Aleksandr’s Blog Tacoma Community College N211 John Miller, Instructor Spring Quarter, 2008 Infantile Colic: Effectiveness of Treatments for Infantile Colic. Teaching a new mother about infantile colic is one of the primary responsibilities of postpartum nursing. Mustafa Aksam (2006) brings to light that infantile colic (IC) is a problem that effects up to 40% of babies. IC presents itself during the first three months of life and usually has its onset during the second week of life (Aksan, 2006). Many parents and caregivers are frustrated by IC especially when they are unable to control or relieve their baby’s pain and crying. A newly discharged mother is overwhelmed by all the changes in her life. Excessive uncontrolled crying of her baby during the day and night may be an additional trigger for postpartum depression (Roberts, 2004). Nurses should insure that all new mothers receive education about the treatments for infantile colic before discharge from the hospital. The result will be that fewer new mothers will return to the hospital with maternal depression. The nurse educator will provide information about infantile colic to a new mother. According to Donna Roberts (2004), colic is often defined by “The rule of three”: an infant who is healthy and well nourished but crying “for more than three hours per day, for more than three days per week, and for longer than three weeks.” A colicky infant has attacks of high-pitched screaming in the evening with associated motor behavior such as furrowed brow, flushed face, clenched fists, distended and tense abdomen, and the legs drawn up to the abdomen. The loud cry may persist for several hours. It may be terminated when the infant becomes fatigued, or passes feces or flatus (Roberts, 2004). It is most important for the mother to have reassurance that her baby is healthy and the colic is self-limited with a short term effect unless there are other signs and symptoms of illness (Roberts, 2006). E. Rosenthal (2004) states that infant colic is considered by many as “stressful yet harmless” (Rosenthal, 2004). According to Donna Roberts (2004), the cause of infantile colic remains unclear, and there is no effective medication that may help to resolve this problem without harming a baby. However, nurses are teaching new mothers several effective treatments that show a significant decrease in the time of infant’s crying episodes (Roberts, 2004). Mustafa Aksam (2006) discusses the study conducted in Isparta Maternity Hospital in Turkey about the effect of oral hypertonic glucose solution in a treatment of infantile colic. In this study, thirty healthy infants with colic were selected and the double blind study with crossover trial was conducted. Two bottles were prepared for each patient: one bottle with 30% of hypertonic glucose solution used for IV injection and another bottle with distilled water. The same patient used one bottle for four days and then used another bottle for four days. All parents were instructed to give 1 mL of solution before each feeding using medicine droplets. The infants were examined in the clinic repeatedly and the parents described the effect of the last treatment on their infants. The study showed that 64 % of the parents reported an improvement in their infant’s condition while using 30 % of hypertonic glucose solution. However, 36 % of the parents also reported an improvement after using distilled water (Aksan, 2006). No one reported any side effect in this study. Since oral hypertonic glucose solution has a significant effect for the treatment of infantile colic, nurses will recommend it for the new mother as a natural, safe, and cheap therapy. According to one study reported by P. Kearney (1998), lactase is effective in management of infantile colic. Incomplete lactose absorption in the small intestine provides carbohydrates for bacteria, which are present in the large intestine. Those bacteria metabolize lactose and produce hydrogen that causes infantile colic. Adding a few drops of lactase to the milk formula 24 hours prior to feeding the baby, significantly (95% or 1.14 hr/day) decreases crying time for babies with infantile colic. However, there is no effect of adding lactase to formula during the baby’s feeding. It is possible that stomach acid destroys lactase making it ineffective. The study showed that there was no difference in stool of the babies who had lactase or placebo in milk. Also, there were no side effects reported during this study (Kearney, 1998). According to Sally Wade (2001), two systematic studies found that the infants fed with soya milk formula have less colic than infants fed with standard milk formula. Soy milk formula compared with standard milk formula reduces the duration of crying by 50-75% (Wade, 2001). However another research suggests that infants fed with soya milk formula do not receive important vitamins and proteins that are found in standard milk formula. Donna Roberts (2004) suggested that herbal mixture containing chamomile, licorice, fennel, and lemon balm is effective in treatment of infantile colic. The mixture should be given to the infant three times a day, 150 mL per dose. However, there is a lack of standardization of strength and dosage, and it is too much for an infant to drink 150 mL of fluid at once. So, the new mother should be cautioned about the use of herbal treatment of infant colic (Roberts, 2004). According to E. Rosenthal (2004), behavioral and environmental modification can decrease infant crying time during the colicky time. Also, E. Rosenthal suggested another herbal mixture called “Gripe Water” which may include cardamom, chamomile, cinnamon, clove, dill, fennel, ginger, lemon ball, licorice, peppermint and yarrow. This product provides relief from flatulence and indigestion, however it has not been scientifically evaluated. Parents should avoid products that are made with sugar and alcohol and are manufactured outside of the US (Rosenthal, 2004). Donna Roberts (2004) suggested behavior modification treatments for infantile colic. Some infants may reduce or even stop crying if placed near clothes dryer or near the room with a vacuum cleaner turned on that makes “white noise”. “Colic hold” is also suggested, which is a gentle pressure on infant’s abdomen (Roberts, 2004). E. Rosenthal (2004) suggested movements such as gentle rocking motion in a baby swing, in parent’s arms with walking or sitting in a rocking chair, or riding in a car also soothes some babies. Taking a warm bath together not only soothes the baby but also his mother (Rosenthal, 2004). According to those studies, there are some effective and safe treatments and behavior modifications for infantile colic. If nurses provide the education about infantile colic to the new mothers, it will significantly increase their physical and mental ability to take care of their infants. Nurses prepare mothers to cope with the challenges that their babies will give them. Health care cost will decrease and the baby’s health will increase because mothers will use safe treatments and behavior modifications to treat infantile colic. Fewer mothers will return to the hospital for treatment of post-partum depression as the result of education that nurses will provide to new mothers prior to discharge from the hospital. Intervention 1. Administering oral glucose hypertonic solutions for infant in treatment of infantile colic. Disadvantage 1. Oral glucose hypertonic solution does not affect all infants similarly. According to the study conducted in Disadvantage 2. Another disadvantage is a knowledge deficit. A very small amount of health care workers and parents in US are familiar with this treatment and even a smaller percentage of them use oral glucose hypertonic solution for treatment of infantile colic. The study about how oral glucose hypertonic solution treats infantile colic was conducted in Intervention 2. Soy milk formula compared with standard milk formula reduces the duration of crying by 50-75%. Disadvantage 1. One disadvantage of soy milk formula is affected by socioeconomic status. Soy milk formula is more expensive than cow’s milk formula. One Internet store shows that soy milk formula cost two dollars more than cow’s milk formula for the same can size (Diper.com, 2008). Disadvantage 2. According to Natalie Reiss, soy milk formula compared to breast milk has another disadvantage. Breast milk reduces the risk of getting infectious and non-infectious diseases in infants. Breast milk also reduces the risk of chronic diseases such as diabetes, cancer, allergies, and asthma in infants. Breast feeding infants also have less risk of becoming overweight compared to infants fed by formula (Reiss, N. 2007). References Akcam, M. & Yilmaz, A. (2006, April). Oral hypertonic glucose solution in the treatment of infantile colic. Pediatrics International, 48(2), 125-127. Retrieved February 12, 2008 from CINAHL database. Badiee, Z. (2006). Pak J Physiol. Oral hypertonic glucose, for analgesia in the premature newborns. 2(2). Retrieved May 5, 2008, from http://pps.org.pk/PJP/2-2/zohrah.pdf Diapers.com. (2008). Baby Formula/Similac. Retrieved May 5, 2008, from http://www.diapers.com/Shop/SubBrand.aspx?CategoryID=2&CategoryName=Baby+Formula&BrandCode=SM&BrandName=Similac Roberts, D. Ostapchuk, M. & O’Brien, J. (2004, August). Infantile colic. American Family Physician, 70(4), 735-741. Retrieved February 12, 2008 from Proquest database. Reiss N. (2007, May). New research suggests that breastfeeding babies for at least six months is best. Pediatrics for Parents, 23(5), 2-3. Retrieved May 5, 2008, from Proquest database. Rosinthal E. (2004, December). Recognizing and treating infant colic. Primary Health Care, 14(10), 45-49. Retrieved February 12, 2008 from CINAHL database. Wade S. & Kilgour T. (2001, August). Infantile Colic. Clinical Evidence, 323(7310), 437-440. Retrieved January 30, 2008 from Pubmed central database.
Monday, May 26, 2008
Effectiveness of Treatments for Infantile Colic
Tuesday, May 20, 2008
Role of the Nurse Educator in Preventing Teenage Osteoporosis
Role of the Nurse Educator in Preventing Teenage Osteoporosis
Kelly Johnson
Tacoma Community College Associate Degree in Nursing
Nursing 211: Caring for the client with Acute Problems
John Miller, Spring 2008
The risk of osteoporosis among the teenage population has become a major health concern because of the high intake of carbonated beverages and the low consumption of dairy products such as milk. Soft drink consumption by teenagers is twice the consumption of milk. In addition to the already unhealthy high sugar content, these beverages increase the excretion of calcium in a calcium depleted diet. Therefore, the nurse plays a pivotal role in educating the teenage population about the risks and consequences associated with the unhealthy intake of carbonated beverages. Strategies the nurse should implement in osteoporosis prevention include teenage education regarding prevention and early detection, positive role modeling, and self-care implementation, specifically, diet and exercise.
The high levels of sugar contained in some carbonated beverages increase excretion of calcium through homeostatic processing. Teenage boys and girls alike consume twice as many soft drinks as compared to milk and research indicates that this trend is contributing to an earlier onset of teenage osteoporosis (Hightower, 2000). When reduction in bone mass is sufficient to compromise normal function, osteoporosis develops (Martini, 2006). As the human body ages, it naturally loses bone thickness and strength. Usually, osteoporosis is detected between the ages of 30 and 40 and affects women sooner than men; however, due to lack of proper diet and education, the disease is progressing at an alarming rate among teenagers. When education is absent or delayed, the nurse misses the opportunity to prevent the next generation from developing osteoporosis.
Teenage education regarding prevention, early detection, and self-care should focus on well-balanced diets and well-planned exercise regimes. Prevention includes reducing sugar and caloric intake, encouraging water to quench thirst instead of soft drinks, and going to the gym instead of playing video games. In order to effectively present this educational strategy at the local public school, the nurse educator could include visual aids provided by the National Dairy Council. Prior to the nurse’s presentation to the class of teenage students, the nurse educator should first analyze the dietary profile of one of the students in the class (Borchardt, 2000; Hunt, 1998). This preparation by the nurse is a good strategy to get the students more involved. An important goal of the presentation is to educate the teenagers on the importance of the proper intake of calcium and vitamin D through healthy food choices because unhealthy diets leave the adolescent at a much higher risk for osteoporosis later in life. Exercise that promotes bone strength, such as weightlifting, must also be emphasized and encouraged.
Positive role modeling is an important aspect of the educational strategy. This can be achieved by the individual nurse being fit and healthy himself. According to Bandura’s Social Learning Model described by (Borchardt 2000), individuals learn by observation. In the same way children learn from observing their parents, the teenager can learn from positive role models to become an agent of his own care. Role modeling is not a responsibility of the nurse alone, but rather involves all those who have an impact on the adolescent. This includes the parent who carefully plans meals, the physical education teacher who encourages the students to be fit, or the nurse educator who is passionate about the prevention of this disease. When a student displays interest, enthusiasm, and ownership as a result of positive role modeling, his motivation is increased and he is much more likely to participate and remain compliant with healthy expectations (Fitzgerald, 2003).
The American teenagers’ eating and exercise behaviors are not the only obstacles in this silent disease (Berarducci, 2004). One of the most difficult hurdles to overcome for the teenagers is the commercialization of carbonated beverages, fast foods, and candy bars. This pressure has enormous impact. For example, grocery stores are set-up for the compulsive shopper with candy bars and soda pops strategically close to the checkout line. It is through education that teenagers can begin to recognize these influences and question their eating and exercise habits. Information can be provided for teens and their families on self-care in brochures and pamphlets given during the presentation. This should include information on free or sliding scale clinics where providers evaluate clients, and the nurse offers educational sessions regarding healthy diets and exercise classes (Hightower, 2000; Curry, Hogstel, Davis & Frable, 2002). The consequences of having a poor diet and exercise routine must be honestly and thoroughly presented so that teenagers do not remain unconcerned or defenseless in the face of this disease and its long term effects on their health.
Osteoporosis due to poor diet and insufficient exercise is a preventable disease. The staggering increase in consumption of carbonated beverages and the decreased consumption of calcium have caused a rise in the incidence of osteoporosis in the teenage population. Education is crucial for teenagers if they are to develop healthy habits to reverse this trend. When the nurse encourages osteoporosis-preventative behaviors and promotes healthy lifestyle strategies, prevention of osteoporosis is the focus. This is much preferable to coping with the long term consequences of this disease. Prevention through education is best accomplished by a well-educated, healthy and fit nurse who really wants to see the teenage population improve their diet and exercise habits so they can live longer and healthier lives.
Role of the Nurse Educator in Preventing Teenage Osteoporosis
Intervention #1
Teenage education regarding prevention and early detection of osteoporosis.
Disadvantage #1
Because osteoporosis is a pediatric disease with geriatric consequences, failure to educate the teenage population is a disadvantage. This disease is silent and remains dormant for several years with no signs or symptoms until a disabling fracture occurs. “The key to prevention of osteoporosis is early detection and prevention within the vulnerable, at-risk population” (Hunt, 1998 p. 56). Health promotion has always been an integral part of nursing, and has become increasingly important. In fact, most state Nursing Practice Acts mandate patient education. Since osteoporosis develops during adolescence, the nurse needs to target this age group at the public schools with aggressive presentations in the classrooms. Without education about the risk factors and prevention of osteoporosis to this vulnerable population now, the next generation has acquired the disease, increased the risk, and the window of opportunity to prevent this debilitating disease has closed.
Disadvantage #2
The nurse educator who is compassionate about his/her desire to help prevent teenage osteoporosis should take the prime opportunity and major responsibility to initiate osteoporosis prevention education. The education must emphasize health promotion and disease preventions, not on treating the disease. “It is imperative that nurses possess the required knowledge base and resources to adequately provide instruction to healthcare consumers in an effort to promote wellness, manage illness, and prevent disease” (Beraducci,2004, p. 121). In addition, the nurse educator needs greater access to knowledge and information about the identifiable behaviors of those at risk for developing osteoporosis, and the pathogenesis of osteoporosis to be effective in their presentations at the public schools. If the nurse is not well educated the outcomes will be as debilitating as the disease.
Intervention #2
Self-care implementation, specifically, diet and exercise.
Disadvantage #1
Positive role modeling is an important and effective aspect of the educational strategy. The reflection of the nurse’s personal values will impact the teenagers, and help pave the way for. When the nurse educator’s lifestyle cannot be viewed as healthy, the teaching opportunity has lost its effectiveness. “Awareness of one’s self-care patterns, and implementing strategies to maintain or change these patterns, can be an important step in helping others achieve a high level of wellness” (Borchardt, 2000, p. 30). By taking the leading role in delivering healthcare messages, the nurse educator needs to view him/her self as healthy, or more importantly, the classroom full of teenagers needs to have that perspective of the nurse. When the nurse instructs about the importance of the combination of diet and exercise, the nurse needs to be that healthy living example. “We as nurses and health educators are expected to provide good examples of healthy lifestyles” (Borchardt, 2000, p. 30). When the nurse is viewed as unhealthy through the eyes of the students, the opportunity to promote wellness has been lost.
Disadvantage #2
Lifestyles and diet are closely related. The selection of food is heavily influenced by one’s socioeconomic status. The foods of choice are usually cheap, energy-dense, and nutrient poor. These choices have adverse effects on the growth of the child. There is a great deal of evidence compiled that shows that childhood socioeconomic status contributes to disease later in life, such as osteoporosis (Caballero, 2005). “A growing body of evidence shows that childhood socioeconomic status (SES) is predictive of disease risk in later life, with those from the most disadvantaged backgrounds more likely to experience poor adult-health outcomes” (Lukar, 2007, p. 137). Nutrients, like calcium, in the teenager’s diet will help prevent osteoporosis. Because of cost, carbonated beverages are being purchased instead of dairy products, contributing to the calcium-deficient teenager. The insufficient consumption of calcium in the adolescent diet is leaving them predisposed to osteoporosis. It has been determined that socioeconomic status affects lifestyles, and lifestyles affect diets (Hightower, 2000).
References
Berarducci, A. (2004,Mar-Apr). Osteoporosis education: Orthopedic Nursing. 23(2), 118-127. Retrieved May 15, 2007 from Proquest database.
Borchardt, G. L. (2000,Jul-Sep). Role models for health promotion: The challenges for nurses. Nursing Forum. 35(3), 29. Retrieved April 10, 2007 from Proquest database.
Curry, L. C., Hogstel, M. O., Davis, G. C., & Frable, P. J. (2002). Population-based osteoporosis education for older women. Public Health Nursing. 19(6), 460-469. Retrieved January 10, 2007 from Proquest database.
Fitzgerald, K. (2003). Nurse as Educator: Principles of Teaching and Learning for Nursing Practice (2nd ed., pp. 371-372). Boston: Jones & Bartlett.
Hightower, L. (2000,Sept-Oct). Osteoporosis: Pediatric disease with geriatric consequences. Orthopaedic Nursing. 19(5), 59-62. Retrieved April 17, 2007 from Proquest database.
Hunt, A. H. (1998,Nov-Dec). Assessment of learning needs of registered nurses for osteoporosis education. [Electronic version]. Orthopedic Nursing, 17(6), 55-60.
Martini, F. H. (2006). Fundamentals of anatomy and physiology. San Francisco: Pearson
Caballero, B. (2005, April). A Nutrition paradox – underweight and obesity in developing countries. The New England Journal of Medicine 352(15), 1514-1517. Retrieved July 16, 2007, from Proquest Database.
Hamil-Lukar, J. & O’Rand, A. (2007, February). Gender differences in the link between childhood socioeconomic conditions and heart attack risk in adulthood. Demography 44(1), 137-148. Retrieved July 16, 2007, from Proquest Database.
Tuesday, May 13, 2008
Diabetes Complication: the Nurse’s Role in Reducing Diabetic
Sun Young Kim
About 17 million people in America are currently suffering from diabetes. “A significant public health problem, diabetes is the seventh leading cause of death in the United States.” (Black, 2005, p.1244)
Because diabetes can cause serious complications such as retinopathy, neuropathy, renal failure, and even death, nurses play a critical role in reducing diabetic complications through holistic care and education. Nurses can prevent diabetes complications in patients by providing diabetes education to newly diagnosed patients, creating a multidisciplinary diabetic control regimen with the patient, nutritionist, and diabetes educator, and calling patients bimonthly to check upon patients’ compliance with diabetes control regimen. Through these interventions, nurses can greatly reduce diabetes complications in patients.
Diabetes mellitus is a “chronic systemic disease characterized by either a deficiency of insulin or a decreased ability of the body to use insulin.” (Kronmal, 2006, p.401) Diabetes mellitus can be divided into either type I or type II. Type I diabetes is characterized by absolute insulin deficiency caused by destruction of pancreatic beta cells. Patients with type II diabetes produce insulin, but their liver and peripheral tissues are resistant to the effects of insulin. As a result of defective insulin utilization, diabetes patients experience decreased glucose utilization, increased fat mobilization, and increased protein utilization. If untreated, diabetes mellitus can cause more serious complications such as coronary artery disease, hypertension, retinopathy, nephropathy, and neuropathy.
Diabetes is a disease that requires a tremendous change in a patient’s life style. Since patients have to live with diabetes for the rest of their lives, it is essential that they are educated early after the diagnosis on what they need to know to improve the quality of their life. The diabetes education nurse can set up a convenient time for the patient, choose a private room, and explain the pathology, clinical manifestations, and complications of diabetes. During this education session, it is important to emphasize to patients that they did not do anything wrong to cause the disease. Glycemic control is directly linked to the patient’s exercise level and dietary regimen, and thus it is easy for patients to think that they have earned the disease. According to the Diabetes Attitudes, Wishes, and Needs (DAWN) study “diabetes distress was common among patients, with 85.2% of them experiencing a feeling of shock, guilt, anger, anxiety, and depression at the time of the diagnosis” (Funnell, 2006, p.155). The study also stated that these psychological distresses lead to poor glycemic control in patients, so it is critical to educate patients and answer any questions they have, soon after the initial diagnosis.
Once the patient has accepted the diagnosis of diabetes, the nurse can coordinate a multi disciplinary approach to create a diabetes control regimen. The multidisciplinary team can consist of a nutritionist, physician, diabetes education nurse, and the patient. This team can decide on measures to keep patients’ glucose level as normal as possible, such as eating a balanced diet, exercising regularly, and administering daily medication. During the meetings, the nurse should act as a patient advocate and actively involve the patient in the decision making process. Since diabetes is a chronic condition, the control regimen “should be individualized to each patient’s goals, age, lifestyle, nutritional needs, activity level, and type of diabetes” (Davidson, 2003, p.2291) to produce optimal outcome. The nurse plays a critical role in creating this individualized regimen by assessing the patient’s needs and what they are willing to do.
Once the diabetes control regimen has been implemented, the nurse can increase patient’s compliance by calling them bimonthly to check their status. Asking a few simple questions such as the patient’s recent glucose levels, recent meals, or last time that the patient exercised, can give a nurse valuable clues about how the patient is doing. Patients also benefit from these phone calls by building a better care relationship with the providers. Patients can utilize this time to ask any additional questions that they came up with or simply express concerns. According to the research study performed by Taylor, et al, (2003) patients who have received the bimonthly calls from nurses “showed significant reduction in blood glucose level, total cholesterol level, and total LDL level.” (p.1063)
Diabetes is a complex disease that requires extensive change in the patient’s life style. Nurses can help the patients adjust to change in their lives by providing diabetes education to newly diagnosed patients, creating a multidisciplinary diabetic control regimen with the patient, nutritionist, and diabetes educator, and calling patient bimonthly to check upon patient’s compliance with the diabetes control regimen. Nurses can help diabetes patients better than any other healthcare team members, since they spend most time with patients. Through careful observation and active listening, nurses can be more attuned to each patient’s beliefs and attitudes toward diabetes and can come up with individualized diabetes control regimens that can effectively reduce complications from diabetes.
References
Black, J.M., Hawks, J.H. (2005). Management of clients with Diabetes Mellitus. In Medical-Surgical Nursing (pp.1243-1287). Missouri: Elsevier
Davidson, M.B. (August 2003). Effect of a nurse-directed diabetes care in a minority population. Diabetes Care, 26(8), 2281-2291. Retrieved from ProQuest Smart Search database on May 29, 2007. (384283331)
Funnell, M. M. (2006). The diabetes attitudes, wishes, and needs (DAWN) study. Clinical Diabetes, 24 (4), 154-156. Retrieved from ProQuest Smart Search database on May 23, 2007. (1166450571).
Kronmal, R.A., Barzilay, J.I., Smith, L.N, Psaty, B.M., Kuller, L.H., et al. (2006) Mortality in Pharmacologically Treated Older Adults with Diabetes: The Cardiovascular Health Study, 1989–2001. Public Library of Science Medicine 3(10), 400-404. Retrieved from PLoS Medicine database on April 30, 2007. (p.0030400)
Taylor, C. B., Miller, N.H., Reilly, K.R., Greenwald, G, et al. (2003). Evaluation of a nurse-care management system to improve outcomes in patients with complicated diabetes. Journal of Diabetes Care, 26 (4), 1058-1064. Retrieved from ProQuest Smart Search database on April 19, 2007. (324968961).
Intervention #1
Nurses need to provide diabetes education to newly diagnosed patients.
Disadvantage #1
One problem with nurses providing education to diabetes patient is that nurses have to spend extra effort and time to learn about diabetes. Diabetes is a complex disease that impacts patient’s overall health status. As a result, nurses first have to become knowledgeable about different aspects of diabetes management before they can educate their patients. According to a study in Magson-Robert’s paper, only 38% of nurses responsible for diabetes education had “attended a diabetes study day within the past two years.” Nurses are not mandated to regularly update themselves in diabetes management, and this lack of continuing education can lead to nurses giving invalid or inappropriate advice to their patients.
Disadvantage #2
Some patients might not follow instructions given by the diabetes education nurses, due to the faulty perception that nurses don’t have the authority or knowledge to educate them. In his paper, Martin stated that “authorities seen as credible sources of information are particularly effective as agents of behavior change.” Conversely, patients’ compliance will decrease if the patient view nurses as having no authority. Thus, nurses need to be creative in devising a way to convey their expertise to the patients to increase patient’s compliance.
Intervention #2
Nurses need to call their patients bimonthly to check upon patient’s compliance with diabetes regimen.
Disadvantage #1
One problem that occurs with this intervention is that nurses are so short staffed that they don’t have time to call all their patients’ bimonthly. Nurses’ workload are heavy as it already is and added responsibility of telephone checks can lead to dissatisfaction of the nursing staffs. According to study done on 43,000 nurses, more than 40% of the nurses working in the hospitals in the US reported dissatisfaction with their jobs(Mees, 2008). Also only 34% of surveyed nurses reported that they had enough RNs to provide high-quality care in the facility where they work.
Disadvantage #2
Another barrier to this intervention is that the patient’s might not have adequate socioeconomic means to participate in the program, even if it is offered. For instance, according to Borsky’s research article, Asian Americans were less likely than whites to receive eye examinations, physiological testing, and self – care instructions. This can be attributed to the fact that Asian Americans have the highest rate of uninsurance (6%), compared with white (0.2%), reflecting different work pattern. This socioeconomic status of having no insurance had significant influence on health outcomes for Asian Americans since diabetes is the fifth leading cause of death among Asians, and the prevalence of diabetes is higher among Asians compared with whites.
Works Cited
Borsky, A..E., Greenberg, L., Moy, E. (2008). Community Variation: Disparities In Health Care Quality Between Asian And White Medicare Beneficiaries. Health Affairs, 27(2), 538-550. Retrieved May 10th, 2008from ProQuest Smart Search database (1447860551)
Magson-Roberts, S. (2007). The Role of the District Nurses in Diabetes Management. Journal of community Nursing, 21 (3), 10-12. Retrieved May 10th, 2008 from ProQuest Smart Search database (1240618771)
Martin, Steve (2008). The Science of Compliance: Believing in an Expert. Practice Nurse, 35(7), 39-40. Retrieved May 10th, 2008 from ProQuest Smart Search database (1470885181)
Mee, C.L., Robinson, E. (2003). What’s Different About this Nursing Shortage? Nursing, 33(1), 51-53. Retrieved May 11th, 2008 from ProQuest Smart Search database (276207061)
Monday, May 12, 2008
Childhood Obesity: How Nurses Can Work
There are more than one billion people affected by obesity in the world. In fact, the second-leading cause of death is from the effects of obesity (Miller, Rosenbloom, & Silverstein, 2004).
Worldwide, there are over 22 million children under the age of 5 who are considered obese or overweight based on their body mass index (BMI) (Miller, Rosenbloom & Silverstein, 2004). Emphasis needs to be placed on prevention of obesity, rather than correction of the problem. Three nursing strategies that can be implemented to help reduce this trend are educating children on health lunch and drink choices while they are at school, promoting increased physical activity and working with the media to reduce junk food advertising.
Statistics show the number of overweight children in North America could reach 50% in the next 4 years (The Associated Press, 2006). Obesity results in high blood pressure, higher insulin levels, increased heart rate and cardiac output, and a high level of low-density lipoprotein cholesterol (LDL) (Davis, Kolar, Morthington, Davis, & Moll, 2002). These factors contribute to the development of diabetes, heart disease and strokes at an earlier age than children of normal weight (The Associated Press, 2006). Overweight children also have higher rates of infertility (Dehghan, Danesh, & Merchant, 2005). Due to these health trends, this generation may have a shorter life expectancy than their parents (The Associated Press, 2006). There are several contributing factors to the problem of obese children. One factor is a movement toward a more sedentary lifestyle. This results from increased television viewing and playing computer games. There is also a decreased sense of safety, resulting in fewer children walking to school each year and to other activities due to safety concerns. More parents are working and have their children stay inside while they are gone. Working parents also lack time to cook nutritional meals and have higher rates of fast food consumption. By addressing these contributing factors, nurses can help to reduce the rates of childhood obesity.
One nursing strategy is to educate children and parents on healthy food and drink choices. School and public health nurses have an opportunity to do this with school age children, especially since children eat one to two meals while at school. Nurses can go into classrooms and teach children how to make nutritional food choices through demonstration, visual aids and class discussion. Nurses can place educational emphasis on improving nutrition, the importance of exercise, preventing obesity and discouraging unhealthy lifestyle practices like smoking, alcohol and drug use to school age children (Davis et al, 2002). This will encourage children to make healthier lifestyle choices, decreasing obesity levels which will result in lower levels of cardiovascular disease and diabetes. Schools can provide healthy lunch option, such as fruits, vegetables, and whole-grain foods, which will help to encourage positive practice for making nutritional meal choices (Davis et al, 2002). Soda machines can be replaced with water and milk machines (Laing, 2002). In order to get parents involved, a child’s weight problem can be addressed on a report card. Studies have shown that parents who received health and fitness report cards for their children were more likely to address the weight problem and encourage health activities (Dehghan, Danesh, & Merchant, 2005).
While eating a healthy diet is essential to reducing childhood obesity, other lifestyle choices must also be made to correct the overweight trend. Another nursing strategy that can be implemented to help reduce increasing childhood obesity is to promote increased levels of physical activity. This can be accomplished through several different avenues. Since a sense of safety is vital for children and parents to participate in outdoor activities, nurses need to work with the local government to create safe play areas for children. Parks and ply zones that will be monitored for safety can be created in neighborhoods. These areas need to be easily accessible to children and need to promote play, exercise and physical recreation (Laing, 2002). Nurses can also work with parents and children to increase participation in sports activities. Children would be involved in regular physical exercise during which they receive positive support from their peers (Davis, et al, 2002). Schools can develop physical education programs that are longer in time and emphasize cardiovascular health (Dehghan, Danesh, & Merchant, 2005). With decreased caloric intake, the metabolism will slow down so physical activity is vital to promoting weight loss among obese children. Physical activity will also help increase insulin sensitivity and increase cardiovascular fitness (Miller, Rosenbloom, & Silverstein, 2004).
A third and final nursing strategy for reducing childhood obesity is to work with the media and marketing groups to promote healthy lifestyle choices and reduce junk food advertising. By using toys, music and easily identifiable characters, fast food chains promote their products to children (Miller, Rosenbloom, & Silverstein, 2004). Snacks, fast foot and other junk food products are most heavily advertised during children’s television programs (Laing, 2002). Nurses need to work with the media to change the advertising emphasis to healthy food and lifestyle choices. Making healthy food choices easy to identify for both parents and children while grocery shopping is another way nurses can work with marketing companies to reduce childhood obesity. Packaging can be changed to include easy to read nutritional information. Characters can be created and associated with nutritional food products (Dehghan, Danesh, & Merchant, 2005)
The number of overweight children is growing worldwide. This trend poses several health risks such as cardiovascular disease, diabetes, hypertension, and infertility. If this trend is not corrected soon, the lifespan of this generation and those to follow will shorten. Nurses can focus on strategies such as educating parents and children on healthy food choices, promoting physical activities through the creation of safe play areas and organized physical activity, and reducing the marketing of poor nutritional foots to children in order to help reduce this growing problem. These strategies will promote healthy lifestyles in children and reduce the percentage of overweight children which will help them to live longer and healthier lives.
References
Davis, S., Kolar, K., Northington, L., Davis, M., & Moll, G. (December 2002). Childhood Obesity Reduction by School Based Programs. Association of Black Nursing Faculty Journal. Retrieved January 16, 2008 from http://findarticles.com/p/articles/mi_m0MJT/is_6_13/ai_95915535/pg_1
Dehghan, M., Akhtar-Danesh, N., & Merchant, A. (September 2005). Childhood Obesity: Prevalence and Prevention. Nutrition Journal, 4. Retrieved October 14, 2007, from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1208949
Laing, P., RN. (2002) Childhood Obesity: A Public Health Threat. Pediatric Nursing Journal, 14(10), 14-16.
Miller, J. Rosenbloom, A., & Silverstein, J. (September 2004). Childhood Obesity. JCEM, 89(9):4211-4218. Retrieved January 16, 2008, from http://jcem.endojournals.org/cgi/reprint/89/9/4211
The Associated Press. (March 7, 2006). Study: Childhood Obesity Expected to Soar. Retrieved September 28, 2007, from http://www.msnbc.msn.com/id/11694799/
Intervention #1
Nurses need to educated children and parents on healthy food and drink choices.
Disadvantage #1
A problem that arises with nurses educating children and their parents is the lack of motivation on the client’s end toward learning and change. They are either comfortable in their lifestyle, don’t seen the future health concerns, or are too busy with work and other time limitations to take the time to correct their knowledge deficit (St.Onge, Keller, and Heymsfield, 2003). Studies have shown that homes with two parents working are more likely to consume fast food due to the convenience rather than prepare meals for nutritional value (St.Onge, Keller, and Heymsfield, 2003). Once families can be educated on and realize the importance of nutritional meals and are taught the skills needed to implement proper nutrition choices they will overcome this barrier.
Disadvantage #2
Another disadvantage for nurses trying to educate children and their parents is the lack of reimbursement by either insurance companies or other healthcare corporations for their time and resources used. Studies have shown that clinics specializing in pediatric obesity were rarely reimbursed for their expenses by insurance companies. Healthcare workers are not given any incentives to go out into the community and provide education and resources for preventing childhood obesity through proper nutrition (Story, Neumark, Sherwood, Holt, Sofka, Trowbridge, & Barlow, 2002). If insurance companies can see the importance of obesity prevention in children and the long term health benefits for the children, they may start to reimburse and invest in nutritional education for children and their families.
Intervention #2
Nurses need to focus on promoting physical activity for children by working with the community to develop safe play areas and parks.
Disadvantage #1
Socioeconomic status could prevent nurses from working to develop safe play areas for children. Low-income neighborhoods may not have the community involvement or resources needed to develop safe and monitored play areas. Since unsafe communities lead to children not being able to play outdoors, it will be more challenging to ensure children’s safety while playing in these neighborhoods (Laing, 2002).
Disadvantage # 2
If a community is already thoroughly developed, it may be difficult to gain support for the building of parks and walking trails (Dehghan, Danesh, & Merchant, 2005). Losing business and profit-generating areas for physical activity promotion may not be welcome by a community. These parks and trails also need to be placed near neighborhoods for easy access if they are to be used regularly. This may prove to be a difficult task in existing communities.
Nursing Management in Multiple Sclerosis
Multiple Sclerosis (MS) is a disease that affects a person’s entire life. Since MS has major neurological effects that are progressive, it can force a person to alter many routine activities within their daily life.
MS, a chronic illness, causes those affected to balance their disease and feelings about their illness within their already busy and bustling life. Keeping this in mind, nurses and MS nurse specialists can have a profound impact on helping a patient manage their Multiple Sclerosis. Because it is the MS nurse that helps manage patient expectations, it is imperative for the MS nurse to develop a therapeutic relationship with the patient, help patients and their families incorporate the disease into their lives and to encourage the patient to seek medical interventions early.
According to the Multiple Sclerosis Society website (2007), “MS is the result of damage to myelin- a protective sheath surrounding nerve fibres of the central nervous system. When myelin is damaged, this interferes with messages between the brain and other parts of the body” (Paragraph 1). Multiple Sclerosis is a disease that has caused a host of problems from a patient care and disease management perspective. For instance, “for the majority of people diagnosed many years ago and told to ‘get on with life,’” today new treatments and support are offered to those who are diagnosed with this life changing disease (D’Arcy, 2005, p. 2). Though there is no cure for MS, great strides “have focused on pharmacological management and therapeutic strategies, education, provision of emotional support and advocating change in governmental policies” (D’Arcy, 2005, p. 2). Hence, the disease management process for MS has come a long way since it was first discovered as being a life threatening and altering disease. The health care community is working hard to educate people living with this disease while at the same time alleviating the unnecessary complications that come with Multiple Sclerosis.
Multiple sclerosis brings with it a multitude of issues. One of the most important topics to address is patient expectations. A significant way this can be done is for the nurse to develop a healthy, therapeutic relationship with the patient and the patient’s family during the patient’s first visit to the clinic. The nurse should concentrate on establishing a connection with the patient and their family, having an open dialogue with them about how things are going and how they are feeling. People who are affected by MS are looking for that one person who will truly listen to their needs and feelings. Furthermore, “the desired outcomes for this relationship are for patients to have an increased awareness and knowledge about MS, DMDs, and the rationale for treatment” (Ross, Costello, & Kennedy, 2005, p. 1). This piece is so important to the nurse/patient relationship. Honesty and trust are key in developing the therapeutic relationship needed and these characteristics of successful communication pave the way to success for the relationship and health goal at hand.
Incorporating any disease into ones life is so important, which stands true for Multiple Sclerosis. According to D’Arcy (2005), one way a nurse specialist may help a patient and their family incorporate a disease into their lives is by “[helping] deliver personlised, patient focused care and [giving] appropriate information so that patients can make informed choices” (p. 3). Often, a newly diagnosed MS patient does not know what his/her needs are going to be. The nurse specialist may help this patient with focused goals, such as continuing with daily activities and exploring new treatments, to better manage the disease and prevent relapse. These goals may be set over a few visits with the nurse specialist and will change as the person’s disease progresses. “Part of the MS nurse’s role involves the correct identification of relapse, assessment and the application of appropriate intervention” (Embrey, 2003, p. 2). A relapse, also called an exacerbation, could be the patient developing optic neuritis, which would than be treated.
