J.Adderton

For individuals diagnosed with AFib, the risk of stroke is very real. In fact, a person with Afib is 5x more likely to suffer a stroke than someone with a regular heart rhythm. In order to order to understand how the implant works, you must first be familiar with the basics of Afib. In Afib, the heart’s atria flutter and send erradic electrical signal to the ventricles. As a result, blood pools and clots in the heart’s left atrial appendage (LAA). In non-valvular Afib, more than 90% of blood clots resulting in a stroke are formed in the LAA. A stroke occurs when these clots travel to the brain and prevent adequate blood flow. Afib is more common after age 50 and often occurs without symptoms. Watch an animation of Afib from the American Heart Association The goal of Afib treatment is to prevent clots from forming, control pulse rate and restore normal heart rhythm. Anticoagulants (warfarin, others) are given to prevent blood clots and reduce the risk of stroke. There are individuals that require blood thinners long-term. The risk of bleeding is higher when taking blood thinners. The Watchman implant is an alternative to long-term anticoagulant therapy for stroke prevention when the risk of bleeding outweighs the medication’s benefit. The WATCHMAN device is for people meeting the following criteria: Diagnosed with Afib not caused by a heart valve problem Diagnosed with Afib and physician is recommending blood thinners Are able to take warfarin but need an alternative ***Individuals may need an alternative to warfarin for the following: History of serious bleeding while taking blood thinners Are at risk for major bleeding to due lifestyle, occupation or physical condition Take warfarin but have difficulty maintaining therapeutic PT/INR, have difficulty getting regular blood tests or cannot take a different type of anticoagulant The WATCHMAN device is not for patients: Who are unable to take warfarin, aspirin or clopidogrel Who should not or cannot have a heart catheterization Allergic to the device materials With a LAA that is too large or small for the device to fit appropriately Doing well and expect to continue doing well on anticoagulants. "Ed is a 74-year-old patient with a long history of Afib. Over the years, Ed has undergone multiple cardioversions and cardiac ablations. Due to Ed’s high stroke risk, he was placed on warfarin and has been taking for several years. Ed has had multiple falls and remains a high fall risk secondary to vertigo. When Ed visits his cardiologist, he expresses fear of causing a major bleed because of his falls. However, he wants to continue to be active with his grandchildren and occasionally golf. The cardiologist explains the WATCHMAN procedure to Ed as an alternative to warfarin." How It Works The actual Watchman implant is about the size of a quarter and fits directly into the LAA. The implant permanently closes the LAA- preventing clots from leaving the heart and entering into the bloodstream. Since the implant is permanent, placed once and does not have to be replaced. The Watchman procedure is minimally invasive and typically performed in a heart catheterization lab. The procedure is monitored by the medical team and utilizes imaging to visually guide the device in place. A thin catheter is inserted through a vein in the groin and guided into the heart’s right atrium. A second puncture is made in the muscle wall between the right and left atrium. The catheter is then advanced into the left atrium. The physician uses imaging to advance a smaller inner catheter, with the compressed device enclosed, into the LAA. Once the implant is in the right place, the implant will open- much like an umbrella. Within 45 days, a thin layer of tissue will grow over the implant. Always a Risk Any medical procedure carries risks and the Watchman is no exception. Review common risks here. Clinical Studies and Evidence The Food and Drug Administration approved the Watchman implant in 2016 based on long-term data from clinical trials. The trials ( PREVAIL study, PROTECT AF study and CAP Registry) included over 2400 patients and >8000 patient-years of follow-up. Data from the trials supporting FDA approval include: Device successfully implanted in 95% of patients 45 days after implantation, 92% of patients were no longer taking blood thinners >99% were no longer taking blood thinners by 1 year Significant decrease in disabling and fatal strokes (largely due to the reduction in hemorrhagic stroke) Demonstrated similar ischemic stroke reduction when compared to warfarin Reduced major bleeding events vs warfarin by 72% at 6 months In addition to clinical trials, the Watchman procedure has been performed over 20,000 times worldwide. It is the only device of its kind approved by the U.S. Food and Drug Administration. What new and emerging advances in stroke prevention have you seen in your area of practice? For additional information, visit www.watchman.com

I think the reaction is tied to your short monitoring period.

