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  1. SUSAN “Our problem child is back.” Ann whispered as I sat down at the nurses’ station to chart. “You mean Susan? I hope she’s okay, I’m worried about that girl.” I said. “Will you take her? I’m getting so sick and tired of dealing with these freshmen. I think most of the time they just miss home and want someone to talk to. I’m not in the mood to be mommy today.” I raised my eyebrows at Ann, thinking for the umpteenth time that she was really in the wrong business if she didn’t want to talk to students, but nodded affirmation. I reviewed Susan’s chart. This was her fourth visit in one month. She was an out of state student, here on scholarship. She had first come in just a few weeks after the semester had begun. She stated she had fallen in the stairwell after a dizzy spell and hit her head on the railing. I had seen her then and assessed her for a concussion, but she was asymptomatic, with no loss of consciousness, just a large lump on her forehead and a headache. I educated her about the signs and symptoms of concussion and brain injury and then asked if she had anyone she could check-in with in case symptoms did arise later. “Have you made a friend yet? Someone who checks up on you and vice versa?” She looked away and shook her head. I asked about her parents and she had expressed anxiety over being away from home for the first time. I asked her about the possibility of a visit home, or her parents visiting and she had looked sad and uncomfortable, saying, “I love my mom, I really miss her, but my dad, well it’s my stepdad actually, he and I just don’t get along.” Something about her pulled on my maternal heartstrings. She seemed so bedraggled and lost. She had shared that her father had died when she was quite young and her mother had remarried a few years ago. I encouraged her to call her mom, just for a chat and she had promised to think about it, though her parting words had worried me, “He wouldn’t like it.” I wanted to follow up on that statement, but the clinic was busy, and the PA was motioning to me to hurry up for a procedure and I had to let it go. She was coming back in a week for a follow-up and I made a note in her chart “ask about the home situation.” Unfortunately, when she returned the following week, I had been out sick, so I read through the chart and saw that she had stated “no problems” from the head injury. The nurse had charted a subjective note about a different problem - deja-vu. “It’s so weird. I know it’s silly, but I will be walking to class, or sitting and having lunch in the caf and I will just feel so strongly that I’ve been there before. It happens at least once a day.” A few weeks ago, she had returned complaining of a rapid heart rate and feelings of impending doom before taking a biology test, and that time it had been my day off. The PA had talked to her about test anxiety and referred her to a counselor. Ann documented education about meditation and calming techniques, but there was nothing about her home life. Her vital signs had all been within normal limits and there was nothing unusual about her health history. She was on no medications, no birth control, and had normal menstruation. I approached Ann to clarify, “did you talk to Susan about her home life, her social situation? I’m worried about her. Something’s off with this one.” “No, both times I saw her, the clinic was slammed. Honestly, she strikes me as a lonely, scared little girl who is homesick. I think it’s all in her head.” Ann had worked here a lot longer than me, and I wondered if I would become that jaded if I stayed. “It’s not just about physical health, Ann. I’d like to think we are here for mental health, spiritual health, all of those things.” I replied, deciding that advocating for Susan was a better choice than keeping the peace with Ann. She signed and rolled her eyes, “That’s what the school counseling center is for. I barely have time to chart vital signs, much less be a therapist.” She grabbed her laptop and hurried off to see her next patient. I opened the door to call Susan back and saw her sitting in the waiting room, tapping on her smartphone. Her greasy hair was pulled back in a ponytail, and her shoulders were slumped. She looked exhausted. As she walked to the vital signs station I asked, “Susan, how are you feeling today?” “I’m okay, I guess. I’m sorry I keep coming back so much. I’m kind of freaking out. I’m not sure what’s going on.” “Are you still having deja-vu?” “Yes, that’s still happening, and, I’m still having dizzy spells.” “How about the anxiety? Have you had a chance to see the counselor?” “Yeah, I’ve been to see the therapist, and she gave me some good ideas for calming myself before exams, but I’m still struggling with anxiety. It’s happening at odd times, like not just before tests, but when I lie down to go to bed, or when I’m walking home from classes. And there’s this new thing. It’s so weird, I don’t even know how to tell you about it.” “It sounds like you’ve had a frustrating semester so far. I’m glad you’ve come here, that you’re reaching out.” Susan looked at me gratefully, and I could see her body relax a little bit. I got her vital signs and motioned her into the exam room. Once she was seated I looked at her and said, “Tell me what’s been going on.” She said, “Okay, but I think you’re going to think I’m crazy when you hear this. When I listen to my favorite album, I’ve been getting into Queen, listening to them a bunch since the movie came out.” “Oh, that was such a good movie. I’m glad you younger kids are getting to hear some Queen!” “Yeah, I’ve seen it like, 5 times.” Susan looked down, and I noticed her hands twisting together. I decided to wait her out until she finally said, “So whenever I listen to Bohemian Rhapsody, I smell peppermint.” She blurted the last part out, looking up at me with wide eyes. There was a faint flush of embarrassment on her cheeks. “It sounds like you're saying that when you listen to that song, you have the sensation that you are smelling peppermint. Does it happen at any other times? To any other songs?” “No, just that song. It’s so bizarre. It’s so strong. It’s like I’m sucking on a candy cane, or I’ve got some peppermint oil on me somewhere, but there’s nothing there. It’s just so…I don’t know. I feel like I might be going crazy.” “You sound scared.” “Yeah, I’m alone