The Role of the Nurse in Supporting Client Use of Complementary and Alternative Therapies

The current healthcare system is on the verge of great change, and driving this change is the popularity of complementary and alternative methods of healthcare. As the use of complementary and alternative methods (CAM) becomes increasingly common, traditional allopathic practitioners must incorporate knowledge of alternative therapies into their standard Western medical practice to accommodate client preferences, safeguard patients, and further client healing.

The Role of the Nurse in Supporting Client Use of Complementary and Alternative Therapies
The current healthcare system is on the verge of great change, and driving this change is the popularity of complementary and alternative methods of healthcare. As the use of complementary and alternative methods (CAM) becomes increasingly common, traditional allopathic practitioners must incorporate knowledge of alternative therapies into their standard Western medical practice to accommodate client preferences, safeguard patients, and further client healing. Clients are often unwilling to disclose their use of nontraditional methods to physicians (Chiravalle & McCaffrey, 2005; Fowler & Newton, 2006; Mantle, 2006; Tracy et al., 2005), so nurses are uniquely positioned to learn about client care preferences and client use of alternative and complementary therapies (Brolinson, Price, & Ditmyer, 2001). Because CAM provides multiples benefits to patients such as cost efficiency, less invasiveness, and greater control and choice over personal health, and because promoting client health and safety is a nursing priority, nurses must actively support the addition of complementary and alternative health care options in traditional health care settings, must promote the inclusion of complementary and alternative therapies in nursing school curriculum, and must actively educate themselves and their clients regarding the safe use of nontraditional methods. In doing so, nurses will improve client satisfaction and outcomes, and will empower their patients and themselves as healers.
CAM use by consumers has been growing steadily since the 1990’s (Brolinson, Price, & Ditmyer, 2001). According to Eisenberg et al (1998), in 1997, visits to alternative practitioners, totaling 629 million, represented a 47% increase over visits in 1990, with 42% of American adults spending $27 billion dollars on CAM (as cited in Brolinson, Price, & Ditmyer, 2001). Of this amount, between 12.2 and 19.6 billion dollars were spent out-of-pocket by consumers for CAM, a greater amount than out-of-pocket payments for hospitalization and close to half the amount paid out-of-pocket to physicians (Center for Medicare and Medicaid Services, 1997, as cited in Barnes, Powell-Griner, McFann, & Nahin, 2004, para. 4). In 2002, the results of a national survey of 31,044 American adults 18 years old and older, found when prayer for health is included, 75% of those surveyed used CAM and 62% had used CAM during the 12 month period preceding the study (Barnes, Powell-Griner, McFann, & Nahin, 2004). CAM’s increasing popularity points toward the necessity of its inclusion in traditional settings.
As patient advocates, nurses must request that complementary and alternative methods be made readily available to clients in hospitals and clinics, stressing the noninvasiveness and cost effectiveness of alternative therapies (Fowler & Newton, 2006). Many complementary and alternative methods, such as massage, therapeutic touch, use of essential oils, and Reiki can be practiced by nurses and have been shown to have positive impact on pain reduction and patient recovery time (Mantel, 2006; Vitale & O’Connor, 2006). Other positive facets include CAM’s potential to prevent reoccurrence of disease and increase the quality of life (Beebe-Dimmer et al, 2004; Henderson & Donatelle, 2004, as cited in Fowler & Newton, 2005), to ease the stress associated illness and hospitalization (Tracy et al, 2005), and to facilitate long term positive behavioral changes (Mantle, 2006). Alternatives, such as acupuncture which has a long history of use (White & Ernst, 2004) and proven efficacy in pain management (Zang-Hee, 2001), should be made available to patients. By lobbying for the inclusion of CAM and influencing the development of policies and procedures relating to CAM use in traditional healthcare settings (Fowler & Newton, 2006), nurses will further patient’s healing and assert themselves as healers within the current healthcare modality.
To lobby successfully for CAM inclusion and provide safe care to their patients, nurses must be knowledgeable about the effectiveness and safety of CAM (McDowell & Burman, 2004). The extensive variety of alternative practices points toward the need for inclusion of CAM education in nursing school curriculum and the importance of CAM related continued nursing education (McDowell & Burman, 2004). Studies indicate that while interested in promoting CAM, lack of knowledge, training, and time prevents nurses from endorsing or implementing complementary and alternative methods (Tracy et al, 2005). In addition, because CAM not only positively impacts patient health, the potential for negative impact, such as combining certain herbal medicines with Western medicines (Fowler & Newton, 2006), makes both nursing education and patient education imperative.
Because patients may engage in alternative practices that may be potentially harmful, nurses are an important link in patient education regarding the use of CAM. In 2002, Norred reported that 34% of patients use alternative herbal therapies that either potentiate or interfere with standard medicines (as cited in Fowler & Newton, 2006, para. 18). Examples of potentially harmful combinations include the use of St. John’s Wart with warfarin and the use of nettles with cardiac glycosides, for St. Johns Wart potentiates warfarin and interferes with anticoagulation (Fowler & Newton, 2006), and nettles enhance the effects of cardiac glycosides (Mantle, 2006). Many patients do not inform their primary care providers about their CAM use (Fowler & Newton, 2006; Mantle, 2006; Tracy et al., 2005), so nurses must educate their patients about safe uses, preventing possible complications. Additionally, patients should also be made aware of methods that do not interfere with traditional medical treatments. Offering suggestions for methods that compliment and enhance traditional therapies, such as use of prayer, mediation, yoga, massage, acupressure, and Bach Flower and homeopathic remedies (Mantle, 2006), enhances patient knowledge, especially in patient populations who do not have prior knowledge of CAM (Fowler & Newton, 2006). Health screening and fairs are excellent avenues for furthering patient education. In educating their clients about complementary and alternative methods, nurses not only empower their clients, they empower themselves as healers.
As healers, nurses take on many roles when assisting clients to attain and maintain health. They act as confidant, educator, clinician, and advocate when providing care, serving as a bridge between client and physician. Because nurses are “one of the largest groups of health professionals…in contact with the public” (Brolinson, Price, & Ditmyer, 2001), nurses have tremendous impact patient health practices. By lobbying for inclusion of CAM in traditional health care settings, continuing professional education and expanding nursing school curriculum to include CAM, and educating patients on safe and effective complementary and alternative therapies, nurses can once again serve their patients, affording them greater choices and opportunity for healing and self-empowerment.

Barriers to Supporting Client Use of Complementary and Alternative Therapies

Intervention 1: Patient Education in the Use of Complementary and Alternative Therapy

Disadvantage 1: Knowledge Deficits Related to Inadequate Understanding of Complementary and Alternative Therapies

Inadequate nursing knowledge related to complementary and alternative methods of treatment (CAM) prevents nurses from adequately educating patients regarding CAM use. Because the potential for negative interaction between traditional allopathic medical treatment and nontraditional alternative methods exists (Fowler & Newton, 2006; Mantel, 2006), both nursing and patient education are imperative to ensure the safe provision and utilization of CAM. Studies indicate that while interested in promoting complementary and alternative methods of treatment, lack of knowledge regarding CAM prevents nurses from endorsing nontraditional methods (Tracy et al, 2005). The extensive variety of complementary and alternative therapies points toward the need for inclusion of CAM in nursing curriculum and the importance of CAM related continuing education for nurses (McDowell & Burman, 2004). According to Brolinson, Price and Ditmyer, the majority of nurses perceive their education in this area to be “fair to poor” (2005, para. 23), with only one in four nurses perceiving the acquisition of adequate preparation and education regarding CAM use in their coursework (2005).

Disadvantage 2: Perceived Potential for Discrimination by Clients Leads to Nondisclosure of Complementary and Alternative Therapy Use

Client perceived bias by medical professionals against the use of complementary and alternative therapies leads to inadequate client disclosure of CAM use. While it has been shown that an increasing number of Americans use complementary and alternative treatments (Eisenberg et al., as cited in Brolinson, Price, & Ditmyer, 2001), most do not disclose CAM use to their healthcare providers (Chiravalle & McCaffrey, 2005; Fowler & Newton, 2006; Mantle, 2006; Tracy et al., 2005). This nondisclosure directly leads to inadequate client education regarding the safety and efficacy of CAM, for awareness of client need and healthcare practice directs the focus of client education efforts.

Intervention 2: Lobbying for Inclusion of Complementary and Alternative Therapies within Traditional Care Settings

Disadvantage 1: Knowledge deficits related to the Benefits of Complementary and Alternative Methods of Treatment Leads to Inadequate Promotion

Without a strong knowledge base, nurses can not lobby effectively for the inclusion of complementary and alternative therapies in hospitals and clinics. Knowledge is essential in identifying complementary and alternative methods appropriate to and beneficial in traditional settings. Lack of nursing education and familiarity with the myriad of complementary and alternative methods currently available (Brolinson, Price, & Ditmyer, 2001) directly undermines CAM promotion by nurses, for nurses are unwilling to promote complementary and alternative therapies due to lack of knowledge about the safety, efficacy, and benefits of non-allopathic methods of treatment (McDowell & Burman, 2004; Tracy et al., 2005).

Disadvantage 2: Inadequate Insurance Coverage of Complementary and Alternative Methods of Treatment Renders Lobbying Efforts Ineffective

Lack of insurance coverage for complementary and alternative methods is a stumbling block to the inclusion of CAM within traditional healthcare facilities. While a large percentage of complementary and alternative therapy is paid for out-of-pocket by consumers (Center for Medicare and Medicaid Services, as cited in Barnes, Powell-Griner, McFann, & Nahin, 2004), consumer use of complementary and alternative methods correlates positively with insurance coverage (Wolsko, Eisenberg, Davis, Ettner, & Phillips, 2002); expanded insurance coverage of CAM is necessary before its acceptance within traditional settings can be accomplished. Successful lobbying by nurses for CAM inclusion in hospital and clinical settings will be hampered until insurance coverage of alternative treatment modalities is deemed adequate by financial managers within traditional settings.

References

Barnes, P. M., Powell-Griner, E., McFann, K., & Nahin, R. L. (2004). Complementary and alternative medicine use among adults: United States, 2002. Retrieved May 26, 2007, from http://nccam.nih.gov/news/report.pdf

Brolinson, P. G., Price, J. H., & Ditmyer, M. (2001). Nurses’ perceptions of complementary and alternative medical therapies. Journal of Community Health. 26(3), 175-. Retrieved January 6, 2007, from Expanded Academic ASAP database (A77048779).

Chiravalle, P., & McCaffrey, R. (2005). Alternative therapy applications for postoperative nausea and vomiting. Holistic Nursing Practice. 19(5), 207-210. Retrieved from Expanded Academic ASAP database (A137016222).

Fowler, S., & Newton, L. (2006). Complementary and alternative therapies: the nurse's role. Journal of Neuroscience Nursing, 38(4), 261-265. Retrieved December 25, 2006, from Expanded Academic ASAP database (A150366888).

Mantle, F. (2006). What’s the alternative? Complementary and alternative remedies can have significant side effects when combined with conventional treatments. Fiona Mantle urges emergency nurses to be aware of the problems that can arise from their use. Emergency Nurse, (14)1, 16-19. Retrieved January 14, 2007, from Expanded Academic ASAP database (A144869682).