Inquiring about interventions and following through with them is essential with a disease like Multiple Sclerosis. According to a study done by Fleming-Courts (2004), MS focus groups “support nursing interventions that empower and teach self-management techniques” (p.1). It is very important for the patient to understand the options he/she has to fight this disease. The patient should be prepared to "Fight your own fight…be your own advocate and [take] charge (Fleming-Courts, 2004, p. 12).” During routine visits with the MS nurse specialist, the patient is encouraged to use various interventions and follow through with therapies. The nurse may follow-up with the patient after their appointments to ensure that the patient left with all of the information needed and questions answered. The MS nurse specialist is a great resource and in a unique position to help the person on a medical regimen and be forthcoming with therapies.
Within any disease process, it is important for the nursing staff to assess the patient’s expectations, which help guide the MS nurse specialist to the appropriate treatments for patients and their individual needs. Further assessment of these expectations provides focus to the nurse and their responsibility to develop a therapeutic relationship with the patient; help patients and their families incorporate the disease into their lives; and to encourage the patient to seek medical interventions early. Essentially, these steps provide a very good start to the management and treatment of a disease that is progressive and unrelenting, yet treatable to whatever extent the patient is willing to go.
Intervention #1
Nurses need to guide patients through the process of setting realistic expectations and getting the right treatments early for the patient.
Disadvantage #1
There are several things that happen when a person is diagnosed with Multiple Sclerosis (MS). Patients are often new to the disease and have to deal with the knowledge deficit that they face because of this newly diagnosed disease. Because of this knowledge deficit, the nurse is expected to help guide the patient through the entire process. The nurse is responsible for filling in where there is a deficit in knowledge as well as being abreast of the latest resources and treatments that are offered. With being knowledgeable about these treatments, at times practitioners and patients can get over excited with the “hype” of new products that show promise in treating MS. With this “hype,” unrealistic expectations may be set by the patient and nurse. Therefore, the nurse must stress that the Disease Modifying Drugs (DMD’s) “reduce exacerbation and slow disease progression but are not cures” (Ross p. 2). The patient must understand that relapse is expected with a disease like MS. If the nurse prepares the patient for this kind of reality, the patient will be less likely to be emotionally distraught during a relapse. Nurse must ensure that patients are setting realistic expectations for their disease process.
Disadvantage #2
With setting realistic expectations also comes choosing the right treatment and getting the patient treated early. The nurse must help the patient decide on the correct treatment by taking into consideration several factors. Lifestyle, stage or severity of disease and the patient’s ability to adhere to treatment are all things that should be considered when choosing a treatment. Another very important aspect of treating MS is to start early. Early interventions should include “pharmacological management and therapeutic strategies, education, provisions of emotional support, and advocating change in government policy” (D’Arcy p. 2). Though early intervention is key, “some [patients] refused the medications because the physician would not assure them of its effectiveness, they were doing well at the moment, and the cost was a deterrent” (Ross et al p.7). MS is a disease that needs time and attention right away; however, high costs, ineffective explanations and poor communication practices with practitioners perturb patients from seeking the health care needed.
Intervention #2
The MS Nurse Specialist should begin to develop a therapeutic relationship with the patient, and help patients and their families incorporate the disease into their lives.
Disadvantage #1
Developing relationships with patients can prove to be challenging. Some times nurses will see patients for the first time after the disease has already progressed. Furthermore, “there is often limited time to discuss individual concerns and provide counseling” (Ross p. 3). This means that the nurse must establish a healthy, therapeutic relationship within a limited amount of time and possibly take over care of a patient that has or has not been established with MS treatments. These issues listed above make it difficult for the nurse to help the patient and family come to terms with MS and its effects.
Disadvantage #2
Though it would seem that following the interventions listed above is easy to do, it can prove to be difficult. Establishing the relationships are important to ensure patient adherence and family support. However, in some case adherence is an issue. In Counseling Points, Ross states, “There are signs that indicate patients may not be adhering to therapy. In some cases, patients try to act as if everything is going well or they avoid giving direct answers. It is up to the nurse to be aware of these signs and to be able to assess what is really going on” (p. 6). Therefore, nurses must try to counteract these types of situations with consistent and frequents follow-ups with the patient and their family. This may help with patient adherence and family participation.
References
D’Arcy, C. (2005, Oct). Managing multiple sclerosis: working in partnership: Caroline D'Arcy describes how healthcare professionals can respond to the needs of people with long term conditions such as multiple sclerosis. Nursing Management. 12(6) 32-35. Retrieved on April 3, 2007 from Expanded Academic ASAP database.
Embrey, N. (Feb. 12, 2003). Benchmarking best practice in relapse management of multiple sclerosis. Nursing Standard, 17(22), 38-42. Retrieved May 28, 2007, from the Expanded Academic ASAP database
Fleming Courts, N., Buchanan, E., & Werstlein, P. (2004). Focus groups: The lived experience of participants with multiple sclerosis. Journal of Neuroscience Nursing, 36(1), 42-47. Retrieved April 3, 2007, from the Expanded Academic ASAP database.
Multiple Sclerosis Society. May 23rd, 2007. Retrieved on May 29, 2007 from http://www.mssociety.org.uk/index.html
Ross, A., Costello, K., Kennedy, P., & Pfohl, D., (2005). Managing patient expectations. Multiple Sclerosis: Counseling Points. 1(1). Retrieved April 28th, 2007, from http://www.iomsn.org/pdf/counseling_pts_Vol1_Num1.pdf
Assisted Reproductive Technologies: the Nurse’s Role in Preconception Counseling
Infertility prevents around 6.1 million people in the United States from having children. As a result, infertile couples and individuals often seek to become parents through assisted reproductive therapies (ART).
Each client has a different situation, so there are a number of assisted reproductive techniques available to suit their needs. Because assisted reproductive technology is a successful option for managing infertility, nurses must assess and evaluate factors affecting fertility, screen for genetic problems, and educate clients about the reproductive options available depending on each individual situation.
Involuntary infertility affects 10% of reproductive-age individuals. Basic infertility services may be used to treat the majority (85-90%) of infertile males and females, but the remaining 10-15% require assisted reproductive technologies. ART also provides options for individuals with or at risk for transmitting a genetic disorder and those experiencing infertility due to advanced maternal age. Since 1992, there have been over 850,000 ART cycles in the U.S. resulting in over 210,000 children conceived (Jones, 2004, p.116). The most common adverse outcome from ART treatment is multiple births which may lead to complications during pregnancy; though studies have found that many patients seeking ART treatment prefer to have twins or triplets instead of just a single infant (Grainger, Frazier, & Rowland, 2006, p.162). “Experience with and refinement of these technologies continue to increase the likelihood that an infertile woman, man, or couple is able to conceive and give birth to a child through the various technologies now available” (Jones, 2004, p.115).
Nurses are often the first healthcare providers that women encounter for preconception and prenatal issues. Preconception care involves the “assessment of risk factors for having a child with a genetic disorder, providing information about preconception, prenatal testing, and reproductive options to minimize the chance of having children with genetic problems.” Nurses obtain the family, medical, obstetric, and genetic history, physical examination, and laboratory results which provide vital information for determining risk factors. Once the risk factors have been assessed, appropriate lifestyle modifications (ex. diet, medications, environments) can be made to optimize preconception and prenatal care (Shapira & Dolan, 2006, p.143).
Nurses provide appropriate preconception and prenatal care, education, and medical counseling for those with known genetic problems to decrease the risk of complications or genetic disorders. Genetic screening of both parents is helpful in diagnosing risks for transmitting a genetic disorder. Around 85-90% of repeated pregnancy loss is due to genetic problems. If one or both parents are carriers of a genetic disorder, or have a genetic disorder themselves, preimplantation genetic diagnosis (PGD) is a very effective option. PGD involves determining the sex and chromosomal make up of an embryo produced through in-vitro fertilization. One benefit of this option is knowing the genetic health of the embryo before it is implanted, therefore eliminating the decision of whether to terminate or not if a genetic condition was found later in the pregnancy. It is possible to find out if embryos are affected with disorders such as cystic fibrosis, sickle cell anemia, and Huntington’s disease (Jones, 2004, p.126). Gender selection is helpful when the parents have been screened with either an X-linked recessive, or a Y-linked disorder. Gender selection is also available for non medical reasons and is virtually always accurate (Barad & Gleicher, 2007, p.2).
Comprehensive preconception care requires building a strong nurse/patient relationship and knowledge of the advances in genetics and reproductive health options. It is critical for nurses to use this knowledge to provide anticipatory guidance and encourage clients to think through their options. The most common assisted reproductive options available include the following: in-vitro fertilization (IVF), preimplantation genetic diagnosis (PGD), and intracytoplasmic sperm injection (ICSI) (Barad, 2007, p.3). In-vitro fertilization is a useful option for clients with diagnoses such as: fallopian tube defect, ovulatory disturbance, or idiopathic infertility (Jones, 2004, p.124). Male infertility is a factor in about 40% of couples seeking ART. Intracytoplasmic sperm injection (ICSI) may be used to achieve pregnancy in this situation. Since only one sperm is needed to fertilize the egg, only very small quantities of semen are needed. This method is used for male clients with semen anomalies, congenital or surgical absence of vas deferens, spinal cord injury, impotence, azoospermia, or idiopathic infertility. An established nurse/patient relationship provides psychosocial support and allows the opportunity for nondirective, nonjudgmental reproductive decision making. Care is delivered in a nondiscriminatory manner, protecting and respecting client autonomy, dignity, and rights. Privacy and confidentiality issues are regulated by state, and federal laws and standards of practice by the ANA (Wille, Weitz, Kerper, & Frazier, 2004, p.37). Nurses also provide referrals to other healthcare providers or professional resources such as genetic counselors, support groups, religious groups, or social workers when needed.
There are a number of factors affecting fertility (ex. diet, exercise, medications, work conditions). Nurses identify risk factors, suggest any modifications needed to maximize fertility, and provide appropriate preconception and prenatal care. Since there are a number of options available for clients experiencing infertility, nurses provide information, resources, and support to help clients make the best possible reproductive decisions. Nurses are effective in the assessment of factors affecting fertility, identifying risks for genetic problems, and providing education and support for clients making the reproductive decisions unique to their situation.
References
Barad, D., & Gleicher, N. (n.d.). Treatment options assisted reproductive technology. Retrieved May 6, 2007, from http://www.centerforhumanreprod.com/treatment_assisted.html
Grainger, D. A., Frazier, L. M., & Rowland, C. A. (2006). Preconception care and treatment with assisted reproductive technologies. Maternal and Child Health Journal, 10(7), 161-164. Retrieved May 28, 2007, from PubMed Central database.
Jones, S.L. (2004). The confluence of two clinical specialties: Genetics and assisted reproductive technologies. MedSurg Nursing, 13(2), 114-122. Retrieved April 16, 2007, from Expanded Academic ASAP database.
Shapira, S. K., & Dolan, S. (2006). Genetic risks to the mother and the infant: Assessment, counseling, and management. Maternal and Child Health Journal 10(7), 143-146. Retrieved May 28, 2007, from PubMed Central database.
Wille, M. C., Weitz, B., Kerper, P., & Fraizer, S. (2004). Advances in preconception genetic counseling. Journal of Perinatal and Neonatal Nursing, 18(1), 28-41. Retrieved April 16, 2007, from ProQuest database.
Intervention 1: Nurses must assess and evaluate factors affecting fertility.
Disadvantage 1: Clients may not be able to provide complete family history for both partners or may not be completely honest.
Disadvantage 2: Clients may be unwilling to make the necessary lifestyle changes to improve fertility (such as smoking cessation, avoiding drugs and alcohol, and hazardous environments).
Intervention 2: Nurses must screen for genetic problems.
Disadvantage 1: One disadvantage could be the cost of genetic testing. Heteroduplex analysis costs $260, DGGE tests cost $250-$800, ASO and PTT tests can cost between $190-$450, while sequencing tests can cost $500-$3,000 each. A few reasons for the high cost are that genetic tests are rare, labor intensive, and undergo multiple levels of review. There may be additional costs to you besides the actual cost of the genetic test. These may include any cost for blood draw or specimen collection, Federal Express or other shipping costs, and genetic counseling or physician fees (Toland, 2000, pg 2).
Disadvantage 2: Clients may not want to know what the risk factors are and leave things up to chance. Others may not want to make the ethical decision of what to do if they conceive a child with a genetic disorder.
References
Toland, A. E., (2000). Genetic testing: Costs of genetic testing. Retrieved May 12, 2008, from http://www.genetichealth.com/GT_Genetic_Testing_Costs_of_Genetic_Testing.shtml
Breastfeeding: the nurse's role
Breastfeeding has been proven to have many positive outcomes on the child. It has been shown to have effects on the child’s intelligence, immunologic development, weight, social development, and overall health.
There are many positive results on the mother as well. Because research shows many positive effects of breastfeeding, nurses should include breastfeeding education in both prenatal care and when teaching new mothers. Nurses can implement the following strategies to address this issue: involving lactation consultants in prenatal care, making it policy that lactation consultants are involved in educating new mothers during the immediate puerperium period, and making follow-up home health appointments with nursing standard during the puerperium period.
Historically, the popularity of breastfeeding has had its ups and downs. Like many other things, it has faded in and out of favor by people throughout the years. This partially could have been due to the fact that people didn’t know or fully understand all of the effects of breastfeeding. However, enough is now known about breastfeeding that the benefits are no longer debatable. In every situation (but very few cases) it is the best option for the baby. Not everyone is educated enough about the subject to understand the strong case for doing it. Most people understand it’s good for the baby, but they may not understand just how good it is and the numerous effects it will have on that child throughout its lifetime.
Involving nursing lactation consultants during prenatal care or even prior to pregnancy is extremely beneficial. It helps the woman (or couple) make a more informed choice about breastfeeding. “A woman’s decision about the method of infant feeding is made before pregnancy; thus it is essential to educate women of childbearing age about the benefits of breastfeeding” (Hockenberry, Lowdermilk, Perry, Wilson, Wong, 2006, p. 277). Doing so earlier could make a huge difference. Making comprehensive breastfeeding education a standard part of prenatal care would impact the number of people that decide to breastfeed. Most people at this point know that breastfeeding is good for the baby, but they may need more thorough education by nursing to understand the vast number of ways that it is beneficial for the baby throughout its lifetime.
Having nursing lactation consultants present very soon after birth is very helpful for the woman. It provides her with the education, support and encouragement that are necessary when beginning to breastfeed. “Mothers often identify support received from healthcare providers as the single most important intervention the healthcare system could have offered to help them breastfeed” (CDC, 2006, p. 1). This immediate education and attention by the nurse lactation consultant would start the woman “off on the right foot” when it comes to breastfeeding. It would give them an opportunity to spend time with someone who is focused solely on the success of their breastfeeding experience. Implementing a policy by the hospital’s nursing committee, which makes it standard practice to have nursing lactation consultants present for education and coaching during the first breastfeeding experience, could make a significant difference in a woman’s breastfeeding experience. Research has shown a “positive relationship between delivering at a hospital that employed IBCLCs (International Board Certified Lactation Consultants) and breastfeeding at hospital discharge” (Castrucci, Hoover, Lim, Maus, 2006, p. 6).
It is recommended by the American Academy of Pediatrics that breastfeeding be done for at least 12 months. Follow-up home health visits by nurses are a great way to help mothers accomplish this goal and a very positive addition to breastfeeding education. Surveys conducted by the CDC in 2004 have shown that 73.8% of babies were ever breastfed, 41.5% were still being breastfed at 6 months of age and 20.9% were still being breastfed at 1 year. “The key reason women stop breastfeeding before the recommended 6-month period is because of perceived difficulties with lactation rather than maternal choice” (Krueger, Sheehan, Sword, Watt, 2006, p. 1). Continuing to provide constant professional nursing support has been shown to increase the number of women who continue to breastfeed, despite experiencing a perceived breastfeeding barrier or lactation crisis. This support, for many women, needs to include education on continuing breastfeeding even after returning to work. The lactation consultants coach women on how to use breast pumps, how to store the milk or anything else that could be a potential breastfeeding barrier. Home health visits by lactation consultants could have a significant impact on breastfeeding duration.
Breastfeeding is extremely beneficial for both mother and baby. Mothers who breastfeed have been shown to have lower rates of some types of ovarian and breast cancers, hip fractures and osteoporosis after menopause as well as other health conditions (U.S. Department of Health and Human Services, 2005). Breastfeeding also helps mothers lose their “baby weight.” Babies who are breastfed have lower rates of asthma, ear infections, SIDS, diabetes, leukemia, lymphoma; the list of benefits for babies goes on and on (U.S. Department of Health and Human Services, 2005). There are societal benefits as well, the greatest being that breastfeeding saves on healthcare costs because breastfed babies need less medical care than those who aren’t breastfed. The three outlined nursing strategies: involving nursing lactation consultants in prenatal care, in the immediate puerperium period and in home health visits during the postpartum period would make a significant impact on the number of women who not only initiate breastfeeding, but also those who choose to continue.
References –
Castrucci, B., Hoover, K., Lim, S., & Maus, K. (2006). A comparison of breastfeeding rates in an urban birth cohort among women delivering infants at hospitals that employ and do not employ lactation consultants. Journal of Public Health Management and Practice, 12 (6), 578-585. Retrieved April 29, 2007 from Expanded Academic ASAP database (A154690153).
Centers for Disease Control. (2006, August). The CDC guide to breastfeeding interventions: Professional support. Retrieved on May 29, 2007 from http://www.cdc.gov/breastfeeding/pdf/BF_guide_5.pdf
Davies, B. & Edwards, N. (2003, September). Breastfeeding best practice guidelines for nurses. Retrieved on May 7, 2007 from http://www.rnao.org/bestpractices/PDF/BPG_Breastfeeding.pdf
Hockenberry, M., Lowdermilk, D., Perry, S., Wilson, D. & Wong, D. (2006). Nursing care during pregnancy. In Maternal Child Nursing Care (pp. 277-278). Third Edition. St. Louis: Mosby Elsevier.
Krueger, P., Sheehan, D., Sword, W., Watt, S. (2006). The impact of a new universal postpartum program on breastfeeding outcomes. Journal of Human Lactation, 22 (4), 398-408. Retrieved May 28, 2007 from Expanded Academic ASAP database (A152872149).
U.S. Department of Health and Human Services, (2005, October). womenshealth.gov: Benefits of Breastfeeding. Retrieved on February 18, 2008 from http://www.4woman.gov/breastfeeding/index.cfm/index.cfm?page=227
Intervention #1 - Involving lactation consultants in prenatal care.
Disadvantage #1 – One disadvantage of this intervention would be cost. It would be a struggle to get insurance companies to cover this in addition to the other things that are covered in prenatal care. And many people would not be able to afford to pay for this out of their pocket or more accurately would not choose to spend their money on this. The only way this intervention could truly be successful is if it was something that was standard for everyone. This intervention is aimed at educating those who aren’t planning to breastfeed and those who belong to groups of people that typically don’t breastfeed. Even though the long-term benefits far outweigh the cost and even though the insurance companies have the potential to save themselves a significant amount of money down the road, convincing the insurance companies of this would not be such an easy sell.
Disadvantage #2 – Another disadvantage of this intervention would be that it would not be able to address many of the problems that arise that cause women to stop breastfeeding. “The key reason women stop breastfeeding before the recommended 6-month period is because of perceived difficulties with lactation rather than maternal choice.” (Krueger, Sheehan, Sword, Watt, p. 1). It would be extremely valuable to start educating parents on the many benefits of breastfeeding as soon as possible, however, because this education happens so early it could not focus on helping mothers solve some of the problems that arise during breastfeeding, mothers that want to breastfeed but end up stopping early because of problems doing it.
Intervention #2 - Making it policy that lactation consultants are involved in educating new mothers during the immediate puerperium period.
Disadvantage #1 - One disadvantage of this intervention would again be cost. It would be difficult to convince insurance companies to cover this in addition to other costs associated with having a baby or convincing hospitals that it’s in their best interest to have a lactation consultant on staff. “The odds of breastfeeding at hospital discharge for a women delivering at a facility that employed an IBCLC were more than 2 1/4 times higher than women delivering at a facility that did not employ an IBCLC.” (Castrucci, Hoover, Lim, Maus, p. 6). Despite the fact that the initial cost would be minimal, I suspect insurance companies would still just view this as another cost, as opposed to viewing it as paying a little now to save big later. The same goes for the hospital, they may not see it as their responsibility to address the breastfeeding issue and therefore a cost that’s not in their best interest to spend.
Disadvantage #2 - Another disadvantage of this intervention would be that most people have made up their minds by then whether or not to breastfeed. If they have decided to breastfeed they would be very receptive to this additional education, however, if they have decided not to breastfeed they would most likely not be very receptive to receiving this education. They may actually perceive it as disrespectful if they have already made their plans known. This intervention would probably not be able to make much of an impact on breastfeeding initiation, but it could potentially effect breastfeeding duration.
Disadvantages of Cardiovascular Disease Prevention Methods
Diet and exercise have been proven to help prevent cardiovascular disease, yet according to the American Heart Association (AHA) it continues to be the leading cause of death in the United States (American Heart Association, 2008). There are 79.4 million adults currently living in the U.S. with one or more forms of cardiovascular disease including angina pectoris, myocardial infarction, and heart failure (Parkosewich, 2008). It is important that action be taken to help reverse the prevalence of cardiovascular disease. Patients need to be taught how to eat right, how to create an exercise plan that is manageable for them, and what healthcare actions can be taken to detect and prevent the disease. Because preventive care activities reduce the incidence of cardiovascular disease nurses must educate patients on the importance of diet and exercise.
Nation-wide, obesity is becoming an increasing problem. AHA recommends that disease prevention begin by age 20, however younger and younger patients are presenting with signs and symptoms of cardiovascular disease (American Heart Association, 2008). There are many factors that come together to contribute to one’s risk of developing the disease such as lifestyle, age, sex, race, and genetics (Berra, Miller, Fair, 2006). Unfortunately many of these factors are out of the patient’s hands.
Because many of the reasons that lead to an increased risk of cardiac disease are unable to be controlled it is important for nurses to emphasize what can be controlled. Nurses can collaborate with patients to develop an exercise regimen that will fit into their lifestyle and is tailored to meet their level of ability. Exercise plans need to be individualized for each patient and it is important that nurses pay close attention to what is available to the patient and their perception of the need for intervention. Ideally, the
U.S. Surgeon General recommends 30 minutes of moderate-intensity exercise most days of the week to prevent diseases associated with a sedentary lifestyle such as cardiovascular disease, cancer, and diabetes (Swain, 2006). Although moderate-intensity exercise is beneficial, it is not as beneficial as vigorous-intensity exercise (exercise that can be maintained for no longer than 5 minutes) and if possible, vigorous-intensity exercise should be recommended to patients (Swain, 2006). However, not all patients are capable of such intense exercise and therefore, it is important that exercise plans are suitable for each patient.
Along with exercise, diet is another contributor to cardiovascular disease that can be controlled. There are many effective dietary modifications that can be made. The modifications include eating foods that are low in cholesterol, saturated fat, and trans-fat, foods that decrease the body’s absorption of cholesterol, and foods that are high in fiber (Scott, 2005). It is important for nurses to teach patients to avoid foods that are greasy like fried foods and instead eat more lean meat and fish, fruits, vegetables, nuts, and healthy carbohydrates like oatmeal (Scott, 2005). It is also important to tell patients that they can still enjoy the foods they like, but caution needs to be taken in regards to portion size, as moderation is key.
Although eating healthy and getting adequate exercise are extremely important in maintaining a healthy lifestyle, they do not guarantee the prevention of developing heart disease. Preventive care and the early detection of cardiovascular disease are equally crucial. Stress tests, cholesterol tests, and regular physical exams are all ways that one’s risk for the development of cardiovascular disease or the presence of existing disease can be assessed. These methods help in the avoidance ever having a cardiac event or the
recurrence of additional events by determining whether education and treatment need to focus on preventing disease in the future or managing the disease that has already taken place and avoiding worsening. Monitoring and reporting progress toward a healthy lifestyle is a key to success in cardiovascular health (Flynn, Cafarelli, Petrakos, and Christophersen, 2007). Nurses need to stress the importance of preventive care to patients and encourage them to take the initiative to keep on top of their health maintenance. Everyone has the potential to develop cardiovascular disease; therefore preventive methods and nursing education need to be aimed at every patient regardless of current level of wellness.
The incidence of cardiovascular disease is an increasing problem and is occurring in younger and younger people all the time. Poor nutrition and sedentary lifestyles are leading to shorter life spans and a decreased quality of life in millions of people. Prevention of cardiovascular disease is extremely important and it is crucial for nurses to educate patients on the value of eating a proper diet and getting adequate amounts of exercise. The three primary components to cardiovascular disease prevention are participating in an individualized exercise regimen, eating a healthy diet that consists of foods low in fat and cholesterol, and having regular health screenings that include a close examination of cardiovascular health. Through nurse-patient collaboration and encouragement of a healthy lifestyle, patients can live longer, more enjoyable lives.
Intervention 1 - Diet in Relation to Cardiovascular Disease
Disadvantage 1 – Difficulty in Making Lifelong Dietary Changes
While cutting down on the intake of saturated fats, trans fats, and cholesterol can reduce the risk of developing cardiovascular disease (CVD) many people have difficulty making the necessary dietary modifications. When viewing the recommended dietary changes, patients may feel overwhelmed as changes in eating habits need to become a lifelong way of living. Patients may also have misconceptions regarding what foods can be included in a heart-healthy diet. The perceived inability to make this lifestyle change can make patients feel discouraged and unwilling to comply, therefore doing nothing to lower the risk of CVD development. To make dietary changes feel more manageable and realistic to patients, emphasis should focus on the accomplishment of small goals such as eating a piece of fruit rather than potato chips for lunch, and healthy fat consumption like those in olive oil and fish. Better education needs to be provided to patients on what foods should be eaten and how to make “healthy foods” better tasting so that patients will want to eat them. By setting and meeting small goals, patients may gain a sense of accomplishment and have better success at making healthy eating a way of life.
Jefferson, A. (2008). Nutritional management of coronary heart disease. Journal of Community Nursing, 22(5), 28-30.
Disadvantage 2 – Cultural Factors Leading to Obesity
High consumption of high calorie food and sedentary lifestyle is the overall cause of the obesity epidemic that is occurring. There are many reasons fast foods have become a way of life for so many people including convenience and inexpensiveness. Such a high level of fat consumption with so little physical activity is causing the prevalence of CVD to increase quickly. In addition to peoples’ ever-expanding waistline is portion size. Opportunities to “super-size” are available at most fast food restaurants and the readiness of people to order “super-sized” meals can be attributed to wanting the best value for the money spent. To overcome this issue of overeating high calorie foods without adequate energy expenditure, cultural modifications need to be made. Consumer education on the reduction of portion size needs to be made a focus as well as providing healthier, less expensive options for on-the-go eating.
Hill, J., & Peters, J. (1998). Environmental contributions to the obesity epidemic. Science, 280(5368), 1371-1374.
Intervention 2 – Health Prevention in Relation to Cardiovascular Disease
Disadvantage 1 – The Uninsured Population
Preventive health care is extremely important in detecting and reducing the development of CVD, however preventive care is unobtainable to many due to the lack of health care insurance. Although the knowledge of the need for medical management may be present, many people simply cannot afford to receive care. Because many people do not seek prevention and treatment for CVD, the occurrence of complications and premature death that results from CVD is much higher. The cost of health insurance continues to rise which causes employers to take larger and larger amounts of money out of employee paychecks or discontinue the benefit of health care altogether, and according to the Association of Operating Room Nurses (AORN), nearly 45 million Americans were uninsured for all of 2005. With better health care coverage, less people would forego or delay treatment, and therefore better patient outcomes would be achieved.
Thompson, J. (2007), The effect of health insurance disparities on the health care system. AORN Journal, 86(5), 745-764.
Disadvantage 2 – Complications with Prevention
Patient education by health care workers is of huge importance to CVD prevention. It is necessary for healthcare workers to provide information to at risk patients on the importance of issues such as diet, exercise, smoking cessation, and medical management of CVD. However, increased demands being placed on health care employees and the health care provider shortage are causing the amount and quality of patient education to be compromised. Because the workload placed on health care staff has increased, they are forced act more as problem focused care providers rather than holistic, preventive providers. Without adequate time to spend with each patient, education falls away from what is considered priority. In order to correct this problem, the importance of providing patient education needs to be emphasized to employees and re-implemented as a responsibility to providing overall quality patient care.
Anonymous. (2008). Practice nurse barriers to prevention. Australian Nursing Journal, 15(8), 6.
References
Berra, K., Miller, N., & Fair, J. (2006). Cardiovascular disease prevention and disease management: a critical role for nursing. Journal of Cardiopulmonary Rehabilitation, 26(4), 197-206.
Flynn, F., Cafarelli, M., Petrakos, K. & Christophersen, P. (2007). Improving outcomes for acute coronary syndrome patients in the hospital setting: successful implementation of the American heart association “get with the guideline” program phase I cardiac rehabilitation nurses. Journal of Cardiovascular Health, 22(3), 166-176.
Hill, J., & Peters, J. (1998). Environmental contributions to the obesity epidemic. Science, 280(5368), 1371-1374.
Jefferson, A. (2008). Nutritional management of coronary heart disease. Journal of Community Nursing, 22(5), 28-30.
Parkosewich, J. (2008). Cardiac rehabilitation barriers and opportunities among women with cardiovascular disease. Cardiology in Review, 16(1), 36-52.
Scott, S. (2005). Medical report: preventing coronary artery disease. American College of Sports Medicine, 9(6), 27-29.
Swain, D. (2006). Moderate- or vigorous-intensity exercise: what should we prescribe?. American College of Sports Medicine 10(5), 7-11.
Thompson, J. (2007), The effect of health insurance disparities on the health care system. AORN Journal, 86(5), 745-764.
Preventing, Recognizing and Treating Hepatitis C Virus
The spread of the Hepatitis C Virus (HCV) is a significant health issue across the United States. An estimated 4.1 million Americans are infected with HCV, and about 80% of those are presenting with no symptoms (National Center, 2006).
It is the nurse’s role to provide education about prevention, exposure, and treatment of HCV in all aspects of the disease. If the nurse successfully fills the role of a patient advocate, collaborator and teacher before, after and during treatment, chances are much higher the patient will become an active participant in the process as well.
There are six major strains of HCV, identified genotypes 1 through 6. The genotypes can be broken down more specifically into subtypes (1a, 1b, etc.). Genotypes are important in the diagnosis and treatment of HCV because they indicate how well patients will respond to treatment. HCV is a blood-borne virus, spread primarily through the sharing of needles and paraphernalia used to inject illicit drugs. Other possible, yet less prevalent, modes of transmission include that from infected mother to newborn, sexual transmission, needle sticks in health care workers, tattoos and body piercing. A small amount of those infected with HCV have been by exposure through hemodialysis and transfusion of blood products. Most people with chronic hepatitis C are asymptomatic for the first two decades of infection (Fahey, 2007). Patients who experience symptoms may present with jaundice, abdominal pain, decreased appetite, nausea, dark urine, fatigue and depression. Because HCV is “silent” it is extremely important for high risk individuals to be tested regularly. Blood tests for HCV begin with EIA (enzyme immunoassay) or CIA (enhanced chemiluminescence immunoassay) if positive, the diagnosis should be confirmed with RIBA (recombinant immunoblot assay), a test used to confirm a positive EIA test. If a patient has a positive HCV blood test the next step is to measure the level of ALT (alanine aminotransferase), a liver enzyme in the blood, which indicates inflammation of the liver. Liver biopsy can provide additional information, including extent of fibrosis and cirrhosis, but is no longer a requirement for diagnosis and treatment decisions. Liver biopsies are often recommended for other reasons, usually as a way of determining the extent of the disease (Fahey, 2007). Those at increased risk for contracting HCV include people who have injected drugs at any time, children of mothers infected with HCV, health care workers, and people with tattoos and piercings performed in environments with poor infection control procedures.
There is no vaccine to prevent HCV, making education an extremely important part of preventing the spread of HCV. It is vital that nurses ensure patients’ understanding of the following practices in keeping themselves and others safe from HCV. If patients use intravenous drugs, encourage attending a treatment program and the use of clean needles and other paraphernalia. Do not share items with potential for the presence of blood (e.g. razor, toothbrush). Health care workers use precaution to avoid contact with bodily fluids (e.g. gloves, safety syringes). Follow good health practices when tattooing and body piercing. If infected with HCV never donate blood, organs or tissue.
Hepatitis C is a treatable disease, with many advancements is treatment over the years. Combination therapy is the recommended, and most common, treatment for infected patients. Standard combination therapy with pegylated interferon alpha (peginterferon alpha) and ribavirin has been found to be most effective. Over 50% of patients receiving combination therapy have undetectable HCV in blood tests six months after treatment is completed (Zic, 2005). It is important for patients to know about the medication therapy they receive, as it can be difficult, with many side effects. Interferon alpha is a naturally occurring protein produced by cells after viral infection. The goal of treatment is to eradicate the virus and prevent progression of liver disease before cirrhosis, liver failure, cancer or death occur (Fahey, 2007). Peginterferons are a version of the natural interferon alpha which has been chemically modified to reduce the rate of elimination, therefore increasing the amount of time it is effective (Zic, 2007). Ribavirin is a nucleoside analogue with the ability to act as an inhibitor of the virus, HCV. The mechanism of action of treatment is not yet fully understood and holds no guarantee of success (Fahey, 2007).
Adverse reaction to treatment can vary in intensity, severity, nature and management. It is important to monitor side effects on an individual basis and create a plan for management individually as well. Many patients experience flu-like symptoms early in treatment, these typically lessen as treatment continues. Additional side effects resulting from interferon may include fatigue, hair loss, difficulty focusing, moodiness, and depression. Severe side effects are rare (seen in less than 2% of patients) and include thyroid disease, depression with suicidal ideations, seizures, acute heart or kidney failure, eye and lung problems, hearing loss, and sepsis. In addition ribavirin can cause serious anemia. In treating patients with history of anemia or conditions increasing risk for anemia, such as kidney failure, combination therapy should be avoided until anemia has resolved. Ribavirin causes birth defects and pregnancy should be avoided during treatment. It is imperative to review the product manufacturer information with the patient prior to treatment (National Center, 2006).
Success of treatment of HCV is dependent on patient adherence to the treatment program. Because of the many side effects, frequency of medication administration and patient responsibility to administer the medications, it is not uncommon for patients to discontinue the therapeutic regimen prematurely. The nurse has an important role in encouraging the completion of treatment. After formation of a relationship based on mutual trust and development of a nurse-patient bond the nurse can provide education, empowering the patient to make informed decisions regarding treatment options and other interventions (Zic, 2005) It is important for the nurse to be open and trusting of the information provided by the patient and not be judgmental, as this attitude will be conveyed to the patient. A survey involving nursing care of the HCV infected patient revealed patients discussed issues with the nurse, regarding infection and treatment, that in some cases, they did not address with the physician (Zic, 2005). If a patient offers information they are still using illicit drugs it is imperative the nurse address the issue immediately. Drug users can be offered much support to attain a drug-free status and it is felt to be unethical to offer treatment to patients still using drugs, because of the complications involved with both treatment and drug use (Fahey, 2007).
A number of supports groups exist for the HCV infected patient, along with friends, family members and caregivers. Support groups are an important piece of treatment as they provide a comfortable environment for patients to discuss concerns and hear others, similar to them, share experiences. HCV support groups provide a place for patients to compare challenges of infection and treatment and give suggestions and encouragement to complete treatment (Cormier, 2005).
As more people are diagnosed with viral hepatitis C there is a growing need for nurses in this specialized field. Acknowledging the relationship social support, health promotion and education is the first step in successful treatment of the HCV infected patient. Nurses involved in the care of HCV patients must evaluate and facilitate the need for services to ensure success for the patient.
References
Cormier, M. (2005). The role or hepatitis C support groups. Gastroenterology Nursing,
28(3), S4-S9.
Fahey, S. (2007). Developing a nursing service for patients with hepatitis C. Nursing
Standard. 21(43), 35-40. Retrieved February 12, 2008 from Academic Search Premier.
National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. (2006,
December 8) Viral hepatitis C. Retrieved February 16, 2008 from http://www.cdc.gov/nchhstp/.
Zic, I. (2005). Peginterferon alpha/ribavirin comination therapy for the treatment of hepatitis C infection. Gastroenterology Nursing, 28(4), 317-328.
Interventions and Disadvantages
A. Provide education about prevention, exposure and treatment of HCV
I. Difficult to reach and receive follow through from patients/high risk individuals
Many high risk individuals hear stories about how difficult treatment can be and decide not to even attempt seeking diagnosis or treatment as a result. Some were informed that hepatitis treatment was inaccessible if they were currently injecting drugs. Others perceived treatment as inaccessible to those without health insurance. Many state they were likely to accept testing if it were more readily available. Since there seems to be a lack of awareness of locations offering free testing and lack of transportation to the testing and treatments sites, high risk individuals have been deterred from getting tested and treated (Page-Shafer 2002).
II. Low income, under educated, drug addicted patients make education challenging.
There are many factors which hinder education regarding Hepatitis C virus (HCV). It seems that disease specific information is lacking, creating a barrier for preventative health services. This lack of information is evidenced by the injection drug user’s (IDU) perception of low risk for contracting HCV, despite self-reported needle sharing. Because they do not consider themselves to be at risk many IDUs do not get tested. Despite “constant” HIV education many IDUs express little or no exposure to information regarding HCV. HIV and HCV education should be delivered concurrently, as many IDUs report receiving HIV information during drug treatment programs. Drug treatment facilities are prime sites to offer testing and treatments opportunities as well. Limited knowledge of HCV is evidenced during interviews with IDUs.
“Hepatitis has got something to so with HIV, doesn’t it? Your body turns yellow, or some shit like that? No. No. I don’t be around yellow people.” 42-year-old African American woman, lives with
her grandmother. (Lally et al, 2008)
Patients who actually got tested were often confused and frustrated related to lack of information and
education delivered at the time of diagnosis.