here, you know? My parents aren’t…” She trailed off and stared at the wall. “Did you have a chance to call your mom?” I regretted asking as soon as the words came out because Susan instantly tensed up. “I did call her, but…” she trailed off again. I nodded encouragingly, “What happened Susan? Is there something going on at home that you want to talk about? Whenever you talk about your dad, you tense up.” “Not my dad, my stepfather.” She said and I could hear anger in her voice. I waited, mustering up as much nursing presence as I could. Letting the silence spin out. In a small voice, so low I could barely hear her, she said, “My stepfather…he um. Well, he hurts us.” Now it was my turn to tense up. My internal alert level went to Defcon 5 and I felt like an alarm bell was going off in my brain. I had trained for this but had never had a patient tell me about abuse before. I wanted to get this right. Susan burst into tears. I put down my computer and asked, “Can I put my hand on your shoulder?” She nodded and I handed her a tissue as I did my best to comfort her with that small touch, sending out healing energy through my hand into her shaking back. “Susan, I’m here for you and I’m listening.” She clutched her stomach and said, “It’s happening - the deja-vu, and I feel so dizzy. And my stomach hurts so bad.” She leaned over and then suddenly slumped forward in a full-on faint. I assisted Susan safely to the ground, and then alerted Ann to the situation. She called 911, and we got a set of vital signs while we waited for the EMTs. Susan’s BP and pulse were elevated, but respirations, temp. and pulse-ox were normal. I told Ann what Susan had said, and she went to get the NP as I tried to arouse Susan. I kept calling her name while protecting her head and neck. Her eyelids fluttered and she finally opened them, asking, “Where am I? What happened?” WHAT’S GOING ON HERE? After reviewing all of Susan’s symptoms and assessment data, what do you think is happening? Is it related to the fall in the stairwell? Is it a brain tumor? What other information do you want? What’s next for Susan? In the hospital, Susan got the full workup – labs and a CT scan. The NP also recommended an EEG. What do you think they found? If you enter the following symptoms into google: dizziness, nausea, deja-vu, panic attacks and synesthesia, (the production of a sense impression relating to one sense or part of the body by stimulation of another sense or part of the body – as in when Susan heard the song but smelled peppermint) you get what you’d expect: brain tumors being number one, migraine is on the list and epilepsy, specifically temporal lobe epilepsy (TLE). Of course, all possibilities have to be explored for a differential diagnosis, but TLE fits with her symptoms: SYMPTOMS OF TEMPORAL LOBE EPILEPSY: Sensations such as déjà vu (a feeling of familiarity), jamais vu (a feeling of unfamiliarity) Amnesia; or a single memory or set of memories A sudden sense of unprovoked fear and anxiety Nausea Auditory, visual, olfactory, gustatory, or tactile hallucinations. Visual distortions such as macropsia and micropsia (Alice in Wonderland hallucinations in which things appear larger or smaller than they are in reality) Dissociation or derealisation Synesthesia (stimulation of one sense experienced in a second sense) may transpire. Dysphoric or euphoric feelings, fear, anger, and other emotions may also occur. Often, the patient cannot describe the sensations. Olfactory hallucinations often seem indescribable to patients beyond "pleasant" or "unpleasant". 1 WHAT CAUSES SEIZURES? There’s a wide variety of etiology for seizures: traumatic brain injury (maybe Susan did have a concussion after all), infections like meningitis (common in freshmen), stroke, brain tumors, blood vessel malformations, genetic syndromes, and childhood trauma (AHA!). THE BODY KEEPS THE SCORE Research shows that childhood abuse has enduring negative effects on brain development. In a groundbreaking book, The Body Keeps the Score, author Bessel van der Kolk pulls together research and years of practice to make the case for the complex impact childhood trauma has on the mind, body and spirit.2 Physical, sexual and psychological trauma in childhood may lead to psychiatric difficulties that show up much later. Anger, shame and despair can also be directed inwards, resulting in depression, anxiety, impulsivity, delinquency and substance abuse. Recent research into the impact of childhood trauma on the brain focuses on the limbic system. In the popular movie Inside Out, the audience gets to see cartoon characters acting out the various emotions of a pubescent girl. This film does a great job of showing what the limbic system does. The limbic system lies deep to the cerebrum and includes the hypothalamus, the hippocampus and the amygdala. It supports a variety of functions including emotion, behavior, motivation, long term memory and olfaction. Recent research points to brain abnormalities associated with childhood abuse including limbic irritability, manifested by increased symptoms suggestive of temporal lobe epilepsy, and an increased incidence of clinically significant EEG abnormalities.1,2 TLE is difficult to diagnose because its symptoms mimic those of other psychiatric and non-psychiatric illnesses. Common psychiatric disorders associated with childhood trauma are a somatoform disorder (patients experience complaints with no discernible medical cause), panic disorder with agoraphobia (fear of open spaces), borderline personality disorder and dissociative identity disorder (formerly called multiple personality disorder). PTSD has also been linked to childhood trauma, in which people re-experience the traumatic event in waking life or in dreams.1 The characteristic electrical discharge of TLE is observed with an EEG during a seizure. The authors of a recent study have developed a Limbic System Checklist (LSC-33) which calibrates the frequency with which patients experience symptoms of TLE. I've included a presentation that shows the LSCL-33 and included the first page of the tool so you can see what it looks like.3 In patients who acknowledge both physical and sexual abuse, the average score on the LSC-33 is 113% greater than patients reporting no abuse.4 SUSAN’S CASE In Susan’s case, the EEG was positive for TLE. Her lab results were normal and there was no sign of brain