If you have ever cared for a patient with shingles, you probably hope you never have the shingles experience- intense itching and pain. Unfortunately, according to the Center for Disease Control (CDC), 1 in 3 people in the United States will be diagnosed with shingles. This is a surprising 1 million cases diagnosed each year. Shingles, also known as herpes zoster, is caused by the varicella zoster virus- the same virus that causes chickenpox. Those at greater risk for shingles include the following individuals: With medical conditions that weaken the immune system Receiving immunosuppressive medications Over the age of 50 Recent illness or trauma Under stress Despite the high rate of occurrence, there are still common myths and misconceptions associated with shingles. Do you still believe any of these myths? Myth #1: It is all about the rash. Fact: The shingles rash is usually a group of small blisters that eventually dry and scab over in about a month. This itchy rash is one of the tell-tale characteristics of shingles but pain often causes the most discomfort. The pain can be severe and may occur as early as 2 to 4 days before the rash. Unfortunately, the nerve pain caused by shingles can also continue long after the rash disappears. Myth #2: Shingles only occur on one side of the back. Fact: It is true shingles often occur on one side of the body, is linear and follows a nerve pathway (dermatome). However, shingles can occur anywhere on the body, including eyes and ears. Approximately 2% of cases are disseminated (shingles on both sides of the body) and occur along multiple dermatomes. Myth #3: Only older adults get shingles. Fact: It is true that as you age, your risk of shingles increases and about 50% of shingle cases are in the over 60 age group. However, shingles can occur in anyone at any age. Individuals with compromised immune systems, due to illness, medications, trauma or stress, are at greater risk. MYTH #4: Shingles and Chickenpox are the same disease. Fact: Shingles is caused by varicella zoster- the same virus that causes chickenpox. However, shingles and chickenpox are not the same illness. Here are key differences: Chickenpox is milder and usually affects children under 10 years of age Once you have chickenpox, the varicella zoster virus lies dormant in the body. People get shingles when varicella zoster is reactivated in the body. Shingles is not spread from person to person. However, if someone has not had chickenpox (or the chickenpox vaccine) they can contract chickenpox from direct contact with fluid from shingle blisters. Myth #5: There is no treatment for shingles, you just have to suffer through it. Fact: It is possible to reduce the severity of shingles by starting antivirals (acyclovir, famciclovir and valacyclovir) within the first three days of an outbreak. The nerve pain associated with shingles can be treated at early onset and with persistent nerve pain after the outbreak has resolved. Treatment to treat pain may include: Topical capsaicin and numbing agents (i.e. lidocaine) Corticoid steroids Oral analgesic and narcotics Anticonvulsants Tricyclic antidepressants Myth #6: There is nothing you can do to avoid the shingles. Fact: Two vaccinations against shingles are currently available- Shingrix and Zostavax. Zostavax has been used since 2006 and is a live vaccine. The newer Shingrix (a recombinant zoster vaccine) is recommended over Zostavax by the Center for Disease Control. The CDC recommends healthy adults, 50 years or older, receive Shingrix in two doses, separated by 2 to 6 months. Shingrix has proven to be up to 90% effective in preventing shingles compared to Zostavax 65% effectiveness rate. Shingrix is available to individuals who have had shingles or have received Zostavax in the past. Studies have shown 99% of individuals over the age of 50 have had chickenpox and Shingrix is recommended even if you don’t remember having chickenpox. **Note: Zostavax may still be given to individuals that prefer Zostavax, are allergic to Shingrix or prefer vaccination with only one injection. Prevention of Complications The shingles vaccine is the only way to prevent shingles and the complications of shingles. The most common complication is a condition called postherpetic neuralgia (PHN). People with PHN have severe pain in the areas where they had the shingles rash, even after the rash clears up. The pain from PHN may be severe and debilitating, but it usually resolves in a few weeks or months. Some people can have pain from PHN for years and it can interfere with daily life. About 10 to 13% of people who get shingles will experience PHN, although it is rare among people under 40 years of age. Shingles may also lead to serious complications involving the eye such as vision loss. Although rare, shingles can also lead to pneumonia, hearing problems, blindness, brain inflammation (encephalitis), or death. What are your thoughts on the shingles vaccine? Has your geographical area experienced shortages of the vaccination? For additional Information: Center for Disease Control, Shingles Vaccine: What You Should Know