McDowell, J. E., & Burman, M. E. (2004). Complementary and alternative medicine: a qualitative study of beliefs of a small sample of Rocky Mountain area nurses. (Research for practice). MedSurg Nursing, 13(6), 383-390. Retrieved January 14, 2007, from Expanded Academic ASAP database (A126848898).

Tracy, M. F., Lindquist, R., Savik, K., Watanuki, S., Sendelbach, S., Kreitzer, M. J., et al. (2005). Use of complementary and alternative therapies: A national survey of critical care nurses. American Journal of Critical Care, 14(5), 404-415. Retrieved January 14, 2007, from Expanded Academic ASAP database (A136510788).

Vitale, A. T., & O’Connor. (2006). The effect of Reiki on pain and anxiety in women with abdominal hysterectomies: A quasi-experimental pilot study. Holistic Nursing Practice, 20(6), 263-274. Retrieved May 26, 2007, from Expanded Academic ASAP database (A155294447).

White, A., & Ernst, E. (2004). A brief history of acupuncture. Rheumatology 43(5), 662. Retrieved May 26, 2007, from Research Library database. (Document ID: 626689341).

Wolsko, P. M., Eisenberg, D. M., Davis, R. B., Ettner, S. L., & Phillips, R. S. (2002). Insurance coverage, medical conditions, and visits to alternative medicine providers: Results of a national survey. Archive of Internal Medicine. 162(3), 281-287. Retrieved October 28, 2007, from ProQuest database.

Zang-Hee, C., Young-Don, S., Jae-Yong, H., Wong, E., Chang-Ki, K., Kyung-Yo, K. et al. (2001). fMRI neurophysiological evidence of acupuncture mechanisms. Medical Acupuncture: A Journal For Physicians By Physicians, 14(1). Retrieved May 26, 2007, from http://www.medicalacupuncture.org/aama_marf/journal/vol14_1/article1.html

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Best Practices in Nursing: Developing and Implementing Positive Outcomes when Dealing with Negative Behaviors in Dementia Patients

by Lyn Yorgensen
Alzheimer’s Care Quarterly is a peer-reviewed journal designed for health care professionals which provides information on dementia care practices which can be used in any setting. Author Carly R. Hellen (BS, OTR/L, Nursing Home Services Director, Rush Alzheimer’s Disease Center, Chicago, Illinois) focuses on developing hands-on care strategies and behavioral refocusing interventions allowing Alzheimer’s patients to be treated with dignity and respect.

“I was always looking for a way to ‘connect’ with my care receivers”, says Hellen (Hellen, 2004, para. 2). The author’s approach includes sensory bridging which provides a sensory connection by having the person with dementia hold an item in his or her hand that is similar to the one the caregiver is using to provide care. For example, as the caregiver attempts to comb the resident’s hair he becomes angry and pushes the caregiver away. The caregiver then provides the resident with his own comb to hold, in his hand which gives him something to see and feel, allowing the caregiver to complete the task, the resident now feels he had a part in the task. The author provides many useful care and refocusing strategies along with examples on how to implement each one. The article is particularly useful for the nurse responsible for the care of Alzheimer’s patients and has provided much information for the research topic.

Gleeson, M., & Timmins, F. (2004). Touch: A fundamental aspect of communication with older people experiencing dementia. Nursing Older People, 16 (2), 18. Retrieved July 18, 2007 from Academic Search Premier database.
Nursing Older People is published by the Royal College of Nursing and is
designed particularly for health professionals who work with older people in
any setting. Author Madeline Gleeson RPN, RGN, BNS is the Clinical
Placement Coordinator at Saint Patrick’s Hospital in Dublin Ireland. Co-
author Fiona Timmons RGN, BNS, RNT, FNRCSI, NFESC, MSC is a lecturer at
Trinity College in Dublin Ireland. The authors did an extensive literature
review to explore the use of touch with dementia patients. From the results
of their research three particular aspects of touch emerged: “Physical
touch as an aspect of nursing care, the effect of touch, and the use of touch
with those clients with a diagnosis of dementia” (Gleeson, 2004, para. 4).
Research revealed that task-oriented touch or necessary touch is more
common with nurses working with the elderly than other age group. It was
found that non-necessary touch by a nurse gave patients a sense of safety.
Plus, it provided comfort that helped to keep them calm. In one study,
patients who had poor nutritional intake increased their caloric intake
when they were given a gentle touch and spoken to as they ate. Other
studies revealed that the effect of expressive verbalization (EPT/V) such as a
hand massage reduced anxiety and negative behavior in dementia patients.
Overall, the authors concluded that those in long term care are often
deprived of touch. However, nurses are in a unique position to provide this
vulnerable group of older adults the comfort provided by a simple pat on the
hand or touch on the shoulder. This article provided insight relating to the
importance of touch and provided much information for the research topic.

Ragneskog, H., Gerdner, L., Josefsson, K., & Kihlgren, M. (1998). Probable reasons for expressed agitation in persons with dementia. Clinical Nursing Research 7(189), 2. Retrieved January 20, 2005 from Expanded Academic ASAP database.
Clinical Nursing Research is an international journal published by SAGE
Publications and is designed for practicing nurses to provide information on
clinical research for discussion and professional enrichment. Author Hans
Ragneskog R.N., Dipl. Nurse Ed. is a lecturer in nursing at The Gokteborg
University College of Caring Sciences, Goteborg, Sweden. Co-author Linda
Gerdner R.N., M.A., is a doctoral candidate at the University of Iowa, Karin
Josefsson, R.N., Dipl. Nurse Ed., M.S., is a research assistant at Orebro
Medical Center Hospital, Orebro, Sweden, and Mona Kihlgren, R.N., Ph.D., is
a senior lecturer Orebro Medical Center Hospital, Orebro, Sweden. This
study was conducted at a nursing home in Sweden where dementia patients
were videotaped to help identify possible causes of agitation. As the data
was analyzed it revealed that agitation was often a used as a means of
communication. According to the authors the most common causes
for agitation were, “discomfort, a wish to be served immediately, conflicts
between patients or with nursing staff, reactions to environmental noises or
sounds, and invasion of personal space” (Ragneskog, 1998, para. 1). The
article presented relevant reasons for the need to assess and identify
possible causes for agitation and thereby implement interventions for
prevention of agitated episodes. Therefore, the article provided useful
information for the research topic.

Van Weert, J. et al (2006). Nursing assistants’ behaviour during morning
care: effects of the implementation of snoezelen, integrated in 24-
hour dementia care. Journal of Advanced Nursing, 53(6), 656. Retrieved July 18, 2007 from Academic Search Premier database.
The Journal of Advanced Nursing is a scientific, international, peer-reviewed journal which focuses on the advancement of evidence-based nursing through the publishing of scholarly research. Researchers, Julia C. M. Van Weert (NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands), Bienke M. Janssen. (NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands), Alexandra M. Van Dulmen (Research Coordinator, NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands), Peter M. M.Spreeuwenberg (Statistician, NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands), Jozien M. Bensing (Professor in Health Psychology, Director, NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands), and Miel W. Ribbe (professor in Nursing Home Medicine, Department of Nursing Home Medicine, University Medical Center/EMGO Institute, Amsterdam, The Netherlands). conducted research at six Dutch nursing homes in twelve different wards using a person-centered approach which incorporated multisensory stimulation techniques known as Snoezelen (Van Weert et al, 2006). Researchers defined a sensory stimulus as “the explicit use of visual, auditory, tactile, olfactory or gustatory stimuli to make contact with the resident and/or elicit a response from the resident” (Van Weert et al, 2006 para. 14). The focus was on improving the quality of caregiver behavior by training nursing assistants to integrate multisensory stimulation in morning care. The study revealed that the positive behaviors exhibited toward the residents by the CNAs “resulted in the improved levels of well-being for nursing home residents suffering from dementia” (Van Weert et al, 2006, para. 37). This article proved valuable for the information that it provided regarding the positive impact multisensory therapy has in dementia care.