“When I was pregnant they said, “You know you have hepatitis C?” And I said, “Yeah, why?”…They said, “It’s no big deal”…so I thought, why should I even bother following up?...Maybe I misinterpreted that…But I did learn…you can get very sick and die from it…The only thing I know of is changing your diet and interferon.” 36-year-old white homeless woman. (Lally et al, 2008)
The most serious barrier is prioritization of obtaining drugs over attention to one’s health. IDUs report that during times when they are actively using they are less likely to get tested, treated or follow up because time is consumed by obtaining and using drugs, interfering with ability to attend to health needs. These barriers are confirmed in statements by drug addicted women.
“When you’re using you just don’t have time for really anything …not your children, not bathing…not eating, not sleeping…not being responsible. It basically consists of money and using. And worrying how to contact your connections. And trying not to get arrested in the process…Users have a 25 hour a day joc.” 33-year-old, white, homeless woman (Lally et al, 2008)
“The last thing on my mind is going to get tested…I got to be tested and I know that. But I care about being an addict more than I care about my health.” 23-year-old, African American woman.( Lally et al, 2008)
B. Administer pharmaceutical treatment with regular visits to monitor effectiveness of treatment
I. Lack of health insurance/financial resources to fund Hepatitis C treatment programs
Injection drug users (IDU) are a medically underserved population, nationally, and confront many barriers to accessing medical services. Lack of regular medical care and low to non-existent levels of insurance coverage represent significant obstacles. Because IDUs access to and utilization of medical care is inconsistent, current medical complaints often override infectious disease detection, diagnosis and education during instances when care is sought. (Lally et al, 2008) Once diagnosed payment for treatment remains a huge concern to patients.
"I though of [treatment] a lot. I've got to go to the doctor…Oh my God, I don't know how much it's going to cost. Let me see if I can get medical first, and then I'll go." 31-year-old white woman, stays with brother (Lally et al, 2008).
Patients on Medicaid are significantly more likely to be treated for HCV than patients with only Medicare coverage or private/commercial insurance. Patients with Medicaid are more likely to seek and follow through with treatment because Medicaid pays the total cost of prescription medications including interferon-based combination treatments. Medicare alone does not cover the total cost of medications resulting in large out of pocket expenses for patients (Narasimhan et al, 2006). Free, federally funded HIV testing and counseling is much more accessible through local agencies and health departments than for Hepatitis C, services which would seem to fit hand in hand.
II. Difficult to follow up for continued treatment and monitoring for many reasons, including, lack of transportation, accurate and stable contact information, mental illness and patient priorities other than health care follow up
Common reasons for non-treatment include minimal/mild disease on biopsy (38%), noncompliance (31%) , patient refusal (22%) and significant psychiatric problems (8%) (Narasimhan et al, 2006). A study reveals very low income is the strongest correlating group of HCV infected patients. Four California counties participated in the study which revealed 60% of those infected earn a monthly household income of less than $999 and only 7% earning over $3000 per month. 90% had not earned a college degree and 41% did not complete high school. 62% of those infected with HCV were single, 54% having more than 5 sex partners and 45% diagnosed with an STD other than HCV (Page-Shafer et al 2002). Lack of education and financial resources make continuation of treatment and monitoring very challenging for healthcare professionals.
Many patients indicate that a lack of transportation hinder their ability to receive testing, results, treatment and monitoring.
"Transportation…would help a heck of a lot because people are out here catching buses and they're [drug] sick. Who wants to go out there in the snow, rain, sleet, whatever, even when they're not sick?...I haven't been making appointments because I don't have a ride out there. And I'm not going to get on no bus and all that shit when I don't feel good." 43-year-old CapeVerdian woman, homeless (Lally et al, 2008)
References
Lally et al (2008). A qualitative study among injection drug using women in Rhode Island: attitudes toward tesing, treatment, and vaccination for hepatitis and HCV. AIDS Patient Care and STDs. 22(1). 53- 63. Retrieved May 9, 2008 from Academic Search Premier.
Narasimhan, G. et al (2006). Treatment rates in patients with chronic hepatitis C after liver biopsy. Journal of Viral Hepatitis. 13. 783-786. Retrieved May 4, 2008 from Academic Search Premier.
Page-Shafer, K. et al (2002). Hepatitis C virus infection in young, low-income women: The role of sexually transmitted infection as a potential cofactor for HCV infection. American Journal of Public Health. 93(4). 670-676. Retrieved May 4, 2008 from Academic Search Premier.Preventing, Recognizing and Treating Hepatitis C Virus
Nursing Strategies for Perinatal Care
A pregnancy has the potential to raise many emotions and questions. What’s going to happen to her body? Will anything go medically wrong? The healthcare team is often one of the only sources of information that the pregnant woman will consult with such questions. Because the prenatal and perinatal periods are a critical time in preserving healthy mother and child outcomes, nurses have a crucial role in providing emotional, medical, and educational support to their obstetric patients. Strategies that nurses can use to provide such support include encouraging pregnant women who statistically do not receive prenatal care to seek care through avenues such as social services and other community organizations, identifying high-risk mothers as soon as possible in the pregnancy so that interventions may be made in time to avoid adverse outcomes, and functioning as a labor coach for women who come to the hospital without a support partner and/or childbirth education.
In 2005, there were over four million births in the United States, as recorded by the CDC (Martin et al, 2005). Many of these women may have had little or no prenatal care, which correlates with higher neonatal care unit (NICU) admission rates (Stankaitis, Brill, & Walker, 2007). A lack of prenatal care can lead to many other adverse health outcomes, including low birth weight babies, mother-child transmission of various diseases, and complications of drug addiction, diabetes, and other disease processes. In fact, babies born to mothers who received no prenatal care are three times more likely to be born at low birth weight, and five times more likely to die, than those whose mothers received prenatal care (Health Resources & Services Administration, 2008).
One strategy that nurses can use to enhance maternal-child outcomes is to facilitate the use of prenatal care for those women who do not often receive complete care. These include women of low socioeconomic status, as well as women of color. One study of low-income African-Americans in Florida showed that prenatal care was begun in the first trimester for only 50% of the population in Brevard County. When this percentage was increased via a nurse-led social service program that focused on culturally competent care, the number of low birth-weight infants decreased by 33% (Browne-Krimsley, 2004). In another study, the number of Medicaid-dependent pregnant women who delivered babies admitted to the NICU was vastly decreased by the use of a nurse-coordinated program called Healthy Beginnings. In Healthy Beginnings, the nurse employs outreach workers to provide home health prenatal care and other social services to women of low socioeconomic status (Stankaitis, Brill, & Walker, 2007). The nurse plays a crucial role in opening the door to prenatal care during the critical first trimester, as well as following up throughout the pregnancy.
In addition to facilitating prenatal care for those who do not usually seek it out, the nurse should endeavor to identify high-risk mothers early in the prenatal period so as to administer interventions to avoid adverse maternal-child outcomes. Brenna L. Anderson (2004) showed that the rate of human immunodeficiency virus screening during pregnancy was increased by the use of a trained nurse educator. Without the nurse educator, many women refused the screening process, which interfered with the ability of the medical team to provide zidovudine during pregnancy to avoid mother-child transmission of the disease. In another project, Dr. Yvonne Hauck (2007) worked with community health nurses to develop better mental health services for mentally ill pregnant women. The project focused on factors that the women could plan to change, including appointment attendance, smoking cessation, and nutritional advice. Mentally ill women often do not comply with prenatal care advice, or stop taking their medications, which can adversely affect the fetus. The project is currently in progress, and the staff are optimistic about the outcomes.
Along with nurse-mediated prenatal care, nurses are crucial to the actual birth experience as labor coaches. Many women do not take advantage of childbirth education during their pregnancy, or do not have family or friends to help them during labor. In these cases, nurses must function as the labor coach to promote healthy outcomes for mother and child. One study showed that continuous labor support provided by a nurse present throughout the birth process correlated to a 7% increase in spontaneous vaginal births as opposed to C-section. “Continuous support patients” had less incidence of C-section, were less likely to request analgesia, and were more satisfied with their experiences (Nicholson, 2007). The reasons for these occurrences is thought to be that patients feel more at ease with trained personnel at hand throughout the labor and more opportunity for nurse-provided education along the way.
As the previous studies have shown, nurses are really at the forefront of prenatal and perinatal care, leading to better maternal-child outcomes. Clinics, social services, nurse hotlines, and other resources are even promoted by the insurance companies in the endeavor to avoid costly adverse outcomes in pregnancy and labor. This should lend great anticipation to those nurses with interest in the field. Obstetrical, labor/delivery, and postpartum nurses are both a necessity and a blessing to the perinatal process when they use strategies such as acting as labor coaches, identifying high-risk mothers early in the prenatal period, and encouraging mothers who statistically do not receive any prenatal care to do so through social and community services.
Intervention #1
Identify high-risk mothers early in the prenatal period so as to administer interventions to avoid adverse maternal-child outcomes.
Disadvantage #1:
One problem that arises with identifying high-risk pregnancies is that women in general often do not find out that they are pregnant until many weeks into the pregnancy, and the first prenatal appointment may not be available until after the window when such interventions should be made. According to Michael Lu in an American Family Physician article, “by the time pregnant women have their first prenatal visit, it may be too late to prevent some placental development problems or birth defects.” Lu also stresses that in early prenatal care, it is often too late to restore allostasis and that pregnant women with under-functioning allostatic systems are more susceptible to pregnancy complications (2007). All women, and especially women at high risk, should seek pre-conception care to avoid these kinds of complications. However, this becomes difficult when a woman does not even know she is pregnant, or is not trying to get pregnant. This is one reason why physicians are stressing that women of child-bearing age have a high intake of folic acid.
Disadvantage #2:
Another barrier to providing prenatal care for high-risk mothers is that, in many cases, these women refuse prenatal care. This is true in many different classes of women, including poor and rich, young and old, across the ethnic lines. One study that looked at the effectiveness of policies that implement HIV testing for pregnant women found that women older than 30 years of age were less likely to accept the testing (Samquist et al., 2007). Perhaps the reason for this is that these women feel that they are too old to have contracted the disease—they are married or in committed monogamous relationships. Other groups that may refuse prenatal care are the poor and/or uninsured. The rates of uninsured pregnant women are growing every year as the cost of insurance rises. Many of these uninsured women decide that it is too expensive to get prenatal care, and they may feel that it is expendable.
Intervention #2
Nurses can function as the labor coach, giving continuous labor support to promote healthy outcomes for mother and child.
Disadvantage #1:
Continuous labor support is rarely available, related to the cost of staffing and the nursing shortage. The author of a study concerning continuous labor support states that “there isn’t technically such a thing as a continuous caregiver during labour…as far as nurses or midwives or regular hospital staff, it’s very unusual that they can spend the entire time with just one woman in labor” (Nicholson, 2007). Hospitals have the mindset that they can’t afford to staff their birth centers with that kind of personnel load. However, if hospitals reorganize their staffing to cross-train OB nurses and post-partum nurses, this kind of staffing may well be possible.
Disadvantage #2:
Continuous labor support is only as helpful as the one giving the support. Just as there are nurses out there on the med-surg floor that a student would either choose to emulate or choose to use as the example of “what not to do,” there are labor support nurses and/or midwives in those same categories. Some nurses give wonderful labor support, while others merely bark out orders, placations, or blatantly belittle the woman in labor. Imagine the horror for the woman who received a nurse from the latter category for her entire labor! In a study by three midwives,
“Care interpreted as unethical was characterized by physical closeness and prescriptions of what had to be experienced and done, or by neglecting the nontechnical aspects of caring related to the birthing woman, the expectant father, the new parents and the newborn baby. Bergstrom and co-workers emphasized the importance of being open to what is happening with a woman ‘rather than to what is supposed to happen according to an outdated and inaccurate script of how labour and birth should proceed.’ “ (Hallgren, Kihlgren, and Olsson, 2005).
Nurses who aspire to work in the labor and delivery unit should be prepared to provide continuous labor support, and should undergo specific training for this endeavor. This will aid in providing quality continuous care for every woman, not only those who get the “good nurses.”
References
Anderson, B. (2004). Improving universal prenatal screening for human
immunodeficiency virus. Infectious Diseases in Obstetrics and Gynecology,
12(3/4), 115-120. Retrieved April 17, 2007, from ProQuest database.
Browne-Krimsley, V. (2004). Lessons learned: providing culturally competent care in a
nurse-managed center. Association of Black Nursing Faculty Journal, 15.4 (July- August 2004), 71-74. Retrieved April 17, 2007, from Expanded Academic
ASAP database.
Hallgren, A., Kihlgren, M., and Olsson, P. (2005). Ways of Relating During Child-
Birth: An Ethical Responsibility and Challenge for Midwives. Nursing Ethics, 12
(6), 606. Retrieved May 9, 2008, from ProQuest database.
Hauck, Y. (2007). Project to improve pregnancy outcomes. Australian Nursing
Journal, 14,(10), 33. Retrieved January 29, 2008, from ProQuest database.
Health Resources and Services Administration (2008). A Healthy Start: Begin before
baby is born [WWW document]. Retrieved February 20, 2008.
URL http://mchb.hrsa.gov/programs/womeninfants/prenatal.htm
Lu, Michael C. (2007). Recommendations for Preconception Care. American Family
Physician, 76 (3), 397. Retrieved May 9, 2008, from ProQuest database.
Martin, J., Hamilton, B., Sutton, P., Ventura, S., Menacker, F., Kirmeyer, S., & Munson,
M. (2005). Births: Final Data for 2005. National Vital Statistics Reports, 56 (6).
Retrieved January 18, 2008, from general search engine.
Nicholson, P. (2007). Continuous labour support linked to best births, but rarely
available. Medical Post, 43(27), 44. Retrieved January 29, 2008, from ProQuest
database.
Samquist, C., Cunningham, S., Sullivan, B., & Maldonado, Y. (2007). The Effective-
ness of State and National Policy on the Implementation of Perinatal HIV
Prevention Interventions. American Journal of Public Health, 97, 6, 1041.
Retrieved May 9, 2008, from ProQuest database.
Stankaitis, J., Brill, H., & Walker, D. (2007). Reduction in neonatal intensive care unit
admission rates in a Medicaid managed care program
[Electronic version]. American Journal of Managed Care, 11, 166-172.
Spirituality in Nursing: the Nurse's Role in Holistic Care
With the incredible advancements in technology, it seems that the spiritual dimension of nursing is an area that has been neglected. Because spiritual care is an important aspect of health care, nurses must be knowledgeable about and in touch with their own spirituality in order to be completely available to their patients.
Nursing faculty need to have tools available in their curricula that may be used to develop spiritual knowledge in their nursing students. There are several strategies that can be used to implement a higher degree of spiritual awareness in today’s nurses. Given the increased focus on spirituality, it is imperative that nurse educators teach spiritual assessment techniques, the art and science of spiritual care, and measure students’ knowledge and understanding of spirituality and spiritual care.
Arriving at a common definition of spirituality presents a challenge. Many experience spirituality as an abiding presence. As the essence of being, spirituality manifests in relationships with one’s self, others, nature, and a divine being or life force. “Nurses are better prepared to promote the spiritual health of patients within clinical settings when they are aware of their own spirituality” (Lovanio, 2007, ¶ 8). Students must be able to assess their own spirituality before they can relate to someone else’s spiritual needs. Nurses spend more time with their patients than do other health care
workers. Spirituality can be referred to as ‘a way of seeing’, not with our eyes, but with our inner eye, our consciousness (Wright, 2007, ¶ 5). Therefore, the spiritual needs of patients must be recognized as a domain of nursing care. How should spirituality be addressed in the nursing curricula?
One nursing strategy is to integrate a spiritual assessment skills course into nursing curricula. “Emphasis on spirituality in the nursing program as rated by students and faculty served as the most significant environmental predictor of the student’s perceived ability to provide spiritual care” (Mitchell, 2006, ¶ 10). The student’s ability to provide spiritual care is a two part process. Before the students can assess a client’s spirituality, they must be capable of a spiritual self-assessment. If a student can recognize their own woundedness and the source of strength that they used to grow from that experience, the self-assessment exercise can be used to promote reflection and introspection. This can be a non-judgmental, supportive assignment that transcends reflection from an academic exercise to a working part of the mind for the student. The self-assessment can help the student recognize the client’s strengths and coping styles, while enhancing the student’s capability of assessing the client’s spiritual needs. The nurse’s ability to connect with the client on a spiritual level can contribute to the client’s healing process, sometimes more so than technology (Pesut, 2003).
Nursing faculty have been responsible for delivering knowledge regarding spiritual care to nursing students since the beginning of modern day nursing with Florence Nightingale. Another key strategy to incorporate spirituality in nursing is to base curriculum on ethical principles. There are several ethical principles on which a spiritual care curriculum is based. The first principle outlines respect for others and for
human rights. Nurses must have the ability to respect religious choice and the client’s use or neglect of these. A second ethical principle is autonomy, which involves the client’s right to self-determination. Nurses must set aside their own belief systems and support their client’s autonomous needs for spiritual care. A third ethical principle is advocacy. Nurses must become advocates for client’s spiritual needs. Taking into account the client’s spiritual needs and advocating for them is part of the ethical duty of the nurse. Both the client and the nurse benefit from the interpersonal relationship that is forged through spiritual care. “When all is said and done, a nurse needs to look into his or her soul and ask, ‘Am I am nurse or a technician?’”(Nussbaum, 2003, ¶ 12).
A third key strategy is to measure students knowledge and understanding of spirituality and spiritual care before and after implementing some simple tools such as reflective journaling, spiritual writing assignments, discussion, and faith-based clinical experiences to promote spiritual awareness. A sample of ten traditional undergraduate nursing students experiencing their first clinical rotation was selected to participate in this study. The students’ knowledge was measured with the Spirituality and Spiritual Care Rating Scale (SSCRS). After participating in these activities, the students’ scores were higher on the post-test than the pre-test. They verbalized an appreciation of the strategies associated with improving spirituality. The students also demonstrated “increased awareness of the main principles associated with spiritual care” (Lovanio, 2007, ¶ 18). The project focused on the importance of addressing the spiritual needs of clients when providing holistic care, while augmenting the student’s perception of spirituality, facilitating them to be involved in giving spiritual care.
Nursing students have the capability to promote spiritual well-being and transcend barriers between themselves and their clients with a spiritual connectedness that can be more powerful than technological advances. Implementing curricula into current day nursing programs that enhances the nursing students’ spiritual awareness needs to be an integral component of the educational process. Because spiritual care is an important aspect of health care, nurses must be knowledgeable about and in touch with their own spirituality in order to be completely available to their patients. A few simple strategies such as teaching assessment techniques, the art and science of spiritual care, and measuring students’ knowledge and understanding of spirituality can work towards the development of spiritually competent nurses.
Spirituality in Nursing: the Nurse’s Role in Holistic Care
Intervention #1
There is a need for more emphasis on spiritual assessment skills and the education of these skills in current nursing curricula.
Disadvantage #1
Nursing education has risen to the challenge of teaching spiritual care theories and interventions to students, despite the absence of policy to guide educators. According to Lantz (2007) “there seems to be a conflict with traditional nursing education being based on Western medical methods, and that perhaps a shift to a partnership model that includes holistic and intuitive approaches may enhance the educational process.” Without a clear cut policy guiding the education of spirituality in current nursing curricula; implementing more spirituality courses will be continually hindered.
Disadvantage #2
Nursing education textbooks lack information that provides clear direction in the matter of integrating spirituality into the curricula. Textbooks focusing on professional issues, medical-surgical nursing, maternal-child health nursing, critical care nursing, and community health nursing contained the least spiritual content (McEwen, 2004, ¶ 3).
One of the most prominent reasons for nurses’ lack of preparedness to provide spiritual care is that their basic education only minimally discusses spirituality and related issues.
If nurses are to enhance incorporation of spiritual care in their practice, they need instruction. It falls in the hands of nursing authors and faculty to address the current educational deficits throughout the entire nursing curricula.
Intervention #2
Another intervention is incorporating spirituality into nursing by basing curricula on ethical principles.
Disadvantage #1
By basing curricula on ethical principles, nurses must have respect for their patients’ religious choices and religious differences. Respect for human rights can be viewed as inclusive of religion and as a component of spirituality to be valued ethically. Public institutions are bound by the First Amendment regarding the separation of church and state. “Public institutions must maintain a neutral stance regarding religious beliefs and activities” (Lantz, 2007, ¶ 20). It can prove difficult for nurse faculty to educate their students about the concept of spirituality which has a patient’s religion, or lack thereof, at the center of the patient’s being, when assessing religious practices and spiritual needs.
Disadvantage #2
It is also possible that with a multitude of spirituality teaching based on ethical principles incorporated into nursing curriculum; there are still going to be nurses who do not have it in their mental armory to offer this facet of care. The nurse may not have the ability to derive inspiration from the workplace or the nurse-patient relationship. According to McEwan (2004), “nursing is too biologic, professionalism is synonymous with distancing, and nurses are not comfortable with or able to recognize their own spirituality.” To achieve self-fulfillment at work depends on the individual philosophy cherished by the nurse.
References
Lantz, C. (2007, Jan). Teaching spiritual care in a public institution: Legal implications,
standards of practice, and ethical obligations. Journal of Nursing Education.
46(1), 33-39. Retrieved May 6, 2008, from Proquest database.
Lovanio, K., & Wallace, M. (2007, Jan-Feb). Promoting spiritual knowledge and
attitudes: A student nurse education project. Holistic Nursing Practice.
21(1),42-47. Retrieved May 7, 2007, from Expanded Academic ASAP.
Thomson Gale database.
McEwan, W. (2004, Jan.-Feb.) Spirituality in nursing. Orthopaedic Nursing. 23(5), 321-
326. Retrieved May 5, 2008, from Proquest database.
McEwen, M. (2004, Jan.) Analysis of spirituality content in nursing textbooks. Journal of
Nursing Education. 43(1), 20-28. Retrieved May 7, 2008, from Proquest database.
Mitchell, D. L., & Bennett, M. J., & Manfrin-Ledet, L. (2006, Sep). Spiritual development of nursing students: Developing competence to provide spiritual
care to patients at the end of life. Journal of Nursing Education. 45(9), 365-370. Retrieved April 10, 2007, from Proquest database.
Nussbaum, G. B. (2003, Jul-Sept). Spirituality in critical care: Patient comfort and
satisfaction. Critical Care Nursing Quarterly. 26(3), 214-221. Retrieved April 28, 2007, from Expanded Academic ASAP. Thomson Gale database.
Pesut, B. (2003, Nov-Dec). Developing spirituality in the curriculum: Worldviews,
Intrapersonal connectedness, interpersonal connectedness. Nursing Education
Perspectives. 24(6) 290-294. Retrieved January 14, 2008 from EBSCO database.
Wright, S. (2007, Oct .). The Spirit of Good Nursing. Nursing Standard. 22(8), 21-22.
Retrieved January 14, 2008, from EBSCO database.
Eliminating Apprehension Among Nurses Towards End-of-Life Care.
Improvement in palliative care can happen with more interest from nurses towards this area of practice. Nurses are the health care providers that spend the most time with the patient and their families, making them advocates for patients who need end-of-life care.
Nurses can also change the quality of care that is given. There are many ways to change the concepts of palliative care through both schools, hospitals, and nurses themselves. Since there is apprehension among nurses to provide end-of-life care, nursing schools should promote further education in this area, and allow students more clinical time to build the necessary skills and therapeutic technique to care for patients as well as specific training for caring for the family members, as well as teaching nurses how to deal with their own fears and emotions related to working with patients during their final days.
There are several factors that keep nurses as well as newly graduated nursing students from choosing palliative end-of-life care as their focus in their nursing career. Having little or no exposure to end-of-life care in school is a contributing factor, as well as the increased needs of the patient’s family during this time. Another obstacle is the nurse’s own fears about death and the potential feelings of loss for each patient. When a patient is referred to palliative care, the focus is no longer on curing. Palliative nursing is focused on caring for the patient and making them a comfortable as possible. Caring for a patient during this time involves several emotions and nurses should have training on how to deal with these feelings.
Encouraging nurses to explore this area of nursing is critical. More clinical experience in palliative care is needed. Training for nurses dealing with dying patients is needed as well, in order to recruit new nurses choosing this area of focus. Being exposed to end-of-life care will help nurses deal with apprehension issues, and allow the student to work through their own fears with the dying process. It may also be an enlightening experience as it may be an area some students would never chose until they are exposed to it, and realize it is something they are comfortable with. Exposure in nursing school can be beneficial even if the student does not intend to focus on end-of-life care. Integrating palliative end-of-life care into the daily practice of every nurse, regardless of specialty, can improve healthcare overall (Rushton, 2004). Patients can pass away on any floor of a hospital or nursing home, before they are referred to palliative care. The nurse working with this dying can implement some of the same strategies without specializing in end-of-life care. These strategies can also be implemented if a patient is not dying, such as assisting a family of a patient with an acute or chronic illness. The dying process includes psychological, social, spiritual, physical, and existential aspects. Facing a terminal illness is a stressful experience that affects many aspects of life (Smith, 2005). If nurses could specialize in this area, their focus would be on all of these aspects instead of just one or two (Smith, 2005). Further training in these areas, as well as exposure to dying patients will help the nurse to cope with his/her own apprehension about providing end-of-life care. Including palliative care in nursing schools would enable perspective palliative nurses to adjust to working with a dying client base. Since an important component of palliative nursing is to achieve the trust of the patient, the nurse-patient relationship can be further explored in schools, as well as in hospitals (Chiu, 2003). End-of-life care patient training should also be implemented early in nursing school and continued throughout one’s nursing career. With baby boomers aging, it is evident that end-of-life care will become an important part of nursing (Weigel, 2007).
Because end-of-life care involves caring for the patient’s family as well as the patient themselves, a nurse should keep the family informed and allow them to participate in the care of their loved one. Nurses have the most contact with the patients families, so they play a critical role in assessing the needs of the family during this sensitive time (Brajtman, 2005). Although, the death of the patient is unavoidable, providing sensitive, caring nursing will comfort the loved ones. A nurse should communicate with the family and provide information about the patient’s condition including things a family can do to provide care. Including the family members in the implementation and planning of care of their loved one with alleviate questions and concerns as well as giving them the sense of involvement. Informing the family of what is being done as the nurse performs tasks, i.e. pain meds, and their expected effects will help calm their fears and allow them to know what signs to look for, as well as giving family members the peace of mind that their loved one is comfortable. Nursing schools should implement caring for more than just the patient as curriculum. It is an emotional experience for the patient as well as for the family they are leaving behind. One of the most important things a nurse can do for the family is to listen to their concerns.
Caring for patients who are entering their final days of life is an emotional experience (Weigal, 2007). Nurses are hesitant to care for patients in this state because of the fear of their own emotional experience during the process. The fear of death itself is a factor that makes some nurses concerned about choosing this specialty to apply their skills. The fear of working with the family at such an emotional and life altering time is also an obstacle. As a nurse providing end-of-life care, there is an intense amount of time spent with the patient as well as the family members involved. Some healthcare professionals may find themselves with feelings of hurt and loss with each patient that passes away, because of the bond that was built during the patient’s final days. This is something a nurse working in this area would have to overcome. Hospitals could implement a counseling service as well as support groups for nurses to talk about their experiences and to deal with their emotions throughout these critical times.
There is apprehension among nurses to provide palliative care. Some ways to alleviate their hesitation are having curriculum in nursing schools as well as more clinical time with end-of-life patients. Schools, as well as hospitals should provide additional training for nurses on how to address and care for patients families during end-of-life care, and counseling for nurses individually to assist them in dealing with their own fears and emotions both before they work in palliative and continuing on during their career. One way for schools to consider these suggestions is for current palliative nurses to voice their concerns and advocate for student nurses to be exposed during their education. This is an important area of nursing. Patients deserve the best care possible regardless of the prognosis. Having more, quality trained nurses chose this area of nursing will ensure that.
Intervention 1: Nursing schools should have curriculum and clinical time devoted to end-of-life care.
I: Disadvantage 1 Time constaints
There is a nursing shortage in all areas, and having nursing schools devote more time to certain areas will only prolong the amount of time it takes to produce new nurses. If nursing schools were to implement curriculum with a special emphasis on end-of-life care, the curriculum would need to be updated continually (Dickinson, 2007), further taking up both time and money which are both scarce at this time in nursing education. The entire course may not fit into curriculum causing an extension of time nurses spend in training (Dickinson, 2007).
II: Disadvantage 2 Lack of Teachers
Many faculty feel under prepared to teach, and fail to provide adequate feedback about communication in end-of-life care (Sullivan, 2003). It is also a view that patient’s in end-of-life care offer too few learning opportunities and are not assigned as often (Sullivan, 2003). It is difficult for some medical professionals to teach about something that contradicts what they have been taught, which is to save lives (Sullivan, 2003).
Intervention 2: Hospitals could implement a counseling service for nurses to talk about their experiences and emotions felt about the dying process.
I. Disadvantage 1: Comforts levels about dying are different with each individual.
Everybody has different views and beliefs about death. Counseling and support groups may not curb reservations about dealing with this issue. Some people can’t be trained to be comfortable with the topic (Dickinson, 2007). Personal attitudes may also hinder ones ability to deal with this type of client.
II. Disadvantage 2: Funding and staffing for this unit
If hospitals implement counseling services specific for end-of-life care nurses, there would have to be funding and staffing for the unit. Anxiety levels may increase from increased exposure to death (Dickinson, 2007) causing an increased number of counseling sessions. Anxiety in the workplace can also show through in home life.
Reference Page
Brajtman, S. (2005). Helping the family through the experience of terminal restlessness. Journal of Hospice & Palliative Nursing, 7(2), 73-81. Retrieved January 30, 2008 from Expanded Academic ASAP database.
Dickinson, G. (2007). End of life and palliative care issues in medical and nursing schools in the United States. Death Studies, 31: 713-726. Retrieved May 12, 2008 from EBSCO Research database.
Johnston, B., Smith, L. (2006). Nurses’ and patients’ perceptions of expert palliative nursing care. Journal of Advanced Nursing, 54(6), 700-709. Retrieved January 30, 2008 from Expanded Academic ASAP database.
Mok, E., Chiu, P. (2004). Nurse-patient relationships in palliative care. Journal of Advanced Nursing, (48)5, 475-483. Retrieved January 30, 2008 from Expanded Academic ASAP database.
Rushton, C., Spencer, K., Johanson, W. (2004). Bringing end-of-life care out of the shadows. Holistic Nursing Practice, 18(6), 313. Retrieved January 30, 2008 from Expanded Academic ASAP database.
Sullivan, A., Lakoma, M., Block, S. (2003). The status of medical education in end-of-life care. Journal of General Internal Medicine, 18(9), 685-695. Retrieved May 12, 2008 from Pubmedcentral database.
Weigel, C., Parker, G., Fanning, L., Reyna, K., Gasbarra, D., (2007). Apprehension among hospital nurses providing end-of-life care. Journal of Hospice & Palliative Nursing, 9(2) 86-91. Retrieved January 30, 2008 from Expanded Academic ASAP database.
Diabetic Foot Care: the Nurse’s Role in Preventing Diabetic Foot Ulcers
Diabetes is a complex metabolic disorder that if not treated properly, can lead to peripheral neuropathy and peripheral vascular disease creating complications such as foot ulcerations and amputations later on in life. With the increasing numbers of diabetics world wide, it is essential to ensure they are receiving the information they need to properly care for themselves. Because foot ulcers are a debilitating complication of Diabetes Mellitus, nurses must educate diabetics about proper foot care, the importance of routine foot exams, and blood glucose management to prevent them.
Diabetes Mellitus is a chronic systemic disease characterized by either a deficiency of insulin or a decreased ability of the body to use insulin (Black & Hawks, 2007). To control this disease, diabetics take insulin injections or oral medication to control their blood glucose levels. Insulin is a hormone that the body uses to break down glucose. When the body is unable to use insulin or does not produce enough, glucose can build up in the blood causing poor circulation leading to more serious complications (www.mayoclinic.com/health/bloodsugar). When blood glucose levels are not properly monitored, a diabetic’s glucose continues to build up in the circulatory system and eventually leads to such diseases as peripheral neuropathy and peripheral vascular disease. According to Myles (2007), peripheral neuropathy is a complication in which damage to, or degeneration of the nerves can lead to loss of sensation in the feet. Peripheral Vascular Disease, on the other hand, results in ischemia (deficient blood supply, relative to requirements) causing pain to the patient’s feet, and predisposes them to the development of ulcers (Myles, 2007).
One way nurses can help prevent the development of foot ulcers in diabetics is to educate and encourage them to participate in proper foot care. An early intervention can be to teach diabetics about the precursors to foot ulcers, such as red spots on pressure points or calluses. Nurses can educate on the need to wear properly fitting socks and shoes that promote circulation, and reduce pressure points and calluses which could potentially develop into ulcers (Jones, 2006). According to Potter and Perry (2005), diabetics should inspect their feet daily, including the tops and soles of the feet, the heels, and the areas between the toes. Also, they should use a mirror to help inspect the feet thoroughly, or ask a family member to assist them with their daily check. Along with that, Potter and Perry (2005) mention washing the feet daily in lukewarm water (do not soak), and dry feet thoroughly, including between the toes. Diabetics need to know proper nail care as well, like filing the toe nails straight across and square, and to consult a physician for ingrown toenails (Potter & Perry, 2005). By teaching diabetics these fundamental principles, nurses can reduce the number of hospital stays for diabetics with foot ulcerations and possible amputations.
Encouraging diabetics to participate in routine foot exams by their health care provider, is another intervention nurses can implement. A trained practitioner can test for signs and symptoms of foot ulcerations that diabetics themselves are not able to assess, such as assessing for neuropathy by using a monofilament pen. The specialists can also assess the feet for clawing of the toes, distended veins on the dorsum, pedal pulses, the temperature of the feet, capillary refill, edema, decreased pedal hair, and nail atrophy (Evans & Chance, 2005). These can all be signs of peripheral neuropathy or peripheral vascular disease which lead to foot ulcers. Without proper care, diabetics are putting themselves at risk for possible amputations.
Another benefit of participating in routine foot exams is that while examining their feet, the nurse can educate clients on proper blood glucose monitoring to prevent complications. Complications such as diabetic ketoacidosis, hyperglycemia, and hypoglycemia are considered preventable diabetes related problems (Davidson, Ansari & Karlan, 2007). Educating diabetics on keeping their blood glucose levels from fluctuating between highs and lows can potentially decrease the number of diabetics with foot complications. The nurse can help with these problems by teaching diabetics how to monitor their blood sugar using target ranges, such as a reading between 90-130mg/dl before meals, lower than 180mg/dl after meals, and between 110-150mg/dl before bed (www.mayoclinic.com/health/bloodsugar). Along with testing their blood sugars, the nurse should encourage diabetics to participate in proper diet and exercise, and educate on what to eat or what medications to take before exercising to decrease the chances of a sudden drop in their blood sugar level. Fluctuating blood sugar levels greatly contribute to diabetic complications including foot ulcerations, but with proper nursing information and guidance, it can be controlled (Davidson et al, 2007).
The number of diabetics today is on the rise, and hospitals are seeing more and more visits due to diabetic foot complications and amputations. In many of the cases it was found that the foot complications were secondary to a knowledge deficit on proper diabetic care. To put an end to this debilitating complication of diabetes mellitus, nurses must educate diabetics about proper foot care, the importance of routine foot exams, and blood glucose management. Nurses can also send reminders to patients letting them know when their next appointment is, and encourage them to come back. Educating and encouraging patients to get involved in their diabetes care is a big step to reduce diabetes related complications.
Intervention #1
Nurses need to educate diabetics on the importance of routine foot exams.
Disadvantage #1
Routine foot exams are pertinent for diabetics, however, the lack of available, affordable and adequate health care insurance makes this impossible for them. For example, many people do not receive health insurance through there jobs and therefore must attain it themselves, and because of their health status being diabetic many times they are considered uninsurable. There are high-risk pools that have been established for individuals who are turned down by private insurers, however, a lot of times they charge higher premiums making it unaffordable. “Studies show that when health coverage is lost, people in poor health are more likely to experience lengthy spells of uninsurance compared with people in good health”( Pollitz, Bangit, Lucia, Kofman, Montgomery and Whelan, 2005). A lot of times people search for health insurance for so long without success that they end up giving up on the system altogether. Nurses need to be aware of this fact and be available to help people with pre-existing diseases in seeking out suitable health insurance.
Disadvantage #2
There are a limited amount of providers that are qualified to provide foot exams. Not only that, but not all providers make diabetics bare there feet for a proper exam when they come in for check ups. According to Jawaid and Jawaid, “only 14% of doctors treating diabetics ask patients to take off the shoes to examine feet,” (2006). Providers need additional training to manage high-risk foot conditions, as well as additional expertise in footwear modifications, nail and callus care, and surgical management of the foot (American Diabetes Association, 2003). By increasing the number of health care providers that are trained in proper foot examination including nurses, routine foot exams will be more beneficial to the diabetic client.
Intervention #2
Nurses need to educate diabetics on proper blood glucose management.
Disadvantage #1
Blood glucose management is critical to a diabetic’s health, but with limited access to adequate health insurance the supplies needed to do this are unaffordable for most. “Just the routine costs of managing diabetes (to test and control blood glucose levels) can reach hundreds of dollars per month,” ( Pollitz et al., 2005). In one such case involving a 40 year old married woman whose kids have asthma, she puts her kids’ medical needs before her own since they can’t afford them both, and her blood glucose levels get out of control (Pollitz et al., 2005). By advocating for better health insurance policies for diabetics and others with pre-existing conditions, nurses help reduce the occurrence of diabetic foot complications.
Disadvantage #2
Blood glucose monitoring is critical in management of diabetes, however, blood glucose monitoring alone will not do the trick, proper diet is also important in keeping your glycosylated hemoglobin levels down. A study using a PDA to track your low glycemic index diet daily resulted in glycosylated hemoglobin levels (Ma, Olendzki, chiriboga, Rosal, Sinagra, Crawford, Hafner, Pagoto, Magner, and Ockene, 2006). With blood glucose (BG) monitoring alone you can still eat something high in sugar that will send your BG levels sky rocketing. When this happens the glycosylated hemoglobin levels in your blood go up and are not brought down when insulin is administered like BG levels are. Nurses can educate diabetics about glycosylated hemoglobin and diet management along with blood glucose management to reduce diabetic complications.