As a nurse, it is likely you have found (or will find) a niche or specialty and keep up with pertinent news in your area of practice. I enjoy stepping outside of my “box” to catch up on medical news outside of my specialty. The world of healthcare changes everyday and it is impossible to touch on all that has occurred during the year However, let’s look at a few updates and raise awareness about what is happening in our communities. The Opioid Crisis: Progress, Kratom and Dsuvia The opioid crisis continues to evolve daily, but 2018 did show signs of progress. The Health and Human Services Secretary announced that deaths related to opioid misuse plateaued during 2018. Youth opioid misuse had declined over the past decade. Other significant news: - In October, the Senate passed a bipartisan opioid package aimed at combating the opioid crisis. The package will give the U.S. Food and Drug Administration authority to require specific product packaging for opioids. The legislation will also promote research to identify non-addictive medication alternatives for treating pain. The legislation will help stop the flow of illegal drugs coming into the U.S. through the “STOP ACT”. - The FDA identified kratom, a popular over the counter herbal supplement, as an opioid and warned of risk associated with kratom ingredients. - The FDA approved the powerful opioid Dsuvia, made by AcelRX Pharmaceuticals. Dsuvia has an opioid potency 5-10% higher than fentanyl. Because of abuse and addiction risks, the drug is recommended for individuals who have not benefit and/or tolerated other pain management options. Read the FDA statement on the approval of Dsuvia Steep Increase in Sexually Transmitted Diseases STDs have reached an all-time high with 200,000 more reportables than occurred in 2016. The increased occurrence of gonorrhea and syphilis stand out: Gonorrhea rates increased by 67% Syphilis rates doubled Young individuals are the most vulnerable Review the CDC's 2017 STD Surveillance Data here The cause behind the increased incident in STDs is multifactorial. Local, state and federal funds have been cut, reducing the budget for STD prevention. Sexual behaviors of gay men have changed over the past decade and correlates with an increase in syphilis rates. This increase correlates with improved HIV treatments and the perceiption of less risk. A Severe and Deadly Flu Season: According to the CDC’s Summary of the 2017-2018 Influenza Season, 2017-2018 flu season recorded influenza like illnesses (ILI) occurring at the highest percentage since 2009. For 19 consecutive weeks, the rate of ILI was as high as the peak of 2009’s H1N1 pandemic. As of October, 2018, 185 children died during the 2017-2018 season. This is the highest number of flu related child deaths in any other regular flu season. In 80% ofchild deaths, a flu vaccination was not received. Read the full CDC Summary here. Hurricane Maria and Drug Shortages On September 20, 2017, hurricane Maria slammed into Puerto Rico, causing devastating damages to homes and infrastructures. Puerto Rico manufactures approximately 40 drugs (approximately 10% of U.S. supply) for shipment to the U.S. In 2018, the medical community continued dealing with the effects of Hurricane Maria. The most significant shortages are linked to IV saline, levothyroxine and amino acids. Consumers experienced an increase in price for levothyroxine post Hurricane Maria. Virtual Check-Ins a Medicare Reality Beginning January 1, 2019, Medicare will cover virtual care services. In 2018, the Center for Medicare Services published the final rule for the physician fee schedule. Providers will be able to use real time telephone interactions, as well as, audio with video. Virtual check-ins will allow physicians to provide management and evaluation services to an established patient. Read 10 FAQs on This New Service 2018 Nobel Prize for Medicine Goes To…. James P. Allison from the U.S. and Tasuku Honjo from Japan are the recipients of the 2018 Nobel Prize for Medicine for advances in discovering how the immune system can be used to fight cancer. Their work includes work to understand how proteins can act as a brake system on the body’s immune system. Read Press Release Here It is impossible to touch on all the news worthy medical advances in 2018 in this article. However, I would enjoy reading the advancements, changes or challenges that stand out to you. Take a minute to add your reflection in the comment section.

A great follow up article topic would be concierge services as above. Thanks!

I enjoyed reading your perception and experience living in Australia.

Thanks for the suggestions. I look back and as a new nurse, I did not have the "tools" experience brings to not take the behaviors of VIP personally.

