“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
Thursday, December 13, 2007
Disadvantages of Nurses Strategies That Would Assist the Military With Post-Traumatic Stress Disorder (PTSD) In Veterans of Foreign Wars.
Tuesday, December 11, 2007
Sunday, December 9, 2007
Prayer in Nursing
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
Wednesday, December 5, 2007
Controversy of Hand Washing vrs Alcohol Based Hand Rubs
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.
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
Tuesday, December 4, 2007
Preventing Child Abuse and Neglect
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
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.
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Pressure ulcers Know How to Stop the Pain
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
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
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.