trauma or tumor with CT or MRI. Upon further discussion with Susan, it was discovered that she had suffered several years of physical and sexual abuse by her stepfather. The good news is that there is treatment available for TLE induced by childhood trauma. Though more severe forms of epilepsy can require medication and/or surgery, psychotherapy has been shown to alleviate TLE symptoms in those with childhood trauma. I’ve written about treatments for childhood trauma in two other articles: Keep What You Love, Return the Rest: Healing from Trauma with EMDR https://allnurses.com/keep-what-you-love-return-t663711/?tab=comments#comment-6947680 EMDR: Another Tool for Your Mental Health Toolbox: https://allnurses.com/emdr-another-tool-your-mental-t665133/?tab=comments#comment-6962360 PART 2 I hope you’ll check back in on my blog and read part 2. I’m going to discuss the specific impact of childhood trauma on the amygdala and hippocampus as well as the Adverse Childhood Events (ACEs) Study. I will also cover some innovative new treatments like the use of psilocybin to treat PTSD. REFERENCES 1. Wounds That Time Won’t Heal: The Neurobiology Of Childhood Abuse: http://www.dana.org/Cerebrum/2000/Wounds_That_Time_Won’t_Heal__The_Neurobiology_of_Child_Abuse/ 2. Van der Kolk, B. (2015). The body keeps the score: Brain, mind and body in the healing of trauma. New York, NY: Penguin Books. 3. Reference for attached image, which is only part of the LSCL-33 (You can view the entire LSCL-33 in this pdf starting on on page37):https://drteicher.files.wordpress.com/2011/06/nesttd_keynote_post-key1.pdf 4. Teicher, M. H., Gold, C. A., Surrey, J. & Swett, C. (1993). Early childhood abuse and limbic system ratings in adult pyschiatric outpatients. Journal of Neuropsychiatry and Clinical Neuroscience, 5(3), 301-6.
  2. SafetyNurse1968

    The Wrong Dose - A True Story of Medication Error

    THANK YOU for doing an incident report on this - you've prevented some harm down the road. I so appreciate the share.
  3. I sat down with Margo in her dining room one evening to talk about a medication error she made when she was a new nurse. I asked Margo to tell me a bit about herself. She hadn't always wanted to be a nurse. She was studying entomology (bugs) at NC State, when the forest service instituted a hiring freeze, so she switched her interest to nursing. We talked a bit about the oncology unit where she was hired as a new nurse - we share a bond because I was a baby nurse on the same unit and some of the same nurses who trained me are still there! Below are excerpts from our conversation - to get the full interview, listen to the podcast (link is at end of article). I have put all of Margo's comments in italics. SN: Tell me about the error... Margo: I was 4-6 months into my career as an RN, and had finished a 3-month long orientation as a new graduate but was still feeling overwhelmed. The med error started with an accidental duplication of an insulin order. 44 units of Lantus was ordered for bedtime, but there was also an order for 44 units of regular insulin. I remember flipping through the order and thinking that it didn't look right, I was still feeling overwhelmed, and it's embarrassing to admit, I wasn't familiar enough with insulin to verbalize to myself why I thought it was wrong. I just remember I knew something was off. I had great support from my peers, but I was always asking questions - and I was trying so hard to practice independently. I fell into a trap with nurses who make med errors in that I became task focused. That's what we teach in nursing schools. We teach tasks because it is so easy to teach and evaluate. In our orientation program, we don't teach nurses how to precept other nurses, and we don't teach nurses how to think critically. In my mind, I knew something was wrong, but I had to get through the night, and I totally relied on the computer and the system. I remember thinking, there is no way this can be in the computer and be wrong. The NP wrote this order, a pharmacist reviewed it, another nurse checked it...wouldn't the computer catch it? I went to pull the insulin from the pyxis knowing something was wrong, but still unable to say why. And I know I shouldn't have given it at all if I couldn't say why it was wrong. I was task oriented and not thought oriented. I pulled up the lantus, and then I went to pull up the 44 units of regular insulin and I remember thinking, this is the part where the pyxis will stop me, but it didn't. I walked in the patient room and said, "I have your 44 units of Lantus and 44 units of regular insulin - is this what you do at home?" The patient said yes, but who knows why - maybe he was poorly educated, maybe he didn't feel empowered. I wasn't skilled enough to ask open-ended questions, instead, I asked for confirmation. I should have asked, "tell me about your home med regimen" instead of asking a yes or no question. So he confirmed, and I gave him the large dose, still knowing something was wrong. Part of my reasoning was his previous dosing - he got large meal boluses during the day, and on an oncology unit, we give big doses of insulin to people on high dose steroids. I remember trying to justify it... I walked past his room about 4 hours after giving the medication. His light was still on, he was laying contorted position, he was unresponsive, seizing and incontinent. I called for assistance, and the charge nurse called a code blue immediately. I remember saying over and over, get a glucometer, it's his glucose. We got a reading and it was 12. He pulled out his IV while seizing and we had to put in a new one. He was minutes away from him dying or losing all brain function. I had to admit in that moment what happened to save his life. I had to scream "his blood sugar is low, because I gave him too much insulin" while everyone was running around in a panic trying to resuscitate him. There was no hiding it - pride could have killed him. I hope I never harm someone like that again. I pushed dextrose all night, and the next day there was no discernable loss of function. SN: Margo let me know she shares this story with coworkers and with all the nurses she precepts. She wants to emphasize the importance of owning and reporting mistakes, but also of knowing you can recover from an error- it is survivable. Margo: I don't think every nurse will harm someone, but you can't tell me