Have you ever been given a patient assignment and hear the words "You have a VIP"? I cringe when I am assigned the Very Important Patient (VIP)- a.k.a. Very Influential and Very Intimidating Patient. My resentment begins to bubble over and I find it offensive that I am expected to treat one patient "better" than another. I also resent the additional pressure from my supervisor, administration and the VIP. I have never cared for a famous celebrity, but I have witnessed the effects of VIP syndrome when caring for local politicians, CEOs, influential and local celebrities. Although nurses do care for high profile celebrities, this article will focus on the more frequently occurring local VIPs. What makes an individual a VIP? Any patient whose status has the potential to influence the judgment and care of healthcare providers is a VIP patient. The first VIP image to pop into my mind is the national celebrity. However, this article will focus more on VIP status due to occupation, position or social status. Common VIPs may include hospital administrators, physicians, local athletes and any patient with influence. The ethical and moral issues surrounding the care of a VIP is often referred to as "VIP Syndrome" and results in care that can be of greater or lesser quality. Let's take a closer look at common ethical issues that surface when treating a VIP. Social Justice The principle of social justice implies patients will be treated fairly and with equal distribution of access to care and resources. Providing preferential treatment is often a difficult, if not impossible, pill for a nurse to swallow. V.I.P. treatment deviates from the nursing code of ethics of approaching all patients with the same level of attention and care regardless of social status. VIP Syndrome challenges the principle of social justice by resulting in greater access, attention and resources from healthcare providers, including nurses. Examples include: Schedules adjusted to accommodate physician appointments, consults, diagnostics and treatment Decreased waiting times (MD office, emergency department, hospital call light) Access to additional resources (diagnostics, specialists, equipment, transportation) When providing VIP treatment, the healthcare team often steers away from standard practices, protocols, policies and procedures. Therefore, care surrounding the VIP often becomes chaotic and pulls resources away from other patients. Autonomy Autonomy is the right patients have to make informed decisions about their medical care independently without the healthcare provider attempting to influence their decisions. Therefore, patients have the right to receive clear information and education regarding care so that an informed decision can be made. Let's look at a case study: Mr. Jones is a well-known local meteorologist on a popular morning news program. Mr. Jones fell at home and presents to the emergency department with a broken femur. The triage nurse notes a strong odor of alcohol from the patient. The nurse does not want to embarrass Mr. Jones, therefore, does not complete a thorough history or physical. The physician, not wanting to upset the patient, does not determine if alcohol was a contributing factor in the fall. The patient is impatient and to avoid inconvenience, minimal lab work is ordered. In this scenario, only a limited patient history and assessment is performed to avoid inconveniencing the patient. The VIP will be asked to make decision regarding treatment, but does not have the benefit of a thorough assessment. The patient's drinking habits are not explored,therefore, the patient will not have the opportunity to make decisions on participating in an alcohol protocol. Healthcare providers often deviate from standard practices and protocols. Breaking rules when treating VIPs occurs when staff do not want to inconvenience, cause anxiety or tell the patient (or family) "no". This deviation places the VIP at risk for lower care quality and substandard outcomes (Alfandre, 2017) Privacy Privacy often becomes an issue for VIP patients. In my career, I have been tempted to share details a VIP's situation and had to make a conscience effort to maintain confidentiality. Staff may bend rules safeguarding privacy and share details of the VIPs situation to other staff or individuals outside of the hospital. To protect privacy, high profile patients may be moved to a more secure area of the hospital. Tips for Care of the VIP In 2011, The Cleveland Clinic published "Caring for VIPs: Nine Principles" to address the challenges of VIPs. Although the principles are geared towards physicians, the article provides several "takeaways" for nurses. Do not bend rules. Provide care with effective clinical judgement and practices congruent with standards of practice and the institution's policies and procedures. Work as an interdisciplinary team and communicate frequently. Avoid assigning only certain nurses to care for the VIP. This will help to maintain the usual flow of care. Always protect the patient's confidentiality and follow your institutions policies and procedures regarding communication with media. Be careful about accepting or declining gifts. Speak with a supervisor if questions regarding gifts. Caring for VIPs brings the potential of ethical dilemmas to healthcare providers. Being aware of common challenges will help to reduce pressure and frustration when assigned a VIP. What challenges have you personally experienced? What tips would you like to share with readers? Supporting Literature: David Alfandre et at. Caring for "Very Important Patients" -Ethical Dilemmas and Suggestions for Practical Management. Am J Med. 2016:129:143-147. Gusman et al. Caring for VIPs: Nine Principles. Cleve Clin J Med. 2011:78(2):90-94. Davis, M. Do You Know Who I Am? Treating a VIP Patient. BMJ 2016:358:i2857.

I took a 28,000 pay cut to teach nursing. I always maintained a "side gig"- for me it was PRN nsg where I taught clinicals. If you are out for summer, perhaps you could work PRN as financially needed.