Best Practices in Nursing: Developing and Implementing Positive Outcomes when Dealing with Negative Behaviors in Dementia Patients
Nurses that work in specialized care units with dementia patients face some particularly unique situations. Due to the disease process, these individuals are no longer able to express their needs appropriately. In addition, they may misunderstand the actions of others who are trying to help them. As a result, those that suffer from dementia sometimes exhibit behaviors that can put themselves and other at risk. The role of the nurse is to look at all factors that may contribute to negative behaviors, implement strategies, and provide caregiver training that can lead to positive outcomes.
In 1998 a study was conducted by a group of researchers at a nursing home in Sweden where dementia patients were videotaped, to help identify possible causes of agitation (Ragneskog et al, 1998). As the data was analyzed, it revealed that agitation was often used as a means of communication. According to researchers, the most common causes of agitation were, “discomfort, a wish to be served immediately, conflicts between patients or with nursing staff, reactions to environmental noises or sounds, and invasion of personal space” (Ragneskog et al, 1998, para. 29). Since dementia patients are often unable to verbalize their feelings or needs, recognizing and identifying causes for agitated behavior is essential for developing a plan of care and implementing interventions, so that their needs can be met and quality of life improved.
Meeting the communication needs of those with dementia may be one of the key elements in alleviating the expression of negative behaviors. One method developed by Carly Hellen, Nursing Home Services Director at Rush Alzheimer’s Disease Center in Chicago, Illinois focuses on developing hands-on care strategies and behavioral refocusing interventions. This strategy allows Alzheimer’s patients to be treated with dignity and respect (Hellen, 2004). “I was always looking for a way to ‘connect” with my care receivers”, says Hellen (Hellen, para. 2). Her approach includes sensory bridging, which provides a sensory connection by having the person with dementia hold an article in his or her hand that is similar to the one the caregiver is using to provide care. For example, as the caregiver attempts to comb the resident’s hair he becomes angry and pushes the caregiver away. The caregiver then provides the resident with his own comb, which gives him something to see and feel, thus allowing the caregiver to complete the task, the resident now feels he had a part in the task and helps maintain his sense of independence and control.
Touch is another method that has proven successful, in reducing anxiety and negative behavior. Gleeson and Timmons (Gleeson, 2004) in their extensive literature review found that three particular aspects of touch emerged: “Physical touch as an aspect of nursing care, the effects of touch and the use of touch with those clients with a diagnosis of dementia”. (Gleeson, 2004, para. 4) Research revealed that task-oriented touch or necessary touch is more common with nurses working with the elderly than any other age group. It was found that non-necessary touch by a nurse gave patients a sense of safety. In addition, it provided comfort that helped keep them calm. One study showed that patients who had poor nutritional intake increased their caloric intake when they were given a gentle touch and spoken to as they ate. Other studies revealed that the effect of expressive verbalization (EPT/V), such as hand massage, reduced anxiety and negative behavior in dementia patients. Overall, the authors concluded that those in long term care are often deprived of touch. Fortunately, nurses are in a unique position to provide this vulnerable group of older adults the comfort provided by a simple pat on the hand or touch on the shoulder.
Todd Hutlock, assistant editor at Nursing Homes, reports on Project RELATE – Research and Education for Living with Alzheimer’s Disease: Therapeutic Eldercare. The study took place in 2001 at a SNF in Grand Rapids, Michigan and “set out to investigate whether specialized training and person-centered approach for caregivers can lead to improved quality of life for residents” (Hutlock, 2004, para.1). The team headed by Iris Boethcher, MD, CMD, began by developing training sessions for the CNAs. Each week for five weeks, the certified nursing assistants were trained in the following areas: practical information about residents with dementia, communication techniques, beginning and sustaining life activities specific to the individual, and assisting residents with need-driven or agitated behavior. According to Dr. Boethcher, the primary focus of the training was “empowering CNAs to approach the residents with dementia as people as opposed to demented people. The focus is on the person and not the disease” (Hutlock, 2004, para 12). Also, nurses attended sessions on how to mentor the CNAs. Their four training sessions incorporated strategies in helping the CNAs develop observations skills, provide feedback, and set goals. The training yielded positive results as reported by Dr. Boethcher, “We saw a trend toward reduced agitated behaviors and also a reduction in depressive symptoms. We also saw a trend toward families noticing that the care was different, which also translates into improved and favorable” (Hutlock, 2004, para. 13). In addition, three months after the training ended, they discovered that “caregivers also expressed a more positive attitude toward their jobs and improved relationships with supervisors” (Hutlock, 2004, para. 14). In retrospect, the person-centered care method focuses not only on the residents but on the caregivers as well. The emphasis on caregiver training validates the role of the caregiver and respects the vital part that they play in the lives of their residents. This translates in to decreased episodes of agitation and improved quality of life for the residents.
Researchers in the Netherlands took the person-centered approach a step further and incorporated multisensory stimulation techniques known as Snoezelen in their study (Van Weert et al, 2006). Researchers defined a sensory stimulus as “the explicit use of visual, auditory, tactile, olfactory or gustatory stimuli to make contact with the resident and/or elicit a response from the resident” (Van Weert et al, 2006 para. 14). The focus was on improving the quality of caregiver behavior by training nursing assistants to integrate multisensory stimulation in morning care. Research was done at six Dutch nursing homes, in twelve different wards. The nursing assistants in the experimental group received four days of ‘snoezelen’ training. Those in the control group did not receive any additional training (Van Weert et al, 2006, para.8).
Several methods of sensory stimulation were used by the CNAs when providing morning care. For example, caregivers engaged the residents in conversation centering on the care they were providing and had the residents smell soap, body lotions, or aftershaves. Tactile stimulation was encouraged, by having the residents feel the “heat of the water or the softness towels, clothes and cuddly animals” (Van Weert et al, 2006 para. 28).
The results of the study revealed that the use of multisensory stimulation in dementia care produced positive changes in CNAs. The Snoezelen-trained CNAs “showed a statistically significant increase in the total number of verbal utterances (more social conversation, agreement, talking about sensory stimuli, information and autonomy” (Van Weert et al, 2006, para. 33). It was also noted that they demonstrated affective touch, looked and smiled at the residents more often. The study concluded that the positive behaviors exhibited toward the residents by the CNAs also “resulted in the improved levels of well-being for nursing home residents suffering from dementia” (Van Weert et al, 2006, para. 37).
Clearly, research supports the importance of providing caregiver training which focuses on the well being of the individual rather than the disease. Learning to communicate by demonstrating person-centered care, touch, and multisensory stimulation techniques provide methods for CNAs to connect with their residents and see them as people rather than behavior problems. As a result, this produces decreased episodes of agitation and positive outcomes for those with dementia.

References
Gleeson, M. & Timmins, F. (2004). Touch: A fundamental aspect of communication with older people experiencing dementia. Nursing Older People, 16 (2), 18. Retrieved July 18, 2007 from Academic Search Premier database.
Hellen, C.R. (2004). Enabling success: Hands-on care strategies and behavioral refocusing interventions. Alzheimer’s Care Quarterly, 5 (2), 178. Retrieved July 18, 2007 from Academic Search Premier database.
Hutlock, T. (2004). Project Relate: Managing the person with Alzheimer’s disease. Nursing Homes, 53(4), 60. Retrieved July 18, 2007 from Academic Search Premier database.
Ragneskog, H., Gerdner, L., Josefsson, K., & Kihlgren, M. (1998). Probable reasons for expressed agitation in persons with dementia. Clinical Nursing Research, 7(2), 189. Retrieved January 20, 2005 from Expanded Academic ASAP database.
Van Weert, J. et al (2006). Nursing assistants’ behaviour during morning
care: effects of the implementation of snoezelen, integrated in 24-
hour dementia care. Journal of Advanced Nursing, 53(6), 656. Retrieved July 18, 2007 from Academic Search Premier database.


Intervention 1: Overcoming Barriers to communication
Disadvantage 1: Knowledge Deficit Related to Lack of Training
Beck, C., Ortigara, A., Mercer, S., & Shue, V (1999). Enabling and empowering certified nursing
assistants for quality dementia care. International Journal of Geriatric Psychiatry, 14, 197
Retrieved October 24, from Academic Search Premier database.
The International Journal of Geriatric Psychiatry, is devoted to communicate the results of original research in the causes, treatment and care of all forms of mental disorders which affect the geriatric population. The Journal is designed for psychiatrists, psychologists, social scientists, nurses and others engaged in therapeutic professions, as well as other researchers. The authors are professors from the University of Arkansas and include a director from the Rush Alzheimer’s Disease Center in Chicago. The article addresses issues regarding barriers to dementia care and providing a framework for training.
In contrast, not all long term care facilities are as enlightened as the previously mentions communities. Most CNAs nationwide have high school education or less and work for a little more that minimum wage (Beck et al, 1999, para. 3). Beck states that CNAs have, “a tremendous impact on residents’ quality of life, but significant barriers limits their care giving effectiveness. These barriers include poor pay, minimal long-term benefits and insufficient training”.
Training is the key to providing quality care and improving communication between resident and caregiver. Federal regulations require a minimum of twelve hours of training before working with residents and at least twelve hours of in-service each year. Regulations also require dementia training for those CNAs working with dementia residents but do not specify the amount of training required (Beck et al, 1999, para. 22).
Disadvantage 2: Knowledge Deficit Related to Using Lying to Gain Compliance
James, I. et al (2006). Lying to people with dementia: developing ethical guidelines for care
settings. International Journal of Geriatric Psychiatry, 21, 800-801. Retrieved October 24,
from Academic Search Premier database.
The International Journal of Geriatric Psychiatry, is devoted to communicate the results of original research in the causes, treatment and care of all forms of mental disorders which affect the geriatric population. The Journal is designed for psychiatrists, psychologists, social scientists, nurses and others engaged in therapeutic professions, as well as other researchers. The authors are from the University of Newcastle, Newcastle upon Tyne, UK and Newcastle General Hospital, Newcastle upon Tyne, UK. The article focuses on the unethical use of manipulation and lying when dealing with dementia patients.
Building a bridge work for communication among caregivers and their residents is essential to developing a trusting relationship. However, Ian James reports in his article, Lying to people with dementia: developing ethical guidelines for care settings, that a questionnaire was given to staff concerning lying to residents in a care setting. Upon completion of the survey it was found “that staff working in a dementia day care setting used a variety of responses to maintain a patient’s safety, including benign manipulation, lying and pretending”. However, staff members also stated that there were problems associated with lying such as: increased confusion due to lack of consistency of the lies being told, developing mistrust between residents and staff, causing tension and confusion with family members (James et al, 2006, para.5).
Intervention 2: Person Centered Care
Disadvantage 1: Socioeconomic barriers to care
Mor, V. et al (2004). Driven to tiers: socioeconomic and racial disparities in the quality of nursing
Home care. Milbank Quarterly, 82(2), 227-256. Retrieved October 24, 2007 from
Academic Search Premier database.
Milbank Quarterly, is an academic journal which contains scholarly articles regarding issues in health and heath care policy for clinicians and policy makers. The authors from both Brown and Temple Universities, report on the two tiered system of care in long term care facilities. The article focuses on the lower tier which consists mainly of Medicaid residents and facilities that have very limited resources.
Not all long term care facilities have the resources to provide innovative care strategies that can lead to a better quality of life for their residents. Facilities that are highly dependent on Medicaid as a source of income have the most difficulty securing the resources needed to provide good-quality care (Mor et al, 2004, para. 2). It was also noted that for profit Medicaid facilities had fewer RNs and CNAs per resident. Medicaid dependent facilities also had a higher incidence of restraint use, use of antipsycotics, and inadequate pain control (Mor et al, 2004, para. 18). As a result, many of the facilities that are Medicaid dependent do not have the financial resources or staffing needed to develop specialized programs to decrease incidents of negative behavior.
Disadvantage 2: Discrimination and Quality of Care
Smith, D. et al (2007). Separate and unequal: racial segregation and disparities in quality
across U.S. nursing homes. Health Affairs, 16(5), 1448-1458. Retrieved
October 24, 2007 from Academic Search Premier database.
Health Affairs, is an academic journal which is committed to the exploration of policy issues in the domestic and international health arenas. It contains papers from industry, labor, government and academe. Plus, it contains book reviews. The authors are all professors from Brown and Temple Universities. In the article the authors note racial segregation in nursing homes and the differences in quality of care.
Private pay long term care facilities are the ideal setting for both dementia or non-dementia residents who need assistance with ADLs. However, not everyone is financial able to afford such accommodations and the quality of care that they provide. This is most evident among the black population. In the study conducted by Smith et al, it was noted that black nursing home residents were more likely to be in a facility with higher total weighed deficiencies and were even more likely to be in nursing homes with cited deficiencies that caused actual harm or put them in immediate jeopardy, “that was subsequently terminated from Medicare and Medicaid participation” (Smith et al, 2007, para.6). It is evident that disparities in treatment and care are directly related to the quality of the facility.

References

Beck, C., Ortigara, A., Mercer, S., & Shue, V (1999). Enabling and empowering certified nursing
assistants for quality dementia care. International Journal of Geriatric Psychiatry, 14, 197.
Retrieved October 24, from Academic Search Premier database.
James, I. et al (2006). Lying to people with dementia: developing ethical guidelines for care
settings. International Journal of Geriatric Psychiatry, 21, 800-801. Retrieved October 24,
from Academic Search Premier database.
Mor, V. et al (2004). Driven to tiers: socioeconomic and racial disparities in the quality of nursing
Home care. Milbank Quarterly, 82(2), 227-256. Retrieved October 24, 2007 from
Academic Search Premier database.
Smith, D. et al (2007). Separate and unequal: racial segregation and disparities in quality
across U.S. nursing homes. Health Affairs, 16(5), 1448-1458. Retrieved
October 24, 2007 from Academic Search Premier database.
Best Periodical Articles
Hellen, C.R. (2004). Enabling success: Hands-on care strategies and behavioral refocusing interventions. Alzheimer’s Care Quarterly, 5 (2), 178. Retrieved July 18, 2007 from Academic Search Premier database.

