovative solutions such as exploring patient’s expectations of spiritual care by concrete definitions, working on improvement of the end-of-life process through a well-orchestrated system and lastly, providing resources for the development of spirituality of the future nurses along with end-of-life-focused nursing programs in order to maintain fair and appropriate standards of patient care.

Why is the spiritual dimension of holistic nursing being ignored in the plan of care despite the potential impact of nursing on spiritual health? Spirituality differs from Religion. The article by Lantz, (2007) includes the explanation of Amenta (1986) that defines spirituality as “the part of each individual which longs for ultimate awareness, meaning, value, purpose, beauty, dignity, relatedness and integrity” (para. 5) meanwhile “religion refers to the organized belief systems, and works of human beings” (para. 6). According to Lovanio and Wallace (2007), “Whether a person practices a particular religion or chooses to explore spirituality privately, the exploration of meaning in life is common to the human race” (para.4). In connection, it is essential that nurses integrate these concepts to achieve realistic outcome of patient’s maturity of the therapeutic healing of their bodies as well as their spirits.

One way a nurse can incorporate the spiritual aspect of care is by defining high-quality end-of-life spiritual care through exploration of patient’s expectations. Care is very individualized in all clients of health care and each one of them has their own values and beliefs on how they perceive it. One patient might define spiritual care as religious affiliation, practices and rituals like prayer and nurses could refer them to a chaplain or a minister. Another patient would define it as a feeling of comfort and connection after developing a trusting relationship wherein the nurse supports and facilitates things that give meaning to their lives. Good nursing care is not only competence and efficiency but also productive time and presence when addressing patient’s concerns. According to the study conducted by Davis (2005), “One of the most compelling conclusions reached with regard to spiritual care, based on the responses of study participants, is that existential spiritual care is the hallmark of good nursing care” (para. 52). Davis (2005) also reports that realizing appreciation of spiritual concern received by the patient develops the awareness of divine interventions presented by the nurses (para. 3). Through these responsible health care providers, spiritual needs are met and maintained.

While end-of-life spiritual care is recognized, another key strategy must be addressed by working on improvement of the end-of-life process through a well-orchestrated system of nursing care. According to Virani and Sofer (2003), “A peaceful death doesn’t depend entirely on one person. The way a person’s final days will be spent depends on the patient, the family, the physicians, the nurses, the policies of the hospital or hospice, and the insurance providers” (para. 11). All of these support groups have a specific responsibility of care with a particular dying patient. They work hand in hand together in satisfying the needs and filling all the gaps that the person may leave on his/her life at the present time. Virani and Sofer (2003) also emphasize that having advanced stages of end-of-life process from community to the nurses, themselves is a great addition to the overall patient well being (para. 12). In view of that, nurses cannot revoke death, but they can make dying more peaceful for patients and families.

As a result of improvement, another critical strategy is identified which is providing resources in the development of spirituality of the future nurses along with end-of-life-focused nursing programs in order to maintain fair and appropriate standards of health care. The article by Mitchell, Bennett & Manfrin-Ledet, (2006) includes the research of Meyer, (2003) that reports “emphasis on spirituality in the nursing program as rated by students and faculty served as the most environmental predictors of the student’s perceived ability to provide spiritual care” (para. 8). One great example of the tools that faculty introduced to the students is the use of spiritual concept in care mapping and identification of spiritual nursing diagnosis. Another study by Lovanio and Wallace (2007), point out that “the purpose of this project was to develop and test a spirituality-focused nursing student education project designed to enhance the knowledge and understanding of spiritual care among nursing students” ( para. 1). Some of the other concrete examples include assessment of patient’s spiritual needs and nursing interventions, such as prayer, music and devotional reading. These are only few of the awareness programs for future nurses that give way to an innovative learning experience in their chosen career.

Spiritual care is not acknowledged in the world of the nursing care plan. “The Nursing Interventions Classifications (NIC) standardize nursing behaviors that address the mental, physical, and spiritual needs of patients; however, nurses seem uncertain what constitutes spiritual care and report that they rarely provide spiritual care” (Davis, 2005, para. 2). There is limited literature and information on promoting spirituality in health care. For this reason, nurses should recognize abrupt ground-breaking solutions such as exploring patient’s expectations of spiritual care, working on improvement of the end-of-life process through a system and lastly, providing resources for the development of spirituality of the future nurses along with end-of-life-focused programs in order to maintain reasonable and suitable principles of patient situation. To sum up, Lovanio and Wallace (2007) stated that “the role of nursing as caring assumes the spiritual dimension of being and is thus, a priority for nursing care” (para. 2) which is a strong fact.

References

Davis, L. A. (2005). A phenomenological study of patient expectations concerning nursing care. Holistic Nursing Practice, 19, 126-. Retrieved April 13, 2007, from Expanded Academic Index ASAP database.

Lantz, C.M. (2007). Teaching spiritual care in a public institution: legal implications, standards of practice, and ethical obligations. Journal of Nursing Education, 46, (1) 33-. Retrieved April 17, 2007, from ProQuest database.

Lovanio, K., & Wallace, M. (2007). Promoting spiritual knowledge and attitudes: a student nurse education project. Holistic Nursing Practice, 21, 42-. Retrieved April 17, 2007, from Expanded Academic Index ASAP database.