References
Black, J.M. & Hawks, J.H. (2005). Metabolic Disorders. In B. Cullen (Ed.), Medical-Surgical Nursing Clinical Management for Positive Outcomes (pp.1243-1249). Missouri: Elsevier Saunders.
Davidson, M.B., Ansari, A., & Karlan, V.J. (2007). Effect of a nurse-directed diabetes disease management program on urgent care/emergency room visits and hospitalizations in a minority population. Diabetes Care, 30(2), 224-228. Retrieved April 15,2007 from ProQuest database.
Evans, J., & Chance, T. (2005). Improving patient outcomes using a diabetic foot assessment tool. Nursing Standard, 19(45), 65-77. Retrieved January 16, 2008 from Academic Search Premier database.
Jawiad, S.A. & Jawaid, M. (2006). Management of diabetic foot ulcers: some bitter facts and harsh realities. Current Research in Pakistan Journal of Medical Sciences. 22(2). Retrieved May 5,2008 from http://www.pjms.com.pk/issues/aprjun06/article/editorial1.
Jones, R. (2006). Exploring the complex care of the diabetic foot ulcer. Journal of the American Academy of Physicians Assistants, 19(12), 31-37. Retrieved October 7, 2007 from Expanded Academic ASAP database.
Ma, Y., Olendzki, B.C., Chiriboga, D., Rosal, M., Sinagra, E., Crawford, S., Hafner, A.R., Pagoto, S.L., Magner, R.P., & Ockene, I.S. (2006). PDA-assisted low glycemic index dietary intervention for type II diabetes: a pilot study. European Journal of Clinical Nutrition. 60, 1235-1243. Retrieved on May 5, 2008 from www.nature.com/ejcn.
Myles, J. (2007). Management of diabetic foot ulcers. Practice Nurse, 33(2), 38-42. Retrieved January 16, 2008 from Academic Search Premier database.
Pollitz, K., Bangit, E., Lucia, K., Kofman, M., Montgomery, K., & Whelan, H. (2005). Health Insurance and Diabetes: The Lack of Available, Affordable, and Adequate Coverage. Clinical Diabetes. 23(2), 88-90. Retrieved May 5, 2008 from http://clinical.diabetesjournals.org/cgi/content/full/23/2/88.
Potter, P.A. & Perry, A.G. (2005). Hygiene. In S. Epstein (Ed.), Fundamentals of Nursing (pp. 1038-1040). Missouri: Mosby.
Type 1 diabetes. (2005). Mayo Clinic. Retrieved May 19, 2007 from http://www.mayoclinic.com/health/type-1-diabetes/DS00329
Promoting exercise for the Senior Client and the Nurse’s Role
As the populous baby boomers approach senior age status and the nursing shortage continues it becomes critical for the health care worker to understand the importance of promoting a preventive approach to the health-care needs of the older population. Because the nurse is often the one who has the most consistent contact with these clients, he or she plays a vital role in promoting a lifestyle for them that includes an exercise protocol geared to their unique needs. Many of the chronic illnesses that affect this era of life can be prevented or at least improved with an appropriate activity level geared to their needs. Understanding the barriers unique to seniors, the particular activities which are the most beneficial, and giving individualized encouragement with a caring, multidisciplinary approach are strategies that the nurse can implement to promote a more active lifestyle for the aging client.
Research in the field of aging has clearly shown that there are many changes that occur such as cardiovascular changes, slow progressive decline in body mass, and decrease in muscle strength and mass. As we age our physiology changes but many of these changes respond well to a variety of interventions, especially an active lifestyle that includes cardiovascular and muscle strengthening protocols. Hartman (2003) states that even frail older adults can benefit from resistance training but that a proactive, rather than a reactive approach, should be taken for the baby boomers. Even moderate levels of physical activity have been shown to reduce the risk of dying from heart disease (Sabin 2005). Preventive medicine, in this case promotion of an active lifestyle, is clearly beneficial for the aging population and can be part of the nurse’s role in servicing the aging client.
There are barriers unique to the older client and the nurse needs to understand them. Barriers include past experiences with exercise, how the individual feels about her/himself as a worthwhile human being, and physical changes that occur with aging including brain chemistry changes. Though there might be barriers, the nurse can teach the older client that even small changes in lifestyle may result in large changes in health, especially preventive health. Emphasizing the potential benefits for exercise participation, the potential undesirable consequences for nonparticipation and implementing short-term goal-making will help motivate and encourage. Keeping the given information simple and understandable will also help to ensure success. Belza (2004) addresses several factors that help the senior to succeed in an exercise program. The most common motivational factor is social interaction. With this knowledge, nurses can encourage walking which is an activity that can also be shared in a social context with others. The nurse should be aware of local community agencies, senior centers, and family structures to be able to implement a strategy which includes social contact as well as a more active lifestyle for the senior.
Knowing where to refer the clients will help them succeed because of the social aspects to these places. Encouraging the types of activities that will give the most benefit with the least amount of discomfort are also important strategies. Although walking is the preferred activity, there are also other activities which can greatly increase health for the older person. Yoon (2006) points out that although a multi-set training program resulted in greater improvements in some exercises, one study of thirty-two sedentary older men and women revealed that low-volume resistance training produced very significant improvements and was found to be an effective strategy for the mature population. In other words, one set of 10 repetitions of one exercise, such as biceps curls, rather than several sets, can be nearly as effective as several sets. The nurse can refer older clients to programs that incorporate strength-training exercises geared to the aging person that emphasize single-set, simple, and relatively easy exercises that also give good results.
Seniors will benefit from these strategies because of their increased strength and energy level which may also help prevent osteoporosis and falls. Finally, the nurse’s caring, multidisciplinary approach will help the older client to achieve a healthier activity level as well. This type of caring is demonstrated by the Escalante Health Partnership, a community-based, nurse-managed health promotion and wellness center that was initiated in 1991 by representatives from a college of nursing, a local health department, and social service crisis network in Arizona (Nunez 2003). It has resulted in significantly less doctor visits per year in comparison with the others who did not participate in this program. When caring nurses collaborated with other caring individuals and organizations a difference was made to address the health issues of that population. The nurse shows care by being educated in the specifics of the older adult, by encouraging the individual client, and by teaching them the benefits of simple, uncomplicated lifestyle changes. The caring nurse also networks with a multidisciplinary approach that includes other health care workers and organizations.
The registered nurse’s impact on seniors and the coming baby-boomer seniors is significant. Because exercise and a healthy lifestyle are important in health promotion for seniors, one role of the nurse is to promote it to them. Understanding the barriers unique to seniors, encouraging the types of activities that will give the most benefit with the least amount of discomfort or complication, and finally, giving individualized encouragement with a multidisciplinary approach are strategies that have worked towards helping seniors to live healthier, stronger lives.
(Intervention 1) Understanding the barriers unique to seniors
(Disadvantage 1) Discrimination
One of the barriers to understanding the senior and the particular barriers to the implementation of a healthy exercise program for the senior is the practitioner’s own discrimination or prejudice. There are many misconceptions about older adults, such as that most elderly people are sick, that they don't pull their own weight in society, that they are set in their ways (you can't teach an old dog new tricks), aren't mentally or physically sharp and alert, or just are incapable of making lifestyle changes such as smoking cessation for instance. Kelly (2005) states that Nursing older people is often perceived as low status and that a positive reframing of gerontological nursing is needed.
(Disadvantage 2) Lack of relationship with the senior client
Another barrier to understanding the unique barriers to a healthy exercise program for seniors is the lack of relationship with the client. Liking or not liking other participants or staff are both reasons for attending or not attending a health-promoting exercise program. When relationships are negative or undeveloped encouragement cannot be given as appropriately, likes and dislikes will not be known, and various other hindrances will also result. Social contact and personal knowledge of the client is clearly important and needs to be addressed to effectively plan interventions which take into account the particular, unique needs of the senior client. Buijs ( 2008) states that relationship is key and that frequent contact with other participants and staff contributed to social support, which plays an important role in the development and maintenance of active living.
(Intervention 2) Understanding which activities are the most beneficial for the senior client
(Disadvantage 1) Knowledge Deficits
Although the nurse can have a pretty good idea of which activities will be most beneficial for the senior client, an important barrier to implementation for the client is the knowledge deficit of the client. They may not understand how a particular exercise program will benefit them and it can take a while for the benefit to be realized. They may have faulty beliefs about exercise or believe it could even do them harm. Seniors (and older middle-aged clients) have a high need for education in health needs including many areas that interrelate to physical exercise health promotion such as healthy diet, and psychosocial (family communication for instance) and fitness. Su (2007) states that ideally, when planning health-promoting education programs for this age group, course content should be influenced by the knowledge needs of the particular client or group of clients.
(Disadvantage 2) Feeling powerless
The nurse and the client may understand which activities will be beneficial but the client may still have a sense of powerless in his or her ability to act on this knowledge. They may be unwilling or too embarrassed to discuss their particular challenges such as hearing impairment for example. Visual impairment may also be a challenge causing the client to feel powerless. The client may believe that somehow the healthcare provider or team can make them better and not have a sense of personal responsibility for their own health issues. Oliver ( 2005) states that in addition to teaching the client, it is the aim of nursing care to empower older people in their choices and control over their lives.
References
Belza, B. (2004). Older adult perspectives on physical activity and exercise: Voices from multiple cultures [Electronic version]. Preventing Chronic Disease Public Health Research, Practice, and Policy,(4),1-12.
Buijs, R., Ross-Kerr, J., O'Brien Cousins, S., & Wilson, D. (2003, Summer). Promoting Participation: Evaluation of a Health Promotion Program for Low Income Seniors. Journal of Community Health Nursing, 20(2), 93-107. Retrieved April 23, 2008, doi:10.1207/153276503321828022
Hartman-Stein, P., & Potkanowicz, E. (2003). Behavioral determinants of healthy aging: Good news for the baby boomer generation. Online Journal of Issues in Nursing, 8(2), 127-146. Retrieved January 29, 2008, from Academic Search Premier database.
Kelly, T., Tolson, D., Schofield, I., & Booth, J. (2005 2). Describing gerontological nursing: an academic exercise or prerequisite for progress?. Journal of Clinical Nursing, 14(3a), 13-23. Retrieved April 23, 2008, from CINAHL database.
Nuñez, D., Armbruster, C., Phillips, W., & Gale, B. (2003, January). Community-Based Senior Health Promotion Program Using a Collaborative Practice Model: The Escalante Health Partnerships. Public Health Nursing, 20(1), 25-32. Retrieved January 29, 2008, from Academic Search Premier database.
Oliver, S., & Hill, J. (2005, July). Arthritis in the older person: part 2. Nursing Older People, 17(5), 23-5. Retrieved April 24, 2008, from Academic Search Premier database.
Sabin, K.L. (2005). Older adults and motivation for therapy and exercise: Issues, influences, and interventions. Topics in Geriatric Rehabilitation, 21(3).18-19 Retrieved March 16,2007,from Expanded Academic ASAP.
Su, C., Annells, M., & Wood, B. (2007, February). Health-promoting education needs of middle-aged persons in a rural community in Taiwan. International Journal of Nursing Practice, 13(1), 52-60. Retrieved April 24, 2008, doi:10.1111/j.1440-172X.2006.00603.x
Yoon, B. & Kravitz, L. (2006). Single-versus multiset resistance exercise in older adults: comparing the two for muscular-fitness and functional-performance benefits. IDEA Fitness Journal, 3. 18-22. Retrieved March 16,2007, from Expanded Academic ASAP database.
MRSA; Reducing Nosocomial Transmission Rates
Over the past thirty years, the community has become increasingly aware of nosocomial infection—specifically methicillin-resistant Staphylococcus aureus (MRSA). According to the Centers for Disease Control and Prevention (CDC), hospitals must commit additional resources to sponsor comprehensive infection control programs aimed at reducing the incidence of transmission in acute care facilities. An effective infection control program includes education of staff on measures for prevention and control of infection as well as access to the infection control team for support and advice. Today’s nurse must understand why “superbugs” such as MRSA are of so much concern and how best to combat the threat of cross-infection. Nurses who use evidence-based strategies to manage MRSA in a hospital environment will achieve a reduction in nosocomial transmission rates.
The incidence of hospital acquired MRSA is on the rise. According to the CDC, “over 126,000 hospitalized patients are infected with MRSA annually, leading to approximately 5,000 deaths. Hospitalized MRSA patients have an increased length of stay up to 9.1 days, with roughly $30,000 in additional costs per episode” (as cited in Forsha, 2007, p. 23). The impact on this nation’s healthcare system is dramatic. Unfortunately, this has become a global issue requiring immediate attention. In the early 1980’s, MRSA affected only 3% of the populations of the United States and Europe; however by the 1990’s, as many as 40% were infected (Ott, 2005).While the consequences to healthcare facilities include increasing costs, MRSA is rising in significance to nursing staff as well. Nurses are at increased risk of becoming colonized and ultimately face the risk of developing an active infection themselves.
Staff can easily transmit bacteria between patients when not practicing proven infection control strategies including effective hand hygiene and contact precautions. Studies such as those by Cepeda, Whitehouse, Cooper, Hails, Jones, Kwaku, Taylor, Hayman, Cookson, Shaw, Kibbler, Singer, Bellinghan, and Wilson (2005), have searched for the most effective way to reduce nosocomial transmission of infection—specifically MRSA. Cepeda, et al questioned whether isolation of infected intensive care unit (ICU) patients would reduce the rate of infection. This study was very well organized and controlled. It examined the effectiveness of placing MRSA positive ICU patients either in single room isolation or in groups, while providing designated staff to care for them. The nursing staff practiced infection control strategies that were noted to be between standard and contact precautions. According to Cepeda, et al, (2005), “Our findings challenge the prevailing view that isolation of the intensive-care unit patients who are colonized or infected with MRSA in single rooms or cohorts reduces the transmission of MRSA, over and above the use of standard precautions, in an environment which is endemic.” This supports the widely held view that a comprehensive infection control program is essential to controlling the spread of MRSA in a hospital environment.
A study conducted by the VA Pittsburgh Healthcare System (VAPHS) aimed at reducing healthcare-associated infections took a somewhat different tactic by applying principles used by the Toyota Corporation (Forsha, 2007). According to Forsha (2007), “[t]he Toyota Production System (TPS) uses a systems engineering approach to change structures and processes within an organization…our challenge was to facilitate a culture change so that nursing staff adopted TPS and the related interventions as a component of the traditional, sacred ‘nursing process’” (p. 23).
In order to bring about such transformation, full dedication from all areas of the medical center, including the executive team, was required. The employees attended a training program aimed at educating the staff on areas identified as having significant impact on infection transmission. Forsha (2007) explains the importance of active surveillance, vigilance in regard to effective hand hygiene, as well as the necessity for observance of contact precautions required when caring for infected patients. In addition to offering classes, online education, and providing RN TPS facilitators on the unit, patients and families were included in the push to reduce infection rates by inviting them to practice proper hand hygiene as well. In an effort to expand the program to other units throughout the medical center, another, more cost effective method of empowering staff was integrated into the plan. Positive deviance is an approach to spreading change that recognizes those people within a group who are able to identify solutions to problems and implement change. This method empowers the staff to take ownership of problems and discover workable solutions, thereby increasing the probability of success. The results of the study at VAPHS identify successful strategies to reduce nosocomial infection. Forsha (2007) reported that “over an 8-month period there were only two surgical site infections, compared to a previous average of 40 surgical site infections a year. Through positive deviance, VAPHS has created and implemented a staff-owned and operated MRSA prevention program that’s efficient, measurable, and sustainable” (p.26). This study demonstrates the necessity for a comprehensive infection control program in order to reduce rates of nosocomial MRSA infection.
In addition to effective hand hygiene and contact precautions, it is vital that the nurse educate the patient and family about MRSA. The patient and family should be taught methods for combating transmission as both an inpatient and after discharge. The nurse should also evaluate the patient’s response to isolation and level of anxiety and fear. Providing emotional support and distraction as needed, as well as being readily available are essential to providing quality care. It is also very important that the patient’s privacy is protected as often times feelings of alienation exist during isolation.
In summary, a comprehensive infection control program, use of contact precautions, and effective hand hygiene together will decrease nosocomial MRSA infection. Isolation of infected patients is an important component of contact precautions, however this must be in conjunction with other measures to be effective. Today’s nurse must be aware of MRSA and its threatening effects. He or she must also be prepared to educate patients and families on the subject. Anxiety about MRSA is often based on ignorance about the organism, the risk of infection and the precautions that can be undertaken to prevent transmission. It is essential that control of infection remains at the forefront of good clinical practice.
Intervention #1: Instituting a comprehensive infection control program will reduce nosocomial transmission of MRSA.
Disadvantage #1: Increased costs associated a comprehensive infection control program may be viewed negatively by hospital administrators. “Difficulty in achieving support for infection control is the Catch-22 in prevention activity. If effective, the outcome is negative, ie: no infection. Thus, it is seen to provide a service and is undervalued.” (Lindsay Nicolle,2001)
Disadvantage #2: Staff willingness to comply with precautions set forth in infection control policy is essential. “Implementation is accomplished by changing the pattern of workflow and identifying and eliminating impediments to infection prevention and isolation procedures.” (Forsha,2007) However, if the staff is unwilling to comply, this approach will not be as effective. Forsha further explains, “The nurses must adopt a “not in my house” demeanor when healthcare team members forget to comply.”
Intervention #2: Educating patients and families about the patient’s condition, treatment, and preventative measures necessary to avoid further transmission is essential.
Disadvantage #1: According to Forsha, “Staff surveys uncovered a knowledge gap regarding MRSA prevention. ..Shared learning enables staff to quickly apply innovative precautions.” Undereducated staff cannot teach patients effectively, regardless of the subject to be taught.
Disadvantage #2: “We know that a patient who has a complete understanding of what his or her diagnosis is and what needs to be done to further address it will be able to more fully participate in his or her care. Taking the information down to the level of the patient is a critical first step in helping the patient understand his or her unique situation.” (Faut Rodts,2005) Understanding the level of comprehension of a patient is of utmost importance.
References
Cepeda, J., Whitehouse, T., Cooper, B., Hails, J., Jones, K., Kwaku, F., et al., (2005, January
22). Isolation of patients in single rooms or cohorts to reduce spread of MRSA in
Intensive care units: Prospective two-centre study. The Lancet, 365, 295-304. Retrieved
January 22, 2008, from Pub Med database.
Faut Rodts, M. (2005, May/June). Educating our patients and families. Orthopaedic Nursing,
24(3), 173. Retrieved May 5, 2008, from ProQuest database.
Forsha, B. & Richmond, I. (2007, August). Best-practice protocols: Reducing harm from MRSA.
Nursing Management, 22-27. Retrieved January 23, 2008, from PubMed database.
Murphy-Knoll, L. (2007, January). The Joint Commission’s Infection Control National Patient
Safety Goal. Journal of Nursing Care Quality, 22(1), 8-10. Retrieved January 23, 2008,
from PubMed central database.
Nicolle, L. (2001, May/June). Infection control in acute care facilities: Evidence-based safety.
The Canadian Journal of Infectious Diseases, 12(3), 131-132. Retrieved May 5, 2008,
from PubMed Central database.
Ott, M., Shen, J., Sherwood, S., (2005, February). Evidence-based practice for control of
methicillin-resistant Staphylococcus aureus. Association of Operating Room Nurses.
AORN Journal, 81(2), 361-4, 367-72. Retrieved January 24, 2008, from ProQuest
Database.
Harm Reduction Efforts for Illicit IV Drug Users
Illicit drug use through the intravenous route introduces pathogens into the body via shared needles and a lack of sterile preparation and injection techniques. The number of blood-borne infections like hepatitis C and Human Immunodeficiency Virus (HIV) continues to rise with persistent drug use, thus nurses attention should address various methods of harm reduction. Because nurses are educators providing the skills for open and honest communication, they are most effective in reaching out to the drug using community promoting safe injection practices thereby decreasing the spread of infectious disease. Addressing essential nursing strategies, such as collaborating with the government to gain financial support for supervised injecting centers, promoting legal syringe access through syringe exchange programs, as well as offering educational programs at the injection rooms within health care facilities are necessary harm reduction efforts that contribute to saving lives.
“Approximately one-third of HIV cases in the United States is associated with the practice of sharing of injection equipment and is preventable through the once-only use of syringes, needles, and other injection equipment. Injection drug use is also the principal mode of hepatitis C transmission” (Stancliff, 2003 para. 1). Variables responsible for the transmission of lethal diseases among IV drug users relates to equipment sharing between users, a deficit in disease knowledge, as well as a lack of awareness of health services offered. Additionally, the population abusing illicit drugs is more likely to participate in unsafe sexual practices, which contributes to the transmission of infectious agents. All of these factors are preventable by providing education and supplies. This emphasizes why it is crucial that nurses address such issues with specific strategies. According to Bradley-Springer (1998), “If patients fail to practice prevention, providers must offer preventative care to reduce danger of infection among themselves and to continually educate patients” (page 17).
One nursing strategy is to join forces with the government to encourage financial support for supervised injecting facilities. The only supervised injecting center operating in North America offers “heroin addicts a medically supervised injecting site” (Jones, 2006, page 859). At the Insite clinic, nurses and doctors are present to provide general health care including sterile syringes, as well as medical interventions if users overdose (Jones, 2006). Nurses must help the government understand that the tremendous cost to the health care system for tertiary care far exceeds the cost for primary care. Gaining government support will aid in the expansion of supervised injecting facilities in more locations. If additional centers existed, nurses would be able to communicate with more IV drug users spreading the word on disease transmission along with preventing second time use of syringes by providing sterile equipment. Nurses working at these centers believe in “harm minimization” and feel that in the long term, they are “educating users to stop the spread of disease and help them get off drugs” (Buckis, 2005, page 24).
Sterile syringes are not only provided at supervised injecting facilities, they are offered at syringe exchange programs as well, which is the second nursing strategy that should be addressed. “Several studies have shown that when given access to sterile syringes, drug users readily make use of them, reducing their high-risk behavior and rates of disease transmission” (Edlin, 2006, para. 14). Promoting legal access to syringes enhances drug users’ adherence to using sterile equipment, thus decreasing transmission rates. According to Edlin (2006), “substantial progress can be made if existing knowledge and resources are to bear” to the community (page 1). Nurses are great candidates for educating the public about syringe exchange programs, due to their effective communication skills and knowledge of what the program offers. The education of the public will contribute to a “significant decrease in needle reuse” thanks to the availability of “clean needles and persistent prevention messages offered at syringe exchange programs” (Cowlitz County Health Department, 2007, page 3).
In addition to offering sterilized injection equipment in places like supervised injecting facilities and syringe exchange programs, another strategy to reduce harm is to offer educational programs at injection rooms within health care facilities. A short history review on infectious disease as well as a “teaching plan for sterilization of needles and syringes with the underlying message of health and the invitation for rehabilitation” should be the focus of these classes (Edwards, 2006, page 257). Offering such classes within the health care facility would make them easily accessible to the public, which would increase the attendance rate; thus more effectively spreading the message on disease and drugs.
Because some IV drug users will continue to use illicit drugs, the problem will never be solved entirely. However, implementation of several nursing strategies such as government collaboration for financial support, promotion of legal syringe access via syringe exchange programs, and offering educational programs within the health care facility are essential in reducing the problem and are “lifesaving interventions” (Edlin, 2006, para. 1). The existence of the programs mentioned above directly relate to decreasing numbers of infectious disease transmission by intravenous drug use. The goal of these programs is wellness promotion; therefore nurses must strive to promote harm reduction to those in need, because expecting people to quit would be unrealistic. Intervention #1:
Nurses must collaborate with the government to gain financial support for supervised injection centers.
Disadvantage #1:
Financial support from the government as well as obtaining a permit to operate is needed to establish new supervised injection centers. This in itself creates a barrier for these centers because attaining governmental support is a challenge. Many of its members argue that “it’s morally wrong to aid illegal drug addiction” (Jones, 2006, page 175). A prominent supervised injection facility in Vancouver, Canada called Insight, barely received a permit extension to continue operation of their experiment. Finally, a “deferring decision was made on Insite pending more research” (Jones, 2006, page 178). The Canadian Conservative government is not confident that safe injection sites contribute to lowering drug use, fighting addiction, and inhibiting spread of infectious disease at this time thus keeping them from fully supporting these services. “Evidenced-based practice is being compromised by the politicization of science, and efforts by corporations and lobby groups undermine research that threatens profits or offends moral positions” (Kerr, 2008, page 964). Politics affect supervised injection centers greatly, for the government is the deciding factor as to whether these facilities stay open or not. Their hesitancy of supporting supervised injection centers hinders the existence of new ones as well as the continuation of those in existence.
Disadvantage #2:
Nurses possess effective communication techniques to persuade others, though convincing an entire conservative government is a challenge. The feelings these critics posses are strong and the evidence based research proving center’s effectiveness are limited. Governmental critics say “this approach is too accepting of drug use and that it does not make sense to make heroin illegal and than set up healthcare facilities where people can inject it” (Buckis, 2005, page 24). Because critics feel so strongly about their concerns for this controversial subject, convincing them to change their minds is difficult. Nurses are faced with a great challenge, for the Canadian government is not the only critics opposing supervised injection facilities. They are supported by other agencies and governments as well who oppose such facilities. The International Narcotics Control Board has looked down upon countries implementing supervised injecting facilities. The United States “has maintained a ban on federal funding” of related services as well (Kerr, 2008, page 964). Nurses have yet to gain support from those opposing the facilities, which is keeping more from existing.
Intervention #2:
Nurses must promote legal syringe access through syringe exchange programs.
Disadvantage #1:
There are internal factors that exist within an intravenous drug user that create barriers to adherence of sterile technique. Many intravenous drug users are uneducated about how syringe exchange programs operate, so they prefer to stay away. Syringe exchange programs require “no appointment or identification; relying on exchange of used syringes for sterile ones is an integral part of the service” (Stancliff, 2003 para. 9). Lacking knowledge of syringe exchange program’s requirements along with concerns for privacy and confidentiality, keep a client from taking advantage of these services. The “social stigma and embarrassment surrounding drug use” also play a major role in keeping someone from obtaining sterile equipment from syringe exchange programs (Bradley-Springer, 1998, page 17). The reason for their visit to the facility is obvious, which can be a problem for those who posses strong feelings of keeping their habit a secret.
Disadvantage #2:
Along with existing internal barriers that prevent adherence to sterile technique, external barriers, or environmental factors exist as well. A primary drawback to syringe exchange programs is “their lack of accessibility; there are approximately 130 exchanges in the entire United States” (Stancliff, 2003, para. 9). Additionally, because of syringe exchange programs policies of needle exchange, intravenous users are obligated to “carry and return medical waste containing drug residue that may put them at risk of arrest” (Stancliff, 2003, para 9). And because only 130 centers exist, the distance one must travel might be too risky for intravenous drug users, outweighing the benefit of access to sterile equipment.
References
Bradley-Springer, L. Prevention: The original adherence issue. Journal of the Association of Nurses in AIDS Care. (1998) 9(3) 17-18 Retrieved April 27, 2007 from Expanded Academic ASAP Database.
Buckis, C. (2005) High and dry: Controversy has plagued Sydney’s supervised injecting center for heroin users. But the nurses who run the place say they are simply saving lives. Nursing Standard. 20(10) 24-26. Retrieved April 09, 2007 from Expanded Academic ASAP Database.
Edlin, B. R. (2006) Prevention and treatment of Hepatitis C in injection Drug users. Pub Med Central Retrieved January 13, 2008, from
Edwards, K. (2006) A new role for pediatric nurses: Teaching teen drug users how to sterilize their equipment for prevention of infectious disease; a course outline. Pediatric Nursing. 33(1) 257-263 Retrieved from April 09, 2007 from Expanded Academic ASAP database.
Jones, D. (2006, October 10) Injection site gets 16-month extension. Canadian Medical Association Journal – JAMC. 175(8), 859 Retrieved from January 13 2008 from
Kerr, T. & Wood E. (2008, March 25) Misrepresentation of science undermines HIV prevention. Canadian Medical Association Journal. 178(7), 964. Retrieved from April 29, 2008 from Proquest database.
Stancliff, S., Agins, B., Rich, J. D & Burris, S. (2003) Syringe access for the prevention of blood borne infections among injection drug users. BMC Public Health. 3 Retrieved January 13, 2008, from
The 2005 annual report of Cowlitz County’s syringe exchange program. Cowlitz County Health Department. (2005) Retrieved September 25, 2007 from
Sunday, May 11, 2008
Spiritual Care in Nursing: Assessment and Implementation
The current trend in nursing care is a holistic approach: connection of mind, body, and spirit. A person’s interpretation of meaning and beliefs can be a great instrument in the healing process (Potter, 2004). Nurses may have some difficulty in evaluating spiritual needs and implementing spiritual care to their patients. However, their involvement is essential in promoting spiritual health among patients, and spiritual training should be incorporated in nursing education. To address the lack of adequate spiritual nursing care, it is important to establish a straightforward definition of “spirituality”, teach nurses how to address the subject of spirituality, and to introduce approaches of assessing spiritual distress in patients.
In a survey performed in 2002, 50% of Americans indentified themselves as religious, whereas another 33% considered themselves as spiritual, but not religious (Arnold, Herrick, Pankratz, & Mueller, 2007). “Meeting patients’ spiritual needs” is a medical professional duty as defined by the Joint Commission on Accreditation of Healthcare Organizations (Bensing, 2000). In fact, the North American Nursing Diagnoses Association lists “spiritual distress” as a nursing diagnosis. Spiritual well-being is proven to be helpful in dealing with stressful events in life. Previous studies demonstrated the positive outcomes of nursing spiritual care, but they were generally focused on certain nursing specialties such as oncology, hospice nursing, mental health, and parish nursing (Grant, 2004). According to the research, 77 percent of the patients prefer to talk about their spiritual concerns as part of their care (Brown, 2007). All these studies support the importance of addressing spirituality in nursing care.
The difficulty nurses face in implementing spiritual care with patients starts with their incorrect interpretation of the concept of spirituality. Results of the research by Grant (2004) suggest that most nurses believe in the usefulness of spiritual care. They feel that spirituality can “produce a variety of emotional and physical benefits, ranging from inner peace to bodily healing” (Grant, 2004, p.40). However, many nurses associate spirituality with religion. Bensing notes that common words heard from nurses are, “I’m not a religious person and I don’t know anything about the patient’s religion” (2000, p.1). Theses non-religious nurses are not comfortable talking about patients’ spiritual needs. That is why it is essential to have a clear-cut and easy definition of “spirituality” that makes sense to both nurses and patients. Spirituality is defined as an experience that a person has had that gives purpose and meaning to life and death; it may or may not include relationships with God, or other divine power (Power, 2006). Once the clarity is established, the next step is teaching nurses how to address their patient’s spirituality.
Most nursing schools incorporate the subject of spirituality in the program of study. However, for some it is still a challenge. There are several strategies used when encouraging spirituality awareness in novice nurses. One of the main approaches is to promote understanding of one’s own spirituality. This understanding can help nurses in providing adequate spiritual care to the patients. Research shows that the majority of patients regard a God as a healer (Pesut, 2003). Not talking about God and spirituality in nursing education is to eliminate the beliefs of a significant part of the population the nursing student would be caring for. Discussions of the topic might be sensitive in the classroom setting, but instructors need to promote open dialogue and encourage all students to reflect critically. Beginning nurses need to recognize differences in people and acknowledge the distinctive traits each person possess (Pesut, 2003). Once the knowledge foundation is laid, the next step is implementing it in practice.
The third strategy in eliminating lack of spiritual care among nurses is to establish a spiritual assessment tool that would help nurses evaluate a patient’s spiritual needs. Spirituality is diverse and personal. There is no one assessment tool that works on every patient. Power (2006) suggests several spiritual assessment methods such as direct questioning, the indicator-based tool, Likert scale, informal assessments, and the Spiritual Index tool. Direct questioning works well in rehabilitation, continuing care and long-stay settings where patients and staff have a chance to develop therapeutic relationships. It could be intrusive and is not appropriate as a first admission tool, or in acute and critical care. Using the indicator-based tools the nurse indentifies verbal and non-verbal cues that show spiritual distress, but there is a chance of misinterpreting the information, which could lead to an incorrect spiritual diagnosis and unsuitable care plan. The Likert scale and Spiritual Index assessments include asking patients to what extent they agree or disagree with certain statements. Some hospitals use a chaplaincy team to perform spiritual assessments. They encourage people to talk about themselves, their lives, illness, and worries. Due to the diversity of patients, nurses need to be able to ask adequate questions during spiritual assessment and to not discriminate between different belief systems (Power, 2006).
The nurse’s role in providing holistic care should include a spiritual assessment. As research shows nurses have difficulty in addressing spirituality of their patients. Identifying the problems that lead to nursing inadequacy in spiritual care helps to eliminate the problem. Educating nurses about the meaning of spirituality, implementing spiritual knowledge and understanding in nursing practice, and establishing proper spiritual assessment tools are some of strategies that lead to satisfactory spiritual care of patients. Putting in practice these strategies helps nurses to become more competent in attending spiritual needs of the patients.
References
Arnold, S., Herrick, L., Pankratz, S., Mueller, P. (2007). Spiritual well-being, emotional distress, and perception of health after a myocardial infarction. Internet Journal of Advanced Nursing Practice, 9(1), 4-11. Retrieved January 15, 2008 from Academic Search Premier database.
Bensing, K. (2000, March 27). Spirituality in Nursing: Part 1- enhancing the journey. Retrieved January 16, 2008 from nursing.advanceweb.com/Editorial/Content/Editorial.aspx?CC=9046
Brown, M. (2007, December 5). Spiritual advocacy. Nursing Standard, 22(13), 24-25. Retrieved January 15, 2008 from Academic Search Premier database.
Grant, D. (2004, Jan/Feb). Spiritual interventions: How, when, and why nurses use them. Holistic Nursing Practice, 18(1), 36-42. Retrieved January 16, 2008 from Academic Search Premier database.
Pesut, B. (2003, Nov-Dec). Developing spirituality in the curriculum: worldviews, intrapersonal connectedness, interpersonal connectedness. HYPERL I NK "http://find.galegroup.com/itx/infomark.do?&contentSet=IAC-Documents&type=retrieve&tabID=T002&prodId=EAIM&docId=A111695097&source=gale&userGroupName=tacoma_comm&version=1.0"Nursing Education Perspectives, 24(6), 290-295. Retrieved January 16, 2008 from Academic Search Premier database.
Potter P., Perry, A., (2004). Fundamentals of Nursing. St. Louis: Elsevier Mosby.
Power, J. (2006). Spiritual assessment: developing an assessment tool. Nursing Older People, 18(2), 16-19. Retrieved January 16, 2008 from Academic Search Premier database.
Intervention 1. It is essential to have a clear-cut and easy definition of “spirituality” that makes sense to both nurses and patients.
• Disadvantage 1. Diverse perception of spirituality.
Unfortunately, there is no precise terminology in defining the idea of spirituality. There is a variety of opinions and views on what spirituality is based on people’s faith, cultures, and experiences. As a result, there are a lot of misunderstandings of what adequate nursing spiritual care comprises of. A number of nurses associate spirituality with religion, some see spirituality totally separate from religion, and some have hard time relating to the idea of spirituality. “The concept of spirituality (as used in health care) may not be universally recognized, emphasizing the need for caution when trying to apply directly the concept to diverse groups” (McSherry, Cash, Ross, 2004, p.939)
• Disadvantage 2. Spirituality is not the same as religion.
Quite often terms “spirituality” and “religion” are used interchangeably. In reality, they are two distinct concepts. “Spirituality is characterized by an experience of the individual. Religion is characterized as formal, organized, associated with rituals and beliefs, and sometimes conflated with culture” (Pesut, 2008). Spirituality might include religious beliefs, but it can exist independently as well. Addressing spiritual needs of client doesn’t necessarily mean dealing with religious needs. Therefore, nurses shouldn’t disregard spiritual assessment and evaluation of spiritual needs of patients who claim to be nonreligious.
Intervention 2. One of the strategies in eliminating lack of spiritual care among nurses is to establish a spiritual assessment tool that would help nurses evaluate a patient’s spiritual needs.
• Disadvantage 1. Finding the right spiritual assessment tool for diverse patients.
There are several spiritual assessment tools used currently in the hospital settings. Some of the most well-known and widely used are Spiritual Well-Being Scale, which measures psychological dimensions of spiritual well-being, and the Religious Orientation Scale, which measures the degree of spiritual motivation within religious traditions. Unfortunately, no single assessment method would be appropriate for all situations. Patients have diverse needs and interests. An assessment method that works well with one client may be inappropriate with another (Hodge, 2005). Some methods are more appropriate for acute settings, and some for long-term care or palliative care situation. Furthermore, the nurses need to take in consideration the developmental stages of the patients when assessing the spiritual needs as they vary (Farneti, 2006).
• Disadvantage 2. Spiritual assessment could be seen as intrusive by the patients.
The purpose of a spiritual assessment is to encourage spiritual well-being. Many existing spiritual assessments are uncomfortable, irrelevant, and lengthy. Most spiritual assessments focus on detailed and specific information often related to religious preferences. Patients get irritated and tired when completing these assessments. Some patients might take offense to or be confused by reasons of such evaluations. That is why it is important to explain the reasons for these questions to the patients. It is recommended that spiritual assessment takes place after the nurse has established therapeutic relationship with patients to improve sharing (Mitchell, Bennett, Manfrin-Ledet, 2006).
References
Farneti, S., (2006, November 1). Spirituality and the NP role. Retrieved March 8, 2008 from http://nurse-practitioners.advanceweb.com/editorial/search/aviewer.aspx?cc=78917
Hodge, D. (2005, Nov). Developing a spiritual assessment toolbox: a discussion of the strengths and limitations of five different assessment methods. Health & Social Work, 30(4), 314-323. Retrieved May 11, 2008 from Academic Search Premier database.