there is a single nurse out there who hasn't made some kind of error. SN: Margo said she got excellent support from her unit, her manager and the hospital. She was referred to the Employee Assistance Network, but she said after her first Root Cause Analysis session, she felt like that was enough therapy. We talked briefly about the new RCA guidelines that recommend not including the person who made the error, and she is strongly opposed. Margo: Being involved in that RCA process kept me in nursing. Without it, I wouldn't have recovered from this at all. It was a healing experience for me. RCA helps you realize it's not just you, it's also the system. I got to weigh in on "what will we do next so it doesn't happen again" and I got to design the changes to the programming so it would fix the problem. It was a group of people who supported me and we stood together - we were able to say, "this is what we made so no one has to go through this again" I asked Margo for tips on how not to make an error Margo: In nursing school, they treat error as something really rare - the Quaid twins with the heparin, the antibiotic being given through the epidural, and the tube feeding hooked up to the IV - sensational cases - so you think, that's what a med error is. I would never do that! I'm a careful person. We need to teach nurses, you WILL make mistakes. I was precepting a new nurse, and we were talking about med errors, and she said something like, "well I would never do that, not me" and I said, "Well I have. I hurt someone very badly" She looked at me like, "why are you telling me this" I said, "I hope you never hurt anyone - what is important is to recognize that when you do make an error, you can recover, you can still be here." Safety Rules! Podcast is on stitcher, if you don't like iTunes Links (what you'll be clicking on if you hit the hotlinks above): iTunes: Safety Rules by Kristi Miller, RN, PhD, CPPS, HNB-BC on Apple Podcasts Stitcher:Safety Rules | Listen via Stitcher Radio On Demand
  4. WHAT DOES THE RESEARCH SAY? Google “How to pass the NCLEX-RN the first time” and you’ll get many results, some of them more reliable than others. You’ve learned in nursing school that it’s important to look for evidence-based resources, so I thought I’d back up my NCLEX success tips with hard facts. Evidence for educational strategies that support NCLEX success is rare, but there are some studies out there with interventions that correlate with NCLEX success. Success on the NCLEX-RN actually starts before admission to nursing school. Studies have shown that pre-admission scores on reading and math assessments, pre-clinical GPA and scores on the NLN-PAX-RN are all predictors of NCLEX success.1, 2 Several studies stressed the importance of setting up a test preparation plan and sticking to it. A few hours each day of nonnegotiable study time is crucial. Put it on your calendar.2, 3 A qualitative study asked nursing students what they thought contributed to their first-time success on the NCLEX-RN. She interviewed 12 students and grouped their responses into four categories: 1) practicing NCLEX-RN questions; 2) nurse clinical experiences; 3) receiving support; 4) participating in an NCLEX-RN review course.4 Another study was an evidence-based education project with BSN students. They provided students with coaching, test-taking strategies, study groups, review courses, review books, self-assessment, as well as time management, relaxation and anxiety reduction techniques.3 There are many comprehensive exams that mimic the NCLEX (Often called RN-CAT): Mosby, NLN, HESI, ATI all assess preparedness. There is a correlation between scores on standardized exam like HESI or ATI and passing the NCLEX. 1 NCLEX-RN FORMAT Multiple studies mentioned the importance of understanding the test format, so let’s review1, 4: You will have between 75-265, and that includes non-scored experimental items. You will also have 6 hours. As I am sure you know by now, the test is adaptive and the length of the exam and the specific test items depend on the candidate’s knowledge level and ability. If you get one right, a more difficult item is next. If you get one incorrect, an easier item is next. The test is scored with something called a logit, a unit of measure used to calibrate items. It is a prediction of the probability of an event. The higher a person’s ability relative to the difficulty of an item, the higher the probability of a correct response. This means the computer can make a pass/fail decision with 95% confidence. The idea is to determine at what point the candidate is answering items correctly about half the time. After item 75, the computer calculates the standard error to estimate candidate competence. If it’s at or above competency, the computer shuts off. If it’s below, the computer shuts off. It only keeps going if more items are needed for a statistically significant measurement. Two things can happen to cause the computer to use the last 60 items to estimate your score: you reach 265 questions, or time runs out.2 HOW TO FAIL Students who failed the NCLEX-RN the first time, identified inadequate study habits, lack of knowledge about how to prepare for the exam, difficulty setting priorities and poor test-taking skills. Students felt most prepared for patient priorities and delegation and least prepared for maternity/newborn, pediatrics and pharmacology.1 There are some factors beyond your control. If you are a student who is experiencing English as a second language, if you have educational deficits, a low preclinical GPA or test anxiety, studies show you are more likely to fail the NCLEX-RN.1,2 In addition, there is a strong relationship between a delay of more than 3 months post-graduation before taking the NCLEX-RN and failing.1 PRACTICE, PRACTICE, PRACTICE I know you’ve heard this so many times from your professors and your friends, but it’s true. The more questions you do, they better you’ll do on the exam. It’s important to understand question structure and use practice questions to prepare. Practice questions force you to analyze the stem and understand what the question is asking. You’ll improve if your practice questions have the rationale for content and for incorrect answers. SAMPLE QUESTIONS ONE A client had an IV started at 0900. At 0930 the client rings to complain of shortness of breath. The client has a blood pressure of 