Mitchell, D.L., Bennett, M.J. & Manfrin-Ledet, L. (2006). Spiritual development of nursing students: Developing competence to provide spiritual care to patients at the end of life. Journal of Nursing Education, 45, (9) 365-. Retrieved April 13, 2007, from ProQuest database.

Virani, R., & Sofer, D. (2003). Improving the quality of end-of-life care. American Journal of
Nursing, 103, (5) 52-60. Retrieved January 18, 2007, from http://www.nursingcenter.com/JournalArticle.asp?Article_ID=411323.

a. Intervention 1 (Defining high-quality end-of-life spiritual care through exploration of patient’s expectations)

i. Disadvantage 1 (Knowledge Deficit)

End-of-Life spiritual care is very individualized in all patients of the
healing community and everyone of them has their own values and beliefs on how they see it. According to the study conducted by McEwan (2004), “Because spirituality is vast in its entirely, it necessitates a discussion only of those areas that can affect the daily life of patients and those who care for them” (para. 2). Not everybody know the importance of spiritual care once they are in a health care facility, it is because it is not even a part of a routine care plan. McEwan (2004) also emphasizes that “from the literature, there are many highly negative reports of how nurses fail to provide spiritual care for their patients, and noting the comments on what is spirituality, it is possible to perceive why this may be so” (para. 8). Having knowledge about the conceptual interpretation of spirituality and the use of care plans for the promotion of health may enable health care providers to modify treatment approaches to better meet the client needs.

ii. Disadvantage 2 (Religion)

Religion is one of the respected sections in every health history
interview. It is important to value this belief because every person has their own culture and traditions. Therefore, being ignorant of this faith will not improve the meeting of patient’s expectations and defining end-of-life spiritual care. McEwan (2004) stresses out that “religious tolerance and awareness is only part of the spirituality equation, because the enlightened literature tells us that the essence of the “God and religion” discussion is having the faith to find purpose in life and not necessarily having a religion” (para. 19). Mohr (2006) also argues that “Few systematic studies have shown that religious involvement and spirituality are associated with negative physical and mental health outcomes. Like any other lifestyle choice, religion can have adverse consequences” (para. 18). Exploration of patient’s expectations will not be complete then until religion is recognized.

b. Intervention 2 (Working on improvement of the end-of-life process through a well-orchestrated system of nursing care)

i. Disadvantage 1 (Socioeconomic status)

Support groups and community resources have a purpose and specific
responsibility to a particular dying patient. Howarth (2007) reports that “In the eyes of death, we are all attractive: rich and poor, black and white, male and female, young and old. While this is true, it is only part of the story, for death is also a social event and how we understand and experience it depends on the social environment in which we live” (para. 6). The author also accentuates that “social class status will affect the nature and timing of death” (para. 7). End-of-life story is a long course of ups and downs with issues involving politics, social life and financial ability. In the article of Hardwig (2007), he mentions that “health care costs are rising much faster than GDP in almost all developed nations. Even countries that have prided themselves on an efficient, one tier health system are finding their systems unsustainable” (para. 25). It is thus known that a well-orchestrated system will not work unless the acknowledgment of these provisions.

ii. Disadvantage 2 (Discrimination)

A bias result through differences of every client in health care and
nurses, sometimes fails to understand the whole representation. They tend to side with what their own spiritual practices would be and specifically with the same people. According to the multidisciplinary review conducted by Easom (2006), White Americans viewed health promotion practices that include activities related to religious beliefs, such as church attendance and being “spiritually moved”, African American perceive spirituality differently than White Americans because studies support the adults in this race participate in spiritual activities to a high degree, lastly, Hispanics studies reflect a high degree of participation in spiritual activities for health promotion of their population as well (para. 17). It is then professed that discrimination between the races may be a hindrance in working on improvement of the end-of-life process through a series of systems in health care.

References

Easom, L.R. (2006). Prayer: folk home remedy vs. spiritual practice. Journal of Cultural Diversity, 13, (3) 146-. Retrieved October 4, 2007, from ProQuest database.

Hardwig, J. (2007). Ending life: ethics and the way we die. Social Theory and Practice, 33, (3) 501-. Retrieved October 4, 2007, from ProQuest database.

Howarth, G. (2007). Th social context of death in old age. Working With Older People, 11, (3) 17-. Retrieved October 4, 2007, from ProQuest database.

McEwan, W. (2004). Spirituality in nursing: what are the issues? Orthopaedic Nursing, 23, (5) 321-. Retrieved October 4, 2007, from ProQuest database.

Mohr, W.K. (2006). Spiritual issues in psychiatric care. Perspectives in Psychiatric Care, 42, (3) 174-. Retrieved October 25, 2007, from ProQuest database.