McSherry, W., Cash, K., Ross, L. (2004, Nov). Meaning of spirituality: implications for nursing practice. Journal of Clinical Nursing, 13(8), 934-941. Retrieved May 11, 2008 from Academic Search Premier database.
Mitchell, D., Bennett, M., Manfrin-Ledet, L. (2006, Sept). Spiritual development of nursing students: developing competence to provide spiritual care to patients at the end of life.
Journal of Nursing Education, 45(9), 365-70. Retrieved May 11, 2008 from Academic Search Premier database.
Pesut, B. (2008, Apr). Spirituality and spiritual care in nursing fundamentals textbooks. Journal of Nursing Education, 47(4),167-173. Retrieved May 8, 2008 from Academic Search Premier database.
Multiculturalism
Today, nurses work with a growing diversity of both colleagues and patients, therefore it is very important to recognize cultural diversity and understand the meaning of culture. The main problems in caring for patients from diverse cultural backgrounds are the lack of understanding and tolerance. Developing cultural competence is an ongoing process. For nurses, it is very important to demonstrate that they are not only clinically proficient but also culturally competent. Because lack of culturally appropriate care affects patients’ experience, it is very important that nurses use different strategies to promote and practice cultural competence. The strategies that nurses can use are recognizing differences (biological and cultural), using proper communication skills, and understanding specific cultural beliefs.
Culture influences how people seek health care and how they behave toward health care providers. Some cultural groups have different approaches to their disease problems therefore, health care providers need to have the ability and knowledge to communicate and understand health behaviors influenced by culture. Having this ability and knowledge can eliminate obstacles to the delivery of proper care. Cultural competency is a complex developmental process, which includes an understanding of one’s own culture, values, and beliefs. It also includes the awareness and acceptance of cultural differences, recognizing that different groups have their own way of communicating, behaving, problem solving, and interpreting health and illness (Gibbons & Servonsky, 2005).
In our society, nurses do not have to travel to other places to see cultural diversity therefore, with an increase of culturally varied patient populations, it is essential for nurses to recognize these differences. Nurses should incorporate knowledge of biologic and cultural variations in their assessments and care plans. For example, skin color variations in African Americans might make it difficult for nurses to assess inflammation, jaundice, or cyanosis. For that reason, they should assess the patients’ other body parts in order to recognize signs and symptoms of their health problems. In addition, African Americans may respond differently to medications so it is very important to pay close attention to any changes after medication administration (Denman-Vitale, Green-Hernandez, Judge-Ellis, and Quinn, 2004). Patients of Asian heritage have a high incidence of lactose intolerance. As a result, it is essential to watch their dietary habits (Denman-Vitale, et al., 2004). Native Americans may wear ceremonial pouches, so nurses or other health care professionals should not remove these pouches during the physical examination. Religious beliefs may also affect how nurses can perform assessments. For example, Muslim men may not want to be touched by a female care provider (Denman-Vitale, et al., 2004). Recognizing these cultural and biological variations will help nurses better understand what is going on with their patients and what they should do or should not do during physical examinations.
With the importance of recognizing diversity, nurses should also know how to use their communication skills. Communication skills begin with the ability to communicate effectively with those of other cultures. This deals with everything from the need for interpreters to nuances of words in various languages. Many patients are reluctant to talk about personal matters such as sexual activity or chemical substance use for that reason; nurses need to learn how to ask questions sensitively and in a nonjudgmental way. For instance, Arab husbands may accompany their wives for health visits and act as interpreters limiting confidential communication with female patients. In this case, it is important that nurses discuss with the family the need for a same sex interpreter so they can provide necessary care for these patients. Furthermore, nurses can learn some important phrases in at least the most common languages to facilitate accurate communication (Denman-Vitale, et al., 2004). Effective communication is a fundamental component of nursing practice, but respect for the belief systems of others and the effects of those beliefs on well-being are critically important as well.
Most of the world’s cultures have beliefs about the causation, diagnosis, and treatment of the disease. For example, Western medicine is focused on the germ theory of disease using blood tests and other diagnostic tools for disease detection, whereas some non-Western cultures believe that illness is caused by object intrusion, spirit possession, soul loss or taboo (Reznik, Cooper, MacDonald, Benador, and Lemire, 2001). For instance, the Hmong culture has a very different approach to the illness process and it is often contrary to Western medicine. “The Hmong often seek the care of a txiv neeb, a shaman or Hmong spiritual healer” (Reznik, et al., 2001, p.28). So showing respect for different cultural beliefs and using negotiating techniques in terms of what kind of practices can be used will allow nurses to create care plans in order to achieve the ultimate goal, the well-being of their patients.
Culture is inseparable from the person therefore, showing sensitivity to the needs and culture of the populations being served is essential (Sharon, Censullo, Cameron, and Baigis, 2007). Using different strategies will improve the ability of the nurses to deliver appropriate care to culturally diverse clients and help them in the process of becoming culturally competent. In addition, according to Rosehjack Burchum (2002), culturally competent care will be better received by the client and will result in increased client satisfaction. Finally, approaches such as recognizing cultural differences, using proper communications skills, and understanding specific cultural beliefs will help the nurses to provide the best possible care for their culturally diverse patients and help them to establish a respectful provider-client relationship.
Intervention # 1
In order to provide culturally competent care, it will be beneficial for nurses to have thanscultural education, which will help them to understand how patients perceive their health problems.
Disadvantage # 1
Cultural education is the best possible way to provide knowledge about different cultures; unfortunately, this training cannot possibly cover the uniqueness of every culture and give detailed information about the traditions, beliefs, and taboos regarding that particular culture. Its major disadvantage is being limited to general cultural concepts and because of that, in some situations, even being culturally educated will not help the nurses to be fully prepared to provide ethnically knowledgeable care for diverse clients. For example, trying to treat a Vietnamese person with head injuries can present difficulty: “Some Vietnamese consider the head to be sacred and housing the soul, and touching the head can allow the soul to escape” (Anonymous, 1999). Likewise, Chinese people may refuse lab work because “they believe blood is the source of life and that taking any of it could lead to their death” (Anonymous, 1999). Not every nurse, but especially one who is not of that culture or ethnicity, can be expected to understand fully or even know about such cultural nuances, which can affect the possibility and/or quality of patient care.
Disadvantage # 2
In addition to the limitations of knowledge to some cultural concepts, another disadvantage of cultural education is that it does not create any situational scenarios where students can practice to become clinically competent; in essence, the nurses are not given the opportunity to have real-life (or close to real-life) experience with unusual patient scenarios, which would help them be more prepared to deal with a wide range of culturally-relevant situations. Role-playing is a useful teaching strategy where students can demonstrate their ability to care for a patient in a culturally sensitive and appropriate manner: “Role play is a dramatic technique that encourages participation to improvise behaviors that may be encountered in nurse-patient situations. Using this technique, participants may test behaviors and decisions in an experimental atmosphere without risk of negative effects in a relationship” (Shearer & Davidhizar, 2003).
Intervention # 2
Nurses should share their own cultural backgrounds, observations, and possible impacts of cultural factors with each other, thus enhancing their cultural competence and competence of fellow nurses.
Disadvantage # 1
For some people, it is difficult to share their own culture. According to Yearwood (2006), “the individual may feel on the spot or negatively pressured to examine their personal worldview and values; therefore, concerns may exist that differences will be perceived as biased or insensitive” (p.161). Also, sharing one’s own culture may be perceived as an invasion of one’s own privacy, which will serve as a barrier in getting to know someone else’s culture.
Disadvantage # 2
In addition to the above-mentioned barrier, another exists as well: the notion of culture is too broad. There are many cultures and which one or ones should a nurse know? According to Yearwood (2006), culture and cultural diversity may be a “problem” because “for some, it could be viewed as too broad, fluid, dynamic, complex, and difficult to measure thereby rendering it marginal and it correctly represents the absence of a fixed state, thereby rendering it unpredictable. So individuals may distance themselves because of this unpredictability” (p. 161). A possible solution to the “problem” of culture and cultural diversity involves encouraging people to examine, talk about, and feel comfortable to explore multiple views because cultural factors do matter in practice, patient education, and colleague interactions.
References
Cultural differences can affect treatment. (October 1999). USA
Today, 128(2653), 3. Retrieved May 11, 2008, from Platinum Full Text
Periodicals database.
Denman-Vitale, S., Falkenstern, S.K., Green-Hernandez, C., Judge-Ellis, T., & Quinn,
A.A. (July-August 2004). Making primary care culturally competent.
Holistic Nursing Practice, 18(4), 215-. Retrieved January 15, 2008 from ProQuest
Gibbons, M. E., & Servonsky, J.E. (Fall 2005). Family nursing: Assessment strategies for
implementing culturally competent care. Journal of Multicultural Nursing & Health, 11(3), 51.
Retrieved January 16, 2008, from ProQuest database.
Reznik, V., Cooper, T., MacDonald, D., Benador, N., & Lemire. J. (2001). Hais cuaj txub
kaun txub: To speak of all things: A Hmong cross-cultural study. Journal of Immigrant Health. 3(1),
23-30. Retrieved January 16, 2008, from ProQuest database.
Rosenjack Burchum, J. L. (2002). Cultural competence: An evolutionary perspective.
Nursing Forum, 37(4), 5-11. Retrieved January 25, 2008, from ProQuest
database.
Sharon T.L., Censullo M., Cameron D.D., & Baigis J. A. (2007).
Improving Cross-Cultural Communication in Health Profession Education.
Journal of Nursing Education, 46(8), 367-72. Retrieved January 31, 2008, from Platinum Full
Text Periodicals database.
Shearer R., Davidhizar R. (2003). Using Role Play to Develop Cultural
Competence. Journal of Nursing Education, 42(6), 273-6. Retrieved May 11,
2008, from Platinum Full Text Periodicals database.
Yearwood E. L.(2006). The "Problem" of Cultural Diversity. Journal of Child and
Adolescent Psychiatric Nursing, 19(3), 161-2. Retrieved May 11, 2008, from
Research Library database.
Childhood Asthma
Asthma is a common chronic illness in children, causing them to miss school days and limiting their participation in activities. When not properly managed, it can be a life-threatening disease. Because of the prevalence of asthma in children, the chronic nature of the disease, and the importance of education in the management of asthma, the nurse plays a significant role in asthma management in children. In carrying out this role, the nurse’s strategies include forming a quality relationship with the parents and providing thorough education to patients and their parents on asthma and its treatments. To provide effective management, another strategy that can be utilized is providing nurse-led outpatient management of children with asthma.
Asthma is a chronic disease that causes inflammation and resultant narrowing of the airways, leading to difficulty breathing. For children under the age of 15, asthma is the third leading cause of hospitalization. It is the leading cause of school absenteeism attributed to chronic conditions (American Lung Association, n.d.). Not only does it affect a child’s quality of life, it can also lead to death. Asthma attacks can be caused by a variety of physical and environmental triggers, and although effective medical treatments are available, asthma continues to be ineffectively managed in many children. According to McMullen et al. (2007), there are “significant gaps in education, particularly in content areas of communication and development of a relationship between health care provider and patient/family” (p. 43). Improving education is vital in improving the quality of life of children with asthma and reducing mortality.
The first strategy the nurse would use as a basis for all interactions with patients and their parents is to develop a partnership with the parents. A caring attitude and effective communication are key aspects of this relationship. Buford (2005) states that parents felt supported by attentive health care providers, whose approach included “listening to them and their children, validating their perspectives and feeling, and providing comfort in response to their fears and concerns” (p. 158). In communicating with patients and families, the nurse should be aware of and take into consideration the cultural values of the family. Goals should be developed mutually. When a quality relationship is formed, the parents are more likely to trust the nurse and adhere to the guidelines of their asthma action plan. This will aid also in compliance with followup. Communication will be more effective, and the nurse can be more assured that the parents understand what is being taught.
The content of asthma education should be thorough and communicated clearly. According to McMullen et al. (2007), key components of educational content identified by the National Asthma Education and Prevention Program (NAEPP) include “basic facts about asthma, specific skills in symptom monitoring, the role of medications and medication administration, appropriate responses to changes in asthma severity, and environmental controls” (p.37). To aid in this education, nurses can provide appropriate literature, Internet resources, and resources in the community. When providing literature and resources, the nurse should take into consideration the educational level of the families. When teaching about medications, the nurse should ensure that the patient and family understand what the effects of the medications are, including side effects, and the proper administration of medications, including inhalers. It is also essential for nurses to stress the importance of preventing asthma exacerbations by controlling environmental factors and avoiding triggers. Additionally, nurses need to keep current with new treatments and guidelines for asthma management.
The third strategy in asthma management of children is providing nurse-led outpatient management of these children. Followup and monitoring of patients with asthma are vital in ensuring adherence to the asthma action plan, checking for correct medication usage, and reinforcing education. In a study undertaken by Kamps, et al., their results “clearly show that asthma nurses can take over large parts of long term management of mild to moderate childhood asthma from physicians without compromising quality of care or control of disease” (p. 972). In the Community Asthma Program, a nurse-led community program which has adopted a holistic psychosocial approach to asthma management, Wyatt (2002) reports a decrease in numbers of parents reporting their children’s asthma as moderate to severe and a reduction in school absences in children participating in the project. Providing nurse-led outpatient management would facilitate the ability of the nurse to develop a closer relationship with patients and their parents, resulting in more effective asthma management in children.
Childhood asthma continues to negatively affect society as a whole and the individual lives of children and their families. It is a chronic disease without a definite cure. Effective management of the disease is vital in preventing its adverse effects. As education is a major component in asthma treatment, nurses are in the perfect position to affect the outcome of management of children with asthma. By forming a partnership with parents, providing thorough education, and taking an active and leading role in outpatient management of children with asthma, nurses can play a significant part in improving asthma management and control, thus leading to improved quality of life for the child with asthma.
Disadvantage #1
Disadvantage #2
Intervention #2
Nurses can provide nurse-led outpatient management of children with asthma.
Disadvantage #1
One barrier to nurses leading outpatient management of children with asthma relates to the patient’s and family’s perception of a doctor versus a nurse. Parents may be more hesitant to take their children to nurses as primary caregivers, depending on their perception of the nurse. According to a study by Caldow, et al. (2006), “The main perceived differences between doctors and nurses were academic ability and qualifications. Many people thought that if nurse training were longer and more in-depth, then nurses would be as able to deal with medical problems as well as doctors” (p. 41). Overall, however, the study suggests that patients would accept nurses in roles previously the preserve of doctors, particularly if patients receive information on nurses’ capabilities.
Disadvantage #2
Before a child could be seen in a nurse-led practice, the child would first have to be diagnosed with asthma. According to Buford (2005), “Delay in making an asthma diagnosis was the most significant barrier parents reported in their relationship with their health care providers” (p. 159). A delay in making a diagnosis would affect the ability of the family to be seen in an asthma clinic, thus preventing effective management of the child’s symptoms.
References
American Lung Association. (n.d.). Asthma & Children. Retrieved May 1, 2007, from http://www.lungusa.org/site
Buford, T. (2005, July). School-age children with asthma and their parents: Relationships with health care providers. Issues in Comprehensive Pediatric Nursing, 28(3), 153-162. Retrieved January 7, 2008, from Academic Search Premier database.
Cabana, M..D., Lara, M., Shannon, J. (2007, Nov). Racial and ethnic disparities in the quality of asthma care. Chest Journal, 132, 810S-816S. Retrieved April 18, 2008, from http://chestjournal.org/
Caldow, J., Bond, C., Ryan, M., Campbell, N.C., San Miguel, F., Kiger, A., Lee, A. (2006). Treatment of minor illness in primary care: a national survey of patient satisfaction, attitudes and preferences regarding a wider nursing role. Health Expectations, 10, 30-45. Retrieved April 18, 2008, from Academic Search Premier database.
Kamps, A.W.A., Brand, P.L.P, Kimpen, J.L.L., Maille, A.R., Overgoor-van de Groes, A.W., van Helsdingen-Peek, L.C.J.A.M., et al. (2003). Outpatient management of childhood asthma by paediatrician or asthma nurse: Randomised controlled study with one year follow up. Thorax, 58, 968-973. Retrieved January 9, 2008, from http://thorax.bmj.com/
McMullen, A., Yoos, H.L., Anson, E., Kitzmann, H., Halterman, J.S., & Arcoleo, K.S. (2007). Asthma care of children in clinical practice: Do parents report receiving appropriate education? Pediatric Nursing, 33(1), 37-44. Retrieved April 13, 2007, from Expanded Academic ASAP database.
Wyatt, Lessa. (2006, Dec). A nurse-led community approach to asthma management for children. Australian Nursing Journal, 14(6), 18-. Retrieved April 13, 2007, from Expanded Academic ASAP database.
Saturday, May 10, 2008
Nutrition Promotion: Nurses Play a Crucial Role of Malnutrition Prevention in the Elderly
“Thousands of people are starving in the midst of plenty from want of attention to the ways which alone make it possible for them to take food” (Murray, 2006, p. 18). “Frail older adults are particularly vulnerable to both developing malnutrition and succumbing to its consequences, which are significant in this group “(Booth, 2005, p.26). The enjoyable aspects of eating diminish as people age. The causes for this may be the result of illnesses, age-related changes, social, psychological, and economic factors. All of these issues lead to the inadequate consumption of food or malnutrition in older adults. According to Association of Community Health Councils for England, malnourished patients are more likely to experience complications and die in spite of medical advances. Since malnutrition can lead to severe health outcomes and reduce healing in older adults, nurses should educate them about a healthy diet and adapt strategies to encourage their food intake to decrease the risk of malnutrition in elderly. In order to control the problem in the community and hospital settings, the nurse may implement several strategies: use the Malnutrition Universal Screening Tool, implement protected mealtimes, and work to restore appetite in older adults.
Nutrition is a basic human need, which does not always get fulfilled and is taken for granted. “The latest national statistics reveal that three percent of older men and six percent of older women in the community are underweight, rising to 16 percent and 15 percent in care homes” (Holmes, 2006, p. 50). Up to forty percent of the elderly admitted to the hospital are malnourished. At first look, the data appears to show a small percentage, but it represents a significant number of people. The concept of malnutrition is related to improper and inadequate consumption of food. Practice shows that underweight adults usually have a history of decreased appetite, inadequate dentition,
electrolyte imbalance, dry skin, bruising, weakness and fatigue. A Nutritional Survey in 1998 found that the average seventy-five year old had only 15 natural teeth. Lactose intolerance, lack of ability to prepare a meal, or viewing cooking for one as a waste of time may be contributing factors to the malnourishment in older adults. In the hospitals, undernutrition is often unrecognized and, as a result, goes untreated. A lack of emphasis on nutrition may lead to failure to recognize actual nutritional needs or identify those with low nutritional intake. It is the nurse’s responsibility to recognize malnutrition and minimize the chances of its occurrence.
One strategy that nurses can use is Malnutrition Universal Tool (MUST). MUST is an easy-to use screening tool that helps to identify people who are at nutritional risk. The tool uses five steps. In step one, height and weight are measured to calculate BMI (Body Mass Index); in the second step the percentage of unplanned weight loss is noted; in the third step, establishment of acute disease is performed; in the steps four and five the score calculations are done. Based on the score from step four, the management guidelines are developed. Usage of this particular screening tool by a nurse during a routine assessment might minimize the chance of overlooking of malnutrition among elderly population. It may also “help to tailor health promotion advice to individuals to improve overall health and quality of life” (Neno, 2006, p. 65).
In the hospitals, nurses might also implement protected mealtimes. The key principles of this strategy lie in the avoidance of unnecessary interruption by the nurses or supportive staff during the meal hours in the hospitals, creation of a quiet and relaxed atmosphere, providing environment appropriate for eating, and emphasizing the
importance of mealtimes to nursing staff and relatives of the patient. An unwelcoming hospital atmosphere, lack of food choice, and social isolation might diminish the elderly’s appetite as well. The consultation of a hostess might be required in order to create the relaxed and welcoming environment for eating. In order for this strategy to be successful a collaborative approach to the strategy is required.
Due to physiological changes that take place in older adults, loss of appetite is unavoidable. Restoring appetite and promoting salivation in older adults is one of the strategies that help to minimize the risk of undernutrition. “The mechanisms regulating appetite in the elderly are complex and vulnerable to a host of pathologic processes, making anorexia a challenging clinical entity to manage” (Noll, 2004, p. 27). A variety of approaches are used to restore and stimulate the appetite in the elderly. Encouraging social dining, using herbs for seasoning and lemon to enhance flavor, and sucking on ice cubes help to enhance the taste qualities of the meal. According to Noll, medications can also be used to promote appetite and weight gain. Megestrol acetate, for example, is a progesterone agent that may work through alterations in central nervous system neurotransmitters or through suppression of cytokine production and adding fat mass out of proportion to muscle mass. In addition, chronic and acute medical problems can contribute to poor appetite and need to be stabilized whenever possible.
Malnutrition in the elderly is a common problem, which often goes undiagnosed and undertreated. Implementation of easy to use Malnutrition Universal Screening Tool during the routine examination, protected mealtimes at the hospital settings and restoring appetite in older adults by encouraging social dining, enhancing flavor of food, and
administering medication by a nurse may decrease and in the end eliminate the occurrence of malnutrition in elderly.
Intervention # 1
Nurses need to use Malnutrition Universal Screening Tool (MUST) to identify the elderly who are at nutritional risk.
Disadvantage # 1
Discrimination to use the screening tools at the assessments by the nurses or any other healthcare professionals at any particular clinic or hospital. Nutritional screening is not a mandatory requirement. According to Neno (2006), nutrition is rarely included in older people’s screening programs. Therefore, MUST tool often fails to identify the malnourished patients due to lack of usage by healthcare professionals.
Disadvantage # 2
Lack of education and training for medical and nursing staff on the purpose of usage the screening tools and its result’s interpretations. “Although, the nurses are ideally placed to carry out such screening, research has indicated that they do not make the same interpretations of nutritional status as dietitians” (Holmes, 2000, p.44). It is obvious that inadequately read results by the nurse might be the reason for failure to identify the malnourished patient.
Intervention #2
Restoring appetite and improving salivation in older adults through encouraging social dining, using herbs for seasoning to enhance flavor, and sucking on ice cubes to help to enhance the taste qualities of the meal is the one of the strategy that is useful in minimizing the risk of undernutrition in older adults.
Disadvantage #1
The economic and social status of older adults might be the barriers to the promotion of adequate food consumption in older adults. According to Neno (2006), older adults diminish the consumption of food to one time a day with the purpose to save some money; shopping may become difficult as out-of-town shopping centers replace local shops, perhaps increasing expenditure and, in turn, restricting availability of fresh foods (eg fruit, vegetables), particularly for those with physical disabilities or restricted transport. All of the factors, mentioned above, interfere with the major goal as to restore the appetite in the elderly.
Disadvantage #2
The aging population is susceptible to developing the dry mouth due to the physiologic changes (xerostomia). Saliva lubricates and protects the mouth from microbial infections and plays a critical role in daily oral functions. Without adequate amounts of saliva, normal oral functions are compromised and, as a result, quality of life may be negatively affected. According to the Journal of Royal Society for the Health Promotion, there are a lot of products available on the market to manage the dry mouth; however, it is pointed out that the products, which promote salivation do not last for a long time.
References
Booth, J (2005) Implementing a best practice statement in nutrition for frail older people: part 2. Gerontological Care and Practice. 17(1), 22-25. Retrieved April 11, 2007, from Expanded Academic ASAP database.
Holmes, S. (2006) Barriers to effective nutritional care for older adults. Nursing Standard. 21, (3), 50-54. Retrieved January 10, 2008, from Expanded Academic ASAP database.
Holmes, S. (2000). Nutritional screening and older adults. Nursing Standard 15, (2), 42-44. Retrieved May 8, 2008 from Expanded Academic ASAP database.
Matear, D. (2005). Effectiveness of saliva substitute products in the treatment of dry mouth in the elderly. The Journal of the Royal Society for the Promotion of Health 125 (1), (35-41), Retrieved May 8, 2008, from expanded Academic ASAP database.
Murray, C. (2006). Improving nutrition for older people. Journal of Nursing Older People, 18 (6), (18-22). Retrieved April 11, 2007, from Expanded Academic ASAP database.
Neno, R. & Neno, M. (2006). Promoting a healthy diet for older people in the community. Journal of Nursing Standard, 20(29), 59-66. Retrieved April 11, 2007, from Expanded Academic ASAP database.
Noll, D. (2004). Restoring appetite in the elderly. Journal of Clinical Geriatrics, 12(2), 27-32. Retrieved April 28, 2007 from Directory of Open Access Journals database.
The Nurse’s Role in Preventing Depression in the Elderly
Depression is significantly affecting the elderly. The rate of depression in the elderly has increased over the past decade, and awareness and interventions are essential to bringing forth improvements. There is a challenge in detecting depression in the elderly; one thing that must be addressed is that many seniors diagnosed with dementia suffer with depression as well. Depression and other illnesses tend to coincide. Because of this depression is often over looked in order to treat the more prominent/ apparent illness (Cyr, 2007). Because depression in the elderly has a negative impact on one’s health and overall well-being, early detection by nurses is of the utmost importance. This can contribute to the prevention of depression in the elderly and promote healthy strategies towards integrity versus despair through the screening and assessment process. This can be achieved by taking a thorough patient history and by implementing activities that promote both social and physical activities. Most importantly nurses must take the time to educate, listen and observe changes in the patient’s behavior for signs and symptoms of depression which are pivotal for implementing interventions towards a life that ends in integrity rather than despair.
Depression is a frequent problem in the elderly. It is not surprising that the elderly would exhibit signs of depression because as one ages there are losses that they face such as losing their independence, reduced income, death of family and friends, decreasing physical ability, and the loss of one’s role. This accounts for a huge increase of depression affecting the elderly, and has resulted in many suicide attempts and death. According to Scanlon (2006), “suicide was the 9th leading cause of death in the U.S. - deadlier than chronic kidney or liver ailments, Alzheimer’s Disease, or homicides… and twice as deadly as the modern scourge of AIDS” (p. 1). Depression is a huge concern for society, healthcare, and family members, but most importantly for the individual who is suffering, so it is of vital importance that correct diagnosis and treatment occur for the elderly who is suffering from depression. Author Waughn (2006) states it best, “that for some it is the difference between life and death” (p. 30).
One nursing strategy is to get a thorough patient history by asking key questions about their mood, sleep and eating patterns, and by reviewing their medications, because changes may be contributing to depressive symptoms. By asking pertinent questions the nurse is able to identify possible symptoms and risk factors for depression. Some of the symptoms include loss of confidence, reduced appetite/weight loss, feelings of hopelessness, and even suicidal thoughts and behaviors. In addition, “the number of older people who have depression and dementia in later life is considerable, and about 50% of people with dementia have depressive symptoms” (Manthorpe, 2006, p. 3). When working with the elderly the nurses should always think about dual diagnosis. In this way they can understand and communicate that there is more to the problem than what is seen on the surface. Asking appropriate questions and observing changes in behavior can lead to the root of the problem. Key questions that nurses can ask their elderly client are, “How are you sleeping? Do you have much of an appetite? Are you keeping active or have you lost interest in your daily activities? Do you feel happy most of the time?” (Waughn, 2006, p. 3). After assessing signs and symptoms of depression it is up to qualified nurses to critically think and supplement interventions that can help their elderly patient towards successful treatment.
Once the signs and symptoms of depression are confirmed, another key strategy is to encourage activities that promote both social and physical well-being. These activities stimulate the elderly client and consequently increase his sense of worth as a productive member of society. “Daily activities such as reading, discussing the news, watching television documentaries, and engaging in social activities and voluntary work have been shown to improve older clients’ feelings of loneliness and depression” (Murphy, 2006, p. 4). An intervention that should be utilized and would be productive for the elderly patient with depression as well as the youth of our society would be to form a version of Big brother/Big sister connecting teenagers and young adults with the elderly through a YMCA program. This experience would promote and maintain older people’s interest and help them enjoy the experience of everyday living. Therefore, it is extremely important that nurses take the time to listen, educate, and observe changing behaviors in the elderly’s symptoms of depression so that interventions are possible and can lead towards integrity rather than despair. Whether it is their daily activities, medication, or illness, continued reassessment is needed in order to stay on tract towards further improvement and well being.
Maintaining open communication with the elderly who suffer from depression is extremely important. Taking the time to actually talk to a patient can reveal more than ailments, it can determine the cause of their depression or problems. This in turn, can help solve the problem by educating the patient on why, what, and when their symptoms occur and together the nurse and patient can begin to set goals and develop interventions that will be successful in promoting wellness for the individual. “Many older clients welcome the chance to talk to their carers who are seen as playing a pivotal role in providing them with social support” (Murphy, 2006, p.4). Just taking the time to give an extra five to ten minutes can mean helping an elderly client feel valued and heard and leads towards productive treatments and outcomes that result in a life of fulfillment and integrity.
Awareness is key. The issue of elderly depression is becoming more main stream and as elderly depression is discussed, help and interventions can be addressed. Listening and using therapeutic communication is crucial in assessing the elderly for signs and symptoms of depression and implementing interventions can help prevent and treat their depression. Taking a thorough patient history and providing activities that promote social and physical well-being is an essential first step in promoting health strategies that move toward integrity. Most importantly, by listening and by educating the patient on the effects of depression, communication lines are open and the patient is more able to ask for help. Ultimately, this helps with implementing interventions that lead to quality of life. Nurses and healthcare professionals must address key strategies together and continue to brainstorm more ideas because, we all face growing older, and this is a problem that affects us all. The ultimate goal we all hope to achieve is that we look at the end of life with integrity rather than despair.
References
Cyr, Nancy R. (2007, Feb.). Depression and older adults. AORN Journal, 8(4), 397-401.
Retrieved April 10, 2007, Expanded Academic ASAP database.
Manthorpe, J. & Iliffe, S. (2006, March). Depression and dementia: Taking a dual
diagnosis approach. Nursing Older People, 18(5), 24-28. Retrieved April
23, 2007, from Expanded Academic ASAP database.
Murphy, Fiona. (2006, June). Loneliness: a challenge for nurses caring for older
people. Nursing Older People, 18(4), 22-25. Retrieved April 23, 2007, from Expanded Academic ASAP database.
Scanlon, B. (2006, May). Recognizing depression in later years. Retrieved April 23, 2007,
from http://healthyplace.healthology.com/healthy-aging/article23.htm07.
Waughn, A. (2006, September). Depression and older people.
Nursing Older People, 18(4), 27-30. Retrieved April 10, 2007, from Expanded
Academic ASAP database.
Intervention #1
Nurses need to take a thorough patient history when it comes to diagnosing depression in the elderly. By asking pertinent questions nurses are able to identify possible symptoms and risk factors for depression.
Disadvantage #1
More often then not when it comes to depression especially in the elderly their mental health is over looked. “More than 3.5 million people do not receive satisfactory services and support and those using mental health services are often ignored” (Gilbert, 2007, pg. 1). Many elderly patients have admitted that even when they were suffering from depression they never spoke with their doctors at all about their emotional state. A recent study in the Journal of the American Geriatrics Society, reviewed videotapes of 385 appointments with elderly patients and found that the average time spent discussing mental health was only two minutes (Nagourney, 2008, pg.6). An even bigger problem is that when patients told their doctors about their problems, the study found, that the doctors “responses were often ineffective or worse” (Nagourney, 2008, pg. 6). The number of elderly people suffering from depression is on the up rise, so now is the time to put something in place to address it. That is why it is so important that nurses take a thorough patient history and ask pertinent questions that can help identify risk factors for depression in the elderly.
Disadvantage #2
Nurses need to be aware that their own bias and discrimination is at the heart of many problems in mental health services for older people. “The central fallacy is that depression is an inevitable part of getting old” (Lishman, 2007, pg. 30). Even in nursing schools gerontology curriculum is integrated, “but more often the approach often perceives aging as a risk factor for numerous diseases and disabilities but ignores the needs and experiences of healthy older adults. Consequently, students may believe all older adults have chronic illnesses that cannot coexist with healthy or successful aging” (Walker, Newcomb, & Cagle, 2005, pg. 283). The problem of elderly discrimination is not solved by providing specialist services but by training all health and social care professionals to take the time to take a thorough patient history in order to recognize and respond to the mental health needs among older people. Education is key and it needs to start in nursing schools, because depression dose not just happen as one becomes older. That is why it is so important that students as well as nurses in the hospital setting receive a balanced view of aging so bias and discrimination cease to occur.
Intervention # 2
Nurses need to encourage activities that promote social and physical well-being in order
to prevent/alleviate risk factors of depression in the elderly.
Disadvantage #1
There are many challenges that face nurses when it comes to caring for the elderly. One
challenge in particular is the fact that older people may feel alone and isolated and may be
exhibiting signs of depression, but they do not want to do anything about it. “The challenge for
nurses is promoting and maintaining older people’s interest so that they can get back to enjoying the everyday moments of their life” (Murphy, 2006, pg. 25). Many elderly have stated that they are scared to try new things and that they feel they have nothing to offer. Studies show that older people who are physically disabled or who suffer from visual or auditory problems tend to be lonelier (Murphy, 2006). This is due to the fact that they limit their activities and isolate themselves because they attribute their disability as a burden and sometimes prefers to be alone then with others. This ultimately is more debilitating then their physical disability. In turn, they become isolated and feelings of loneliness occur and then ultimately depression sets in. Motivating the elderly to take a proactive role in their mental health can be just as challenging as diagnosing depression. The key is providing them with social support. “By identifying individuals at risk because of poor social networks and of feeling lonely is crucial before the person becomes too weak and unmotivated to participate in healthy alternatives that promote an overall well-being, by helping them to create or maintain better networks” (Murphy, 2006, pg. 24).
Disadvantage #2
Another problem facing the elderly who suffer from depression is that depression is often
under detected because many of the symptoms can be mistaken for dementia and other illness. Often older people with depression may present with physical symptoms such as slowing of thoughts and activity, and many healthcare professionals attribute this to another illness such as dementia than psychological symptoms like depression (Waughn, 2006, pg. 28). The older
person becomes frustrated and even embarrassed that they do not have control of the slowing of their thoughts and motor ability, that they often isolate themselves from the public. They
exacerbate the problem and end up feeling more alone and isolated and in turn become depressed. This misinterpretation that they have dementia or another illness can further frustrate the elderly patient and they become more symptomatic and further withdraw from people and activities. The promotion of social and physical activities have been known to provide a therapeutic effect and slow down the aging process, but when illness hits the elderly person they assume that depression is part of it and seek help only for the more prominent illness. “It has been demonstrated that, if depression is not identified and treated, the elderly have an increased risk of functional, cognitive, and psychological impairment, and early death” (Waughn, 2006, pg. 28). The early promotion of social and physical activities can help, but both nurses and doctors need to be aware of dual diagnoses so that depression can be prevented before it is too late.
References
Gilbert, Helen. (2007, August). No time for patients. Hospital Doctor, 6. Retrieves April 13,
2008, from Proquest database.
Lishman, Gordon. (2007, August). How bias starts at 65. Community Care, 1688, 30-31.
Retrieved April 13, 2008, from Proquest database.
Murphy, Fiona. (2006, June). Loneliness: a challenge for nurses caring for older
people. Nursing Older People, 18(4), 22-25. Retrieved April 23, 2007, from Expanded Academic ASAP database.
Nagourney, Eric. (2008, January). Mental health overlooked in care of elderly patients. New
York Times, p. F6. Retrieved April 13, 2008, from Proquest database.
Walker, C.A., Newcomb, P., & Cagle, C. (2005, June). Age and Ageism: Inhabiting the lives of
older adults through video narratives. Journal of Nursing Education, 44(6), 283-285.
Retrieved April 13, 2008, from Proquest database.
Waughn, A. (2006, September). Depression and older people.
Nursing Older People, 18(4), 27-30. Retrieved April 10, 2007, from Expanded
Academic ASAP database.
Friday, May 9, 2008
Adherence to Treatment: the Nurse's Role in Promoting Wellness in Patients Undergoing Treatment for End-Stage Kidney Disease
With more than 400,000 Americans currently on some form of dialysis, dialysis nurses who know how to provide good patient care and promote positive patient outcomes have become more important than ever (Johns Hopkins Medicine, 2005). One of the biggest obstacles these nurses face in providing quality care is non-adherence by their patients (Kammerer, Garry, Hartigan, Carter, & Erlich, 2007).
However, nurses can provide better quality care with improved outcomes by approaching dialysis care in a holistic manner. This includes giving patients a sense of control over their treatment, using positive reinforcement to help modify behavior, and incorporating spirituality into patient care.
According to White (2004), most American people already have trouble adhering to a healthy lifestyle and complying with prescribed medical treatments. Many diabetic patients do not exercise or control their weight or diet properly, and patients diagnosed with a bacterial infection and prescribed a ten-day course of antibiotics often do not finish out the course. So it is even more challenging for patients who are diagnosed with End-Stage-Renal-Disease (ESRD) because suddenly they are told they must follow a highly restrictive diet, limit their fluid intake, and follow a specific medical regimen which includes many medications and undergoing dialysis treatments at least two times a week. If they do not follow their treatment plans closely, serious complications often develop. Such a lifestyle change is a huge undertaking, and many dialysis patients can feel entirely overwhelmed. Therefore, it is no surprise that one of the biggest challenges dialysis nurses face is getting their patients to adhere to treatment regimens.
Many patients placed on dialysis believe they no longer have control over their lives. Some of these people may try to regain control in a negative way by deciding to shorten their treatment or not taking prescribed medications. Kammerer (2007) notes that some might feel such a loss of control that they develop a “sense of futility” and just give up, discontinuing all treatment (p. 481). Nurses can help combat these feelings of helplessness by involving the patient as much as possible in their healthcare decisions, informing them of all treatment options, and by placing an emphasis on self-care. Landreneau’s (2006) study found that the patients interviewed were not aware that they had any choices concerning treatment; in fact, they did not even know what the available options were. It was discovered that most patients do indeed want to be involved in making decisions regarding their treatment, and that more desirable outcomes occur as a result (Landreneau, 2006). In addition, nurses can give patients a sense of control by teaching them to perform as much self-care as possible. This can include preparing the dialysis machine, performing self-monitoring during hemodialysis, and choosing their own interventions based on signs and symptoms they have self-assessed. This type of self-care has recently been suggested as a strategy to improve adherence (Richard, 2006).