90/60 mm Hg from a baseline of 130/82 mmHg, and a pulse of 110 beats per minute. Which of the following should the nurse do FIRST? Check the IV tubing for air bubbles Assess the IV tubing for loose connections Clamp the tubing and turn the client on the left side Raise the head of the bed Rationale: This client is showing signs of air embolism, which is a complication of Intravenous therapy. When a client complains of shortness of breath, there is a need for immediate intervention, and no further assessment is required. The correct interventions for air embolism include: clamping the tubing, turning the client on the left side with the head of the bed lowered to Trendelenburg to trap the air in the right atrium, assessing vital signs and breath sounds, administering oxygen and notifying the HCP. Complications of air embolism include shock and death. Options 1 & 2) Checking for air bubbles and loose connections are correct prevention activities, but do not address the presence of a presumptive air bubble already in the client’s bloodstream. Option 4) Raising the head of the bed may cause the air embolism to migrate to the lungs or brain. The correct answer is option 3 Competency: Pharmacological and Parenteral Therapies, IV Therapy Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 291 Taylor, C., Lillis, C., Lynn, P. & LeMone, P. (2015). Fundamentals of Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 1510 TWO A nurse on an oncology unit receives verbal report about four patients. Which client will the nurse see FIRST? A client with a total serum calcium level of 10.8 mg/dL, complaining of fatigue and nausea. A client with a temperature of 100.1 oF and a neutrophil count of 950 neutrophils/mcL A client with lymphoma who has shortness of breath, edema of the neck and arms and difficulty swallowing. A client with metastatic breast cancer, complaining of throbbing and aching joint pain and a platelet count of 50,000/mm3. Rationale: 1 & 3 are oncologic emergencies, however, option one indicates hypercalcemia, which is potentially life-threatening metabolic abnormality resulting from calcium release from the bones exceeding the ability of the kidneys to excrete calcium. Symptoms include serum calcium above 10.1, fatigue, weakness, confusion, polyuria, nausea and vomiting. Answer option three is a true oncologic emergency that can progress to cerebral anoxia, bronchial obstruction and death. Signs and symptoms of Superior Vena Cava Syndrome (SVCS) include dyspnea, edema of neck, arms, hands, skin tightness, difficulty swallowing, distended jugular veins and increased ICP. SVCS is associated with a diagnosis of lung cancer and lymphoma. It Option two indicates a client who may be developing neutropenic fever, which is associated with any temperature of 100.4oF and a neutrophil count of <1000 neutrophils/mcL. This client has the potential for developing an emergency but is not a priority. Option four indicates probable pain from bone metastasis. It is important to treat pain, but it would not be the priority. The platelet count is low, but not low enough to be associated with spontaneous bleeding (<20,000/mm3). The correct answer is option 3 Competency: Management of Care, Establishing Priorities, Oncology, Evaluation Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia, PA: Wolters Kluwer. Pgs 372, 377, 382 Taylor, C., Lillis, C., Lynn, P. & LeMone, P. (2015). Fundamentals of Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 1482 THREE The nurse is assessing a client for the possibility of pregnancy. Which of the following statements by the client indicate probable signs of pregnancy? Select all that apply. “I’ve been nauseated every morning and I haven’t had a period in two months.” “I’m just so tired all the time.” “I took a pregnancy test and it came up positive.” “My breasts are much larger, and my nipples are sore.” “I’ve been having irregular contractions.” “My boyfriend felt the baby moving.” Rationale: Options 3 & 5) are probable signs of pregnancy. Although probable signs suggest pregnancy and are more reliable than presumptive signs, they are still not 100% reliable in confirming pregnancy. Options 1, 2 & 4) are presumptive signs of pregnancy. These are the least reliable indicators of pregnancy because any one of them can be caused by conditions other than pregnancy. Amenorrhea can be caused by early menopause, endocrine dysfunction, malnutrition, anemia, diabetes mellitus, long-distance running, cancer or stress. Nausea can be caused by gastrointestinal disorders. Fatigue can be caused by anemia, stress or viral infections. Breast tenderness can be caused by chronic cystic mastitis, premenstrual changes or use of oral contraceptives. Option 6) Palpating for fetal movements is a positive sign of pregnancy when performed by an experienced healthcare provider. Fetal movements that have not been confirmed by an experienced practitioner are considered presumptive signs. The correct answer: options 3 & 5 Competency: Health Promotion and Maintenance, Health screening, Antepartum, Assessment Ricci, S. S., Kyle, T. K., & Carman, S. (2017). Maternity and Pediatric Nursing (3rded.). Philadelphia, PA: Wolters Kluwer. 363-364 Taylor, C., Lillis, C., Lynn, P. & LeMone, P. (2015). Fundamentals of Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 1665 FOUR The nurse has been teaching a client about a new prescription for carbamazepine (Tegretol) for tonic-clonic seizures. Which of the following statements by the client indicates need for further teaching? “I should call the doctor if I notice a rash or blurry vision.” “If I experience nausea or blurry vision, I should stop taking the medication immediately.” “I need to take the medication with food, but not with grapefruit juice.” “I need to take the medication twice daily at the same time each day.” Rationale: Option 1) Toxic effects of carbamazepine include severe skin rash, blood dyscrasias and hepatitis. Visual disturbances and serious skin reactions should be reported. Option 2) Client education about carbamazepine includes teaching that medications should not be discontinued, even if adverse side effects occur such as rash, dizziness, nausea or blurry vision; however the healthcare provider should be called if there are adverse side effects. Option 3: Giving medication with meals can reduce the risk of GI distress, however grapefruit juice may