Heart Failure and Patient Education

2007-12-01T22:34:00.000-08:00

At the age of 36, I was diagnosed with hypertension, hyperlipedemia and weighed 280 lbs. I was started on Norvasc for hypertension and Lipitor for hyperlipidemia. Like a good patient, I took my medications religiously, and did all of the things that my doctor told me to. At the age of 37, I entered the emergency room with chest pain radiating down my left arm. The crushing pressure on my chest made every breath a fight to survive. Statistically five million people over the age of 65 are admitted to the hospital due to poor management of their heart failure. Every year, about 500,000 new cases of heart failure are diagnosed. This number is expected to increase as the age of the American population increases (Rodgers, 2002). When we’re younger, we think we’re invincible. The reality is that every choice we make in life has a consequence. Good or bad, it’s a consequence that we will face some day. Although heart failure may show after the age of 65, the cause can be traced back to the choices we make when we’re younger. By applying some of nursing’s fundamental tasks, such as a basic knowledge base and patient teaching, patients learn that through consistent life style changes they can decrease the frequency of congestive heart failure (CHF) exacerbations, improving their quality of life. These changes include medication management, diet, exercise, and weight management.
Congestive Heart Failure Defined
Nurses are charged with acquiring a basic knowledge base for providing patient teaching. Before we can appreciate the effect that CHF has on the heart, it’s important to understand the normal function of the heart. Over the years, I have learned that in a healthy heart, blood enters through the right side of the heart, passing through the ventricles and into the lungs exchanging carbon dioxide for oxygen. Blood returns from the lungs to the left ventricle exiting the left side of the heart providing nutrients to the body. The heart operates through a fine balance of timing, fluid volume, blood pressure, and muscle elasticity and contraction. Compromised function to any one of these areas will not cause heart failure. However, if one area is compromised the other areas are taxed in an attempt to compensate for the area failing. According to J.M. Black, this persistent strain can cause a chain reaction resulting in the heart becoming an ineffective pump. With left sided CHF, the left ventricle is unable to push blood out to the body resulting in blood back flowing into the lungs. This causes congestion of the lungs and is referred to as systolic failure. If the patient has diastolic failure, the right ventricle is unable process blood returning from the extremities resulting in peripheral edema (Black, 2000). Damage to heart muscle, which leads to heart failure (HF), can occur from a myocardial infarction (MI), viral or bacterial infection, valvular disease, hypertension, or coronary artery disease (Rosenthal, 2004). Now that the cornerstone has been laid, the next step in the education process is a basic knowledge base on medication.