Just possessing the knowledge about their choices and treatment, though, is not necessarily enough to keep patients compliant. Studies have shown that patients must not only be made aware of available resources, but they must also have the motivation to follow a treatment plan (as cited in Kammerer, 2007). A method that has been met with some success by nephrology nurses is cognitive behavioral modification. This works on the premise that patients will not adhere to a treatment plan unless they feel it is “personally worthwhile” and stresses the importance of positive interactions and relationships between nurses and patients (White, 2004). Nurses must be sensitive to the needs and feelings of their patients, and leave them feeling that their opinions are important. Instead of lecturing patients about not maintaining their blood pressures, a nurse using the behavioral modification approach might ask his or her patients if they notice a difference in their appearance or in the way they feel on days when their blood pressure is high. By using this approach, nurses help patients become aware of the way their treatment works and how non-adherence can affect them personally.
Another way nurses can improve adherence while helping patients retain a sense of purpose is by incorporating spirituality into their care. Walton’s study in 2002 found that a patient’s spirituality, which includes faith, prayer-life, and “meaningful relationships,” provides a strong support system that can help the patient through the difficulty of dialysis treatment (as cited in Tanyi, 2006 ). As a result, Tanyi (2006) conducted a study to examine the role of the dialysis nurse in regards to spirituality. It was found that the level of care a nurse is perceived to have provided was directly affected by the nurse’s level of spirituality, their own as well as their patients’. The respondents stated that nurses could incorporate spirituality into their care not just by addressing religious issues, but also by displaying caring behaviors such as showing genuine concern for their patients’ well-being, active listening, and using therapeutic touch (Tanyi, 2006).
Because adherence to treatment is such a problem for dialysis patients, it is important for nurses to incorporate different strategies for adherence into their dialysis care plans. Giving patients more of a sense of control over their treatment, teaching them how the treatment affects them personally, and including spirituality as a part of care are some ways that dialysis nurses can combat non-adherence. When patients have a sense that they are in control of what happens to them, the outcomes are generally better (White, 2004). All three of these nursing approaches have patient empowerment as a common theme. As more of these methods are researched and utilized, dialysis patients will have much better success at consistently following their treatment plans.
Intervention #1
Nurses can use cognitive behavioral modification to promote adherence.
Disadvantage #1
It is important for patients with Chronic Kidney Disease (CKD) and End Stage Kidney Disease (ESRD) to monitor and maintain strict control of their blood pressures, reduce proteinuria in order to slow down the progression of the disease, and to take all medications as prescribed (Costantini, 2008). This requires a patient’s active involvement in his or her treatment and frequent self-assessment of symptoms. However, many of these patients have no apparent symptoms, and therefore find it difficult to take seriously the need for adhering to a treatment plan. It is very difficult for some patients to grasp the severity of their disease, since many experience no adverse effects until the disease has progressed towards the end-stages. As one patient remarked about his disease, “There’s no way it could be that bad, you feel good... (Costantini, 2008).”
Disadvantage #2
In order for cognitive behavioral modification to work, the patient must have a certain level of cognition and ability to learn. Research has suggested that people who have kidney disease can have some cognitive impairment as a result of their disease, and those with End-Stage Renal Disease (ESRD) are much more likely to be cognitively impaired than those in earlier stages of the disease (Hain, 2008). This can be a vicious cycle because pathologies that exist with kidney disease can be exacerbated by non-adherence to treatment and can cause worsening cognitive impairment. Older dialysis patients have many risk factors for vascular dementia which include older age, hypertension, and diabetes. With the number of people who are 65 and older and undergoing dialysis steadily rising, and 16% of the dialysis population 75 or older, cognitive impairment is a big factor in adherence. This is because cognitive impairment can impact decision-making, medication compliance, ability to learn, and the ability of patients to perform self-assessments, all of which are key components of cognitive behavioral modification. Nurses working with these populations will have to learn to recognize when a patient is non-adherent due to cognitive impairment and adopt different approaches to teaching those patients.
Intervention #2
Nurses can improve adherence by incorporating spirituality into their patients’ care.
Disadvantage #1
Heavy patient loads leave little time for addressing spiritual issues, and dialysis nurses tend to have extremely heavy workloads. A dialysis nurse typically oversees the treatment of between 25-30 patients in a 12 hour shift, which can mean administering 200 injections in that time (MacReady, 2008). With this kind of patient load, it can be very difficult to find the time to do things that are usually considered “extras,” such as discussing patients' faith with them, and still practice safe nursing care.
Disadvantage #2
Losing empathy for their patients can be another barrier to incorporating spirituality into patient care. Studies have shown a direct link between nurse burnout and loss of empathy (Bodin, 2008). Because of their heavy patient loads, nurse burnout is a big problem with nurses who work in dialysis units (MacReady, 2008). Burnout can cause job dissatisfaction, which in turn leads to high turnover rates among dialysis nurses, and, as a result, heavier patient loads. It is a problem that continues to perpetuate itself. In a recent survey, twenty percent of the dialysis nurses that were interviewed planned to leave their jobs (MacReady, 2008). It is very difficult for people to be caring and compassionate when they are exhausted, and don’t feel a sense of satisfaction in the work they do.
Health in Dialysis: the Nurse’s Role in Promoting Wellness in Patients Undergoing Treatment for End-Stage Kidney Disease
Julia Morris
Nursing 131
Rachelle Ligrano
With more than 400,000 Americans currently on some form of dialysis, dialysis nurses who know how to provide good patient care and promote positive patient outcomes have become more important than ever (Johns Hopkins Medicine, 2005). One of the biggest obstacles these nurses face in providing quality care is non-adherence by their patients (Kammerer, Garry, Hartigan, Carter, & Erlich, 2007). However, nurses can provide better quality care with improved outcomes by approaching dialysis care in a holistic manner. This includes giving patients a sense of control over their treatment, using positive reinforcement to help modify behavior, and incorporating spirituality into patient care.
According to White (2004), most American people already have trouble adhering to a healthy lifestyle and complying with prescribed medical treatments. Many diabetic patients do not exercise or control their weight or diet properly, and patients diagnosed with a bacterial infection and prescribed a ten-day course of antibiotics often do not finish out the course. So it is even more challenging for patients who are diagnosed with End-Stage-Renal-Disease (ESRD) because suddenly they are told they must follow a highly restrictive diet, limit their fluid intake, and follow a specific medical regimen which includes many medications and undergoing dialysis treatments at least two times a week. If they do not follow their treatment plans closely, serious complications often develop. Such a lifestyle change is a huge undertaking, and many dialysis patients can feel entirely overwhelmed. Therefore, it is no surprise that one of the biggest challenges dialysis nurses face is getting their patients to adhere to treatment regimens.
Many patients placed on dialysis believe they no longer have control over their lives. Some of these people may try to regain control in a negative way by deciding to shorten their treatment or not taking prescribed medications. Kammerer (2007) notes that some might feel such a loss of control that they develop a “sense of futility” and just give up, discontinuing all treatment (p. 481). Nurses can help combat these feelings of helplessness by involving the patient as much as possible in their healthcare decisions, informing them of all treatment options, and by placing an emphasis on self-care. Landreneau’s (2006) study found that the patients interviewed were not aware that they had any choices concerning treatment; in fact, they did not even know what the available options were. It was discovered that most patients do indeed want to be involved in making decisions regarding their treatment, and that more desirable outcomes occur as a result (Landreneau, 2006). In addition, nurses can give patients a sense of control by teaching them to perform as much self-care as possible. This can include preparing the dialysis machine, performing self-monitoring during hemodialysis, and choosing their own interventions based on signs and symptoms they have self-assessed. This type of self-care has recently been suggested as a strategy to improve adherence (Richard, 2006).
Just possessing the knowledge about their choices and treatment, though, is not necessarily enough to keep patients compliant. Studies have shown that patients must not only be made aware of available resources, but they must also have the motivation to follow a treatment plan (as cited in Kammerer, 2007). A method that has been met with some success by nephrology nurses is cognitive behavioral modification. This works on the premise that patients will not adhere to a treatment plan unless they feel it is “personally worthwhile” and stresses the importance of positive interactions and relationships between nurses and patients (White, 2004). Nurses must be sensitive to the needs and feelings of their patients, and leave them feeling that their opinions are important. Instead of lecturing patients about not maintaining their blood pressures, a nurse using the behavioral modification approach might ask his or her patients if they notice a difference in their appearance or in the way they feel on days when their blood pressure is high. By using this approach, nurses help patients become aware of the way their treatment works and how non-adherence can affect them personally.
Another way nurses can improve adherence while helping patients retain a sense of purpose is by incorporating spirituality into their care. Walton’s study in 2002 found that a patient’s spirituality, which includes faith, prayer-life, and “meaningful relationships,” provides a strong support system that can help the patient through the difficulty of dialysis treatment (as cited in Tanyi, 2006 ). As a result, Tanyi (2006) conducted a study to examine the role of the dialysis nurse in regards to spirituality. It was found that the level of care a nurse is perceived to have provided was directly affected by the nurse’s level of spirituality, their own as well as their patients’. The respondents stated that nurses could incorporate spirituality into their care not just by addressing religious issues, but also by displaying caring behaviors such as showing genuine concern for their patients’ well-being, active listening, and using therapeutic touch (Tanyi, 2006).
Because adherence to treatment is such a problem for dialysis patients, it is important for nurses to incorporate different strategies for adherence into their dialysis care plans. Giving patients more of a sense of control over their treatment, teaching them how the treatment affects them personally, and including spirituality as a part of care are some ways that dialysis nurses can combat non-adherence. When patients have a sense that they are in control of what happens to them, the outcomes are generally better (White, 2004). All three of these nursing approaches have patient empowerment as a common theme. As more of these methods are researched and utilized, dialysis patients will have much better success at consistently following their treatment plans.
References
Bodin, S. (Mar/Apr 2008). Keeping individuals with kidney disease safe: raising awareness of the effects of nurse fatigue. Nephrology Nursing Journal, 35, 115-116. Retrieved May 8, 2008, from ProQuest database.
Costantini, L., Beanlands, H., McCay, E., & Cattran, D. (Mar/Apr 2008). The self-management experience of people with mild to moderate chronic kidney disease. Nephrology Nursing Journal, 35, 147-154. Retrieved May 8, 2008, from ProQuest database.
Hain, D. (Jan/Feb 2008). Cognitive function and adherence of older adults undergoing hemodialysis. Nephrology Nursing Journal, 35, 23-29. Retrieved May 8, 2008, from ProQuest database.
Johns Hopkins Medicine (2005, August 1). Dialysis treatment choice affects risk of death in patients with end-stage kidney disease. Retrieved January 14, 2008, from http://www.hopkinsmedicine.org/Press_releases/2005/08_01_05.html
Kammerer, J., Garry, G., Hartigan, M., Carter, B., & Erlich, L. (Sep/Oct 2007). Adherence in patients on dialysis: strategies for success. Nephrology Nursing Journal, 34, 479-486. Retrieved January 16, 2008, from ProQuest database.
Landreneau, K., & Ward-Smith, P. (Jul/Aug 2006). Patients’ perceptions concerning choice among renal replacement therapies: A pilot study. Nephrology Nursing Journal, 33, 397-402. Retrieved April 10, 2007, from ProQuest database.
MacReady, N. (April 2008). System Overload. Dialysis & Transplantation, 118-122.
Richard, C. (Jul/Aug 2006). Self-care management in adults undergoing hemodialysis. Nephrology Nursing Journal, 33, 387-394. Retrieved January 16, 2008, from ProQuest database.
Tanyi, R., Werner, J., Recine, A., Sperstad, R. (Sep/Oct 2006). Perceptions of incorporating spirituality into their care: A phenomenological study of female patients on hemodialysis. Nephrology Nursing Journal, 33, 532-538. Retrieved October 14,2007, from ProQuest database.
White, R. (Jul/Aug 2004). Adherence to the dialysis prescription: Partnering with patients for improved outcomes. Nephrology Nursing Journal, 31, 432-435. Retrieved January 16, 2008, form ProQuest database.
Children with Diabetes: The Nurses Role in Educating Proper Management of Their Care
Type 1 diabetes is a chronic illness that usually begins in childhood. It is the result of pancreatic beta cell destruction which can be caused by an autoimmune process or from other unknown causes (Hernandez & Williamson, 2004). If diabetes is not managed properly it can result in terrible consequences, such as the loss of eyesight, limbs, or even life. All of these complications can affect the person’s personal, social, and work life. Since diabetes that is not managed properly can put a child at risk for long-term health and social problems, the role the nurse plays in educating children and their families on the management of their care is very important. Nurses can provide this information in a variety of settings, such as hospitals, schools, and at diabetic camps.
When diabetes is managed properly, complications like retinopathy, nephropathy, and neuropathy can be prevented (Hernandez & Williamson, 2004). Good management of diabetes can be difficult for anyone, but there are special challenges when the person with the disease is a child. Youth with diabetes have a much higher rate of depression than the general population (Kanner, Hamrin, & Grey, 2003). Young children may not understand why they need to get shots and have their fingers poked all the time, while many teenagers think they are invincible and do not believe poor management of their disease will lead to any consequences for them. The teens are usually more interested in fitting in, and doing whatever their friends are doing at the time (Nabors, Troillett, Nash & Masiulis, 2005). All of these challenges increase the need for good education to prevent diabetes related health problems
Many children are diagnosed with diabetes in a hospital and nurses will provide much of their primary diabetes education during this stay. The average hospital stay for a child newly diagnosed with diabetes is less than three days (Habich, 2006). This is barely enough time for the child, and his or her family, to learn the minimum skills needed to manage this disease at home. Skills include how to check blood sugar, what is the normal range, what to do if it is not within the normal range, and how to administer insulin. To help patients get the most out of their short stay, a task force was put together at a hospital in the Midwest with the sole purpose of implementing a program to improve the education process for pediatric diabetics and their families (Habich, 2006). The hospital admits about sixty children with new cases of diabetes each year. The program the task force developed puts the staff nurse in charge of the education during their stay. This nurse works with a team of individuals on staff to provide the best possible education process. The nurse then works with a certified diabetes educator to transition the patient from an inpatient to an outpatient program. After three years of studies, the readmission rate of children diagnosed with diabetes at this hospital is zero (Habich, 2006).
After being discharged from the hospital, most children spend a good portion of their day at school where the school nurse will play a role in the management of their care. Most school nurses claim to have developed a written health care plan for at least one student during their career (Nabors et al., 2005). The nurses may also be the only ones at school with enough knowledge about diabetes to educate the students’ teachers and coaches about their disease. Educating the staff is important because they need to watch the children for signs and symptoms of hypoglycemia, such as nervousness, shaking, irritability, or blurred vision. They should also know how to check the child’s blood sugar if they suspect it is low, and what to give them if it is. When away from the school, the teachers or coaches should always have juice, soda or something that can raise the child’s glucose level quickly when necessary.
Children can continue to be educated about diabetes during school breaks. Camps designed for children with diabetes provide them with a great opportunity to learn about managing their disease, while meeting other kids in similar situations. Nurses are both educators and managers of care at these camps. The more children are educated about their own disease, the better the chance of it being managed properly. Diabetes camps provide a great place for this to happen. The goal of these camps is to let diabetic children have a traditional camping experience in an environment safe for their medical condition (“Diabetes”, 2007). It is also a good place for kids to feel like they fit in, and be able to talk to others who have had similar experiences. This environment is a perfect place for nurses to educate children about self-management of their disease. They can teach about a variety of topics from blood glucose monitoring, to pump issues, to stress management, or even about possible complications. Most of these camps have a high return rate; this gives nurses an opportunity to reinforce important issues, while adding different types of education as the children get older (“Diabetes”, 2007).
Chronic complications from diabetes can affect almost every organ in a person’s body. These complications can lead to loss of independence, social isolation, and depression (Hernandez & Williamson, 2004). Nurses play an important role in the prevention of these complications by educating diabetic children and their families about the proper management of their care. The initial education nurses provide in a hospital setting will plant the roots for lifelong management. The ongoing education school nurses provide will help the children keep control over their disease while away from home, and the additional education nurses provide at diabetes camps will help the children understand why proper management of their disease is so important, while at the same time provide them with an environment where there are many other children in similar situations.
Intervention #1
In hospitals, nurses play an important role in educating children with diabetes and their families on the proper management of their care.
Disadvantage #1
Many families receive the news that their child has diabetes while in the hospital. It can be difficult for them to take in all they need to know about taking care of a diabetic child while they are still getting over the shock of the diagnosis. Many parents need support just to cope with their own emotions (“Parents Traumatized”, 2005).
Disadvantage #2
Another disadvantage to nurses providing children and their families with their initial diabetes education in the hospital is the short amount of time they have to do it in. “It becomes very difficult to balance the impact of diagnosis and the need to provide critical education in anticipation of a length of stay less than three days.” (Habich, 2006). This short stay barely gives the nurse enough time to teach the basic skills related to managing diabetes.
Intervention #2
School nurses play an important role in educating children with diabetes about the proper management of their disease.
Disadvantage #1
The lack of education the teachers have about diabetes can restrict how well the children are able to manage their disease. If students’ teachers are not knowledgeable about diabetes they may not allow the students to test their glucose levels or have a snack when they need it (Nabors, Troillett, Nash, & Masiulis, 2005). In order for school nurses to have good results when educating students on how to manage their disease, the students have to be able to follow the nurse’s recommendations.
Disadvantage #2
Large ratios of students to nurses can make it difficult for the nurses to have enough time to spend with each student. This ratio would also limit the time the nurses have to educate other staff members about the needs of the diabetic children. According to Guttu, Engelke, & Swanson “The National Association of School Nurses endorses a nurse-to-student ratio of 1:750, but few school systems consistently achieve this ratio.” (2004). A study done in 21 counties in North Carolina showed two counties didn’t have school nurses and of the other nineteen, the ratio ranged from 1:451 up to 1:7440 (Guttu et al., 2004).
References
Diabetes care at diabetes camps. (2007). Diabetes Care, 30, S74-S76. Retrieved April 17, 2007 from Proquest Database.
Guttu, M., Engelke, M. K., & Swanson M. (2004). Does the school nurse-to student ratio make a difference? The Journal of School Health 74(1), 6-9. Retrieved May 6, 2008 from Proquest Database.
Habich, M. (2006). Establishing a standard for pediatric inpatient diabetes education. Pediatric Nursing, 32(2), 113-116. Retrieved April 10, 2007 from Proquest Database.
Hernandez, C. A., & Williamson, K. M. (2004). Evaluation of a self-awareness education session for youth with type 1 diabetes. Pediatric Nursing, 30(6), 459-465. Retrieved January 16, 2008 from Proquest Database.
Kanner, S., Hamrin, V., & Grey, M. (2003). Depression in adolescents with diabetes. Journal of Child and Adolescent Psychiatric Nursing, 16(1), 15-24. Retrieved January 16, 2008 from Proquest Database.
Nabors, L., Troillett, A., Nash, T., & Masiulis, B. (2005). School nurse perceptions of barriers and supports for children with diabetes. The Journal of School Health. 75(4), 119-124. Retrieved April 17, 2007 from Proquest Database.
Parents traumatized by children’s diabetes. (2005). Australian Nursing Journal, 12(11), 33. Retrieved May 7, 2008 from Proquest Database.
Thursday, May 8, 2008
Prevention of Pressure Ulcers in the ICU Patient
Decubitus ulcers have plagued the nursing profession for many years as a major health care problem in term of patients’ pain, disfigurement, prolonged hospitalization and financial cost. Decubitus ulcers, commonly referred to as pressure ulcers, are the most preventable complication of intensive care units (ICU). Nurses, caring for patients in ICU, can exert a positive influence in prevention of pressure ulcer development by taking aggressive measures such as alleviating pressure, implementing meticulous skin care, and providing nutritional support.
A pressure ulcer is defined as “any lesion caused by unrelieved pressure that result in damage to underlying tissue; pressure ulcers are considered both inevitable and preventable” (Pokorny, Koldjeski, & Swanson, 2003, p. 535). Development of pressure ulcers confer significant morbidity and mortality to the critically ill patient and dramatically increase the cost of a medical bill. Research done at Mount Sinai School of Medicine in New York showed that the “cost of complications directly related to hospital acquired pressure ulcer average $225, 615 per patient” (Chronakos & Nierman, 2003, p. 365). Intensive care unit patients, especially the trauma patients, are among the highest risk groups. Chronakos and Nierman (2003) reported that “The incidence of decubitus ulcers average 10% to 15% in acutely hospitalized patients and increases to 30% to 60% in critically ill patients” (p. 365). Every patient in ICU is potentially at risk for developing pressure ulcers due to immobility, decreased sensory perception, low albumin levels, altered nutrition status and medications. Furthermore, many ICU patients have medical devices such as splints, cervical collars, casts and endotracheal tubes which have the potential to cause skin breakdown. Even though the issue of whether or not pressure ulcers are preventable in an ICU setting remains controversial, evidence-based practice suggests that with a systemic approach, the development of ulcers can be substantially decreased. It is the responsibility of each and every nurse to understand the extent and the cause of this problem so actions can be taken to avoid the complication or to treat it in initial stages when treatment is most effective.
Majority of ICU patients are limited in overall physical mobility, resulting in decreased ability to change their position in bed and thus increasing risk of prolonged and intense pressure. This is especially true for patients who are placed in a drug-induced coma because they are unable to communicate or change their position independently. Another frequently encountered problem in a critical care setting is the use of medications such as anesthetics and sedatives which alter sensory perception. All of these patients are enabled to consciously be aware of the damage being accumulated from pressure buildup; therefore, daily examinations of pelvic, sacral, elbow, scapula and heel areas should be an essential responsibly of a nurse. When soft tissue is compressed between external surface and a bony prominence for an extended period of time, the external pressure exceeds capillary pressure. As a result, blood flow becomes restricted; tissue becomes anoxic and release toxic metabolites causing cell death and formation of a pressure ulcer. Some of the signs that would demonstrate that there is skin breakdown are discoloration, warmth, edema and induration. However, methods that prevent patients from getting pressure ulcers is frequent examination and reposition which are based on research done by Chronakos and Nierman (2003), “cornerstones of care” (p. 365). Moreover, as stated by Chronakos and Nierman (2003), intermittent relief of pressure effectively minimizes tissue damage and can reduce the incidence of decubitus ulcers by seventy five percent (p. 368). For repositioning to be effective, the Pressure Ulcer Prevention Protocol states that patients should be repositioned at least every two hours to help alleviate pressure (Wurster, 2007, p. 269). Furthermore, nurses must be conscious to avoid shear and friction associated with positioning and transferring. Keast, Parslow, Houghton, Norton and Fraser (2007), stated that “shear is the mechanical force that moves the bony structures in direction opposite to the overlaying skin” (p. 455). Therefore, particular attention should be directed in not placing patients directly on femoral trochanter and keeping bony prominences from direct contact with underlying surfaces by using pillows or foam wedges. For example, when the patient’s head is elevated, skin remains fixed against the bed linen but gravity pulls the skeleton towards the foot of the bed, which can cause distortion of capillaries, thrombosis and ischemia. Thus, to avoid injury, the head of the bed should not be elevated greater then thirty degrees. ICU patients present a challenge to this protocol due to the risk of aspiration and ventilator-associated pneumonia. These concerns should be balanced when caring for a seriously ill patient who is at risk for developing both pressure ulcers and aspiration pneumonia. Friction is another important aspect that needs to be considered when addressing pressure ulcers prevention. Friction or rubbing is defined as the force of two surfaces moving across one another, often resulting in abrasion. National Pressure Ulcer Advisory Panel recommends using bed linens to lift patients when turning or transferring to avoid dragging a patient who is physically weak (Chronakos & Nierman, 2003, p. 368). Additional beneficial tools used to reduce pressure are pressure-reducing mattresses, which help distribute weight evenly, specialized cushioning devices, and padding. However, studies done to identify types of mattresses to use for patients did not provide definite results. Though ultimately, it was concluded that “a patient who is judged to be at high risk for decubitus ulcers should not be placed on an ordinary hospital bed” (Chronakos & Nierman, 2003, p. 368).
Proper skin care for patients confined in bed for long periods is vital and must be done correctly. According to Chronakos and Nierman (2003), a moist environment increases the risk of pressure ulcer development fivefold (p. 369). Numerous factors such as fecal incontinence, leaking wounds, fever and perspiration due to higher ambient temperatures in the ICU may increase skin moisture and predispose patients to skin breakdown. In addition, moist skin is at increased risk for irritation, rashes and infections such as Candida. Wurster (2007) states that “skin care must be implemented by using a mild cleansing agent followed by thoroughly rinsing the skin with water” (p. 268). The use of warm water is recommended; dry the skin via patting and avoid using alcohol-based moisturizing agents to minimize drying and irritation. Keast et al. (2007) point out that fecal incontinence is a greater risk for skin breakdown than urinary incontinence because of the chemical irritation that results from the enzymes, which are caustic to the skin (p. 454). Therefore, to decrease the risk of developing an ulcer, the incontinence brief should be changed as soon as it becomes soiled. Frequent change of moist, soiled linen to promote evaporation and faster drying maintains dry, intact skin. Special attention should be given to trauma patients who require the use of cervical collars. Power, Daniels, McGuire and Hilbish (2006) report that “up to 55% of patients in a cervical collar for five days or greater develop skin breakdown” (p. 198). Research supports evidence showing that strict adherence to the standards of care, which include cleaning and assessing skin under the collar every twelve hours and changing the pads in the collar every twenty four hours, decrease the incidence of skin breakdown significantly. Care of wound drainage should be another factor to consider. Keast et al. (2007) recommends using appropriate dressings along with protective creams, ointments, films, and solid barrier sheets, such as hydrocolloids, to protect peri-wound skin from wound drainage (p. 454). When dressings have reached their maximum capacity for absorption they need to be replaced in order to prevent maceration of surrounding tissue. Pouching is also an option to control excessive exudates; if location of the wound permits.
Many ICU patients experience altered metabolism function, resulting in a poor nutritional state. Patients with major trauma, burns, and sepsis are particularly at increased risk for inadequate nutritional intake. An altered metabolism can lead to the loss of subcutaneous tissue, resulting in overexposed bony prominences and poor skin condition. Correction of nutritional deficiencies is very important for maintaining skin integrity. Albumin, the most abundant plasma protein, is responsible for the regulation of blood volume by maintaining osmotic pressure, and keeping the blood fluid from leaking out into the surrounding tissues. Thus, low serum albumin level can lead to interstitial edema which impedes the passage of nutrients from blood to the tissues. Studies have shown a significant correlation between levels of albumin and development of pressure ulcers. Chronakos and Nierman (2003) report that up to 75% of patients with albumin levels below 35g/L developed ulcers versus only 16% of patients with higher albumin levels (p. 367). Therefore, ICU patients must be assessed for nutritional deficiencies and proactive interventions should be implemented before malnutrition becomes severe. Wurster (2007), suggests that because nutrition is such an important element in wound prevention “adequate nutritional intake must be managed either by enteral or parenteral administration” (p. 269).
Pressure ulcers are considered a potentially preventable condition and many guidelines have been standardized and published to facilitate healthcare personnel in administering care. Yet current pressure ulcer prevalence and incidence rates in critical care settings remain unacceptably high and account for many unnecessary deaths. In the twenty first century, a world of advanced technology and medical expertise, pressure ulcers remain a major health care setback. It is believed that if nurses provide excellent quality and quantity of care, the patient outcome will be of a greater satisfaction. Therefore, it is a duty of every nurse to be educated and aware of the signs of tissue breakdown and factors that put patients at risk. Evidence-based practice suggests that with the systemic approach in the prevention of pressure ulcers, nurses can improve patients’ outcome significantly. Therefore, understanding predisposing factors and the principles of pressure ulcer prevention such as alleviating pressure, implementing meticulous skin care, and providing adequate nutritional support in conjunction with the ability to select appropriate devices and equipment are the key factors to a successful prevention and treatment plan.
References
Chronakos, J., & Nierman, D. (2003). Managing pressure ulcers in critically ill patients. Journal of Respiratory Disease, 24(8), 363-371. Retrieved February 5, 2008, from ProQuest database.
Keast, D., Parslow, N., Houghton, P., Norton, L., & Fraser, C. (2007). Best practice recommendations for the prevention and treatment of pressure ulcers. Advances in skin and wound care 20(8), 447-462. Retrieved February 1, 2008, from Ovid database.
Pokorny, M., Koldjeski, D., & Swanson, M. (2003). Skin care intervention for patients having cardiac surgery. American Journal of Critical Care, 12(6), 535-543. Retrieved January 29, 2008, from ProQuest database.
Power, J., Daniels, D., McGuire,C., & Hilbish, C. (2006). The incidence of skin breakdown associated with the use of cervical collars. Journal of Trauma Nursing 13(4), 198-201. Retrieved February 5, 2008, from ProQuest database.
Wurster, J. (2007). What role can nurse leaders play in reducing the incidence of pressure ulcers? Nursing Economics, 25(5), 267-269. Retrieved February 2, 2008, from ProQuest database.
nursing 211- disadvantages
Intervention 1: use of special pressure alleviating mattress beds.
Disadvantage 1: improper use of beds.
One of the interventions for prevention of pressure ulcers is the use of the special pressure alleviating mattress beds. There are numerous types of specialty mattresses such as float foam, water filled, air filled and gel filled (Carroll, 2003, p. 43). These beds provide pressure relief if used properly. Some of the disadvantages include time and knowledge for the medical staff to set it up properly, lack of moisture dissipation, staff injuries trying to move it and the cost of the system. For the bed to be effective it should be properly selected for the individual patient. However, according to Carroll, the type of bed therapy selected is often inappropriate due to the lack of knowledge among nurses and physicians (2003, p.46).
Disadvantage 2: high cost of the beds.
In addition, the cost of treating pressure ulcers with this technology can be very high. The national institute for clinical excellence reported that the individual cost of pressure reliving devices ranges from 1,000 to 30,000 us dollars (Theaker, Kuper, & Soni, 2005, p. 395). Therefore, to ensure quality patient care while reducing the cost of health care and improving patient outcomes, it is the role and responsibility of the nurses to make sure that the proper use of the specialty beds is implemented routinely and consistently.
Intervention 2: meticulous skin care.
Disadvantage 1: lack of knowledge of institution’s policies and protocols for pressure ulcer prevention among nurses.
With today’s critical nursing shortage, providing quality skin care to the patients can be a challenge due to factors such as time consumption and lack of knowledge of institution’s policy and pressure ulcers protocols. According to Zulkowski and Ayello (2007), studies done to assess competence of nurses caring for the patients with pressure ulcers reveal a low level of care knowledge (p.34). Prevention and mattress ordering guidelines were identified as deficient areas. Zulkowski and Ayello state that a recent survey of 694 RNs considered their wound education to be insufficient (2007, p.35). Without knowledge, can patients’ outcomes or practices in wound care prevention be changed? Of course, not. Since high prevalence rates of pressure ulcers have been linked to poor or inappropriate knowledge and education, educational program for the nurses and pressure ulcers protocols of the institutions should be readily available to all the nurses. Research suggests that when a nursing staff is educated about wound care and pressure ulcer prevention a positive change can ensue. (Beitz, Fey, & O’Brien, 2003, p.295).
Disadvantage 2: nursing shortage
Wurster (2006) states that with today’s nurse-patient ratio it is difficult to provide quality skin care due to time consumption (p.4). There are at least 135 different wound care products from cleansers to growth factors and to ensure not to cause patients more detriment, nurses need to know how to properly use it. Furthermore, it is equally important that RNs working in teams with nursing assistants ensure that the implementation of proper treatment is carried out routinely and consistently. With patient acuity and limited staffing due to overwhelming workload this can be a challenge. Therefore, developing a shared vision plan within the specific unit can promote common interests and goals which, ultimately, can lead to inspiration, motivation and accountability.
References
Beitz, J., Fey, J. & O’Brien, D. (October, 2003). Perceived need for education vs actual knowledge of pressure ulcer care in a hospital nursing staff. MEDSURG Nursing 7(5), 293-301. retrieved April 29, 2008, from ProQuest database.
Carroll, P. (November, 2004). Pressure ulcer management: cost-effective prevention and care .American Journal of Critical Care 16(3), 32-43. retrieved march 23, 2008, from Academic Search Premier database.
Theaker, C., Kuper, M., & Soni, N. (2005). Pressure ulcer prevention in intensive care- a randomized control trial of two pressure-relieving devices. Anaesthesia, 60, 395-399. Retrieved march 23, 2008, from ProQuest database.
Wurster, J. (October, 2007). What role can nurse leaders play in reducing the incidence of pressure sores? Nursing Economics 25(5), 267-269. Retrieved March 21, 2008, from CINAHL database.
Zulkowski, K. & Ayello, E. (August, 2007). Certification and education: do they affect pressure ulcer knowledge in nursing? Advances in Wound and Skin Care 20(1), 34-38. Retrieved April 18, 2008, from ProQuest database.
Wednesday, May 7, 2008
Pain Assessment in the Neurologically Impaired Child
The inability of nonverbal children to communicate pain and discomfort is a major barrier for pain assessment and management. Nurses must institute specific measures to detect pain and evaluate interventions in this population.
Pain assessment in children with neurological impairments has been the focus of scientific trials only in the last five to six years, despite the fact that these children are at increased risk for experiencing acute, chronic and procedural pain (Hunt, 2002). According to the International Journal of Nursing Studies, this evidence suggests that pain is not adequately treated because it is not adequately recognized, making this already vulnerable population endure an additional burden of unnecessary pain.
“Respect for human dignity, the first principle in the “Code of Ethics for Nurses” directs nurses to provide and advocate for humane and appropriate care” (Herr, 2006). Nurses are obligated to follow the ethical principles of beneficence (the duty to benefit another) and nonmalficence (the duty to do no harm), therefore to provide management and comfort to all patients, including those individuals who can not speak for themselves. According to the authors (Herr, 2006), the gold standard for pain assessment has always been self reporting, if this is not a viable option then there must be other actions that nurses should be prepared to take.
The American Society of Pain Management Nursing, points out general objective assessment strategies, such as using the hierarchy of pain management techniques, establishing a procedure for pain assessment, using of behavioral pain assessment tools, as appropriate, minimizing emphasis on physiologic indicators, and reassessing and documenting.
No single objective assessment strategy is sufficient by itself. The following examples are recommended by the authors (Herr, 2006). Searching for potential causes of pain such as upcoming procedures, should trigger an intervention by the nurse, even when there are no behavioral indicators. It is always a good idea to assume that pain is present. If there is reason to suspect pain, an analgesics trial can be therapeutic as well as diagnostic. Hunt (2003) suggests that “[p]ain assessment needs to be seen not as an objective process, but as an intersubjective process in which the professional engages with the child and family and endeavors to reach an understanding of the meaning that the pain experience has for them”(p. 181). Awareness of an individual’s baseline and familiarity with the patient is crucial in identifying subtle, less obvious changes in behavior patterns that may be indicative of the presence of pain.
An analgesic trial should be initiated if pain behavior continues after all the basic needs and comfort measures have been met. Based on the patient’s analgesic history and pathology, a nonopioid analgesic may be given initially (e.g., acetaminophen every four hours for 24 hours.), if behaviors improve, then assume pain was the cause. The authors suggest that, if behaviors continue, give a single, low dose, short acting opioid (e.g., hydrocodone, oxycodone, or morphine) and observe effects. If the nurse observes no change in patient behavior, she should titrate the dose upward by 25-50%. Continue to increase the dose if there is no change in behavior, observing and assessing continuously until either a therapeutic effect is seen, bothersome side effects occur or no benefit is determined. If behaviors continue the nurse must explore other potential causes (Herr, 2006).
The evidence suggests that the use of behavioral pain assessment tools may assist in recognizing and evaluating attempts to relieve pain in this population. “Standardized tools promote consistency among care providers and care settings and facilitate communication and evaluation of pain management treatment decisions. The appropriateness of a scale must be assessed patient by patient, and no one scale should be an institutional mandate for all patients in a certain group”(Herr, 2006). The authors of Pediatric Anesthesia propose that there is no standard measure of pain that exists for this population. However they propose the revised Face, Legs, Activity, Cry and Consolability (FLACC) observational pain tool as a valid and reliable measure to evaluate pain in children with cognitive impairment. Originally the FLACC tool was designed as a simple observational tool to assess pain in children who could not self report. It contains five categories, which are scored from zero to two to provide a total score ranging from zero to ten. A previous study demonstrated that the original behavior descriptors were not comprehensive, specifically the Legs and Activity categories. The authors point out that some individuals with neurological impairment exhibit a different constellation of pain behaviors compared to the healthy cognitively intact child. “The revised FLACC tool incorporates several additional behavioral descriptors, including: verbal outbursts, tremors, increased spasticity, jerking movements, and respiratory pattern changes such as breath holding and grunting” (Malviya, 2005). This study suggests that adding the specific behavioral descriptors to the relevant FLACC categories improved the reliability of pain assessment in these children. Additionally this allows for individualization via open-ended descriptors in each category. In addition, the authors recommend that incorporating a simple numeric scale for parent-identified descriptors, would better facilitate the assessment of pain in these children. Virtually half of the children in this study were described by their parents as having unique pain behaviors, such as, distinctive facial expressions, leg and body activity including self stimulating behaviors, specific verbalizations, and consoling techniques. This study showed that several parents noted a lack of expression, crying or responsiveness, was the most indicative sign of pain in their children (Malviya, 2006).
Physiologic indicators such as changes in heart rate, blood pressure and respiratory rate are often used to document the presence of pain. According to the authors, these indicators are not sensitive for discriminating pain from other sources of distress. The nurse should minimize emphasis on the use of vital sign changes, since there is little research to support this theory for identifying pain. An absence of abnormal vital signs does not indicate an absence of pain (Hunt, 2002).