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Best Practices For Nurses: Caring and Educating the DVT Patient on Anticoagulation Therapy - Final Draft

“Each year, venous thromboembolism affects about 1 in 1,000 people in the United States” (Bartley, 2006). Typically a venous thromboembolism begins as deep vein thrombosis.
The clot may break loose, travel to the lungs, resulting in a pulmonary embolism, a serious and most times deadly condition. Warfarin has become the drug of choice in treating and preventing deep vein thrombosis and other conditions. Adverse reactions such as skin necrosis and risk factors such as cerebral hemorrhage can be severe; nurses must educate patients regarding the importance of careful monitoring and compliance with anticoagulation therapy.
Deep vein thrombosis (DVT) mostly involves the legs. Certain health conditions such as heart failure, prolonged bed rest and immobility are increased risk factors for developing DVT’s. All patients are different and may not show the same, or any, signs and symptoms. Classic symptoms are acute swelling, redness and warmth in the affected limb. The patient may or may not have pain with Homan’s sign – calf pain when the foot is dorsiflexed. Bartley reports studies have shown a 10% to 40% incidence of hospital-aquired DVT among medical and general surgical patients who do not receive prophylaxis, for patients who undergo major orthopedic surgery, it’s 40 to 60% (2006).
There are interventions to help prevent and manage DVT’s. To better help circulation and reduce risk of blood clots, nurses can make mechanical prophylaxis a part of their care plan. Mechanical prophylaxis includes compression stockings and intermittent pneumatic compression devices and venous pump. For management of DVT’s, the use of anticoagulants includes warfarin and heparin. Warfarin, also known as coumadin, inhibits the synthesis of coagulation factors dependent on vitamin K, which are factors II, VII, IX and X. It also inhibits proteins C and S anticoagulants. Warfarin absorbs rapidly from the GI tract, peaking absorption 60 to 90 minutes after ingestion. The anticoagulation effects of warfarin typically take 3 to 4 days after administration and last 4 to 5 days. Turner states warfarin is 99% plasma protein bound, mainly to albumin. It accumulates in the liver until it is broken down into inactive metabolites and excreted in urine (2006). For a patient with impaired renal function, the dosage of warfarin does not need to be adjusted. Conditions such as cirrhosis or congestive heart failure increases warfarin's anticoagulant effects and decreases its metabolism. Vitamin K reverses anticoagulant effects of warfarin.
In addition to the nurse understanding how warfarin works in the body, the patient needs an understanding of the therapeutic effects of the medication. Nurses accomplish this by monitoring the Prothrombin time and the International normalized ratio (PT/INR) in collaboration with the physician and pharmacist. Prothrombin time uses a reagent called thromboplastin, a substance sensitive to levels of Vitamin K dependent factors. These are factors II, VII and X. Unfortunately, the reagents vary from lot to lot, making the PT values vary in labs worldwide. “To ensure consistency and reliability in reporting PT, the World Health Organization introduced a system known as International Normalized Ratio (INR)” (Gibbar-Clements, 2000). INR takes thromboplastin sensitivity into account, therefore should be used along with PT. Average starting dosages of warfarin are 2 to 5 mg a day. Doses thereafter are adjusted according to the PT/INR results. Daily monitoring is needed until a target therapeutic range is reached for 2 consecutive days. The goal of warfarin therapy is a PT of 1.5 to 2.5 times the control value or an INR of 2.0 to 3.5. There are various INR ranges for various health conditions. The target INR range for DVT’s and pulmonary embolism is 2.0 to 3.0. Turner recommends The American College of Chest Physicians' guidelines in dealing
with elevated INR without active bleeding:
If the INR is above the therapeutic range but below 5, the patient may skip the next dose and the warfarin dosage may be reduced. If the INR is 5 or greater but less than 9, the patient should skip the next one or two doses and restart warfarin at a lower dose, as prescribed, once the INR has stabilized in the therapeutic range. The prescriber also may order oral vitamin K, the antagonist to warfarin in low doses (5mg or less). If the INR is 9 or above, administer higher-dose oral vitamin K (5 to 10 Mg) and discontinue warfarin until the INR stabilizes in the therapeutic range. Once the INR is therapeutic, warfarin can be resumed at a lower dose. (2006, p.44)
Low INR is equally dangerous for the potentiate of blood clotting. While on warfarin, blood testing is indefinite. Once stabilized, testing typically is done weekly from 4 to 6 weeks, then monthly.
Nurses have a large role in monitoring warfarin's therapeutic and side effects, as well as educating patients. One of the most important side effects to monitor for is bleeding. “Teach patients to monitor closely for signs and symptoms of bleeding gums, bruises, nosebleeds, blood in vomit, bloody stools, dark tarry stools, blood in the urine, tea-colored urine, difficulty in controlling bleeding from small cuts and heavy menstruation” (Malacaria and Feloney 2003). If bleeding is noted, hold the next dose of warfarin until the healthcare provider has been notified. If symptoms of shortness of breath, dizziness, weakness and headache presents, internal bleeding may be happening and 911 should be called immediately. Use safe precautions to minimize bleeding such as soft-bristle toothbrushes and electric razors. A patient should discuss the use of
any over-the-counter medications, such as cold medications and herbal supplements, with their provider while on warfarin therapy. Inform patients to wear some type of identification stating he or she is on anticoagulant therapy. Holcomb advises nurses to make sure the patient knows to maintain a consistent intake of vitamin K foods so they do not interfere with the warfarin (2006). Avoid excessive alcohol intake for it can shorten bleeding time. Patients must understand why they are taking warfarin and the importance of monitoring. Warfarin should be administered at the same time every day. If a dose is missed, take as soon remembered; do not take a double dose. Inform the patient that a sometimes rare but serious adverse reaction of warfarin is skin necrosis of the breast, butt, thigh or penis. This reaction usually occurs between day 3 and 8 of therapy. If this develops, warfarin is stopped. The patient will be re-started on IV heparin, followed by a lower dose of warfarin. Other mild adverse reactions that may occur are headache, nausea, diarrhea, GI cramps, rash and hair loss.
Warfarin can be life-saving for many patients with DVT. By educating patients how warfarin works, the importance of monitoring by checking PT/INR and crucial side effects, the patient will benefit from warfarin therapy with decreased risks.




Barriers for the Nurse Caring and Educating the DVT patient on Anticoagulation Therapy

Intervention 1: T he patient needs an understanding of the therapeutic effects for patient compliance and safety. It is especially important once the patient is on an outpatient status.
i.One disadvantage/barrier for the patient is ethnicity/racial background.
A study was done using residents from New Jersey's medicaid or pharmacy assistance for the aged and disabled program, assessing how frequently these patients filled their prescriptions for 3 months of oral anticoagulant therapy and what demographic and clinical factors predicted a less adequate duration of care. “The most recent evidence-based recommendations of the American College of Chest Physicians (ACCP) call for at least 3 months of oral anticoagulant therapy after PE or DVT unless therapy is contraindicated” (Ganz, et al). The study found that of the 437 caucasian particants, 20% had an inadequate duration of therapy. Out of 105 african americans tested, 30% had an inadequate duration of therapy:
Our finding of an asociation between race and inadequate duration of therapy is consistent with prior studies showing undertreatment of African Americans for ischemic heart disease, glaucoma, and other conditions. This association is unlikely to be confounded by income, because enrollment in medicaid did not emerge as an important determinant of short duration of therapy in either univariate or multivariete analyses. A recent study using data on medicare beneficiaries has shown that race remains a persistent determinant of disparities
in the use of a variety of health services, even after adjusting for income.(Ganz, et al, pg 779)
ii.Another disadvantage is knowledge deficit.
“There is evidence that adherence to medical treatment is enhanced by knowledge and understanding of the drug, its benefits and its side-effects” (Nadar, et al). Nurses must pull together all resources to make sure their patients have a clear understanding of why they are taking an anticoagulant. A study published in the Journal of the Royal Society of Medicine tested 180 patients. 135 were white European, 29 were Indo-Asian and 16 were Afro-Caribbean. 45% of the Indo-asian patients, compared with 18% of the Europeans and 19% of Afro-Caribbeans felt they had difficulty understanding their anticoagulant management. 94% of patients knew what type of drug warfarin is but only 54% knew why they were taking it and what dose they were on. “Another reason for the patients' lack of knowledge concerning the disease process and the side-effects could of course , be poor conselling and information-giving by healthcare professionals” (Nadar, et al). As regards written material, (Estrada et al) found that some of the patient information on anticoagulation therapy was above the comprehension level of most patients. This study concluded that many of the patients did not know why they were attending anticoagulation clinic, why they were using anticoagulants, and a poor idea of complications. This can compromise patient safety if they do not fully understand the importance of taking anticoagulant medication and importance of PT/INR monitoring.
Intervention 2: Educating patients of important side effects.
i.A disadvantage is language barriers
Nurses must make sure their patients have a better understanding of side effects by having the patient repeat what they were taught. Also patients that have english as a second language may understand better with literature written in their native language, as well as using an interpreter while educating to make everything more clear to the patient. 49% of the Indo-asian patients attended the clinic with them because “to help them out with language problems” (Nadar, et al). In the study done in the UK when asked about potential side effects, most could mention only one, which was increase in bleeding. All of the participants knew what could happen if they were to stop taking warfarin.
ii.Another disadvantage is ethnicity.
Some patients of different ethnic backgrounds are more comfortable with a provider of the same ethnicity, especially in the older adult populations. “62% of the Indo-Asians preferred to have a doctor of the same ethnic origin” (Nadar, et al). Nadar, et al study also confirmed that many Indo-Asian patients felt more comfortable with a doctor of the same ethnic group , possibly for language reasons but perhaps also because they would feel more at ease in asking questions.

References

Bartley, M. (2006). Keep venous thromboembolism at bay. Nursing 36, 36-41.
Gibbar-Clements, T., Shirrell, D., Bogley, R., and Smiley, B. (2006). The challenge of warfarin therapy. American Journal of Nursing, 100, 38-40.
Holcomb, S. (2006). Coumadin (warfarin) therapy. Nursing, 36, 45-46.
Malacaria, B., and Feloney, C. (2003). Going with the flow of anticoagulant therapy.
Nursing, 33, 36-. Retrieved January 25, 2007 from TCC Proquest database.
Turner, L. (2006). Keeping warfarin therapy in balance. Nursing, 36, 43-44.
Nadar, S. et al (2003). Patients' understanding of anticoagulant therapy in a multiethnic population. Journal of The Royal Society of Medicine, 96: 175-179.
Ganz, D. A., et al (2000). Adherence to Guidelines for Oral Anticoagulation after Venous Thrombosis and Pulmonary Embolism. Journal of General Internal Medicine, 15:776-781
Estrada, et al, (2000). Anticoagulant patient information material is written at high readability levels. Stroke, 21:2966-70.