Thanks for sharing... great insight. I agree, most use a combination of learning strategies.

Students accepted into nursing programs are successful learners and meet impressive admission criteria. Unfortunately, it is not uncommon to discover what has worked in other learning college courses seem ineffective in the strange new world of nursing school. Students start second guessing the learning and study strategies that brought them to this point. If this is your story, there is good news! Understanding your preferred learning style may ease your anxiety and pave the way for new study strategies. It is highly unlikely that faculty can teach to every student's preferred learning style. It is important that you, as the learner, adapt to your instructor's method of teaching. Being aware of your own learning style will ease the frustration of nursing school. Let's take a look at each learning type and strategies for success. Important note: Most students do not fit into just one category. Think outside of the box and discover a variety of strategies....it is all about what works for you. The Visual Learner Visual learners need to "see it first" in order to grasp new concepts. Students often want to see a new skill performed before they move forward. Other helpful tools may include graphs, charts, handouts, videos, written directions and step-by-step instructions. In Class Strategies Pay attention to nonverbal cues that signify important information during class (i.e. instructor body language, gestures, changes in voice volume). It is easier to pick up on your instructor's non-verbal cues if you sit in the front of class. Watch closely for information that is starred or unlined in the instructor's powerpoints, handouts and other teaching tools. Take detailed notes and make lists, charts or sketch images to use when studying. Use colorful highlighters to notate important information. Request in-class demonstration when appropriate. Participate in lab and take advantage of practicing skills during lab "down-time". Study Strategies Rewrite your notes and try using symbols or sketches to highlight important information Create your own visual study aids. Try using Prezi (Prezi.com) or powerpoint to present your notes. Be sure to use images, pictures and other visual aids. Use flashcards made with brief bits of important information for review. Create your own practice exam with potential question from the module materials. Schedule time outside of class to use checklists to practice skills in the lab. The Auditory Learner Auditory learners prefer to learn through listening and often use phrases such as, "tell me how", "talk me through it". Information is best retained when they can hear it first. They also benefit from videos, audiobooks and recordings. When reading, auditory learners can often be heard reading aloud to themselves. In Class Strategies Don't be afraid to ask questions in class. Ask your instructor if you can tape lectures for later review. Participate in class or lab discussion. Sit in the front of the room to hear lecture clearly. Study Strategies Find a place you can read text, read assignment instructions and study out loud. Rephrase your notes and information in your own words. Join a study group and discuss or talk through concepts out loud. Find a buddy to reteach concepts to each other. The Tactile or Kinesthetic Learner Tactile learners use touch (hands on) experiences to learn. These will be the students who enjoy learning in the lab and nursing clinicals. The hands on activity helps tactile learners to concentrate and retain information. These learners like to "jump right into" a learning activity without waiting for instructions and often volunteer to demonstrate or perform a new skill. In Class Strategies Take notes, but don't resist the urge to draw or doodle. Doodle activity actually improves concentration and memory in the tactile learner. When the class is asked, volunteer to demonstrate a skill or role play. Pay attention to nonverbal cues that signify important information during class (i.e. instructor body language, gestures, changes in voice volume). Study Strategies When studying, use your hands to gesture and emphasize key information Rewrite or type class notes in your own words Move around when studying and take frequent breaks. Participate in lab and take advantage of practicing skills during lab "down-time". Make flashcards and use them to play a game with a study buddy. The Mixed Learner Mixed learners are flexible and can benefit from strategies associated with other types. However, the mixed learner usually has a dominant learning style. When learning difficult concepts, mixed learners should use study strategies specific to their dominate type. Nursing school is tough and it is easy to become overwhelmed. Knowing and understanding your learning style will assist you in using the most effective class and study strategies. You can reduce your frustration by focusing on the behaviors and activities that will help you most. Additional Resources: Learning Styles: Columbia College Quick learning style questionnaire: VARK | a guide to learning preferences Florida State University Learning Style Tips

I taught PN program and absolutely not too old. You will bring life experiences that will contribute to your care. Good Luck!

I think it is highly unlikely that you, a good student, would completely and miserably bomb. I took many years ago- no such thing as PeasonVue and I cut off at 75...passed. Good luck

Thank you for sharing your story!

I think doing the 2500 nclex questions is great prep. Also, I wrote an allnurses article on the anatomy of NCLEX questions and you can read it here https://allnurses.com/nclex-discussion-forum/focus-on-students-1170195.html