Medication Management
Medication is paramount to the treatment of any cardiac disorder. The primary goal of medication management is to reduce the overall workload on the heart while maintaining or even improving the hearts current level of function. This is accomplished through two avenues, symptom relief and improved cardiac function. Symptom relief is obtained through diuretic therapy resulting in reduced fluid volume. With left sided failure, reduced fluid volume results in improved gas exchange and improved ejection of blood to the body. With right side failure, a reduction in the fluid volume can reduce peripheral edema. According to Cayley, management of CHF symptoms through diuresis promotes improved gas exchange and tissue perfusion. Compared with other active medications, diuretics can improve exercise capacity in patients with heart failure by about 30 percent. Withdrawal of diuretic therapy from patients with heart failure may increase the risk of hospital readmission or death. About eight deaths are prevented for every 100 patients treated (Cayley, 2006). Cox points out, improved cardiac function can be obtained through the proper application of angiotensin converting enzyme (ACE) inhibitors, beta blockers, or aldosterone blockers. ACE inhibitors maintain circulating fluid in the body through vasoconstriction. Beta blockers influence the sympathetic nervous system through management of the bodies fight or flight response resulting in decreased fluid volume. Aldosterone blockers ultimately reduce the amount of sodium in the blood reducing fluid overload. Coordination between diuretic therapy and medications that directly impact cardiac function are the best option for effective sustained congestive heart failure management (Cox, 2007). Once the actions of medications are understood, the ability to provide safe and adequate patient teaching is underway
Diet Management
The first focus of the heart failure diet is to teach the client to manage their sodium intake (Rodgers, 2002). Education must be practical and safe. With today’s increased awareness of heart disease, an abundance of alternatives have been made available. With this abundance, education is more vital than ever. Caution must be taken when dietary education is provided. Replacing salt with salt substitutes can simply replace sodium with potassium resulting in heart failure exacerbations. Teaching the patient how to read food labels aides the patient in not only making safe decisions but places control of their diet within reach, ensuring the continuation of safe decisions. Involving a dietician can assist with dietary management through guidance surrounding: safe seasoning alternatives, food preparation, and appropriate food choices. This involvement only seeks to strengthen decisions by providing favorable alternatives. Patient education is vital in achieving decreased cardiac stress and improved CHF management.
Exercise
Patient education must contain a well balanced exercise program if positive outcomes are to be attained. According to Rodgers, exercises, such as walking, improve peripheral circulation resulting in improvement of tissue perfusion. Studies show that bed rest and limited activity are detrimental. Patients with stable heart failure should be encouraged to do regular light aerobic exercise or participate in a formal cardiac rehabilitation program (Rodgers, 2002). The New York Heart Association has broken heart failure down into four classifications. “Class I—No limitation of physical activity. Ordinary activity doesn’t cause undue fatigue, dyspnea, palpitation, or anginal pain. Class Il—Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in heart failure symptoms, including fatigue, dyspnea, palpitation, or anginal pain. Class Ill —Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes heart failure symptoms. Class IV—Severe limitation. Symptoms of heart failure (including anginal pain) are present at rest. If any physical activity is undertaken, discomfort is increased (Bosen 2003). To maintain continued and progressive exercise, it is vital to remember exercise requires balance. Self awareness of breathing patterns, energy levels, heart rates, and faintness can help control how much or how little exercise can be safely performed. For a severe heart failure client, passive range of motion may be required in the beginning. Other clients may require assistance walking a few feet while still others may be able to do more. Moderate exercise (i.e., at 60 percent of maximum exercise capacity) improves quality of life, decreases mortality, and decreases hospital readmissions for heart failure in patients with stable chronic heart failure (McConaghy, Smith, 2004). Without proper patient education, the patient is placed at risk of cardiac failure. Balance between cardiac taxing and cardiac limits
Weight Management
According to Mair, the primary focus of weight management centers on fluid retention. A weight gain of 1.35 to 2.25 kg (3 to 5 lb) can be an early indicator of deterioration which may require intervention. Because fluid and weight management go hand in hand, all patients with heart failure should obtain a bathroom scale and monitor their weight each morning. Tracking daily weights provides visual reinforcement, increased awareness, and promotes responsibility of cardiac management. Increased patient awareness of early indicators of deterioration can reduce hospitalizations (Mair, 1996). As medication, diet, and exercise are coordinated through the application of the lessons learned, a level of weight management is achieved. This chain reaction results in the heart being able to increase it’s output reducing the progression of the disease process.
Barriers
In a perfect world, patients take heed to the warnings and follow the advice presented before them. Well, we live in the realm of reality. Although there are many different barriers to consider with many different approaches to each barrier, there are four different barriers that if properly addressed can help with your goal of patient teaching. These barriers are knowledge, religion, socioeconomics, and inadequate insurance.
Knowledge
The Nursing Code of Conduct Provision Seven states: the nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development (ANA, 2007). Failure to possess a competent understanding of the heart and its function places patients at risk of injury or even death. This knowledge deficit can be influenced by many things that we may not even recognize. Arrogance or compliance with one’s current level of knowledge, home interference or even work ethics can silently push our responsibility as a nurse to the back. By general definition, negligence is the failure to do something (omission] which a reasonable person, guided by considerations which ordinarily regulate human affairs, would do or it is the doing of something (commission) under those same considerations which a reasonable person would not do (Collins, 2007). Whether the nurse omits a treatment or the knowledge base required to provide safe care to a patient, nurses are responsible for their actions and how we face these responsibilities define us.
Religion
So, where does the patient’s religion fall into this equation? As our world grows smaller and more cultures are brought closer, how does the nurse overcome barriers to provide the education that is required? A short example from Beth L. Rodgers puts it plainly. “A smart and eager university professor comes to an old Zen master for teachings. The Zen master offers him tea and upon the man’s acceptance he pours the tea into the cup until it overflows. As the professor politely expresses his dismay at the overflowing cup, the Zen master keeps on pouring: ‘A mind that is already full cannot take in anything new’, the master explains. ‘Like the cup, you are full of opinions and preconceptions’. In order to find happiness, he teaches his disciple, he must first empty his cup (Rodgers, 2002). To provide competent care, nurses must remove any prejudice or preconceived ideas. Our chosen task is to care for people and to do that, it is vital to meet patient’s where they are. Failure to do this only serves to build walls and barriers.
Socioeconomics
Poor compliance with medication is a key reason people with HF fail at their disease management. Many times, this is due to incomplete patient teaching. Often, we fail to consider the patient’s socioeconomic status. Many HF patients are primarily older and do not have the resources necessary to manage their disease process effectively. For some people it truly is a choice between food, heat for a loved one or themselves, or the medication that the doctor has prescribed. Thus, even persons with coverage, particularly sicker persons with greater need for medications, may face substantial financial barriers to obtaining essential medications (Saver, 2004). Alternatives approaches are available. Generic forms of medications, contacting a pharmacist to find alternatives for the patients to present to their physician, or government grants provided to contractors specifically for finding alternatives for patients who are defined as needy are just a few. Failure to assist the patient with maneuvering through these obstacles sets up the patient for failure.
Inadequate Insurance
Many times, it is assumed that because patients have insurance they can afford the services that are being provided or required. As a nurse, it is part of our responsibility to discuss these issues with our patients. Patients have a knowledge deficit of the continuum of health care. Being mindful of a patient’s insurance gives insight into the limitations faced by the patient. Most patients have limited resources and many services require copays. Understanding their limitations allows the nurse to facilitate the resolution of needs in a time frame preventing the development of barriers with lasting consequences.
Conclusion
Management of CHF requires effort, continuity, and determination. Lifestyle changes through medication management, diet, exercise, and weight management can decrease CHF exacerbations. This change requires the nurse to be educated knowledgeable and able to instill this knowledge to the patient. In a study performed by the Ahmanson University of California at Los Angeles Cardiomyopathy Center, 214 patients discharged with severe CHF were examined. They were treated aggressively with ACE inhibitors and diuretics, and advised to change diet and exercise habits. In six months, hospital readmissions dropped 85% among these patients (Southwick, 1998). This study and studies like it support not only how fragile the action of the heart is, but also how through simple changes, we can manage the consequences of those choices we made when we were younger. Changes that when pursued can improve not only the quantity of life but the quality of life. These changes made possible through a knowledge base and the ability to articulate that knowledge to a patient in a competent approach. Basic physiologic education is the cornerstone of patient care. Without it, the nurse lacks the understanding of the physiological changes throughout the disease process. This knowledge base allows the nurse to guide patients down the path of wellness and disease management. As the nurse develops a deeper knowledge of the physiological process, the information is passed on providing the patient the potential for optimal cardiac output.