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Pressure Ulcers in the Elderly

Care and Prevention
Nurses working with geriatric patients are aware that they provide care not only for the acute or chronic disease symptoms that bring patients to their facilities, but for other conditions that may detract from quality of life. Elderly patients are vulnerable to pressure ulcers primarily due to decreased mobility and poor nutrition; nurses must be responsible for assessing their elderly patients’ ability to ambulate safely and their risk for decreased nutrition in order to safeguard against this debilitating condition.

A holistic approach to this potential complication may be the best way to medically manage this risk.
For the elderly patient a required initial assessment of the skin is done upon admission. One of the tools used to evaluate the patient's level of risk for skin breakdown is the Braden Scale. It assigns numerical values to levels of sensory perception, moisture, activity, mobility, nutrition and friction/sheer. The lower the assessed number, the higher the risk for impaired skin integrity (Black, Hawks & Keene, 2001, p. 1299). The results of the assessment can identify the interventions that will reduce risk and protect the patient's skin. Some examples include keeping the skin warm and dry, reminding and assisting the patient with frequent position changes, and encouraging safe ambulation and mobility techniques. Physical and occupational therapy may be ordered to evaluate the patient's limits of safety and ability to perform activities of daily living. A dietary evaluation should be made and nutritional supplements may be suggested such as multivitamins with minerals and nutritional supplements. Encouraging a balanced diet with sufficient calories and hydration is also a nursing function (Myles, 2006).
As people get older their ability to move or change positions regularly may decrease due to diminishing muscle strength, joint diseases, loss of sensory perception from chronic disease processes or cerebral vascular accident (CVA), confusion or dementia or various other complications of aging. This reduced mobility can subject skin, stretched over bony prominences such as heels, elbows, the coccyx, the scapula, etc., to experience reduced blood flow (CareNotes, 2006). The decreased circulation to these areas begins a breakdown in the integrity of the skin and unless pressure is relieved, skin ischemia can develop, sometimes in less than two hours. Common interventions to protect the elderly patients skin include using pressure relieving mattresses or air filled overlays, pressure reducing pads in wheelchair seats and special wheelchairs that tilt at different angles to relieve constant pressure from sitting in one position. Specially trained staff work with the therapy departments and provide restorative exercises that are designed to maintain and even improve a patient's mobility, which in turn reduces their risk for skin breakdown. Bed bound patients are placed on turning schedules designed to relieve pressure (Baldwin, 2005).
Skin changes as people age. It becomes thinner and more fragile. Its ability to heal or protect the body from outside forces is reduced. Its vascularity is reduced and the decreased delivery of oxygen and nutrients compromises skin integrity and it's ability to heal. According to Zulkowski (2003), the adhesion between the layers of skin such as the dermis and epidermis declines adding increased risk for friction and sheer injuries. These injuries are not a result of unrelieved pressure but are a breakdown of the skin's integrity when turning or repositioning a patient without properly reducing the pressure on the outer layer of the derma, tearing it from the underlying layers of tissue. These injuries can appear like burns or abrasions. Baldwin (2005) states these injuries can be avoided by using "proper patient lifting and moving techniques.
Nutrition is also an area of concern for the elderly. As people age their ability to taste and smell diminishes and food is not as appealing. They may have an impaired ability to chew their food due to worn or missing teeth or ill-fitting dentures. Some may be cognitively impaired or suffer from dementia and lose the ability to feed themselves. Many may be malnourished, especially in protein, a key nutrient necessary for the healing process and the production of collagen. Collagen is major ingredient of healthy skin and as Zulkowski (2003) states, "is the principal structural body protein." As the body ages, the collagen produced loses it's flexibility and becomes thicker and aging skin has decreased elasticity making it more susceptible to tear type injuries. A dietary consultation is a common intervention that will provide an accurate assessment of the patient's nutritional status (Baldwin, 2005). Protein may be increased with their meals and supplements such as Vitamin C and Zinc can be added to the patient's daily medications. If their appetite is poor, nutritional supplements can be offered (Black, et al, 2001, p. 1297).
If a patient is admitted with a pressure ulcer or one develops during care, the wound should be assessed and staged. The assessment includes documenting the cause, size, location, and dimensions of the wound. It should include a description of exudates or drainage, any local signs of infection, the appearance of the wound and the condition of the surrounding skin, and if there is any undermining or odor. Pain is also documented as to its cause, level, location and management (Benbow, 2006).
Pressure ulcers are staged as follows:
Stage I Non-blanching erythema of intact skin; the initial lesion of skin ulceration.
Stage II Partial-thickness skin loss involving epidermis and/or dermis. The ulcer is
Superficial and presents clinically as an abrasion, blister or shallow crater.
Stage III Full-thickness skin loss involving damage or necrosis of subcutaneous
tissue, which may extend down to, but not through, the underlying fascia.
the ulcer presents clinically as a deep crater with or without undermining
of adjacent tissue.
Stage IV Full-thickness skin loss with extensive destruction, tissue necrosis, or
damage to muscle, bone, or supporting structures.
(Black, et al, 2001, p. 1297).
Wound coverings can range from ointments that promote circulation and provide a moisture barrier to long term wound management. This includes debridement to remove necrotic tissue and encourages increased circulation, which delivers oxygen and nutrients to the site. Irrigation with normal saline may be used to clean the wound and once all the dead tissue is removed, dressings may be applied that keep the wound bed moist and the surrounding tissue dry and healthy. Keeping the patient rested and stress free is also thought to improve the healing process (Myles, 2006).
In short, the prevention of pressure ulcers and the treatment of existing sores requires a holistic approach. It takes a healthcare team to protect our elderly from this health risk, which is a real threat to the quality of their life.




Intervention 1: Encouraging a balanced diet with nutritional supplements, sufficient calories and hydration.
i. Disadvantage 1: Socioeconomic; According to Young (2003) “risks for frailty, besides being old, include ethnicity, poverty, and lower educational attainment, each of which independently predicts poorer health and inferior treatment by the health care system.”
ii. Disadvantage 2: Lack of Insurance; Fixed incomes and costs of medications may force the elderly patient with multiple chronic conditions requiring numerous medications to choose between buying food and buying their medications. An estimated 31% of men and 61% of women over age 65 live on fixed annual incomes under $10,000.00 (Zulkowski, 2003

Intervention 2: Keeping skin warm and dry, frequent position changes, physical and occupational therapy to assist with safe ambulation and mobility techniques.
i. Disadvantage 1: Socioeconomic Income is tied to functional limitations in older adults.
In a study published by the New England Journal of Medicine, community dwelling senior citizens participated in a survey conducted by the National Institute on Aging in collaboration with the University of California, Berkley, and the University of Toronto. According to the survey “nearly one in four respondents reported having a functional limitation, defined as a long-lasting condition that substantially limits one or more basic physical activities, such as walking, climbing stairs, reaching, lifting, or carrying” (Anonymous, 2006)
The researchers report that people living below the poverty line have the most functional limitations but that as the income levels increase, so do the reported limitations and with each increase in educational level as well, a measure that is closely tied to income.
ii. Disadvantage 2: Knowledge Deficit; The Institute of Medicine defined failure to thrive late in life as a syndrome manifested by several identifiable factors including inactivity. According to Robertson & Montagnini, “four syndromes are prevalent and predictive of failure to thrive and they are impaired physical function, malnutrition, depression and cognitive impairment. Elderly patients who are depressed are more likely to complain of physical problems than to mention depressive symptoms such as mood changes. This is a knowledge deficit.














References

Anonymous (2006) Income Tied to Functional Limitations in Older Adults. PT 14(11) 94 Retrieved October 26, 2007 from ProQuest database.
Baldwin, K (2005). How to prevent and treat pressure ulcers. LPN 2005 1(2) 18-25
Benbow, M. (2006). Guidelines for the prevention and treatment of pressure ulcers. Nursing Standard 20(52) 42-44. Retrieved January 20, 2007 from Expanded Academic ASAP database.
Black, J., Hawks, J., & Keene, A., (2001). Medical Surgical Nursing. Management for Positive Outcomes. 6th Ed., Philadelphia: W.B. Saunders Company.
How to prevent pressure sores. (2006, May). CareNotes. Retrieved January 20, 2007 from Expanded Academic ASAP database.
Robertson, R., & Montagnini, M., (2004). Geriatric Failure to Thrive. American Family Physician 70(2) 343. Retrieved October 25, 2007 from ProQuest database.
Myles, J. (2006). Woundcare assessment and principles of healing. Practice Nurse 32(8) Retrieved February 3, 2007 from Proquest database.
Young, K. (2003). Challenges and Solutions for Care of Frail Older Adults. The Online Journal of Issues in Nursing. Retrieved October 25, 2007 from Proquest database.
Zulkowski, K. (2003). Protecting your patient's aging skin. Nursing 33(1) 84. Retrieved February 3, 2007 from Proquest database.
Zulkowski, K. (2003). How nutrition and aging affect would healing. Nursing2003 33(8) Retrieved October 26, 2007 from EBSCO host database.

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Nursing Strategies in the Pregnant Client With Spinal Cord Injuries

Spinal cord injuries (SCI) and pregnancy can be a potentially fatal combination for both the mother and fetus; nurses must be alert to signs and symptoms of complications and be prepared to use interventions including pharmacologic and nonpharmacologic measures along with preventative plans of care. It is the nurse’s responsibility to educate the pregnant, spinal cord-injured client about potential complications of this high-risk situation as most women in this position wonder if pregnancy should be avoided.