increase absorption. Option 4): Strict maintenance of drug therapy is essential for seizure control. The correct answer is option 2 Competency: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions, Evaluation Hodgson, B. B. & Kizior, R. J. (2014). Nursing Drug Handbook. St. Louis, MO: Elsevier. Pgs 180-182 Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14thed.). Philadelphia, PA: Wolters Kluwer. Pg. 2000 FINAL ADVICE Take advantage of end of program review options. The NCSBN offers an online review course of 3, 6 or 9 weeks – the candidate has 24/7 access to material. Since the NCSBN is the organization that “writes” the NCLEX, I think this would be the one to take if you had to pick just one.5 The most important thing you can do to increase your chances of passing the NCLEX-RN is to accept responsibility for your success. For more tips and tricks, check out another article I wrote – it will lead you through strategies for understanding the stem and choosing the correct answer option: Are You Ready for NCLEX? Think PATIENT SAFETY and You Will Be! REFERENCES Higgins, B. (2005). Strategies for lowering attrition rates and raising NCLEX-RN pass rates. Journal of Nursing Education, 44(12), 541-7. Lavin, J. & Rosario-Sim, M. (2013). Understanding the NCLEX: How to increase success on the revised 2012 examination. Nursing Education Perspectives, 34(3), 196-198. Bonis, S., Taft, L. & Wendler, M. C. (2007). Strategies to promote success on the NCLEX-RN. An evidence-based approach using the ACE Start Model of knowledge transformation. Nursing Education Perspectives, 28(2), 82-87. Blazen, B. B. (2008). The road to NCLEX-RN Success. The Journal of the New York State Nurses Association, 45(2), 5-12. https://www.ncsbn.org/4762.htm
  5. SafetyNurse1968

    Help with NCLEX-RN – Let’s do some sample questions

    Thanks for reading and commenting. Yes, this question pertains to probable signs of early pregnancy. The other causes of breast enlargement and tenderness you list are all correct. This is a great opportunity to remind folks to not get sidetracked by overthinking the question or the answer options. Since breast tenderness can be caused by being premenstrual, it is not a probable sign of pregnancy. Focus on the key word - what is the question asking? It's asking about probable signs, not about anything else. Just my 2 cents!
  6. Mistakes Were Made Is it possible to get through an entire nursing career without making a mistake? If nurses are well-trained and careful, can we prevent patient harm? What does it take to get through a hectic nursing shift without making an error? These are the questions that motivate me as an educator and a nurse researcher. I wrote an article a while back talking about how nurses, despite our best efforts, make mistakes that sometimes lead to patient harm (Why Do We Continue to Harm Patients?) At the end of the article I gave a survey asking how many of my readers had made errors. Of the 39 folks who voted, 54% of you said you had never made an error. Compare that to the 18% who weren’t sure. I’m going to make an argument that more mistakes and errors occur than you think by asking another question, how do we know an error has been made? The most common way healthcare organizations track error is through self-report, which is voluntary. We have to know we’ve made a mistake, be willing to report it, know how to report it, have time to report it and feel safe enough to report it before anyone finds out we’ve made an error. That’s a lot to ask for nurses who are often overworked, underpaid and who have zero job security. The evidence suggests we make many more errors than are reported. In one study, over a four-day period, pharmacists, RNs, LPNs and pharmacy technicians directly observed 2556 doses of medication administration in 36 hospitals across the US. They observed 300 errors (11.7%). An in-depth chart review over that same four-day period detected 17 errors (0.7%). And incident reports? You guessed it - there was 1 – giving an error rate of 0.4%.1In another study clinical evidence from 6 different direct observation studies was reviewed, and the differences were even more startling: “true” error detected by direct observation was 65.6%. Chart review yielded an error rate of 3.7%. Self-report gave an error rate of 0.2%.2 Fundamentals I recently taught fundamentals of nursing to some brand-new BSN students. They had to do a simulated medication pass, and I used a checklist to grade them. It looked something like this: My students struggled with performing the three checks each and every time. (I added that they also needed to check the expiration date, something else they couldn’t seem to remember). I know nerves get in the way, and I was supportive and gave cues when needed, because at their level, cues are needed. We only expect a student nurse who is about to graduate to be able to do a med pass correctly, perfectly, every single time. What inspired me to write this article was the experience my newbies had at the clinical site. After 10 weeks in the sim-lab, struggling to learn the basics of nursing care, things like bed making, bed baths, head to toe assessment, medication administration, they finally got to go to an actual facility and observe RNs, LPNs, and CNAs do the real job of direct patient care. They were incredibly nervous about talking to a patient for the first time, so worried they would make a mistake, say the wrong thing, mess up.At the end of the first day, we met for post-conference and some faces were shining with joy, I kid you not, at the realization that I can do this!There were also some hushed conversations about the reality of nursing. See if any of these quotes look or feel familiar: “She didn’t tell the patient what any of the meds were for.” “None of them do the three checks.” “My nurse didn’t even check the patient’s arm-band.” “She gave the wrong dose of insulin, and she realized it afterwards, but I never saw her tell the patient or fill out an error report. I could tell she felt really embarrassed.” What Are We Teaching Kids These Days? Do you remember in nursing school when they taught us about medication administration? Here’s a list of what we are supposed to know about each and every medication (and I am sure I have missed a few): Generic vs. trade Classifications Forms Pharmacokinetics Therapeutic vs. side effects Allergies Interactions