Bibliography

Black, J.M., Hawks, J.H., (2005). Medical surgical nursing, (7th ed.). St Louis, Elsevier
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drugs: benefits, wealth, and health. Value in Health, 7, 134. Retrieved Oct 28, 2007, from
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Breastfeeding Education & Disadvantages to Interventions

2007-12-01T22:21:00.000-08:00

Overwhelming evidence shows that breastfeeding has profound effects on a baby’s immune system, overall development and intelligence however “Baby Friendly Hospitals” with trained maternal nurses and educated parents are two important factors that contribute to a successful breastfeeding experience.
Breastfeeding dates back to ancient civilizations and review of anthropological literature estimates an average nursing duration of 3-7 years in some cultures such as Eskimos and Africans. Scientific evidence is well established, breastfeeding offers overwhelming benefits for mothers and babies. La Leche League International (2006) notes that "Breastfeeding has been shown to be protective against many illnesses, including painful ear infections, upper and lower respiratory ailments, allergies, intestinal disorders, colds, viruses, staph, strep and e coli infections, diabetes, juvenile rheumatoid arthritis, many childhood cancers, meningitis, pneumonia, urinary tract infections, salmonella, Sudden Infant Death Syndrome(SIDS) as well as lifetime protection from Crohn's Disease, ulcerative colitis, some lymphomas, insulin dependent diabetes, and for girls, breast and ovarian cancer. (p. 1)
A mother’s decision to breastfeed is influenced by a variety of social and cultural factors such as education, finances, religion, family values and personal preference just to name a few. Feeg (2001) identifies that "Economic and cultural reasons contribute to a mother’s decision not breastfeed and states that many ethnic minorities are of low socio-economic status. It is important to note that many ethnic minorities more often choose to bottle-feed than to breastfeed. While this is partly caused by their busy lives, it also can be due to cultural beliefs, particularly among immigrants from developing countries. In many developing countries, the ability to bottle-feed is a financial status symbol because it is so expensive. In Mali, for example, a can of formula can cost the equivalent of $2 while the average individual earns only $200 a year. Their idea of it as a status symbol is sometimes carried over to their lives in the US." (p. 5)
While it is important for health professionals to respect a mother’s choice, they also have the responsibility to encourage and properly educate parents on the importance and benefits of breastfeeding. Education is the one variable that healthcare professionals can deliver to the diverse population that may influence their decision to breastfeed. Unfortunately, sometimes that does not happen because the healthcare personnel have not been given the appropriate training. According to Spatz (2005) "Health care providers' lack of knowledge, training, and education pertaining to breastfeeding has been well documented. Eden, Mir, and Srinivasan surveyed program directors of every accredited pediatric residency program in the United States and found that 45% of respondents rated the quality of their own breastfeeding education as mediocre or below, and 43% rated their current program as inadequate or in need of improvement." (p. 1)
The CDC (2003) recognizes that a review by the US Preventive Services Task Force in July 2003 determined education on breastfeeding to by the most effective single intervention for increasing breastfeeding initiation and short term duration.” (p.1) According to Clauss & Hall-Harris (1999) "Minimum training content for a new mom should include the assessment of a correct latch and sucking of the infant, management of sore nipples, how to identify mastitis, and how to express and store breast milk." (p 162) Nurses should also provide prenatal counseling and follow-up support programs help facilitate the continued success of new mothers who initiated breastfeeding at delivery.
The World Heath Organization launched an initiative called The Baby Friendly Hospital Initiative (which will be referred to as BFHI) to encourage and recognize hospitals and birthing centers that offer an optimal level of care for lactation. (Anonymous 2006) writes, “The BFHI assists hospitals in giving breastfeeding mothers the information, confidence, and skills needed to successfully initiate and continue breastfeeding their babies and gives special recognition to hospitals that have done so.” (p. 12) There are very specific guidelines that a hospital or a birthing center must follow to be a Baby Friendly Hospital. One of the criteria is to provide a minimum of 18 hours of training to the nursing staff with the primary responsibility for helping mothers initiate breastfeeding. Nurses should advocate for their facility to become a “Baby Friendly Hospital” so that they are able to reap the benefits of the required training.
In conclusion, nurses should advocate for their facility to become a Baby Friendly environment and increase their knowledge and skills with the goal of delivering quality prenatal counseling and postpartum breastfeeding education to new parents. Nurses that have been trained to properly educate, encourage and support new mothers directly impact the number of women who have successful breastfeeding experience.
References

Anonymous (2006)
Baby-friendly hospitals, Pediatrics for Parents, (22) 4, 12 http://proquest.umi.com/pqdweb?did=992461311&Fmt=3&clientId=3236&RQT=309&VName=PQD

Clauss, J. Hall-Harris, E. (1999)
Development of a breastfeeding support program, Pediatric Nursing, (25) 2, 161-166http://proquest.umi.com/pqdweb?did=41081147&Fmt=4&clientId=3236&RQT=309&VName=PQD