Autonomic Dysreflexia (also known as hyperreflexia), is an exaggerated sympathetic response in clients with spinal cord injuries. The pathophysiology of autonomic dysreflexia begins with a noxious or painful stimulus below the level of the lesion on the spinal cord. There are many precipitants that may trigger this dangerous hypertensive cycle with most common to include: a distended bowel or bladder, a pressure sore, restrictive clothing, an ingrown toenail, or labor (Blackmer, 2003). This noxious stimulus will trigger an afferent motor nerve that sends the message toward the brain about the potential tissue harm, pain, or damage. However, in the client with a spinal cord injury the message is blocked in its path at the level of the lesion and detoured to the autonomic nervous system. Once the autonomic nervous system receives this pain message, it begins to release neurotransmitters which cause vasoconstriction with a sudden and dangerous elevation in blood pressure (20 to 40 mm Hg above baseline). According to Essat (2003) the pressure receptors in the aortic arch of the heart sense the increase in blood pressure and attempt to correct the problem by sending another message asking the brainstem to slow the heart rate via vagal stimulation. In addition to slowing the heart rate, the brainstem also sends an efferent sympathetic message to correct the issue, although the message pathway encounters the same block. Hypertension and bradycardia continue until the noxious stimulus is eliminated.
It is important for the nurse to differentiate between the elevated blood pressure associated with autonomic dysreflexia and preeclampsia. In 2005 Bycroft, Shergill, Choong, Arya, and Shah reported that both autonomic dysreflexia (32%) and preeclampsia (38%) were found at relatively high rates among women with spinal cord injuries. Hypertension with preeclampsia will rise and fall with contractions and will disappear after delivery; a hypertensive crisis associated with autonomic dysreflexia will continue to rise until the noxious stimulus is removed regardless of uterine contractions. Nurses should include the common signs and symptoms of autonomic dysreflexia in the education care plan, because often times this sympathetic nervous system response may be their only sign of the onset of labor. Bycroft et al. (2005) reported that the presentation of this disorder makes the definition of autonomic dysreflexia a difficult syndrome to detect. Diagnostic clinical criteria have been suggested for autonomic dysreflexia; however it has been compromised by the increase in systolic blood pressure by at least 20%, and the following: sweating, chills, cutis anserine ("goose flesh"), headache, or flushing.
Pregnant clients with spinal cord injuries are at great risk for developing deep vein thrombosis (DVT) due to the immobility associated with spinal cord injuries. In consideration of Virchow’s triad (hypercoaguability, stasis, and endothelial injury) it is important to keep the legs moving to promote lower extremity circulation. According to Ethans (n.d.) nurses should recruit assistance from outside departments (such as physical therapy) to educate the pregnant client on active and passive exercises to promote blood flow. Lower extremity edema is common in both pregnancy and spinal cord injuries, so it is important for the nurse to stress the importance of using pressure stockings and leg elevation as much as possible.
Pregnant clients with SCI may have “silent labor” meaning they may have painless contractions and painless cervical dilation. Often too, the signs of labor may go unnoticed because the contractions may be interpreted as a dull ache, and the rupture-of-membranes may be mistaken for urinary incontinence. Obstetric nurses should instruct their pregnant clients on how to use uterine palpation techniques and how to identify other signs of labor, including feelings of anxiety, changes in spasticity or breathing, pelvic pressure, and autonomic dysreflexia (Morantz and Torrey 2002, p. 1781).
Every woman, pregnancy, and spinal cord injury are different and therefore it is a very individualized choice weather or not to consider pregnancy. Women of this population must be made aware of signs, symptoms, complications, and management of autonomic dysreflexia. Nurses in this field must have a detailed plan-of-care prepared to review with these clients including safety precautions, preventative measures, and signs of labor onset. Due to the risk of added blood volume and immobility, it is important to take extra precautions in preventing thromosis and emboli during pregnancy by wearing pressure stockings, active and passive range of motion, and leg elevation. Women with spinal cord injuries may be considered to have high-risk pregnancies. However, it does not mean that pregnancy should be avoided all together. This situation gives the nurse another opportunity to educate on prevention and treatment of complications.

Intervention 1: Client Education
Pregnant clients with spinal cord injuries are considered high-risk cases. They must be educated on their unique pregnancy risks in comparison to pregnant clients without spinal cord injuries.

Disadvantage 1: Knowledge Deficit
Spinal cord injured clients present with the possibility of developing Autonomic Dysreflexia (AD) which can lead to a dangerous rise in blood pressure and can be potentially fatal to both the mother and fetus. Morantz and Torrey (2002) state, “Autonomic Dysreflexia is the most significant medical complication seen in women with SCIs, and precautions should be taken to avoid stimuli that can lead to this potentially fatal syndrome.” These unique obstetric clients should be educated on the signs & symptoms of AD because this autonomic nervous system response may be their only sign of the onset of labor. Uterine contractions, speculum examinations, bladder distension, bladder infections, catheterization, constipation, and cesarean delivery can trigger this syndrome (Demasio and Magriples 1999, p. 225). Symptoms include severe hypertension, headaches, anxiety, diaphoresis with piloerection, and cardiac arrhythmias.

Disadvantage 2: Information Misrepresentation
It is important to differentiate between the elevated blood pressure associated with AD and preeclampsia. This risk for preeclampsia will increase with gestation; however AD can occur at any time during pregnancy. Demasio and Magriples (1999) state, “Autonomic Dysreflexia complicates pregnancy in 85% of SCI women…hypertension is the most common medical complication in pregnancy and complicates 10% of all pregnancies, preeclampsia does not occur more frequently in the SCI woman.” Hypertension with preeclampsia will rise and fall with contractions and will disappear after delivery; a hypertensive crisis associated with AD will continue to rise until the noxious stimulus is removed regardless of uterine contractions.

Intervention 2: Prevention of Avoidable Complications
Due to the fact that SCI clients are non-ambulatory and self-limiting, the pregnant client must take necessary precautions to prevent avoidable complications.

Disadvantage 1: Immobility and Peripheral Complications
This unique population of pregnant women is especially at risk for developing deep vein thrombosis (DVT) due to immobility associated with spinal cord injuries. Morantz and Torrey (2002) state, “For all patients, elevation of the legs and range-of-motion exercises may be implemented as pregnancy advances.” It is also important to note the high possibility of pressure ulcers related to transfer difficulties due to increasing weight, and immobilization in the advancing pregnancy.

Disadvantage 2: Bowel and Bladder ConsiderationsUrinary tract and bowel management are essential for pregnant spinal cord-injured clients. In consideration that many SCI clients have neurogenic bladder, as the fetus increases in size, it can push on the bladder causing incontinence. In addition, toward the end of the pregnancy the client feels the need to increase the frequency of self-catherization to avoid incontinence. This creates a higher risk for developing a urinary tract infection. Ethans (n.d.) states, “Urine infections may be more common, and it’s important to get these treated, as infected urine is more likely to go backwards to infect the kidneys, when there is pressure on the bladder from the baby.” Constipation and fecal incontinence can result from decreased sphincter tone and slowed gastrointestinal mobility as a result from increased progesterone levels. Severe constipation requiring bowel evacuation can cause AD and therefore should be avoided and prevented (Demasio and Magriples 1999, p. 223).

References

Blackmer, J. (2003). Rehabilitation medicine: 1. Autonomic dysreflexia. Canadian Medical Association Journal, 169, 931-935. Retrieved on February 5, 2007 from ProQuest database.
Bycroft, J., Shergill, I.S., Choong, E.A.L., Arya, N., & Shah, J.R. (2005). Autonomic dysreflexia: a medical emergency. [Electronic version]. Postgraduate Medical Journal, (81), 232-235. Retrieved on May 17, 2007 from http://pmj.bmj.com/cgi/content/full/81/954/232
Essat, Z. (2003). Management of autonomic dysreflexia. Nursing Standard, 17(32), 42-44. Retrieved on May 19, 2007, from Expanded Academic database.
Ethans MD, K. (n.d.). Pregnancy in Women with Spinal Cord Injury. Retrieved on May 5, 2007, from www.spinalcord-injury.com/newpregpage.html
Morantz, C. and Torrey, B. (2003). Obstetric Management of Patients with spinal Cord Injuries. American Family Physician, 66(9), 1781-1782. Retrieved on May 7, 2007 from ProQuest database.
Popov, I., Ngambu, F., Mantel, G., Rout, C., & Moodley, J. (2003). Acute Spinal Cord Injury in Pregnancy: An Illustrative Case and Literature Review. Journal of Obstetric and Gynecology, 23(6), 596-598.
Carrie Morantz, Brian Torrey. (2002). Obstetric management of patients with spinal cord injuries. American Family Physician, 66(9), 1781-1782. Retrieved November 2, 2007, from Platinum Full Text Periodicals database. (Document ID: 243996711).
Kafui Demasio, Urania Magriples. (1999). Pregnancy Complicated by Maternal Paraplegia or Tetraplegia as a Result of Spinal Cord Injury and Spina Bifida. Sexuality and Disability, 17(3), 223-232. Retrieved November 2, 2007, from Research Library database. (Document ID: 943918391).
Ethans MD, K. (n.d.). Pregnancy in Women with Spinal Cord Injury. Retrieved on October 29, 2007, from www.spinalcord-injury.com/newpregpage.html

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Obesity: A Nursing Challenge

Obesity is becoming an epidemic in the United States and is changing and challenging health care. Obesity is a problem not only because it can cause other medical conditions in patients, but also because it presents challenges to the nurse caring for a larger client.

The nurse plays a critical role in preventing, treating and reversing obesity and its effects. Clients should be educated by nurses about diet and exercise to prevent and reverse the progression of obesity. Nurses should be knowledgeable about the safe use of equipment made for the larger client and adjustments necessary during assessments to receive accurate results. Nurses are also responsible for preventing and recognizing common problems that coexist with obesity.
Obesity is defined as a body mass index of 30% or greater (Arzouman, Lacovara, Blackett, McDonald, Traver & Fran, 2006, ¶3). According to the Surgeon General, in 1999, 61% of Americans were overweight or obese; the percentage having increased since then (“Overweight and Obesity,” 2007, ¶1). Obesity puts individuals at greater risk for other health problems like hypertension, cardiac and vascular disease, respiratory dysfunction, cancer, Diabetes Mellitus, and depression (“Overweight and Obesity,” 2007, ¶1). Because the incidence of obesity is increasing and the implications on health are so great, nurses must take action to educate and efficiently care for the obese, and those at risk for obesity.
A major aspect of preventing or reversing obesity is maintaining or losing body weight. The nurse should educate clients on how to lose weight during health history intake, while the client is being treated in the facility, and during discharge. The U.S. Surgeon General’s website stresses the importance of balancing calorie intake with calorie expenditure to maintain weight, and using more energy than is taken in to lose weight (“Overweight and Obesity,” 2007, ¶4). The client should also select an enjoyable activity and commit to the exercise regimen; making it more likely for the patient to continue with the regimen (“Overweight and Obesity,” 2007, ¶4). When considering the patient’s diet, Cleator (2004) recommends the “staged approach” (¶36). In step one, Frost (2003) recommends discussing a client’s normal diet in order to evaluate lifestyle, food intake, and food triggers (as cited in Cleator, 2004, ¶38). In step two, it is important to “stabilize eating behavior” by discouraging erratic binging and making meals a routine (Cleator, 2004, ¶39). Step three requires implementing healthier eating and healthier notions about food (Cleator, 2004, ¶42). The last step incorporates decreasing intake by 500 kilocalories which Melanson and Dwyer (2002) attribute to a 1-2 pound weight loss per week (as cited in Cleator, 2004, ¶35 & 43). Along with promoting a healthy diet and adequate exercise, the nurse should seek additional information from the client during health history intake. According to Goldstein (1992), the nurse should identify the patient’s motivation for weight loss because it is an indicator of the likelihood of success depending on how committed the client will be in managing his or her weight (as cited in Cleator, 2004, ¶24). A weight history should also be reviewed in order to identify any setbacks and to allow for realistic goal setting (Cleator, 2004, ¶28 & 31).
Because of the size of the client, the nurse must use equipment tailored for the obese to ensure safety and comfort while providing care. Equipment that should be considered when treating an obese client include specialty beds, wide front-wheeled walkers, wide room chairs, wide beds that lower close to the floor, lifts, transport stretchers, scales, and bed trapeze (Arzouman et al., 2006, ¶10). All of these are necessary for the safety and competent care of the obese client, but also for the safety of staff, as Spratley, Johnson, Sochalski, Fritz, & Spencer (2000) attribute “older nurses moving heavier patients [as a contributor] to workplace injuries (as cited in Arzouman et al., 2006, ¶4). Along with using special equipment, the nurse should use special techniques during head-to-toe assessment to ensure accurate data is collected. Hahler (2002) recommends using an appropriate size blood pressure cuff of obtain accurate readings that are not falsely high and to prevent tissue injury (¶5). Skin folds should be displaced when auscultating breath sounds and the diaphragm of the stethoscope placed in areas where the lung is closest to the chest (Hahler, 2002, ¶6). Hahler (2002) also recommends “nurses should listen for heart sounds either over the left lateral chest wall while the patient is turned toward the left side, or over the aortic or pulmonic areas to the left or right of the sternal border at the second intercostals space” (¶7). Bowel sounds will take longer to distinguish because of the thicker layer of adipose tissue. Marking where the sounds are most easily heard can make assessments from other care team members easier and their findings more consistent with those made previous (Hahler, 2002, ¶7).
In addition to accurately assessing system functions, the nurse should also perform an aggressive skin assessment on the obese client because of his or her high risk for developing skin breakdown and pressure ulcers (Hahler, 2002, ¶8). The nurse should perform a baseline skin assessment as part of the initial head-to-toe assessment, and do regular skin assessments thereafter, in order to identify skin breakdown. All areas of the skin should be assessed especially under folds of the breasts, abdomen, back, and perineal areas because of the presence of moisture, pressure, and friction (Hahler, 2002, ¶8; Arzouman et al., 2006, ¶10). Dermatitis can be prevented by placing gauze or washcloths in folds to help keep the area dry, applying antifungal agents to decrease rashes, and applying lubricants and ointments to treat superficial skin irritations (Hahler, 2002, ¶20). “Often, [patients] are protein deficient, and lack essential nutrients necessary for healing,” so a nutritional assessment is also vital to promote epithelialization. It is the nurse’s duty to obtain this information along with laboratory values in order to track and treat the common problem of skin breakdown found in obese clients (Hahler, 2002, ¶8).
The nurse is an important member of the healthcare team who can do much to aid the fight against obesity. In all clinical settings, the nurse can teach clients about ways to prevent obesity and reverse the process if it has manifested. He or she can effectively treat the obese using bariatric tools and adjusted assessment. The nurse can also identify and care for common problems of those already afflicted with obesity. In all of these actions, the nurse is an integral educator and caregiver who can change the life of obese clients and change the status of the obesity epidemic for the better.