Each patient must be reassessed regularly and overtime with tools and specific pain indicators that are appropriate for that patient. All assessments should be properly documented in a readily visible and consistent manner that is accessible to all health care providers involved in the management and assessment of pain (Herr, 2006).
In summary, the resolution of unnecessary pain in children who cannot self report requires frequent assessment, use of the right assessment tools and administration of analgesics. Foster (2001) declares that “nurses must be able to feel confident in their expert judgment. Judgments are based on comprehensive data gathered in the overall baseline assessment of each child and honed through keen observation of subtle changes in response to physiologic and environmental stimuli.”(p. 90). Nurses must possess a passion and be committed to eliminating pain as an emotional and physiological stressor for these vulnerable children. “When the passion is empowered by evidence based nursing judgment, children receive the best possible care” (Foster, 2001, p 93).
Intervention #1
Physiologic indicators such as heart rate, blood pressure and respiratory rate are often used to document the presence of pain
Disadvantage #1
The cornerstone to this intervention is using vital signs to determine pain in the nonverbal patient. However, physiologic indicators are not always sensitive for discriminating pain from other sources of distress. The nurse should minimize emphasis on the use of vital sign changes, since there is little research to support this theory for identifying pain. An absence of abnormal vital signs does not indicate and absence of pain. (Herr, 2006)
Disadvantage #2
“Physiological changes in variables such as respiratory rate, and heart rate are only loosely correlated with painful events and may occur in response to many other states such as exertion or fever”. An elevated heart rate could be associated with medications, anxiety, or excitement. (von Baeyer, 2006).
Intervention #2
Use of behavioral pain assessment tools such as FLACC (Face, Legs, Activity, Cry, Consolability) may assist in recognizing and evaluating pain.
Disadvantage #1
No one scale is appropriate for all types of pain or across all developmental levels. The FLACC tool was recommended only for procedural pain and other brief painful events, such as postoperative pain measured in the hospital. According to the authors this method can not be used in the home setting. (Foster, 2007)
Disadvantage #2
Not knowing – three forms of knowledge are required for optimal pain assessment and management. Knowing the child, familiarity with children with the same or similar conditions, and knowing the science (Hunt, 2002). Undertreatment of pain in nonverbal children is a danger because of their dependency on caregiving adults. “One of the most notable and serious social barriers to effective pain management has been the persistent myth that children do not experience pain. Of greater importance are the undocumented but countless actions of health care practitioners who have inflicted pain on children or failed to provide analgesia because of these beliefs.” (Kenneth, 1996)
Nurses must be able to feel confident in their expert judgment. The Nurse must be able to identify the subtle responses to physiologic and environmental stimuli to correctly titrate analgesics (Foster, 2001). If nurses lack the skills and abilities to recognize pain in the first place, a decision about how to effectively treat pain can not be made. (Hunt, 2002)
References
Herr, K., Coyne, P., Key, T., Manworren, R., McCaffery., Merkel, S., et al. (2006). Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. The American Society for Pain Management Nursing, 7(2), 44-52. Retrieved January 15, 2008 from Pubmedcentral database.
Hunt, A., Mastroyannopoulou, K., Goldman, A., & Seers, K., (2003). Not knowing-the problem in children with severe neurological impairment. International Journal of Nursing Studies, (40), 171-183. Retrieved January 15, 2008 from Pubmedcentral database.
Malviya, S., Voepel-Lewis, T., Burke, C., Merkel, S., & Tait, A., (2006). The revised FLACC Observational Pain Tool: Improved reliability and validity for pain assessment in children with cognitive impairment. Pediatric Anesthesia, (16), 258-265. Retrieved January 15, 2008 from Pubmedcentral database.
Foster, R., (2001) Nursing Judgment: The key to pain assessment in critically ill children. Journal of Specialized Pediatric Nursing 6(2), 90-96. Retrieved January 15, 2008 from CINAHL database.
von Baeyer, C., Spagrud, L., (2006). Systematic review of observational (behavioral) measures of pain for children ad adolescents aged 3-18 years. International Association for the Study of Pain, (127), 140-150. Retrieved May 6, 2008 from Pubmedcentral database.
Craig, K., Lilley, C., Gilbert, C.,(1996). Barriers to optimal pain management in infants, children, and adolescents social barriers to optimal pain management in infants and children. The Clinical Journal of Pain,12 (3), 232-242. Retrieved May 6, 2008 from Pubmedcentral database.
Delirium in the Elderly
Delirium, also called ICU psychosis, ICU syndrome, or acute confusional state, is defined by Lemiengre et al (2006) as “a disturbance of consciousness with reduced ability to focus, sustain, or shift attention; a change in cognition; or development of a perceptual disturbance that occurs over a short period of time and tends to fluctuate over the course of the day” (p. 685). Advanced age is the greatest risk factor for this acute, reversible condition; however, due to medical staff’s insufficient awareness of delirium and its symptoms, an estimated 66% to 84% of the elderly in the ICU suffering from this condition are not diagnosed and, consequently, not treated (Truman & Ely, 2003). Because the incidence of delirium in the ICU is increasing as the population ages, the ICU nurse must be aware of this syndrome and improve patient outcomes by implementing strategies to reduce the common risk factors of anxiety and pain, sleep deprivation, and disorientation.
When a patient suffers from delirium, his hospital stay is extended, he is at greater risk of medical complications with increased risk of death, and, even if independent prior to admission, he is much more likely to be discharged to a nursing home. He may be depressed, withdrawn, agitated, or aggressive. He may cry and hallucinate and try to remove tubes or catheters (Truman & Ely, 2003). This situation is not acceptable when, according to Inouye et al. (2005), delirium is considered “one of the most common preventable adverse events for older hospitalized persons” (p. 312). There are many risk factors, but pain, anxiety, disturbed sleep cycle, and disorientation are the most common risk factors specifically associated with an ICU stay that can precipitate the onset of delirium (Gillis & MacDonald, 2006). The nurse who understands delirium rejects stereotypes that interpret confused behavior as the normal evidence of “old age” and carefully implements strategies to reduce risk factors for this condition.
Pain is a very stressful and fearful event associated with hospitalization and with many of the procedures common to the ICU experience. This gives rise to what is often the first observable behavior on the path to delirium—a restless anxiety that can progress to extremely agitated behavior. Adequate pain management and verbal assurance of adequate pain management is central to reducing this anxiety. Nurses must assess level of pain and pharmacologic and non-pharmacologic measures (ie. heat and cold, massage, deep breathing, guided imagery, distraction) must be taken accordingly. Explaining the purpose and steps of procedures and the goals of effective pain management reassures the patient and gains his confidence, thus reducing anxiety. Though restraints may be used as a last resort to control agitation that is a safety risk, it is most often a result of the failure to address the patient’s pain and resulting anxiety (Marshall & Soucy, 2003).
Unmanaged pain contributes to a second nursing focus in preventing delirium: sleep deprivation. When the noisy and unfamiliar environment of the ICU is superimposed on pain, sleep becomes extremely difficult. Though noise and interruptions are not always avoidable, they can be minimized by modifying the environment and grouping procedures in patient care whenever possible. The at-risk elderly should be given a single room if available, away from heavy traffic (Gillis & MacDonald, 2006). Otherwise, choosing a roommate whose care needs and disposition are compatible with the promotion of the patient’s sleep is essential. The nurse can ask the patient about his normal sleep pattern, organizing care to respect that pattern, and communicating the importance of sleep to family and friends to encourage timely scheduling of visits. Noise can be minimized by speaking softly in the hall and by keeping only essential equipment in the room with volume controls low.
Finally, the unfamiliar faces and environment of the ICU and the stressful experience of pain, anxiety, and consequent sleep disruption increase the risk for disorientation in the elderly patient. This can trigger delirium. In countering patient disorientation, the nurse can engage the family if she instructs them on their important role. Simply by their presence, they bring familiarity to an unfamiliar place and so can greatly benefit their loved one. Family should be encouraged to touch their loved one, bring in clocks, calendars, favorite music and pictures, and talk about people, places, and experiences they have in common. Patient’s glasses and hearing aids should be worn (Gillis & MacDonald, 2006). However, if symptoms of delirium do develop, the nurse must be careful to assure family members of the “temporary nature and likely fluctuation” of the distressing symptoms (Truman & Ely, 2003, p. 34). It is also very important that the nurse become a humanizing presence in the high technology ICU environment by using therapeutic touch and by patiently and continually explaining the reason for hospitalization and the procedures performed using vocabulary understandable to the patient (Hewitt, 2002).
As the elderly population increases, the ICU nurse must understand delirium and be equipped to implement strategies to reduce the incidence of delirium which Truman and Ely (2003) consider “one of the top three most important target areas for improvement in quality of care in vulnerable older adults” (p. 26). Important interventions must be directed toward reducing his anxiety and promoting sleep by managing the elderly patient’s pain and environment. Maintaining orientation by surrounding him with familiar faces and objects while explaining the reason for and process of procedures is also vital in reducing the incidence of delirium. The ‘acute confusional state’ of delirium is very distressing for both the patient and his family. If not treated, it is also potentially deadly for the patient. Managed pain, familiar faces, increased understanding of the hospital environment and procedures, and adequate sleep create an environment of comfort and a sense of security that is necessary in the prevention of delirium and in the promotion of optimal patient outcomes.
Intervention #1
Nurses need to adequately assess and effectively treat pain in the elderly patient.
Disadvantage # 1
Murphy (2007) purports that there is “a remarkable stoicism” among the elderly related to pain and that, according to a Patients Association survey of nursing home residents, “older people believe pain is an unavoidable part of aging” (p. 32). Residents also reported that nurses did not regularly ask about their pain, implying that nurses often misinterpret the calm demeanor of the elderly patient as an absence of pain or that they also hold the ageist belief that pain is an inevitable consequence of growing old. Unless this false belief is exposed through education for nurses and patients, many elderly patients will hesitate to express their pain and nurses will fail to adequately assess their patient’s pain (Murphy, 2007).
Disadvantage # 2
The use of relaxation, meditation, and guided imagery are non-pharmacological methods of pain management that avoid common side effects that contribute to the development of delirium. These include sedation, confusion, constipation, and adverse drug interactions due to polypharmacy. However, pain management of the elderly is almost entirely focused on the use of pain medication in part because nurses are not knowledgeable in these complimentary therapies. To address this, Antall and Kresevic (2004) state that “Nurses must develop expertise in this area and be able and ready to act as patient educators and advocates in the use of these interventions.” and propose that these complementary therapies be incorporated into all nursing curricula (p.340).
Intervention #2
To counter patient disorientation and promote a therapeutic environment, nurses should encourage family members to visit frequently.
Disadvantage # 1
Frequent visits from family members contribute to a therapeutic environment that counters disorientation in patients. In addition, family members can provide valuable information on the patient’s mental status prior to admission and can identify any subtle changes. However, if the patient’s condition worsens, the acute onset of delirium is “very disruptive and very upsetting to those who may have known the patient as a lucid, rational being, only hours earlier” (Litton, 2003, p.212). To avoid the anxiety this causes nurses must educate family members on delirium and its manifestations and reassure the them that appropriate treatment is being pursued. This can be very time-consuming for busy nurses but is essential if family members are to effectively participate in the patient’s recovery.
Disadvantage #2
Concerned families may visit too frequently. Nurses must ensure that the environment allows the patient to have a balance between independence and supportive care. Concerned family may become a source of anxiety to the patient rather than a source of security and comfort. Nurses may have to ask the family to reduce visits if these exacerbate excitability in the patient with hyperactive delirium. This can be a sensitive issue to address with family members who want to be continually present. Gillis and MacDonald (2006) remark that finding the balance that promotes a therapeutic environment “is both a science and an art” (22).
References
Antall, G., & Kresevic, D. (2004, September/October). The use of guided imagery to
manage pain in an elderly orthopaedic population. Orthopaedic Nursing 23(5),
335-340. Retrieved April 10, 2008, from ProQuest database.
Gillis, A., & MacDonald, B. (2006, November). Unmasking Delirium. Canadian Nurse
102(9), 19-24. Retrieved January 4, 2008 from CINAHL database.
Hewitt, J. (2002, September). Pscho-affective disorder in intensive care units: a review. Journal
of Clinical Nursing, 11(5), 575-584. Retrieved January 4, 2008, from CINAHL
database.
Inouye, S. K., Leo-Summers, L., Zhang, Y., Bogardus, S. T, Leslie, D. L., & Agostini, J. V.
(2005, February). A chart-based method for identification of delirium:
Validation compared with interviewer ratings using the confusion assessment
method. Journal of the American Geriatrics Society, 53(2), 312-318. Retrieved
January 4, 2008, from CINAHL database.
Lemiengre, J., Nelis, T., Joosten, E., Braes, T., Foreman, N., Gastmans, C., et al. (2006,
April). Detection of delirium by bedside nurses using the confusion assessment method.
Journal of the American Geriatrics Society, 54(4), 685-689. Retrieved January 3, 2008,
from CINAHL database.
Litton, K. (July/September, 2003). Delirium in the critical care patient: What the
professional staff needs to know. Critical Care Nursing Quarterly 26(3), 208-213.
Retrieved January 12, 2008, from CINAHL database.
Marshall, M., & Soucy, D. (2003, July/September). Delirium in the intensive care unit. Critical
Care Nursing Quarterly, 26(3), 172-178. Retrieved January 3, 2008, from CINAHL
database.
Murphy, K. (June, 2007). The state of chronic pain in the elderly. Working With Older
People, 11(2), 32-34. Retrieved April 10, 2008, from ProQuest database.
Truman, B., & Ely, E. W. (2003, April). Monitoring delirium in critically ill patients: Using the
confusion assessment method for the intensive care unit. Critical Care Nurse, 23(2),
25-38. Retrieved January 3, 2008, from CINAHL database.
Tuesday, May 6, 2008
Strategies For Decreasing Medication Errors in the Neonatal Intensive Care Unit
Dispensing medications is an important duty for the Registered Nurse. The possibility of serious consequences due to medication errors makes it one of the most important skills to master. Neonates, in particular, are very vulnerable to medication errors. Their size, quickly changing weight, the number of medications they receive, lack of neonate specific dosing, and off label use of medications (prescribed outside the terms of the product license) contributes to the problem. In addition, neonates are less able to tolerate medication errors, as R. Kaushal noted in his 2001 study, which found neonates three times as likely to have an adverse drug effect due to drug error than the general population. Nurses can reduce medication errors in the neonatal intensive care unit by using unit specific strategies, such as improved access to specific information, simplification/standardization, and reduced reliance on memory ( Lucas, 2003).
The most common medication errors in the neonatal intensive care unit are associated with dose. Statistics vary substantially between studies, partly due to differences in definition of an error and the rigor of the method used to identify medication errors (Chedoe, 2007). The rate of medication errors in the neonatal intensive care unit has been reported as high as 5.5 errors per one hundred prescriptions (Kaushal, 2001). Dose errors most frequently occur because of incorrect recording of weight, incorrect recording of the dosage regimen, incorrect units, and misplacement of the decimal point with calculating the dose (Lefrak, 2002). On average, more calculations and dilutions are involved prior to the administration of medications to neonates than compared with adults (Chedoe, 2007). Another factor contributing to medication errors in the neonatal intensive care unit is a high “off label” use of medications (Lefrak, 2002).
One technique for significantly decreasing the likelihood of medication dose errors is improving access to specific information by using of emergency medication sheets at the front of each neonate’s chart. Upon admission, each neonate receives an individualized computer generated emergency sheet. The pharmacy generates the sheets and the nurse verifies the patient weight used for the calculations. Due to rapid weight changes in the neonate population, these sheets are updated weekly. The sheets are placed at the front of the chart for easy access. The first page of the medication sheet lists the four medications needed in the event of cardiac arrest in the neonate population (epinephrine, naloxone, sodium bicarbonate, and a volume expander), with specific doses for each neonate based on their current weight (Lucas, 2003). The remainder of the sheet lists medications potentially needed in other emergencies, with the appropriate dose calculated by computer, based on the neonate’s weight.
Another strategy for reducing medication errors is standardization, such as stocking standardized concentrations of a medication on the unit (Lefrak, 2002). One study, done by Chappell and Newman in 2001, indicated 31% of the prescriptions written for a particular neonate intensive care unit had the potential for 10 fold overdoses (Chedoe, 2007). Standardization is extremely important with many medications, such as heparin, which can come in strengths ranging from ten units per millimeter to ten thousand units per millimeter. If more than one concentration is required, they should be stocked in separate places, with distinctly different labels, to decrease the likelihood of error. To further decrease the likelihood of concentration errors, drug dose, not volume, should be specified in every order (i.e. total milligrams of medication to be given, not milliliters of a specific concentration).
Reducing reliance on memory to decrease the likelihood of miscalculations in medication dosage is a third strategy for reducing medication errors. The American Society of Health-Systems Pharmacists has identified nine categories of medication errors, three of which involve medication calculation (Rice, 2005). In fact, researchers have found that more than one in six medication errors involve miscalculations (Greenfield, 2006). In the neonatal intensive care unit, the number of calculations is high, leading to a greater opportunity for error. The medication order should include specific data for calculation, such as the neonate’s weight and dose per unit weight. This provides sufficient information for the pharmacist preparing the medication, and the nurse administering it, to recalculate the dose as a second, and even third check (Lucas, 2003). Referred to as “built in redundancies”, a multiple step process that requires at least two separate calculations can significantly cut down on calculation errors. A clearly written order, which does not use abbreviations and does use leading zeros and clear decimal points, will also contribute to a decrease in the number of calculation errors (. Lefrak, 2002). Access to standard formulas for medication dosage calculations, easy to reference during medication preparation, allows a nurse to double check her mathematical concepts for formulas used less often. This is an important component given that two studies involving baccalaureate nursing students indicated that 68%-91% of their calculation errors were found to be conceptual (Rice, 2005).
Neonatal intensive care nursing is a highly skilled specialty and it is essential that nurses use all the tools available to them to ensure the safety of medication administration. Improved access to specific information, simplification/standardization, and reduced reliance on memory are three strategies that can be used to ensure neonates get the quality of care they need and deserve.
________
Intervention: Improving access to specific information by using emergency medication sheets.
Disadvantage #1: The key to this intervention is acquiring and recording an accurate weight for each patient, so the pharmacist can calculate each medication sheet. Weights recorded in differing units, such as grams versus kilograms could cause confusion and lead to erroneous dosage calculations (Levine, 2003). Weights in neonates vary widely, while dose ranges by weight are very small. It is more difficult to recognize inappropriate medication orders and there is a smaller margin of safety. Because of the large variations in doses, an overdose that would be obvious in an adult patient may go unnoticed in a neonate (Lucas, 2004).
Disadvantage #2: Medication sheets are reviewed and renewed at least weekly for each patient, as weights change quickly in the neonate population. This intervention can be time consuming for the pharmacy (Koppel, 2005), and the financial cost can be high (Levine, 2003). A technician may also be required to provide a double check (Levine, 2003). The additional staff and training could be a financial burden for the hospital, which would ultimately be borne by the patient.
Intervention: Stocking standardized concentrations of medications.
Disadvantage #1: Stocking standardized concentrations of medications can make it difficult to administer the prescribed dose without causing fluid overload in some neonates. Neonatal fluid requirements vary depending on the level of maturity and the clinical diagnosis of the patient. Some neonates, especially those born prematurely, are fluid sensitive and may require administration of highly concentrated solutions (Hennessey, 2007). In addition, patients may be hypoglycemic or hyperglycemic and require different solution bases for medication delivery (Hennessey, 2007).
Disadvantage #2: Standard concentrations make using “The Rule of Six”, a routine method for calculating continuous infusions in pediatric patients, impossible. The rule of six is a mathematical equation that calculates the amount of drug (in milligrams) to be added to 100mL of fluid so that 1mL/hr delivers the drug at a rate of 1μg/kg/min. This method results in patient specific drug concentrations (Hennessey, 2007). Having only one concentration of a particular medication available precludes using this method.
References:
Hennessy, S. Developing standard concentrations in the neonatal intensive care unit. American Jounral of health System Pharmacy 2007 64(1) 28-30. Retrieved May 5, 2008 from Google.
Koppel, R., Metlay, J., Cohen, A. Role of computerized physician order entry systems in
facilitating medication errors. The Journal of the American Medical Association 2005 293(10) 1197-1203. Retrieved May 5, 2008 from Google
Levine, S., Holbrook, K. Medication safety in the pediatric emergency department.
Hospital Pharmacy 2003: 38(5) 426-435. Retrieved May 5, 2008 from Google.
Lucas, Amber. Improving medication safety in a neonatal intensive care unit. American
Journal of Health System Pharmacy 2004 61(1) 33-37. Retrieved May 5, 2008 from Google.
Childhood Obesity: Nursing Strategies for Prevention and Treatment of Childhood Obesity
The epidemic of childhood obesity carries with it numerous consequences and for the most part is completely preventable, as well as, treatable. Childhood obesity can lead to chronic health problems like cardiovascular disease, type 2 diabetes mellitus, and psychological problems like depression and low self-esteem. Even though obesity can be caused by some genetic conditions, it is mostly caused by poor diet and lack of exercise. Since childhood obesity carries with it detrimental health and mental consequences, nurses must focus strategies on educating families and communities about Body Mass Index monitoring, as well as, the importance of proper diet and exercise to prevent and treat childhood obesity.
Two of the major factors that cause childhood obesity are poor diet and a lack of physical activity or exercise. Singhal, Schwenk, and Kumar (2007) reported that almost all obesity in children is caused by poor food choices that lead to a greater caloric intake than needed. A reduction in physical activity and the increase in sedentary leisure options like video games and watching television contribute to childhood obesity (Australian Centre for Evidence Based Nutrition and Dietetics 2007). Body Mass Index (BMI) is a measurement that is used to tell whether or not a child is at risk for becoming overweight, is overweight, or even underweight (Johnson & Ziolkowski, 2006). BMI is often used because the data is easily obtainable. According to the Centers for Disease Control and Prevention (CDC) a child is considered obese if they fall above the 95th percentile and at risk of becoming obese if they fall between the 85th and 95th percentile on their age and gender specific BMI growth charts. Obesity can lead to hypercholesterolemia, hypertension, dyslipidemia, hyperinsulinism, type 2 diabetes mellitus, menstrual irregularity, low self esteem, and depression (Krebs, Jacobson, Greer, Heyman, Jaksic, Lifshitz, et al 2003). Nursing strategies aimed at the prevention and treatment of childhood obesity could greatly impact this epidemic.
One nursing strategy would be to implement BMI screening and parental notification programs in schools. Most school districts require school nurses to obtain weight and height measurements on their students on a regular basis, and these are the two measurements needed to find BMI (Johnson & Ziolkowski, 2006). By doing a simple calculation school nurses can find where their students fall on the CDC’s BMI screening charts. Some parents may not know the impacts of childhood obesity or even that their children are at risk, but if this information is offered it provides them with the opportunity to follow up with a health care provider or seek more information. In the East Penn School District a BMI screening program like this was implemented by the school district and as a result the children in that school district have been below the national average for childhood obesity for the past 5 years (Johnson & Ziolkowski, 2006).
Along with BMI screening nurses can focus strategies on educating and promoting exercise and physical activity to families and communities. When more calories are taken in than are spent through physical and metabolic activity, weight gain occurs. As a result, sedentary lifestyles and a lack of physical activity have been directly linked to childhood obesity. According to Ruxton (2004) 40% of boys and 60% of girls fail to meet the Health Development Agency’s recommendations of 30 to 60 minutes of physical activity a day. By encouraging families to participate in fun, interactive, structured exercise like sport’s teams, karate, or dance, nurses can help reduce these numbers. According to Krebs et al. (2003), children that watch 4 or more hours of television a day have significantly greater BMIs than children that watched 2 or fewer hours daily. By providing anticipatory guidance about physical activity, nurses can help families recognize that they make an impact of their children’s development of lifelong habits, like exercise that will help prevent and treat childhood obesity.
Educating families and communities about the importance of proper nutrition is another strategy that nurses can employ to combat childhood obesity. Since obesity is linked to poor food choices or excess food intake, nurses can educate families on making small specific changes that can make a huge difference. Some of these changes include: replacing whole milk with reduced fat or skimmed milk, replacing sugary drinks like soda and juices with 100% juice drinks and water, replacing calorie dense snacks like chips and candy with fruits and vegetables, and eating lean meats like chicken and turkey. Foods high in fiber and whole grains should be encouraged in a proper diet, too. When it comes to educating parents about proper nutrition, nurses should remind them of the importance of encouraging a child’s autonomy in self regulation of food intake while setting appropriate limits on choices (Krebs, et al. 2003). Allowing children the time they need to eat and being proper role models are good nutritional practices that nurses should promote in schools, child-care settings, and at home. Providing education about proper diet and nutritional habits is a pertinent nursing strategy that aids in the prevention and treatment of childhood obesity.
Treating and preventing childhood obesity are crucial in helping children to avoid having to suffer from life-threatening diseases and life altering mental health. The epidemic of childhood obesity is on the rise, and nurses have the ability to make a huge impact on it. Employing key nursing strategies that are focused on education about proper diet and exercise, and BMI screening with parental notification are critical in fighting this epidemic. Children who eat a proper diet and get an adequate amount of physical activity have significantly less BMIs than children who do not. Nurses must employ these key strategies aimed at prevention, as well as, treatment in order to make great strides in fighting the epidemic of childhood obesity.
Intervention #1
Nurses can focus on implementing BMI screening programs in schools with parental notification using the CDC’s BMI screening charts.
Disadvantage #1
Even though BMI screening is great in assessing a child’s weight status it still has limitations. BMI is the ratio of weight in kilograms to the square of height in meters. If these measurements and calculations are not done accurately then the percentile on the CDC’s growth charts in which a child falls will be inaccurate, and the measurement will be useless. According to Johnson & Ziolkowski (2006) BMI does not differentiate between central adiposity and peripheral adiposity and it does not differentiate between lean muscle mass and fat tissue mass. When implementing BMI screening programs nurses must keep these limitations in mind.
Disadvantage #2
The subject of childhood obesity is sensitive and sometimes viewed as private, therefore, parents may not view the school nurse’s involvement as positive. In the East Penn School District where a BMI screening program with parental notification was implemented, over half of the parents that receive letters notifying them of what percentile their child was in, viewed the school’s involvement as meddling, (Johnson & Ziolkowski, 2006). When health care professionals discuss the issue of a child’s weight with their parents, the parent’s may feel as if they are being blamed or they are being pressured, (Singhal et al. 2007). When a nurse addresses the issue of a child’s weight with the child’s parents they must show sensitivity and compassion so that further education and intervention can be implemented.
Intervention #2
Nurses need to educate families and communities about the importance of proper diet to prevent and help treat childhood obesity.
Disadvantage #1
Even if nurses provide families and communities with proper education about diet to prevent and treat childhood obesity, a low socioeconomic status could prevent families from implementing a proper diet. “Children from low-income households are more likely to become overweight than are children from higher-income households. Food insecurity and not having access to healthy food choices are reasons for this situation,” (Larsen, Mandelco, Williams, & Tiedman, 2006). Nurses can make every effort to empower families with education about proper diet, but having a low socioeconomic status may prevent them from being able to make proper food choices.
Disadvantage #2
Education about diet alone is not enough to prevent and treat childhood obesity. Since weight is directly linked to caloric intake and energy expenditure, education about diet to prevent and treat childhood obesity should also include education about activity levels and exercise. According to Singhal et al. (2007), the epidemic of childhood obesity is likely the result of a gradually increasing caloric intake and a decreasing level of physical activity. According to Krebs et al. (2003) the best approach in the treatment and prevention of childhood obesity is to incorporate assessment and anticipatory guidance about diet, weight, and physical activity. When nurses are educating families about proper diet to treat and prevent childhood obesity they should also offer education about physical activity and exercise.
References
Australian Centre for Evidence Based Nutrition and Dietetics (2007). Effective dietary interventions for overweight and obese children. Australian Nursing Journal 14(11), 31- 34. Retrieved January 16, 2008, from Academic Search Premier database (A25325766).
Johnson, A., & Ziolkowski, G. A. (2006). School-based body mass index screening program. Nutrition Today 41(6), 274-276. Retrieved April 28, 2007, from Expanded Academics ASAP database (A157267504).
Krebs, N. F., Jacobson, M. S., Greer, F. R., Heyman, M. B., Jaksic, T., Lifshitz, F., et al (2003). Prevention of pediatric overweight and obesity. Pediatrics, 112(2). Retrieved October 6, 2007, from http://aapolicy.aapublications.org/cgi/content/full/pediatrics;112/2/424#RFN1.
Larsen, L., Mandelco, B., Williams, M., Tiedman, M., (2006). Childhood Obesity: Prevention
practices of nurse practitioners. The American Academy of Nurse Practitioners 18(2) 70-79. Retrieved May 5, 2008, from Academic Search Premier database (AN1957198).
Ruxton, C., (2004). Obesity in children. Nursing Standard 18(20), 47-52. Retrieved January 16, 2008, from Academic Search Premier database (13054939).
Singhal, V., Schwenk, W. F., & Kumar, S. (2007). Evaluation and management of childhood and adolescent obesity. Mayo Clinic Proceedings 82(10), 1258-1264. Retrieved January 16, 2008, from Academic Search Premier database (A27176893).
Monday, May 5, 2008
Effectiveness of Treatments for Infantile Colic
Teaching a new mother about infantile colic is one of the primary responsibilities of postpartum nursing. Mustafa Aksam (2006) brings to light that infantile colic (IC) is a problem that effects up to 40% of babies. IC presents itself during the first three months of life and usually has its onset during the second week of life (Aksan, 2006). Many parents and caregivers are frustrated by IC especially when they are unable to control or relieve their baby’s pain and crying. A newly discharged mother is overwhelmed by all the changes in her life. Excessive uncontrolled crying of her baby during the day and night may be an additional trigger for postpartum depression (Roberts, 2004). Nurses should insure that all new mothers receive education about the treatments for infantile colic before discharge from the hospital. The result will be that fewer new mothers will return to the hospital with maternal depression.
The nurse educator will provide information about infantile colic to a new mother. According to Donna Roberts (2004), colic is often defined by “The rule of three”: an infant who is healthy and well nourished but crying “for more than three hours per day, for more than three days per week, and for longer than three weeks.” A colicky infant has attacks of high-pitched screaming in the evening with associated motor behavior such as furrowed brow, flushed face, clenched fists, distended and tense abdomen, and the legs drawn up to the abdomen. The loud cry may persist for several hours. It may be terminated when the infant becomes fatigued, or passes feces or flatus (Roberts, 2004). It is most important for the mother to have reassurance that her baby is healthy and the colic is self-limited with a short term effect unless there are other signs and symptoms of illness (Roberts, 2006). E. Rosenthal (2004) states that infant colic is considered by many as “stressful yet harmless” (Rosenthal, 2004).
According to Donna Roberts (2004), the cause of infantile colic remains unclear, and there is no effective medication that may help to resolve this problem without harming a baby. However, nurses are teaching new mothers several effective treatments that show a significant decrease in the time of infant’s crying episodes (Roberts, 2004).
Mustafa Aksam (2006) discusses the study conducted in Isparta Maternity Hospital in Turkey about the effect of oral hypertonic glucose solution in a treatment of infantile colic. In this study, thirty healthy infants with colic were selected and the double blind study with crossover trial was conducted. Two bottles were prepared for each patient: one bottle with 30% of hypertonic glucose solution used for IV injection and another bottle with distilled water. The same patient used one bottle for four days and then used another bottle for four days. All parents were instructed to give 1 mL of solution before each feeding using medicine droplets. The infants were examined in the clinic repeatedly and the parents described the effect of the last treatment on their infants. The study showed that 64 % of the parents reported an improvement in their infant’s condition while using 30 % of hypertonic glucose solution. However, 36 % of the parents also reported an improvement after using distilled water (Aksan, 2006). No one reported any side effect in this study. Since oral hypertonic glucose solution has a significant effect for the treatment of infantile colic, nurses will recommend it for the new mother as a natural, safe, and cheap therapy.
According to one study reported by P. Kearney (1998), lactase is effective in management of infantile colic. Incomplete lactose absorption in the small intestine provides carbohydrates for bacteria, which are present in the large intestine. Those bacteria metabolize lactose and produce hydrogen that causes infantile colic. Adding a few drops of lactase to the milk formula 24 hours prior to feeding the baby, significantly (95% or 1.14 hr/day) decreases crying time for babies with infantile colic. However, there is no effect of adding lactase to formula during the baby’s feeding. It is possible that stomach acid destroys lactase making it ineffective. The study showed that there was no difference in stool of the babies who had lactase or placebo in milk. Also, there were no side effects reported during this study (Kearney, 1998).
According to Sally Wade (2001), two systematic studies found that the infants fed with soya milk formula have less colic than infants fed with standard milk formula. Soy milk formula compared with standard milk formula reduces the duration of crying by 50-75% (Wade, 2001). However another research suggests that infants fed with soya milk formula do not receive important vitamins and proteins that are found in standard milk formula.
Donna Roberts (2004) suggested that herbal mixture containing chamomile, licorice, fennel, and lemon balm is effective in treatment of infantile colic. The mixture should be given to the infant three times a day, 150 mL per dose. However, there is a lack of standardization of strength and dosage, and it is too much for an infant to drink 150 mL of fluid at once. So, the new mother should be cautioned about the use of herbal treatment of infant colic (Roberts, 2004). According to E. Rosenthal (2004), behavioral and environmental modification can decrease infant crying time during the colicky time. Also, E. Rosenthal suggested another herbal mixture called “Gripe Water” which may include cardamom, chamomile, cinnamon, clove, dill, fennel, ginger, lemon ball, licorice, peppermint and yarrow. This product provides relief from flatulence and indigestion, however it has not been scientifically evaluated. Parents should avoid products that are made with sugar and alcohol and are manufactured outside of the US (Rosenthal, 2004).
Donna Roberts (2004) suggested behavior modification treatments for infantile colic. Some infants may reduce or even stop crying if placed near clothes dryer or near the room with a vacuum cleaner turned on that makes “white noise”. “Colic hold” is also suggested, which is a gentle pressure on infant’s abdomen (Roberts, 2004). E. Rosenthal (2004) suggested movements such as gentle rocking motion in a baby swing, in parent’s arms with walking or sitting in a rocking chair, or riding in a car also soothes some babies. Taking a warm bath together not only soothes the baby but also his mother (Rosenthal, 2004).
According to those studies, there are some effective and safe treatments and behavior modifications for infantile colic. If nurses provide the education about infantile colic to the new mothers, it will significantly increase their physical and mental ability to take care of their infants. Nurses prepare mothers to cope with the challenges that their babies will give them. Health care cost will decrease and the baby’s health will increase because mothers will use safe treatments and behavior modifications to treat infantile colic. Fewer mothers will return to the hospital for treatment of post-partum depression as the result of education that nurses will provide to new mothers prior to discharge from the hospital.
Intervention 1. Administering oral glucose hypertonic solutions for infant in treatment of infantile colic.
Disadvantage 1.
Oral glucose hypertonic solution does not affect all infants similarly. According to the study conducted in Isparta Maternity Hospital in Turkey, only 64% of parents reported an improvement in their infant’s condition while using 30% of hypertonic glucose solution. This means that this treatment did not affect positively other 36% of babies (Aksan, 2006). Another study also suggested that oral hypertonic solution does not have the same effect for all newborn babies. In this study only 23 from 36 babies who received one milliliter of oral hypertonic solution experienced relief in pain (Badiee, 2006).
Disadvantage 2.
Another disadvantage is a knowledge deficit. A very small amount of health care workers and parents in US are familiar with this treatment and even a smaller percentage of them uses oral glucose hypertonic solution for treatment of infantile colic. The study about how oral glucose hypertonic solution treats infantile colic was conducted in 2006, in Turkey (Aksan, 2006). There is no evidence that this study has been repeated in US and implemented in US health care system yet.
Intervention 2. Soy milk formula compared with standard milk formula reduces the duration of crying by 50-75%.
Disadvantage 1.
One disadvantage of soy milk formula is affected by socioeconomic status. Soy milk formula is more expensive than cow milk formula. One internet store shows that soy milk formula cost two dollars more than cow milk formula of the same size of can (Diper.com, 2008).
Disadvantage 2.
According to Natalie Reiss, soy milk formula compared to breast milk has another disadvantage. Breast milk reduces the risk of getting infectious and non-infectious diseases in infants. Breast milk also reduces the risk of chronic diseases such as diabetes, cancer, allergies, and asthma in infants. Breast feeding infants also have less risk of becoming overweight compared to formula feeding infants (Reiss, N. 2007).
References
Akcam, M. & Yilmaz, A. (2006, April). Oral hypertonic glucose solution in the treatment of infantile colic. Pediatrics International, 48(2), 125-127. Retrieved February 12, 2008 from CINAHL database.
Badiee, Z. (2006). Pak J Physiol. Oral hypertonic glucose, for analgesia in the premature newborns. 2(2). Retrieved May 5, 2008, from http://pps.org.pk/PJP/2-2/zohrah.pdf
Diapers.com. (2008). Baby Formula/Similac. Retrieved May 5, 2008, from http://www.diapers.com/Shop/SubBrand.aspx?CategoryID=2&CategoryName=Baby+Formula&BrandCode=SM&BrandName=Similac
Kearney, P. Malone, A. Hayes, T. Cole, M. & Hyland, M. (1998, April). A trial of lactase in the management of infant colic. Journal of Human Nutrition and Dietetics, 11, 281-285. Retrieved February 12, 2008 from CINAHL database.
Roberts, D. Ostapchuk, M. & O’Brien, J. (2004, August). Infantile colic. American Family Physician, 70(4), 735-741. Retrieved February 12, 2008 from Proquest database.
Reiss N. (2007, May). New research suggests that breastfeeding babies for at least six months is best. Pediatrics for Parents, 23(5), 2-3. Retrieved May 5, 2008, from Proquest database.