CDC (2003)
The CDC guide to breastfeeding interventions, Educating Mothers. Retrieved May 1, 2007 from http://www.cdc.gov/breastfeeding/pdf/BF_guide_4.pdf

Feeg, V. (Feb 2001)
Assisting new mothers with infant feeding when breastfeeding is not an option Pediatric Nursing, (27) 1, 47-60 http://proquest.umi.com/pqdweb?did=71037316&Fmt=4&clientId=3236&RQT=309&VName=PQD

La Leche League International (July 2006)
Can breastfeeding prevent illnesses, retrieved on May 1st 2007 from http://www.lalecheleague.org/FAQ/prevention.html

Spatz, D.L. (Sep 2005)
The Breastfeeding Case Study: A Model for Educating Nursing Students
Journal of Nursing Education, (44) 9, 432-434
http://proquest.umi.com/pqdweb?did=891458911&Fmt=4&clientId=3236&RQT=309&VName=PQD

Disadvantages to Interventions for Breastfeeding Education

Breastfeeding should be a livable, comfortable, well-informed option for women. Supporting breastfeeding is not a complicated endeavor. It focuses on educating the parents, reiterating support and addressing the barriers that parents face in the early stages of breastfeeding. When lactation consultants are available at birth and parents are present at follow-up visits to communicate with family care providers, success rates rise. Even with all of this available, there are many reasons why breastfeeding may be an unlivable, unsafe, or difficult choice for women, and especially for socially vulnerable women.

a. Intervention 1: Educate the parents about breastfeeding
i. Disadvantage 1: Social attitudes toward the female breast and emotional factors that the mother must consider
There is no disadvantage to educating the parents about breast-feeding, however even the best education in some circumstances can not persuade a mother to breastfeed.
There are many practical reasons (e.g., inconvenience, lack of suitable facilities outside of the home, conflicts at work) why American mothers choose to avoid or limit breastfeeding, but practical concerns are certainly not the only factors. "In Western societies, particularly in the United States, the social and sexual significance of the female breast rivals, if not exceeds its biological significance. As a consequence, the decision to breastfeed, particularly if it exposes the breast and the woman to public scrutiny, involves a complex decision matrix in which social and emotional factors play prominent roles. Although the waxing and waning of social and medical support for breastfeeding has often been justified in terms of its purported medical hazards or benefits, Fildes' comprehensive survey of nursing practices provides many illustrations of how attitudes toward nudity, acceptance of biological urges, and the Western sexualization of the female breast have been far more influential than nutritional concerns." (Forbes 2003)
Even when the parents know and understand that “Breast is best” our society’s attitude along with the mother’s feelings toward breastfeeding in public can render negative feelings about the whole breastfeeding process.

ii. Disadvantage 2: Unsafe breastfeeding conditions, even in one’s own home
"Breastfeeding opens women to be offended, sexualized, and even violent and punitive gazes. Especially within some ethnic subgroups, women who breastfeed at home in front of other family members, including their babies' fathers, risk strong disapproval and even domestic violence. Indeed, many women, especially poor women and women from ethnic groups that tend to live in more communal and crowded spaces, have literally no safe space in which to breastfeed. These are also the very same women who tend to be more vulnerable to sexual abuse and to charges of inappropriate sexual display, and hence may face intensified risks and more complex codes of privacy when breastfeeding. The problem is that while most low-income and minority mothers have domiciles, they do not necessarily have access to domestic spaces. Their home space is less likely to be neatly separated from their work space and from public gathering space, and it is unlikely to be structured by a sentimentalist domestic aesthetic. This means that by the authoritative norms of our culture, particularly those women whose low breastfeeding rates are of such public concern-literally have no socially appropriate, safe space in which to breastfeed." (Kukla 2006)
Without a safe space to nurse a newborn it’s unlikely that the mother will choose to breastfeed, especially if breastfeeding could trigger violence.

b. Intervention 2: Prenatal Counseling and Follow up support programs
i. Disadvantage 1: Scary stories about painful experiences that influence decision making
Prenatal counseling and follow up support from healthcare professionals are two variables that help a new mother make the decision to breastfeed. "Prenatal counseling includes learning about the maternal and infant benefits of breastfeeding, but the stories that circulate outside of the clinic include influential factors such as pain that may be scary to a new mother.
Although most women interviewed did not actually know anyone who had breastfed, beliefs or anticipation about the pain involved in breastfeeding was common, including stories about cracked and bleeding nipples or pain related to breast engorgement. Most women who talked about the pain of breastfeeding believed it was inevitable, and many thought that it would last until they weaned their infant. Pain is involved here, I know, so it's a state of mind a person is just going to have to adjust to. What I've heard, it takes about three months to get over it, but you do get used to it. (18 yr old pregnant woman)" (Bentley et al 2003)
ii. Disadvantage 2: Formula, intensely marketed
Regardless of whether or not a mother has decided to breastfeed she is sent home with free samples of formula when she is discharged. Prenatal and follow up education includes information on supplementing with formula, which certainly lets the mother explore the convenient option.
"In a culture where infant formula is intensively marketed and the federal nutrition support program Women, Infants, and Children (WIC) provides free formula, it may be too easy to give up on breastfeeding."(Hurst 2007)
No woman should be pressured to breastfeed. It is a very individual decision based on many different factors such as culture, religion, income, career, time, knowledge, home environment… and the list goes on.