Intervention 1: Clients should be educated by nurses about diet and exercise to prevent and reverse the progression of obesity.
Disadvantage1: Although education is a good way to encourage power and change through knowledge, education alone cannot promote the obese or those at risk for obesity to prevent or reverse the disease. Obesity is a multifactorial disease that includes many predisposing factors such as socioeconomic status. In a study surveying the relationship between socioeconomic status and weight in US women, it was shown that women of lower socioeconomic status reported a greater intake of calories (including a higher percentage from fat), and utilized fewer behaviors to promote a low-fat diet (Jeffery & French, 1996, ¶21).
Although obesity and socioeconomic status were shown to be inversely related, the same could not be said about exercise (Jeffery & French, 1996). Jeffrey and French state, “physical activity did not vary significantly by income group […] higher income women were slightly more likely to engage in recreational physical activity, whereas lower income women reported more work-related and home maintenance-related physical activity” (1996, ¶21).
Because studies about the relation between socioeconomic status and obesity are varied due the many factors contributing to obesity, it is important to further evaluate client motives and other aspects of client life that lead to weight gain or weight loss. Further research is necessary to develop a thorough plan of care for obesity especially since general theories point to a correlation between obesity and culture, restricted environmental opportunities and discrimination (Jeffery & French, 1996, ¶2).
• Disadvantage 2: Feelings of discrimination can deter obese clients from making behavioral changes to aid in a healthier living by lowering self esteem. In an interview process conducted by Rogge and Greenwald, subjects reported feelings of stigmatization and oppression due to their obesity (2004). When exploring Western culture and beliefs, feelings of condemnation can be attributed to gluttony and sloth (two of seven deadly sins); unattractiveness, undesirability, and self-indulgence portrayed by media; and lack of personal/social power related to low socioeconomic status (Rogge & Greenwald, 2004). Subjects felt that these and other stereotypes placed on the obese allowed others to feel more superior and cause intentional and unintentional hurt (Rogge & Greenwald, 2004). Rogge and Greenwald found that many obese subjects felt shame and humiliation especially when testifying to experiences during childhood, shopping, eating out, and dating; these situations leading to self-alienation in many subjects, as a coping mechanism (2004).
Rogge and Greenwald state that the stigma transcends into healthcare also – that “the lack of sensitivity to their weight problem was often cited among our research subjects” and as stated in research by Petrich, “healthcare providers, like others in society, describe overweight individuals as repulsive, disgusting, weak, and lacking self-discipline” (as cited in Rogge & Greenwald, 2004, ¶85 & 87). So, not only does the medical aspect of care for the obese need to be addressed, but so also does the psychological and social aspect of care. It is the nurses obligation to be aware and sensitive to the client’s experiences and beliefs.
Intervention 2: Nurses should be knowledgeable about the safe use of equipment made for the larger client and adjustments necessary during assessments to receive accurate results.
Disadvantage 1: Financial issues can contribute to client dilemmas, but the same goes for the hospital. In an article evaluating healthcare challenges regarding obesity, Butch de Castro stated, “Most hospitals are ill-equipped to meet the needs of obese patients, such as having adequate or any lifting devices” (as cited in Trossman, 2005, ¶10). Lack of specialized equipment can disrupt the continuity of care and cause inaccurate assessment. In practice, small room sizes, narrow beds and chairs, inadequate sized blood pressure cuffs, speculums, and many other aspects of care are insufficient for the larger patient (Trossman, 2005). More funds need to be put toward diagnostic equipment, assistive tools, and much more in order to provide quality care to all clients.
Disadvantage 2: Knowledge, assessment, and innovation are key to the nurse’s competent care of his or her clients because with those, appropriate accommodations can be made to increase positive outcomes in obese clients. Barbara Hahler does much to identify ways to improve nursing knowledge where there are deficits in order to improve client outcomes (2002). Hahler suggests many care accommodations such as using a larger blood pressure cuffs, auscultating over areas where there is the least amount of tissue, inspecting the skin thoroughly, and assessing nutrition and related laboratory values carefully (2002). Also, knowledge of common comorbities is essential so that anything from rash treatment to acute respiratory distress or sleep apnea can be addressed or resolved (Hahler, 2002). The nurse is obligated to cultivate a wealth of knowledge regarding proper assessment, treatment, and related factors of the obese client because a knowledge deficit and insufficient assessment could compromise patient care.

Arzouman, J., Lacovara, J., Blackett, A., McDonald, P., Traver, G., & Bartholomeaux, F. (2006). Developing a comprehensive bariatric protocol: a template for improving patient care. MedSurg Nursing, 15, (1), 21-. Retrieved April 19, 2007 from Expanded Academic ASAP.

Black, J. & Hawks, J. (2005). Medical-Surgical Nursing: Clinical Management for Positive Outcomes (7th ed.). St. Louis: Elsevier-Saunders.

Cleator, J., Wilding, J., & Wallymahmed, M. (2004). Putting weight management on the nursing agenda. Journal of Diabetic Nursing, 8, (6), 232-. Retrieved February 19, 2007, from Expanded Academic ASAP.

Hahler, B. (2002). Morbid obesity: a nursing care challenge. Dermatology Nursing, 14, (4), 249-. Retrieved February 5, 2007, from Expanded Academic ASAP

Hahler, B. (2002). Morbid obesity: a nursing care challenge. Dermatology Nursing, 14, (4), 249-. Retrieved October 28, 2007, from Expanded Academic ASAP

Jeffery, R. & French, S. (1996). Socioeconomic status and weight control practices among 20- to 45-year-old women. American Journal of Public Health, 86, (7), 1005-1010. Retrieved October 28, 2007, from EBSCOhost in CINAHL
Overweight and obesity: what you can do. (2007, January). U.S. Department of Health & Human Services. Retrieved April 19, 2007, from http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_whatcanyoudo.htm
Rogge, M. & Greenwald, M (2004). Obesity, Stigma, and Civilized Oppression. Advances in nursing science, 27, (4), 301-315. Retrieved October 28, 2007, from EBSCOhost in CINAHL

Trossman, S (2005). Obesity on the rise: leads to workplace challenges, patient concerns. The American Nurse, 65, (2), 2, 21-22. Retrieved October 28, 2007, from EBSCOhost in CINAHL

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Diabetes: Adherence to Preventive Care

Best Nursing Practice for Promoting Successful Care in Adolescent Type 1 Diabetes:
Psychosocial Risks, Adherence to Preventive Care, and Barriers to Nursing Interventions by Paula Straley
Psychosocial Risks and Adherence to Preventive Care
Adolescent diabetes has been increasing in epidemic proportions.