Rosinthal E. (2004, December). Recognizing and treating infant colic. Primary Health Care, 14(10), 45-49. Retrieved February 12, 2008 from CINAHL database.
Wade S. & Kilgour T. (2001, August). Infantile Colic. Clinical Evidence, 323(7310), 437-440. Retrieved January 30, 2008 from Pubmed central database.
Childhood Obesity: Prevention and the Nurse’s Role
Childhood obesity is on the rise, some would say to epidemic proportions. Something must be done today, and the best defense to this problem is prevention. Preventing children from becoming overweight will assist to reduce the potential problems these kids will experience now and later in life. Because childhood obesity leads to long-term health and social problems, nurses can take a lead role in the prevention of childhood obesity through recognizing and becoming educated on risk factors and using developmentally appropriate strategies for prevention, educating the patient and family on risk factors, problems of obesity, and strategies to make healthy lifestyle choices, and through working with other health professionals to address this multi-faceted issue.
Childhood obesity has been increasing alongside adult obesity. The rate of childhood obesity almost tripled since 1970 (Koplan, 2007). There are many reasons for the increase in obesity, but most can be attributed to lack of activity, amount of television watched, diet, and family attitudes towards eating (MacKenzie, 2000). The health professional failing to recognize the risk factors, inadequate counseling skills, and lack of time with the patients also accounts for unsuccessful prevention (Story, 2002). It is much easier and successful to prevent obesity than to try to treat this disease. Not only is prevention more successful, but the problems associated with obesity can be life-long. Heart issues, diabetes, social stigma, and self-esteem issues are just a few of the problems that can develop with childhood obesity (Ruxton, 2004). Obesity is a national health crisis, and the time to act is now.
For any strategy to work, the nurse needs to be educated on identifying the risk factors for obesity. Some of the risk factors are high birth-weight, overweight parents, socioeconomic status, and more than 1.5 hours TV per day (Ruxton, 2004, p.52). There are standardized criteria for accessing obesity in children. Understanding the criteria used to determine if an adolescent is overweight. For example, on growth charts, a weight at the 85th percentile indicates overweight, and obesity at the 95th percentile, the nurse, with other factors, can determine actual risk (Ruxton, 2004, p.48). If the child is identified at risk for being overweight or already is according to criteria, the nurse can then suggest ways to decrease this risk or at least maintain the risk and the child’s weight. The nurse must know what teaching strategies are appropriate given the patient’s age and gender to be effective. Many parents fail to see their child having a problem with weight or have concern with their lack of activity, which makes the nurse’s job very important in identifying these children at risk.
Nurses need to play a key role in educating the patient and family. Often the nurse spends more time with the patients and family than the doctor or other professional. When the nurse recognizes risk factors in the child, they can teach strategies on preventing obesity. These strategies need to be tailored to where each child is developmentally. For example, parents may be concerned with their toddler being a picky eater and bribe their child to eat more. This can result in the child not being able to regulate their caloric intake. The nurse needs to understand this and educate the parents on other ways to encourage healthy eating by their toddler (MacKenzie, 2000). Another example is educating a pregnant woman or new mother on the importance of breast-feeding and the link between overweight children and being formula-fed. The nurse should provide suggestions for physical exercise. For a teenage boy, this may include encouraging enrollment in a team sport. The nurse is the first line of defense for preventing obesity in children. Because of one obstacle identified as lack of time (Story, 2002), the nurse needs to recognize the need for collaboration to put the education into practice. The nurse needs to address the specific needs of the child, but it is just as important to look at the family unit (Vaughn, 2005).
Collaboration between health care professionals is a must in preventing obesity. The nurse needs to refer patients to a nutritionist if appropriate to help develop healthy eating habits. In addition, the nurse or family can contact the child’s school nurse to address lifestyle choices at school. The school nurse can advocate for the patient by being involved in any behavioral issues that may be developing, or in cafeteria choices. The school nurse needs to ‘act as catalyst for change’ (Harrison, 2004, p.1). The nurse can be an educational resource and teach strategies for making healthy lifestyle choices. The parents’ involvement, as well as siblings, is crucial to successful prevention. Parents need to be educated on risk factors identified in their child and possibly learn themselves what healthy choices to make in regards to diet and exercise. For prevention to work, every aspect of the child’s life needs to work together.
Childhood obesity is a public health issue that can have long-term effects on the child. Waiting until the child is overweight or obese, instead of preventing this problem, is similar to waiting for the car to run out of gas before getting more. Prevention can be effective when the nurse takes the primary role in identifying risks factors and knowing appropriate strategies, educates the patient and family on strategies for a healthy lifestyle, and works with other health professionals in addressing this issue. These three strategies must be established for prevention to work. Successful prevention of childhood obesity starts with the nurse.
References
Harrison, S. (2004). Fill vending machines with healthy food, schools told: school nurses urged to act as 'catalyst for change' in improving children's nutrition.(news). Nursing Standard, 18(1), 6. Retrieved April 10, 2007 from Expanded Academic ASAP database.
Koplan, J.P., Liverman, C.T., & Kraak, V.I. (2005). Preventing childhood obesity. Issues in Science and Technology, 21(3), 57-64. Retrieved April 10, 2007 from Expanded Academic ASAP database.
MacKenzie, N. R. (2000). Childhood obesity: Strategies for prevention. Pediatric Nursing, 26(5), 527-531. Retrieved April 10, 2007, from Proquest Database.
Ruxton, C. (2004). Obesity in Children. Nursing Standard, 18(20), 47-52. Retrieved April 10, 2007 from Expanded Academic ASAP Database.
Story, M.T., Neumark-Stzainer, D.R., Sherwood, N.E., Holt, K., Sofka, D., Trowbridge, F.L., &
Barlow, S.E. (2002). Management of child and adolescent obesity: Attitudes, barriers, skills, and training needs among health care professionals. Pediatrics, 110(1), 210-214. Retrieved April 17, 2007 from http://pediatrics.aappublications.org/cgi/content/full/110/1/S1/210.
Vaughn, K. (2005). A Call to Pediatric Nurse Practitioners in Battling the Childhood Obesity Epidemic. Pediatric Nursing, 31(4), 348,344. Retrieved April 10, 2007, from Expanded Academic ASAP Database.
Interventions and Disadvantages:
Intervention 1: Nurses need to become educated on identifying risk factors and problems of obesity, and able to offer developmentally appropriate strategies for prevention of obesity.
Disadvantage 1: Nurse’s need to be aware that just looking at BMI will not give an adequate picture of whether the child is at risk for being overweight or obese. You must also look at the child’s ethnicity, gender, age, and physical activity (Henry & Royer, 2004).
Disadvantage 2: For the nurse to be able to make appropriate suggestions for health lifestyle and activity choices, the nurse must assess where the patient is at developmentally. The nurse would want to suggest and offer strategies that the patient will want to follow and stick to. Also, since lack of time was cited as a main barrier to successful prevention, you may not get another chance for a year at the patient’s next annual exam to know how they are doing. This is a huge disadvantage, and makes this intervention hard to evaluate.
Intervention 2: Nurses provide education to the patient and family on risk factors, problems associated with obesity, and strategies to make healthy lifestyle choices.
Disadvantage 1: Parents don’t recognize that their child is overweight. According to Dorhan (2002), Differing perceptions, especially in low-income mothers, between the PCP and the mother on what is being overweight. Mothers did not see their children as overweight by the measures of growth charts. To them, having a larger child meant they were well-fed and healthy. In fact 79% of 99 mothers failed to see their children as overweight (Childhood Education, 2003). If parents do not see their children as overweight, no amount of interventions will work, it is crucial to successful prevention of obesity in children.
References
Childhood Education. (2003). Parents’ denial: Most don’t recognize child’s obesity. Childhood Education, 79(4), 228. Retrieved May 5, 2008 from Proquest Database.
Drohan, S. H. (2000). Managing early childhood obesity in the primary care setting: A behavior modification approach. Pediatric Nursing, 26(5), 599-610. Retrieved May 5, 2008 from Proquest Database.
Feeg, V.D. (2004). Combating childhood obesity: A collective effort. Pediatric Nursing, 30(5), 361-362. Retrieved May 5, 2008 from Proquest database.
Henry, L.L., & Royer, L. (2004). Community-based strategies for pediatric nurses to combat the escalating childhood obesity epidemic. Pediatric Nursing, 21(3), 162-164. Retrieved May 5, 2008 from Proquest database.
Prevention of Childhood Obesity: the Nurse’s Role
Childhood obesity is an increasing problem in America today with far-reaching consequences. The nutrition information and eating behaviors learned as children are carried into adulthood, shaping the health status of individuals. The early prevention and treatment of childhood obesity is necessary to reduce health complications and increase the quality and length of life. Because of the increasing prevalence of childhood obesity, nurses must proactively reduce the risk of childhood obesity through nutrition education, behavior modification training for parents and children, and community and school policy changes.
Childhood obesity has been an issue in America for many decades and, according to Sheehan (2004), over the last 20-25 years the number of affected children has tripled. The simple fact that almost 20% of children are currently classified as obese (measured by a BMI of over 30) should indicate the need to attack this epidemic from any and all angles (Henry & Royer, 2004). In addition to the increased number of health issues surrounding obesity, there is also the economical strain this epidemic has placed on the affected individuals and their communities. For example, Ruxton (2004) cited the estimate of treatment costs for obesity in the UK, in the early 2000s, as exceeding half a billion pounds (~$850 million) per year. Given the population difference between the UK and the U.S., it can be extrapolated that the cost to treat obesity in America is considerably higher and climbing each year as the number of obese individuals increases.
As with any prevention plan, knowledge is the logical starting point. Teaching parents and children about proper nutrition can be accomplished by nurses during scheduled well child visits as well as in schools by the school nurse on staff. Nutritional education should provide a sound, strong base from which to build a healthy lifestyle from infancy through adulthood. For example, it has been suggested that food choices during pregnancy influence the food likes and dislikes of the unborn child, so learning about good nutrition is never too early (Sheehan, 2004). Nurses can be involved in the different levels of education offered to parents and children as they grow and as their needs change. Horodynski and Stommel (2005) emphasize that the effectiveness of nutritional education is significantly increased when it is taught to the parents and caregivers of toddlers. They also suggest that the earlier good eating habits begin, the more likely those habits will prevent childhood obesity and last into adulthood. Nurses should take advantage of early doctor’s visits to emphasize the importance of sound nutrition. However, knowledge and education are not enough to affect this growing epidemic.
In addition to nutritional education, nurses must introduce behavior modification techniques to parents and children to help fight obesity. This can be achieved during doctor’s visits for children as well as parents because instilling good eating behaviors is more effective when the whole family follows the same practices. Various practices by parents, such as using food as rewards or bribes to get a child to behave a certain way, have proven to lower the child’s ability to recognize internal hunger and satiety cues for eating properly (Drohan, 2002). These improper uses of food teach children to attach different meanings and emotions to different foods instead of simply viewing them as energy fulfillment. One important behavior modification suggested by Drohan is the reduction of television viewing, especially during mealtimes. Additionally, Drohan (2002) asserts that the home implementation of four core principles of behavior modification—self-monitoring, social reinforcement, stimulus control, and parental modeling—will lay the foundation for positive behaviors that will endure for much longer than knowledge alone.
As well as direct interaction with children and parents, nurses can indirectly assist in the battle against childhood obesity by influencing important policy changes and program introductions in schools and communities. Because children spend an enormous amount of time in school, the environment of those schools should be addressed regarding the nutrition offered and the physical activities available. School nurses are uniquely positioned to observe the health of American youth and to offer strategies for prevention and change. A roundtable conference of school health professionals that convened in Washington, D. C., concluded that prevention is preferred to treatment and that guidance should be provided to students for better food choices and increased physical activity. It was also suggested that schools review their existing policies on physical activities and foods available to the students during school hours. For example, Arkansas removed vending machines in elementary schools in 2002 and Los Angeles banned soda sales in its entire school district in 2005 (School Nurses, 2006). These are just two examples of what can be accomplished in communities through policy changes. Henry and Royer (2004) state that, “Nurses must work together and act now to create a more healthy environment for the young people of our nation” (p. 163).
The increasing level of childhood obesity in America is both startling and frightening. Children are being raised in households and schools where fast food is a staple and fruits and vegetables have become unavailable. These learned eating patterns last into adulthood and are cause for great concern for the health and well-being of the U.S. population. Because of the increasing prevalence of childhood obesity, nurses must proactively reduce the risk of childhood obesity through nutrition education and behavior modification training for parents and children. The nursing strategies of nutrition education, behavior training, and fighting for various policy changes have proven to be effective in changing habits and increasing nutritional awareness. Used in conjunction with each other they will effectively fight the childhood obesity epidemic.
References
Drohan, S. (2002). Managing early childhood obesity in the primary care setting: A behavior modification approach. Pediatric Nursing, 28(6), 599-610. Retrieved April 17, 2007, from Proquest database.
Henry, L. & Royer, L. (2004). Community-based strategies for pediatric nurses to combat the escalating childhood obesity epidemic. Pediatric Nursing, 30(2), 162-164. Retrieved April 17, 2007, from Proquest database.
Horodynski, M. & Stommel, M. (2005). Nutrition education aimed at toddlers: An intervention study. Pediatric Nursing, 31(5), 364-370. Retrieved April 10, 2007, from Proquest database.
Ruxton, C. (2004). Obesity in Children. Nursing Standard, 18(20), 47-55. Retrieved April 17, 2007, from Expanded Academic database.
School nurses, school-based health centers and childhood overweight: A report from a roundtable meeting to explore the role of school health professionals in preventing childhood overweight (2006). Retrieved April 17, 2007 from http://www.healthinschools.org/sh/obesityreport.asp.
Sheehan, J. (2004). Fighting childhood obesity. Retrieved September 24, 2007 from http://www.parents.com/parents/printableStory.jsp?storyid=/templatedata/hk/
story/data/AB0904KidObesity_09172004.xml.
Intervention #1
Nurses need to provide children and their families with proper and adequate nutrition education.
Disadvantage #1
One problem nurses face in providing nutritional education to children and parents is simply being able to reach them in order to convey the information. Lack of health insurance coverage and/or access to health care facilities for patients can greatly hinder this effort. According to Slang and Bayerl 14% of children under the age of 18 lacked health insurance coverage in 1999 (2003). They also stated that poverty stricken children have a greater likelihood of not having a regular source of health care and therefore have reduced access to nutrition education, screening and counseling (Slang & Bayerl, 2003). These obstacles need to be identified so that nurses can find alternate routes for information transfer, including the numerous public food and nutrition programs in existence on local and federal levels.
Disadvantage #2
Another difficulty related to nutritional education is the ability for patients to apply new knowledge. The socioeconomic status of individuals determines how much money is budgeted for food purchase. Due to the low cost of many nutrient-deficient, energy-dense foods and the higher cost of fresh fruits and vegetables, the majority of persons in lower income families choose to purchase the cheaper, less nutritive foods. The study cited by Foster indicated that families were cutting down on the amount of healthy foods purchased because they could not afford them (2007). Simply having the education is not enough when implementation of that education is financially impractical.
Intervention #2
Nurses need to actively seed policy changes and program introductions in schools and communities to decrease childhood obesity.
Disadvantage #1
The media poses one of the biggest barriers to the nursing effort of combating childhood obesity. Television and other forms of food advertising represent the main culprit (Rollins, 2004). Companies are built and maintained based on revenue and advertising products ensures that people will be aware of their existence and look for them while shopping. This same concept applies to children who view the advertisements and consequently request those items while in the supermarket (Rollins, 2004). Decreasing the amount of time children are exposed to media advertisements and/or changing the content of the commercials to promote healthier food choices are policy options presented by public health experts to assist in the prevention of childhood obesity.
Disadvantage #2
Funding for policy changes and program introductions for schools and communities is essential, however, coming up with the money in any budget proves more difficult. These changes need to be permanently instituted in our schools and communities for longterm effectiveness. However, budgeting for these policy changes and programs proves very difficult. Any federal or state mandate targeted towards reducing childhood obesity by requiring nutrition and physical education in every school comes at the financial cost to the school districts (Hayne, Moran & Ford, 2004). Thus, creating obesity reduction programs is less of a dilemma then acquiring the financial means to support them.
References
Foster, M., (2007). Food Cost Influences Choices. The Skanner (Seattle Edition), 12(13), 1-3. Retrieved April 15, 2008 from Proquest database.
Hayne, C., Moran, P., & Ford, M., (2004). Regulating environments to reduce obesity. Journal or Public Health Policy, 25(3/4), 391-407. Retrieved April 15, 2008 from Proquest database.
Rollins, J., (2004). Kaiser Family Foundation releases report on role of media in childhood obesity. Pediatric Nursing 30(2), 165. Retrieved April 15, 2008 from Proquest database.
Stang, J. & Bayerl, C., (2003). Position of the American Dietetic Association: Child and adolescent food and nutrition programs. Journal of the American Dietetic Association, 103(7), 887-893. Retrieved April 15, 2008 from Proquest database.
Role of the Nurse Educator in Preventing Teenage Osteoporosis
The risk of osteoporosis among the teenage population has become a major health concern because of the high intake of carbonated beverages and the low consumption of dairy products such as milk. Soft drink consumption by teenagers is twice the consumption of milk. In addition to the already unhealthy high sugar content, these beverages increase the excretion of calcium in a calcium depleted diet. Therefore, the nurse plays a pivotal role in educating the teenage population about the risks and consequences associated with the unhealthy intake of carbonated beverages. Strategies the nurse should implement in osteoporosis prevention include teenage education regarding prevention and early detection, positive role modeling, and self-care implementation, specifically, diet and exercise.
The high levels of sugar contained in some carbonated beverages increase excretion of calcium through homeostatic processing. Teenage boys and girls alike consume twice as many soft drinks as compared to milk and research indicates that this trend is contributing to an earlier onset of teenage osteoporosis (Hightower, 2000). When reduction in bone mass is sufficient to compromise normal function, osteoporosis develops (Martini, 2006). As the human body ages, it naturally loses bone thickness and strength. Usually, osteoporosis is detected between the ages of 30 and 40 and affects women sooner than men; however, due to lack of proper diet and education, the disease is progressing at an alarming rate among teenagers. When education is absent or delayed, the nurse misses the opportunity to prevent the next generation from developing osteoporosis.
Teenage education regarding prevention, early detection, and self-care should focus on well-balanced diets and well-planned exercise regimes. Prevention includes reducing sugar and caloric intake, encouraging water to quench thirst instead of soft drinks, and going to the gym instead of playing video games. In order to effectively present this educational strategy at the local public school, the nurse educator could include visual aids provided by the National Dairy Council. Prior to the nurse’s presentation to the class of teenage students, the nurse educator should first analyze the dietary profile of one of the students in the class (Borchardt, 2000; Hunt, 1998). This preparation by the nurse is a good strategy to get the students more involved. An important goal of the presentation is to educate the teenagers on the importance of the proper intake of calcium and vitamin D through healthy food choices because unhealthy diets leave the adolescent at a much higher risk for osteoporosis later in life. Exercise that promotes bone strength, such as weightlifting, must also be emphasized and encouraged.
Positive role modeling is an important aspect of the educational strategy. This can be achieved by the individual nurse being fit and healthy himself. According to Bandura’s Social Learning Model described by (Borchardt 2000), individuals learn by observation. In the same way children learn from observing their parents, the teenager can learn from positive role models to become an agent of his own care. Role modeling is not a responsibility of the nurse alone, but rather involves all those who have an impact on the adolescent. This includes the parent who carefully plans meals, the physical education teacher who encourages the students to be fit, or the nurse educator who is passionate about the prevention of this disease. When a student displays interest, enthusiasm, and ownership as a result of positive role modeling, his motivation is increased and he is much more likely to participate and remain compliant with healthy expectations (Fitzgerald, 2003).
The American teenagers’ eating and exercise behaviors are not the only obstacles in this silent disease (Berarducci, 2004). One of the most difficult hurdles to overcome for the teenagers is the commercialization of carbonated beverages, fast foods, and candy bars. This pressure has enormous impact. For example, grocery stores are set-up for the compulsive shopper with candy bars and soda pops strategically close to the checkout line. It is through education that teenagers can begin to recognize these influences and question their eating and exercise habits. Information can be provided for teens and their families on self-care in brochures and pamphlets given during the presentation. This should include information on free or sliding scale clinics where providers evaluate clients, and the nurse offers educational sessions regarding healthy diets and exercise classes (Hightower, 2000; Curry, Hogstel, Davis & Frable, 2002). The consequences of having a poor diet and exercise routine must be honestly and thoroughly presented so that teenagers do not remain unconcerned or defenseless in the face of this disease and its long term effects on their health.
Osteoporosis due to poor diet and insufficient exercise is a preventable disease. The staggering increase in consumption of carbonated beverages and the decreased consumption of calcium have caused a rise in the incidence of osteoporosis in the teenage population. Education is crucial for teenagers if they are to develop healthy habits to reverse this trend. When the nurse encourages osteoporosis-preventative behaviors and promotes healthy lifestyle strategies, prevention of osteoporosis is the focus. This is much preferable to coping with the long term consequences of this disease. Prevention through education is best accomplished by a well-educated, healthy and fit nurse who really wants to see the teenage population improve their diet and exercise habits so they can live longer and healthier lives.
Role of the Nurse Educator in Preventing Teenage Osteoporosis
Intervention #1
Teenage education regarding prevention and early detection of osteoporosis.
Disadvantage #1
Because osteoporosis is a pediatric disease with geriatric consequences, failure to educate the teenage population is a disadvantage. This disease is silent and remains dormant for several years with no signs or symptoms until a disabling fracture occurs. “The key to prevention of osteoporosis is early detection and prevention within the vulnerable, at-risk population” (Hunt, 1998 p. 56). Health promotion has always been an integral part of nursing, and has become increasingly important. In fact, most state Nursing Practice Acts mandate patient education. Since osteoporosis develops during adolescence, the nurse needs to target this age group at the public schools with aggressive presentations in the classrooms. Without education about the risk factors and prevention of osteoporosis to this vulnerable population now, the next generation has acquired the disease, increased the risk, and the window of opportunity to prevent this debilitating disease has closed.
Disadvantage #2
The nurse educator who is compassionate about his/her desire to help prevent teenage osteoporosis should take the prime opportunity and major responsibility to initiate osteoporosis prevention education. The education must emphasize health promotion and disease preventions, not on treating the disease. “It is imperative that nurses possess the required knowledge base and resources to adequately provide instruction to healthcare consumers in an effort to promote wellness, manage illness, and prevent disease” (Beraducci,2004, p. 121). In addition, the nurse educator needs greater access to knowledge and information about the identifiable behaviors of those at risk for developing osteoporosis, and the pathogenesis of osteoporosis to be effective in their presentations at the public schools. If the nurse is not well educated the outcomes will be as debilitating as the disease.
Intervention #2
Self-care implementation, specifically, diet and exercise.
Disadvantage #1
Positive role modeling is an important and effective aspect of the educational strategy. The reflection of the nurse’s personal values will impact the teenagers, and help pave the way for. When the nurse educator’s lifestyle cannot be viewed as healthy, the teaching opportunity has lost its effectiveness. “Awareness of one’s self-care patterns, and implementing strategies to maintain or change these patterns, can be an important step in helping others achieve a high level of wellness” (Borchardt, 2000, p. 30). By taking the leading role in delivering healthcare messages, the nurse educator needs to view him/her self as healthy, or more importantly, the classroom full of teenagers needs to have that perspective of the nurse. When the nurse instructs about the importance of the combination of diet and exercise, the nurse needs to be that healthy living example. “We as nurses and health educators are expected to provide good examples of healthy lifestyles” (Borchardt, 2000, p. 30). When the nurse is viewed as unhealthy through the eyes of the students, the opportunity to promote wellness has been lost.
Disadvantage #2
Lifestyles and diet are closely related. The selection of food is heavily influenced by one’s socioeconomic status. The foods of choice are usually cheap, energy-dense, and nutrient poor. These choices have adverse effects on the growth of the child. There is a great deal of evidence compiled that shows that childhood socioeconomic status contributes to disease later in life, such as osteoporosis (Caballero, 2005). “A growing body of evidence shows that childhood socioeconomic status (SES) is predictive of disease risk in later life, with those from the most disadvantaged backgrounds more likely to experience poor adult-health outcomes” (Lukar, 2007, p. 137). Nutrients, like calcium, in the teenager’s diet will help prevent osteoporosis. Because of cost, carbonated beverages are being purchased instead of dairy products, contributing to the calcium-deficient teenager. The insufficient consumption of calcium in the adolescent diet is leaving them predisposed to osteoporosis. It has been determined that socioeconomic status affects lifestyles, and lifestyles affect diets (Hightower, 2000).
References
Berarducci, A. (2004,Mar-Apr). Osteoporosis education: Orthopedic Nursing. 23(2), 118-127. Retrieved May 15, 2007 from Proquest database.
Borchardt, G. L. (2000,Jul-Sep). Role models for health promotion: The challenges for nurses. Nursing Forum. 35(3), 29. Retrieved April 10, 2007 from Proquest database.
Curry, L. C., Hogstel, M. O., Davis, G. C., & Frable, P. J. (2002). Population-based osteoporosis education for older women. Public Health Nursing. 19(6), 460-469. Retrieved January 10, 2007 from Proquest database.
Fitzgerald, K. (2003). Nurse as Educator: Principles of Teaching and Learning for Nursing Practice (2nd ed., pp. 371-372). Boston: Jones & Bartlett.
Hightower, L. (2000,Sept-Oct). Osteoporosis: Pediatric disease with geriatric consequences. Orthopaedic Nursing. 19(5), 59-62. Retrieved April 17, 2007 from Proquest database.
Hunt, A. H. (1998,Nov-Dec). Assessment of learning needs of registered nurses for osteoporosis education. [Electronic version]. Orthopedic Nursing, 17(6), 55-60.
Martini, F. H. (2006). Fundamentals of anatomy and physiology. San Francisco: Pearson
Caballero, B. (2005, April). A Nutrition paradox – underweight and obesity in developing countries. The New England Journal of Medicine 352(15), 1514-1517. Retrieved July 16, 2007, from Proquest Database.
Hamil-Lukar, J. & O’Rand, A. (2007, February). Gender differences in the link between childhood socioeconomic conditions and heart attack risk in adulthood. Demography 44(1), 137-148. Retrieved July 16, 2007, from Proquest Database.
The Self-Harm Patient: The Need for Change in the Nursing Approach
Self-harm, self-mutilation, or self-injury, the behavior is becoming more prevalent in society, especially among women. This maladaptive coping skill is helping distressed patients to overcome the immediate emotional pain but leaves them physically and emotionally scarred in the long-term. The requirements of female patients with maladaptive coping skills have changed the nurses’ approach and care plan. Nurses must advocate for both physical and psychological treatment to better serve these patients. Other significant changes would be the adaptation of a psychosocial identification system and an out-patient follow-up program.
From the general population of people seeking medical attention, it is “estimated that one in 600 adults self-harm and require hospital treatment.” (Rayner & Warner, 2003). The behavior predominately manifests in female patients in their mid-teens to mid-twenties but can do so at any age. The behaviors breach social class lines and affects people with varying types of support systems. Judith Reece (2005), best describes the behavior;
As a radical response to feelings of total powerlessness and loss of self, a symbolic resistance to the power structures found within society which negates and silences women. (p. 564)
According to Gillian Rayner & Sam Werner (2003), the ratio of injury is 2:1 compared to the male counterparts within the same age range. (p. 306). Patients most commonly use overdose and cutting for self-mutilation. (Tanner, 2007). Whichever method is utilized it causes a rush of endorphins and initiates the pain response sensation to distract them from emotional duress.
The first contact patients receive from medical staff often sets the tone for the entire treatment. Judith Reece (2005) explains that “what the self-injuring woman appears to need is simply to be accepted, and more importantly listened to.”(p. 568). Self-harm patients already feel the stigma from society both with regard to their mental health level and their behavior. They are often ashamed of what they are doing, but feel cutting (or other chosen behavior) is their only option. Nurses must curtail the feelings they have about the behavior. They must involve themselves with the patients in order to gain acceptance within the eyes of the patient. The relationship building process will help the patient to be more willing to participate in care and further future care relationships, such as emotional/mental therapy. The relationship may seem to be easily attainable for the nurse. However it has shown to be a large contributing factor for care refusal, second to the lack of understanding of the behavior in general. According to Gill Tanner (2007) “the prevalence of misinformation about patients who self harm can lead for example to staff withholding analgesia, local anaesthesia or treatment from them.” (p. 21). Nurses are often working with large numbers of patients and may feel overwhelmed. “Advocacy is important to patients, particularly those with mental health problems who are often marginalized or even dismissed as timewasters.” (Tanner, 2007)
Nurses must advocate for multiple avenues of treatment. Treatment should not stop with mere physical treatment of the exterior wounds. The nurse should refer the patient to psychiatric services and be part of the care to assist the patient in a more positive exchange. This would further the relationship the nurse would gain with the patient; inhibiting the patient from internally regressing and negating further treatment options.
Patients with habitual self-harming behavior have an increased response to care when self-harm care principals are initiated rather than suicide watch. (Cook, Clancy & Sanderson, 2004). To better categorize patients, a “psychosocial risk assessment” should be done. (Cook, Clancy & Sanderson, 2004). The assessment would include negotiation of risk factors: age, gender, race, social status and history, health history, substance usage, level of stress and coping strategies. (Cook, Clancy & Sanderson, 2004). Along with this information, the nurse should take into account the means by which care was sought, the current presentation of the patient, the patients regard to the behavior, their mental health and their social situation. (Cook, Clancy & Sanderson, 2004) The assessment would allow a better understanding of the current emotional stance of the patient. The assessment would allow the nurse to separate the habitual self-harm patients from those at risk of suicide. This would allow the nurse to practice the self-harm principles; privacy, confidentiality, note taking, resources and the patient perspective (Cook, Clancy & Sanderson, 2004). The patient would most benefit from a private room, allowing a less stressful environment and one-on-one treatment. Confidentiality, note taking, resources/education are nursing standards. However the final principle of patient perspective is the most difficult. It requires the nurse to step back from the caring and into the understanding. This requires the nurse “recognizing that stopping may not be a desired goal.” (Cook, Clancy & Sanderson, 2004). Empathy becomes the greatest tool the nurse has to assists with the needs of the patient. This may be a directive for specially trained staff, which should involve both psychiatric and medical treatment.
The biggest deficit for self-harm patients is care outside the hospital. A program allowing for home-health visits for these patients in an out-patient follow-up program needs to be initiated. This care can and should be done by nursing staff specially trained and under the directive of a psychiatrist. This would allow for the continued building of the relationship begun during medical treatment and would give these patients stability in care. These visits would allow the patients continued success in governing their feelings and have the added ability for medical staffing to see changes within the patients. The programs should include the social network of the individual, teaching them what to do to be supportive and to help them with their own feelings. The nurse would teach the support network these guidelines from Dr. Gibson (2007) from the National Center for PTSD:
- Take the self-harm seriously by expressing concern and encouraging the individual to seek professional help.
- Don’t get into a power struggle with the individual-ultimately they need to make the choice to stop the behavior. You cannot force them to stop.
- Don’t blame yourself. The individual who is self-harming initiated this behavior and needs to take responsibility for stopping it.
- If the individual who is self-harming is a child or adolescent, make sure the parent or a trusted adult has been informed and is seeking professional help for them.
Suicide is most often a spontaneous event. With these programs in place, the rate of suicide could dramatically be affected. Helping these patients manage their feelings more effectively diminishes the chances of high stress spontaneous harmful behavior. With these adaptations to the nursing approach and plan of care, self-harm patients would be more successfully co-operative during in-house care. Out-patient care programs would allow ultimately for decreased care of these patients by hospital staff, freeing the staff to assist other patients and freeing the patients of the maladaptive coping behavior.
References
Cook, SH., Clancy, C., & Sanderson, S. (2004). Self-harm and suicide: care, interventions and policy. [Electronic Version] Nursing Standard, 18(43), 43-52, 54. Retrieved January 25, 2008 from CINAHL database (2004164849).
Gibson, L. (2007, May) Self-Harm. Retrieved February 2, 2008 from http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_self_harm.html
Kirby, J. (2006, April). Nurses want to help self-harm patients. Retrieved February 2, 2008 from http://icbirmingham.icnetwork.co.uk/0100news/0100localnews/tm_objectid=16994348&method=full&siteid=50002&headline=nurses-want-to-help-self-harm-patients-name_page.html
Rayner, G. & Warner, S. (2003). Self-harming behaviour: from lay perceptions to clinical practice. [Electronic Version] Counseling Psychology Quarterly, 16(4), 305-329. Retrieved January 25, 2008 from CINAHL database (2004137871).
Reece, J. (2005). The language of cutting: initial reflections on a study of the experiences of self-injury in a group of women and nurses. [Electronic Version] Issues in Mental Health Nursing, 26, 561-574. Retrieved January 25, 2008 from CINAHL database (2009003979).
Tanner, G. (2007). Managing wounds in patients who self harm. [Electronic Version] Emergency Nurse, 15(6) 20-25. Retrieved January 23, 2008 from CINAHL database (2009694673).
ADDED INTERVENTIONS:
The Self-Harm Patient:
Interventions in Nursing
Self-harm, the behavior is becoming more prevalent in society, especially among women. This maladaptive coping skill is helping distressed patients to overcome the immediate emotional pain but leaves them physically and emotionally scarred in the long-term. Direct nursing interventions to decrease the likelihood of repetition of the behavior should include special observation and an out-patient follow-up program.
Special observation, also called one-to-one care of the patient will disable the ability for repetition of the behavior. This care will enable the staff to be present with the patient to increase the possibility of a cooperative relationship between the patient and the nurse. This would further allow the skilled nurse the ability to initiate the risk assessment and manage the patient as needed.
Disadvantages to this nursing intervention are infantilizing (Bowers, 2007) of the patient and a discrimination factor concerning patient stereotyping. According to Bowers (2007), “use of special observation has been portrayed as impersonal guard duty, infantilizing, disliked by patients, directed primarily at protection of the organization from scandal.” (p. 13) Scandal resulting when the patient repeats the self harm while in nursing care. The patient often feels confined by this special observation and refuses to partake in activity. Bowers (2007), claims that intermittent observation works better for the nurses and the patients, allowing the nurses to be “more accessible and visible to patients,” providing “greater reassurance and security” without treating the patient as a prisoner. Research has found that “patients appreciated staff efforts to keep them safe” with intermittent regular checks and was “found to be more cost-effective than other safety measures.” (Mental Health Practices, 2007)
Nurses assessing patients can be considered at risk for discriminating against the patients whom self-harm. The risk assessment performed provides the nurses information on which they base the plan of care. However with self-harm psychiatric patients this can increase the likelihood of discrimination. Patients who are considered repeat harmers may automatically be considered for special observation even if they are being seen for an unrelated problem. Care issues or lack there of, can also lead to a view of discrimination. Self-harm patients “are perceived as difficult to deal with.” (Cook, 2004) This has lead to staffing attitudes of the patients being unworthy of treatment, and “many self-harming patients find themselves ignored by health and social care professionals.” (Cook, 2004)
The biggest need for self-harm patients is follow-up care to reduce the repetition of the behavior. An out-patient follow-up program allowing for home-health visits for self-harm patients by specially trained nursing staff and under the directive of a psychiatrist can decrease the number of visits to seek care due to the behavior. This would allow for continued building of the relationship begun during in-patient medical treatment and would give these patients stability in care. These visits would allow the patients continued success in governing their feelings and have the added ability for medical staffing to assess changes within the patients.
Cost and inadequate significance in the reduction in number of repeat hospitalizations is a large disadvantage of this intervention. Cost is a huge factor for patients in seeking care. Although a follow-up program may be advantageous to the patient, the cost may be the largest barrier. Patients may have inadequate insurance that will either not cover home-health visits or only cover part of the cost, leaving the remainder of the cost to be put on an already strained health-care system. One review by Burns (2005) showed that group therapy offered a considerable advantage over standard aftercare. (p. 126) Group therapy is often covered for a set amount of visits, allowing the patient to be free of the cost.
Burns (2005), also shows following a three-year follow-up program, hospitalizations were down 16% in a set experimental group. (p.124). This number may not be considered beneficial over the cost of the program in relation to the money saved in emergency room and hospitalizations. In the program 147 patients were studied. (p.124). This means that only 23 patients did not repeat the behavior seeking further care. This can be taken in multiple ways, either the patients did not re-harm significantly enough to induce need for further care or there behavior indeed was reduced or stopped altogether. A significant amount of study into this area would need to be followed in order to see the true cost benefit.
In all it seems that the best benefit for the patient and the most cost effective would be to have special observation under intermittent conditions. This would maximize the ability of the nurse to care for multiple patients and still monitor the patient in need providing safety and security. This would also maximize the cost of the observation, as a one-to one- staffing can get costly and create an even bigger nursing shortage. A follow-up program still seems like a plausible means, but more research into the effectiveness would need to be reached in order to gauge the cost effectiveness and the increase in patient outcomes.
References
Bowers, L. & Simpson, A. (2007, July). Observing and engaging. Mental Health Practice, 10(10), 12-14. Retrieved May 5, 2008 from CINAHL database (2009625320).
Burns, J., Dudley, M., Hazell, P., & Patton, G. (2005, March) Clinical management of deliberate self-harm in young people: the need for evidence-based approaches to reduce repetition. Australian & New Zealand Journal of Psychiatry, 39(3), 121-128. Retrieved May 5, 2008 from CINAHL database (2005125726).
Cook, SH., Clancy, C., & Sanderson, S. (2004). Self-harm and suicide: care, interventions and policy. Nursing Standard, 18(43), 43-52, 54. Retrieved January 25, 2008 from CINAHL database (2004164849).
Nurse-led study finds that regular checks reduce self harm. (2007, June) Mental Health Practice, 10(9), 4. Retrieved May 5, 2008 from CINAHL database (2009598980).