Timing (peak, trough) Common schedules (AC, STAT) Route Method of measurement Interdisciplinary (pharmacy, prescriber) Types of orders (standing, PRN) Distribution systems Back in 2004, when I was a student, they were still doing five rights: dose, patient, drug, time and route. I did a little research and discovered that the five rights were first seen in The Nursing Sister: A Manual for Candidates and Novices of Hospital Communities,1893.3 Since then, the number of rights has increased, one school even has 12! Some of those additional rights include things like documentation, client education, response, right to refuse. Do you remember how we were taught to check all the rights three times? The three checks: Check 1: when medications are pulled from where they are stored (med drawer, dispensing machine/Pyxis); Check 2: when preparing the medications for administration; Check 3: at the patient’s bedside. I have three problems with this whole set up: 1) there’s no evidence to support this methodology; 2) it places all of the responsibility for patient safety on the nurse; 3) it only works if you do it, and we aren’t doing it. Our responsibility is to administer medication as prescribed while preventing error and patient harm(that’s straight from a Fundamentals texbook4) yet the error rate hasn’t changed.5 We are the last line of defense – physicians and advanced care practitioners prescribe medications, pharmacists fill the prescription, and the nurse gives the medication. As we go through our daily routine of checking and re-checking, nurses prevent up to 70% of prescribing and dispensing errors before they reach the patient.6 We prevent error by intervening when we see a medication order that doesn’t make sense, or identifying an allergy that was missed, or investigating with the patient and family to discover a previous medication issue not found upon initial assessment. Despite our best efforts, nurses may commit between 26% and 38% of medication errors.6In a 2010 survey, 78% nurses admitted to making a medication error, and these are just the ones they were aware of.7 The Fallacy Of The Careless Nurse Some folks who read an article highlighting the nurses’ role in patient harm get angry, and I don’t blame them. Nurses are often vilified for errors that reach the patient. Nurses are at the sharp end of the stick – we are the last stop for safety. When things go wrong, we are often blamed. Yes, there are instances of bad nurses who do bad things. There are incompetent and careless nurses. There are nurses who don’t care. But I believe they are few and far between. What I am suggesting, is that it isn’t always our fault. I’m suggesting that healthcare systems are error-prone places. I’m suggesting that no matter what we do, errors will occur. Healthcare is just too complex. The odds are stacked against us. Statistics show that more than one error occurs per patient per hospital day.8I don’t believe there are that many careless nurses out there. I believe the system is deeply flawed. The culture of nursing is such that many of us are unwilling to even consider that we have made an error. And as you can see, we continue to teach our nursing students that just being carefulwill somehow magically protect them from making a mistake. What To Do? Nurses appear to believe that they should be capable of administering medications without errors, regardless of the external circumstances. When you ask nurses about error, we typically believe it’s all our fault. In 2003, 779 nurses were polled, and 79% agreed that medication errors occur when a nurse carelessly neglects to follow the 5 rights. 958% believed that the commission of a medication error was indicative of nursing incompetence. In 2008 the same poll was conducted, and those numbers have only increased.10This study highlights that negative opinions and individual blame continue to be associated with error making. In the article I wrote about the role of nurses in error, I asked you for solutions and here is a list of your answers: Staffing (over 50% of those who commented on my article suggested that staffing is at the root of the role nurses play in medication error.) Incentives and benefits for senior, experienced nurses to stay at the bedside Barcode medication administration Electronic charting Improving critical thinking Prioritizing patient needs Nurses are understaffed and overworked, caring for sicker patients in greater amounts with less support, experience and training Total overhaul of BSN programs Keep your head down, keep quiet and stay employed Personal Safety Checklist I agree with your ideas, but I’m not sure how to get them implemented, other than to tell you to go work at a magnet hospital in a state with safe staffing laws. I’m working very hard on improving critical thinking in my nursing students, but from the perspective of a BSN instructor, I can tell you a total overhaul isn’t on the horizon. I want you to know there are a few things we can do to safeguard our patients and our license. As a Certified Patient Safety Professional, a long-time nurse educator, a nurse who practices at the bedside, and former patient safety officer, I recommend nurses use the following checklist for personal safety measures. Anything you can complete from the following list has evidence behind it to support improved patient safety. As nurses, keeping patients free from harm is our goal, so why not pick one and get it checked off? Education: BSN, MSN (patients cared for by nurses with higher degrees have better outcomes) Nurse led research (nurses at the bedside are the best folks to initiate research that will make a difference in patient safety) Certification (patients cared for by certified nurses have better outcomes) Self-care (nurses who are stressed out and fatigued are more likely to make an error) Ongoing training – look for the following components in your continuing education: High quality CE (The ANA has some great free CE, and so do I!) Simulation (So many studies show a positive relationship between high-fidelity simulation and improved patient outcomes) Patient safety focus Charting (Chart everything. Chart everything. Chart everything – for your safety as well as your patients’). Use of checklists whenever possible (research shows use of checklists reduces error) Speak up! Join the ANA and contribute to the Political Action Coalition