“In the United States the risk for developing Type 1 diabetes is higher than almost all other chronic illnesses of childhood” (Urban & Grey, 2006, p. 517). A diagnosis of diabetes, while significant, is manageable if the individual is committed to monitoring blood glucose levels and practicing lifestyle modifications. The rising incidence of Type 1 diabetes triggers many stressors in young people during their teenage years; the best nursing practice for promoting successful care in adolescent Type 1 diabetes is achieved by managing psychosocial risks and adhering to preventive care. Nursing strategies include therapeutic communication, providing education, and promoting self-efficacy.
The first important nursing strategy required to promote a successful plan for an adolescent with Type 1 diabetes is to establish a therapeutic relationship. The nurse can begin by reading the patient’s chart to identify any issues of concern to explore. During the initial interview with the adolescent and their parents, the nurse must establish a rapport of trust and empathy to facilitate the sharing of ideas and concerns. The nurse needs to observe and address them in the plan of care. The family’s coping mechanisms need to be monitored for their ability to cope with managed care of the adolescent. The adolescents need to be closely observed for emotional response and encouraged to express themselves.
One reason this nursing strategy is so important is because adolescence is a time of emotional turmoil. The majority of adolescents struggle with parental control and the need to define their own self identity. The need to gain autonomy and independence from parental control poses significant problems, especially for an adolescent with diabetes. Parents face anguish over teenagers’ abilities to manage their diabetes and the rejection of parental influences and guidance. According to Preto (cited in Leonard, Garwick , & Adwan, 2005), parents reported concerns relating to adolescents’ long term well-being, whereas adolescents were concerned about their present situation; the opposing perspectives causes conflict between the parents and adolescents. (Leonard et al.) also report that “parental involvement has been directly associated with better outcomes among youth with Type 1 diabetes” ( p. 406). The authors also suggest that family involvement directly correlates with improving metabolic control and compliance. Parents and teens with strong supportive relationships gained better glycemic control and teens assumed more responsibility for their diabetes. The adolescents with conflicting relationships with their parents had less metabolic control and were less likely to adhere to diabetes management.
Another benefit of developing a therapeutic relationship is that it can allow the nurse to identify symptoms of depression in those adolescents with Type 1 diabetes. According to Hood et al. (2006), nearly 1 out of 7 adolescents with Type 1 diabetes suffers from conditions related to depression. This is nearly double the rate of depression reported for all youths. The authors state that factors associated with the increase of depressive symptoms are diabetes specific and the family’s decreased ability to cope. The authors also noted that poor glycemic control tends to be higher in girls than in boys. An increase in hormonal changes may have some correlation factor in girls having higher blood sugar levels. Parents report diabetes-specific conflict associated with lower levels of emotional functioning in youth. Hood et al. (2006), also points out that parents experience anxiety from the pressures associated with successfully managing the care of teenagers who lack adherence. They become stressed and provide less support. Since the implications of profound psychosocial risks are well-established, the nurse needs to be aware of the risk factors when implementing care of adolescents with Type 1 diabetes and educate parents on the signs and symptoms of depression.
Once a nurse has established a positive therapeutic relationship, the nurse can begin the second nursing strategy of educating adolescents and their parents about necessary blood glucose monitoring, medication and lifestyle changes. A dietician consult is implemented in the plan of care, and the adolescent is taught to monitor his or her own glucose levels and recognize the physical signs and symptoms of excessively high or low levels. Parents are taught how fluctuations in blood sugars can produce mood changes. Repeat demonstrations of drawing up insulin and injections are essential in evaluating the understanding and ability of the process. Support is crucial. Adolescents and their families must be able to restate prescribed insulin dosages as it relates to carbohydrate intake and onset, peak, and duration of medication. The adolescent will understand the need to alternate sites to prevent hypertrophy of subcutaneous tissue. The educational process for Type 1 diabetes is ongoing and is usually initiated by a diabetic nurse educator.
Education is an essential part of the third nursing strategy, promoting self-efficacy, and is supported by a collaborative multidisciplinary team. Nurses can help reinforce autonomy in adolescents by initiating more choices and collaborating with the nurse in establishing a plan of care by allowing teens to be a part of their own care team.
A pilot program, The Nurse Case Managed Integrated Care Model, was initiated by the American Diabetes Association in 1997 (Caravalho & Saylor, 2000). The purpose of the program was to provide a continuum of care through a variety of multidisciplinary teams to educate families and provide self-efficacy in managed care of adolescents’ diabetes. The program initiated the nursing process to evaluate the continuum of care provided. The program also considered the maturity level and age of the individuals during the educational process and self-care management. The program directors, furthermore, considered the psychosocial needs of the patients and their families, and the need for counseling to help build healthy coping skills. Caravalho & Saylor (2000) stated that “Increased self-efficacy is an integral part of an empowerment education program” (section 3, para. 3). The authors also report that self-efficacy was associated with better metabolic control. In the past ten years, a similar multidisciplinary approach has been implemented in the educational process for patients who have diabetes. Among the disciplinarians involved are endocrinologists, dieticians, diabetic nurse educators, support groups, and psychologists. The multidisciplinary approach provides a much needed holistic approach to the management and education of diabetes.
One of the ways the nurse can help adolescent diabetics achieve their goal of self- sufficiency is the insulin pump. The insulin pump enables adolescents to manage their care without the complexities associated with transporting myriad syringes, insulin and diabetic supplies. The pump simulates the pancreas and provides better metabolic control, improving the adolescents’ self-efficacy. The pump programming can be modified to accommodate individual lifestyles. This allows teens to be more spontaneous with their diet. For instance; they can program the pump so they can sleep later without getting up early to administer insulin injections. The flexibility that the pump provides allows self-care management for adolescents and builds autonomy. Nurses assess the adolescent’s readiness before insulin pump therapy can be initiated. Interested adolescents must demonstrate motivation, be developmentally capable in their diabetic management, and show an increase in metabolic glucose levels. They must also be prepared to adhere to instructions mandated by diabetic nurse educators and have strong family support.
When developing a plan of care specifically for the adolescent with Type 1 diabetes, the best nursing practice is to establish a multidisciplinary approach to manage psychosocial risks and encourage adherence to preventive care. The nurse needs to be aware of the teen’s need for autonomy and self-efficacy. Promoting self-care management in the adolescent requires effective therapeutic communication and a positive relationship between the nurse, the adolescent, and the families. The parents and teens need to commit to a neutral ground and trust, to gain support and adherence for an overall better outcome, and the nurse needs to establish a therapeutic relationship to assess the psychosocial risks and educational needs of the adolescents and their families. By clarifying the educational needs and risk factors that can affect the teenagers’ ability to manage their own care, nurses can be more successful in implementing the nursing process to collect data for a knowledge base needed to promote strong self-care management and self-efficacy in adolescents and initiating multidisciplinary approach. Nurses can help reinforce autonomy in adolescents by initiating more choices and collaborating with the nurse in establishing a plan of care by allowing teens to be part of their own care team.
Barriers to Successful Nursing Interventions
Intervention 1
Nurses can experience barriers to promoting a successful therapeutic relationship that is essential to the long term management of Type 1 diabetes in adolescents.
Disadvantage 1
One barrier in promoting a strong therapeutic relationship can occur when an adolescent lacks financial resources or has insufficient insurance. According to Klein, Funnell, and Piette (2006), diabetes related costs are expected to increase significantly to an estimated $192 billion by 2020, for both inpatient and outpatient services (p. 500). Nurses are burdened with limited time and resources to build a positive therapeutic relationship between adolescents and their families. Because of high medical costs there is a lack of follow-up and increased non-compliance. Nurses are unable to provide consistency of care and develop intra personal relationships that are indicative to building a sense of trust among adolescents and their families with their nurse.
The lack of follow up can make it difficult for the nurse to assess and evaluate knowledge deficits as it relates to adolescents’ diabetes and complications related to their illness. The limited ability to assess individual’s specific needs can lead to slowed response to providing community resources and can lead to further secondary complications. According to Hood et al. (2006), among the highest risk factors that affect adolescents who have diabetes are depression, parental pressures relating to managed care, and teens’ lack of adherence. Nearly one out of seven adolescents with diabetes suffers from depression. The profound psycho- social risk involved in successful managed care and a good nurse patient relationship cannot be established during sporadic medical visits. The need to seek counseling is essential, but the lack of medical attention and inconsistencies in follow up care can mask underlying issues that can lead to barriers in adolescents’ and families’ self care management success.
Disadvantage 2
A second barrier to promoting a therapeutic relationship among adolescents with Type 1 diabetes is a lack of age appropriate interventions. An essential tool in successful adolescence care management is to keep them fully involved with their personal care. If a nurse fails to acknowledge the teenager’s needs in the decision making process when developing a successful plan of care, the adolescent is less likely to comply with the plan of care. Without an active participant the nurse hits a brick wall. The nurse needs to talk with the teens and listen to their concerns and respect their need for autonomy. According to Wong and Perry (2006), the development of independence and the ability to make decisions based on their own medical regimen is crucial to compliance in self care management (pp. 1238-1240). The nurse must always address age appropriate interactions when implementing the nursing process.
Intervention 2
Nurses can also experience barriers to promoting a successful educational plan for an adolescent with Type 1 diabetes.
Disadvantage 1
A significant barrier to implementing a successful educational plan of care for the adolescent with Type 1 diabetes is once again economic (Krein et al., 2006). They report that “During the past decade, diabetes was ranked among the fifteenth most costly medical conditions treated in the United States” (p. 500). Nurses have played a crucial role in the education and maintenance of diabetes care with in a continuum of care management among individuals on both an inpatient and outpatient basis. Diabetes is a chronic disease and diabetes education is maintained through a multi disciplinary approach over a prolonged outpatient education service plan. Inpatient diabetes education is based on an anticipated stay of less than three days to teach adolescents and their families or any other newly diagnosed diabetic outpatient survival skills. Outpatient referrals are essential (Habich, 2006).
The process for ongoing diabetic education is very costly and can prevent individuals from seeking help. According to Krein et al. (2006),many patients pay some out-of-pocket expenses for their diabetic supplies and diabetic related services. The overwhelming cost of diabetic services and supplies can lead to decreased compliance and decreases use of prescribed medications that can lead to secondary health complications.
When evaluating the plan of care for the adolescent and their families, nurses need to be aware of the issues of compliance related to lack of insurance or lack of monetary resources.
Nurses can familiarize themselves with community programs that help support families with cost effective interventions. Nurses should always reinforce the importance of diabetes management and preventive care. The Balanced Budget Act acknowledges the value of diabetes self training and provisions of diabetic supplies to those in need (Krein, 2006, p. 504). “Because diabetes care is so costly, diabetes management has been singled out through a mandated benefit and insurance coverage initiatives at both the state and federal levels” (p. 504).
Disadvantage 2
Another barrier to a nurse implementing a successful plan of care for adolescents and their families with Type 1 diabetes is language and literacy barriers. According to Garcia and Benavides-Vaello (2006), “In the United States, non Hispanic blacks and Mexican Americans are two times more likely to develop diabetes than non Hispanic whites” (p. 605). It is extremely important that the nurse faced with the challenge of promoting a strong knowledge base of diabetes management evaluates the knowledge of the family in light of possible cultural or language barriers. Nurses can provide educational material in the family’s preferred dialect if needed to help facilitate understanding or provide staff member who speaks the same dialect. Educational material should be provided in the native language of and at the literacy level of the adolescent or their family. “Patient provider interactions seem to be an important component of diabetes care that can profoundly influence whether and to what degree a patient engages in diabetic self management “(Garcia, p. 613). The nurse should facilitate community involvement and resources (p. 615).

References
Caravalho, J. Y., & Saylor, C. R. (2000). An evaluation of a nurse case-managed program for children with diabetes. Pediatric Nursing, 26, 296-304. Retrieved January 29, 2007, from InfoTrac Expanded Academic database.
Garcia, A. A., & Benavides- Vaello, S. (2006). Vulnerable populations with diabetes mellitus. Nursing Clinics of North America, 41(4), 603-623.
Habich, M. (2006, Apr.). Establishing a standard for pediatric inpatient diabetes education. Journal of Pediatric Nursing, 32, 113-116. Retrieved October 25, 2007, from ProQuest database.
Hood, K. K., Huestis, S., Maher, A., Butler, D., Volkening, L., & Laffel, L. (2006). Depressive symptoms in children and adolescents with Type 1 diabetes: Association with diabetes-specific characteristics. Diabetes Care, 29, 1389-1392. Retrieved January 27, 2007, from InfoTrac Expanded Academic database.
Krein, S. L., Funnell, M. M., & Piette, J. D. (2006). Economics of diabetes mellitus. Nursing Clinics of North America, 41 (4), 500-509.
Leonard, B .J., Garwick, A., & Adwan, J. Z. (2005). Adolescent perception of parental roles and involvement in diabetes management. Journal of Pediatric Nursing, 20 (6), 405-414. Retrieved February 6, 2007, from OCLC First database.
Olohan, K., & Zappitelli, P. (2003). The insulin pump: Making life with diabetes easier. American Journal of Nursing, 103(4), 49-56.
Urban, A. D., & Grey, M. (2006). Type I diabetes. Nursing Clinics of North America, 41 (4),
513-530.
Wong, H.W., & Perry, L. (2006). Maternal child nursing care. (3rd ed.).St. Louis, MO: .Mosby Elsevier.

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