References
Bentley, M.E., & Dee, D.L., & Jensen, J.L.(2003).
Breastfeeding among low income, African-American women: Power, beliefs and decision making, The Journal of Nutrition (133) 1, 305-310 http://proquest.umi.com/pqdweb?did=281514141&sid=2&Fmt=4&clientId=3236&RQT=309&VName=PQD

Forbes, G.B., & Adams-Curtis, Leah, E., & Hamm, N.R., & White, K.B (2003)
Perceptions of the woman who breastfeeds: The role of erotophobia, sexism, and attitudinal variables, Sex Roles, (49) 7/8. 379-388
http://proquest.umi.com/pqdweb?did=530922831&Fmt=3&clientId=3236&RQT=309&VName=PQD

Hurst, C.G. (2007)
Addressing breastfeeding disparities in social work, Health and Social Work, (32) 3, 207-210 http://proquest.umi.com/pqdweb?did=1327667611&Fmt=3&clientId=3236&RQT=309&VName=PQD

Kukla, R. (2006)
Ethics and ideology in breastfeeding advocacy campaigns, Hypatia, (21) 1, 157-180http://proquest.umi.com/pqdweb?did=971368921&Fmt=4&clientId=3236&RQT=309&VName=PQD

Nursing Shortage and Strategies to Minimize its Effects

2007-12-01T17:00:00.000-08:00

The current nursing shortage affects the healthcare system in many ways. The shortage puts a lot of stress on staff nurses to keep up with their patient load. The understaffing creates potential safety and delivery of care issues. Because high patient to nurse ratios diminishes the quality of care nurses are able to provide, putting patients at greater risk, nurses should implement strategies to alleviate and remedy the shortage. Staff nurses should mentor new graduate nurses and join hospital committees to develop programs that help new graduate nurses transition into staff nurses. Hospitals should employ a staff nurse to coach other nurses when job dissatisfaction becomes an issue. These strategies promote job retention and a positive work image.
The current nursing shortage and the demand for healthcare are expected to continue because of the aging population and medicine’s success in keeping ill patients alive longer (Upenieks, 2005). The U.S. Department of Health and Human Services projects the current nursing shortage of registered nurses could hit 750,000 by 2020 (Johnson, 2004). In many nursing units across the United States short staffing and high patient to nurse ratios are increasing patient risk. According to the Joint Commission on Accreditation of Healthcare Organizations’ 2002 report, a shortage of nurses is a factor in about one-fourth of patient injuries or deaths in hospitals (Johnson, 2004). There are several strategies to reduce patient risk by alleviating the local nursing shortage.
Experienced nurses should be teachers and role models for new novice nurses. When novice nurses are not supported in their learning they become discouraged and may develop a negative outlook on their nursing career, possibly leaving the profession and adding to the nursing shortage. The concept of mentoring is a strategy that many nurse managers use on their units to foster socialization and retention of new nurses. However, there have been instances where a formal mentorship program was seen to be detrimental within the nursing unit (Thomka, 2007). Nurses feared that accusations of favoritism would surface and damage the atmosphere of the working environment. Nurse managers of these units did very little to support the idea of mentorship in a positive way. As a result, many mentoring relationships have developed informally with the mentoring nurse unaware of the relationship. Nurses who were identified as mentors were thought to simply be doing their jobs during the normal course of their day, acting like leaders, teachers, and role models who did this for everyone in their work environment (Thomka, 2007). The mentees aspired to grow professionally and acquire the skills their chosen mentors exhibited. As a result of the mentoring, many mentees become mentors for new nurses as a way to give back to the profession. Nurse managers can facilitate the mentorship relationship by encouraging nurses to share their knowledge and experiences with novice nurses. By acknowledging individual nurses for situations in which they supported a novice nurse’s professional growth, nurse managers may also encourage mentoring relationships.
The turnover of new nursing graduates is relatively high when their first year of employment is viewed negatively. This is the reason many nursing managers and hospital administrators seek staff nurses to join committees in helping design orientation programs and residencies for new novice nurses. New hires are more likely to work for an employer that supports the development of the nurse. Experienced staff nurses are able to use their past experiences to develop and implement an internship program that will encourage the professional growth of new nurse graduates. At Children’s Memorial Hospital in Chicago, a Magnet designated hospital, the turnover among new nurse graduates was 29.5% before an improved RN internship program was implemented (Halfer, 2007). The internship program included a greater amount of hours spent in a classroom learning environment, clinical mentors, professional transition group discussions, and working with a preceptor for 4 to 9 months, depending on the nursing unit. As a result of the internship program the turnover rate dropped to 12.3%. Staff nurses are able to make a difference in a new nurse’s career by providing strategies to committees, nurse recruiters, and retention managers on how to increase job satisfaction for new nurse graduates.
Coaching is a short term strategy used to address concerns of job dissatisfaction. When a conflict arises, job dissatisfaction may occur and the end result may be the nurse quitting the position. The nurse might look for employment at another facility or change career, both of which could potentially increase the nursing shortage at that particular healthcare facility. A coach is a nurse that works in the human resources department and coaches employees with job satisfaction issues. Regardless of the cause of the problem, the coaching process shows the employees the seriousness of the hospital’s intent to learn about their dissatisfaction and do something about it (Stedman & Nolan, 2007). Coaching is an approach to conflict resolution and finding strategies to better the work environment with the conflicted nurse. The coach helps the employee and the facility at the same time. By successfully resolving the conflict, the coach relieves the conflicted nurse’s dissatisfaction and job retention is achieved by the employer. Due to the current nursing shortage, keeping qualified nurses as employees is a great strategy in reducing the strain the shortage has created on the healthcare facility.
The current nurse shortage in the United States will persist. Due to high patient to nurse ratios and an increasing amount of paperwork to fill out, many nurses find it hard to provide adequate nursing care leading to job dissatisfaction. By reducing the patient to nurse ratio patient safety, job satisfaction, and job retention increase. Hospitals and individual nursing units can minimize the effects of the shortage by employing mentoring, coaching, and implementing well designed new hire programs.

a. Intervention 1 (Experienced nurses should act as mentors for new novice nurses.)
i. Disadvantage 1 (Formal mentorship may be seen as detrimental.) A mentorship program has many positive effects in a nursing unit. It can foster support and facilitate learning of new graduate nurse. However, there have been instances where a formal mentorship program was seen to be detrimental within the nursing unit (Thomka, 2007). Fear of accusations of favoritism and damage to the atmosphere of the working environment were some reasons experienced staff nurses did not support formal mentorship programs. Also, nurses may feel that quality patient care decreases when mentoring a new graduate nurse. Another reason nurses frown upon mentoring novice nurses is that they do not have the time to deliver quality patient care to their patients as well as answer questions and demonstrate interventions for the novice nurse. In addition, research suggests that mentors frequently feel unsupported by their academic colleagues and poorly prepared to undertake the role (Duffy 2000).
ii. Disadvantage 2 (There is a misunderstanding of what mentorship really is.) Mentorship is often times thought of as preceptorship. Mentorship is a relationship between an experienced nurse and a novice nurse with an emphasis of helping the novice nurse become an expert. It is collaborative approach and there is no time limit within which this process must take place (Loads, Brown, McKenzie, & Powell 2006). In contrast to the mutual relationship of mentoring, precepting is an orientation technique involving the formal assignment of staff RNs and holding them “accountable for the transition of new staff…over short, limited periods of time” (Stewart & Krueger 1996). Mentorship lasts for an extended period of time that culminates in a relationship where both mentee and mentor grow professionally. Preceptorship on the other hand lasts for a disclosed amount of time where usually only the mentee grows professionally.
b. Intervention 2 (Experienced staff nurses are able to develop and implement an orientation program that will encourage the professional growth of new nurses.)
i. disadvantage 1 (Difficult to find willing preceptors) Due to the nurse shortage many units are understaffed and nurses overworked. Adding precepting a novice nurse in addition to an already high patient load dissuades many qualified nurses from becoming preceptors. Nurse preceptors should be given lower patient loads as they integrate and evaluate novice nurses. Both new and experienced nurses can find orientation to an acute care area very demanding and extremely overwhelming experience, producing feelings of disillusionment and failure if not implemented correctly (Maiocco 2003). It is the job of the nurse manager to assess the unit’s capability of providing willing preceptors.
ii. Disadvantage 2 (Orientation and internship programs are costly.) When a nursing unit decides to offer a comprehensive orientation and internship program, the unit coordinator must decide the program’s cost effectiveness. Chicago’s Children’s Memorial Hospital provides two classrooms, a computer lab, and a clinical skills lab (Halfer 2007). Along with providing learning tools and equipment, nurse preceptors and mentor are usually paid a differential for their added duties as teachers. In most instances the benefits outweigh the costs.

References:

Halfer, D. (2007). A magnetic strategy for new graduate nurses. Nursing Economic$, 25(1) 6-11. Retrieved April 18, 2007, from Expanded Academic ASAP database.

Johnson, L. (2004, March 29). Shortage of nurses putting patients at risk: Unions push for limits on patient loads in hospitals. Retrieved January 8, 2007, from http://www.msnbc.msn.com/id/4587667/

Maiocco, G. (2003). From classroom to CCU. Nursing Management, 54-57. Retrieved October 31, 2007, from Proquest database.

Loads, D., Brown, M., McKenzie, K., & Powell, H. (2006). Developing mentorship through collaboration. Learning Disability Practice, 9(3) 16-18. Retrieved October 31, 2007, from Proquest database.

Stedman, M. E., & Nolan, T. L. Jr. (2007). Coaching: A different approach to the nursing dilemma. Nursing Administration Quarterly (31.1), 43-47. Retrieved April, 18, 2007, from Expanded Academic ASAP database.

Thomka, L. A. (2007). Mentoring and its impact on intellectual capital: Through the eyes of the mentee. Nursing Administration Quarterly 31(1) 22-27. Retrieved April 18, 2007, from Expanded Academic ASAP database.

Upenieks, V. (2005). Recruitment and retention strategies: a Magnet hospital prevention model. MedSurg Nursing. (14.2), S21-27. Retrieved April, 18, 2007, from Expanded Academic ASAP database.