today! If every nurse gave $1, we would have $3 million dollars to fund lobbying efforts to get safe staffing laws passed in all states. If we do nothing, nothing will change.11 End Note Here’s one final item I have removed from the checklist because it isn’t a goal, though it is most likely a certainty in your life. The odds that a nurse will make it through a career without making a mistake are close to zero. Previous involvement in error (nurses who have made errors that they recognize and take responsibility for are less likely to make them in the future) I wrote a story about a wonderful, well-trained, careful nurse who made a mistake that harmed a p.html), and I encourage to you read it. It inspired me and I hope it inspires you as well. We must admit to and report error. If we don’t, we can’t know what problems need to be fixed. For more information on how organizations can improve, please read: This Nurse Quit, Will You? What to look for in an organization. REFERENCES 1. Barker, K., Flynn, E., Pepper, G., Bates, D., & Mikeal, R. (2002). Medication errors observed in 36 healthcare facilities. Archives of Internal Medicine, 162(16), 1897-1903. 2. Kiekkas, P., Karga, M., Lemonidou, C., Aretha, D., & Karanikolas, M. (2011). Medication errors in critically ill adults: A review of direct observation evidence.(report). American Journal of Critical Care, 20(1), 36-44. 3. Wall, B. (2001). Definite lines of influence: Catholic sisters and nurse training schools.Nursing Research, 50(5), 314-321. 4. Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016).Fundamentals of nursing (9thed.). Philadelphia, PA: Elsevier. 5. Landrigan, C. P., Parry, G. J., Bones, C. B., Hackbarth, A. D., Phil, M., Goldmann, D. A., & Sharek, P. J. (2010). Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine, 363(22), 2124-2134. 6. Bates, D. W. (2007). Preventing medication errors: A summary. American Journal of Health-System Pharmacy, 64(14), S3-S9. doi:10.2146/ajhp070190 7. Jones, J. H., & Treiber, L. (2010). When the 5 rights go wrong: Medication errors from the nursing perspective. Journal of Nursing Care Quality, 25(3), 240-247. 8. Anderson, D. J., & Webster, C. S. (2001). A systems approach to the reduction of medication error on the hospital ward. Journal of Advanced Nursing, 35(1), 34-41. 9. Cohen, H., Robinson, E. S., & Mandrack, M. (2003). Getting to the root of medication errors. Nursing, 33(9), 36-46. 10. Cohen, H., & Shastay, A. D. (2008). Getting to the root of medication errors: survey report. Nursing, 38(12), 39-47. 11. https://www.nursingworld.org/practice-policy/advocacy/
  7. SafetyNurse1968

    Is It Possible to Never Make an Error? The Perfect Nurse Fallacy

    Thank you so much for pointing out my mistake.
  8. SafetyNurse1968

    tips for studying for NCLEX

    I teach nursing school, and I also teach an NCLEX prep course for Kaplan. Please read my very short article on preparing for NCLEX. I hope it helps!
  9. WHY ME? When I was asked to give a speech for my upcoming nurse pinning ceremony, my first thought was, who am I to talk about the value of joy? But then I realized, this is what doctoral students do - we search the literature looking for evidence. I can't even switch laundry detergent without finding a minimum of three relevant, evidence-based articles, published within the last 5 years. In addition to my research abilities, I'm a joyful person. Mark Twain said, "To get the full value of joy you must have someone to divide it with." I certainly have a joyful partner, and four silly, wonderful children. I seek happiness, like anyone else, but I hadn't thought to ask myself about value - why feeling happy is so important. As you may know, the first step in any research proposal is to define terms. The dictionary defines joy as, "The emotion evoked by well-being, success, or good fortune, a state of happiness or felicity, to experience great pleasure or delight."1 That's kind of a boring definition though - I like how one of my favorite authors, C. S. Lewis (he wrote the Chronicles of Narnia) said it's "that sharp wonderful stab of longing - has a lithe, muscular lightness to it. It's deft. It produces longing that weighs heavy on the heart, but it does so with precision and coordination. It dashes in with the agility of a hummingbird claiming its nectar from the flower, and then zips away. It pricks, then vanishes, leaving a wake of mystery and longing behind it." No matter what you call it: joy, amusement, serenity, happiness, contentment, gratitude -these emotions have a positive impact on our lives. But why, as Maya Angelou said, do "we need joy as we need air?" WHY JOY? The answer isn't immediately obvious. Take the English language for instance - there's only one positive word for every three or four negative words (I'm pretty sure my seven-year-old has said every single one of them). With non-verbal communication, it's easy to identify an angry, sad or fearful face, but positive emotions have no unique signal value - all share the same signifier, a smile. Anger, fear and sadness each elicit distinct responses in the autonomic nervous system, but positives do not. Negative emotions have an obvious adaptive value - if you are fearful, you run, if you are angry, you attack, if you are disgusted, you spit (I'm thinking of bad tastes here folks, not how you feel when your spouse leaves a wet towel lying on the floor.) But what is the adaptive value of positive emotions?2 As I dug into the literature of joy, I discovered Dr. Barbara Frederickson, one of the premier researchers into positive emotions. In her "broaden-and-build" theory (yes of course there's a theory, graduate students love theory as much as children love skittles) she posits that momentary experiences of mild, everyday positive emotions broaden people's awareness in ways that, over time and with frequent recurrence, build consequential personal resources that contribute to their overall emotional and physical well-being. Evolutionarily speaking, if you feel good, you are more likely to survive and pass on your DNA. Her research is providing a blueprint for how pleasant emotional states like joy contribute to resilience, wellbeing and health - an important idea for nurses, yes?3 One study showed that physicians who experienced positive emotions were faster to integrate case information and less likely to come to premature conclusions. In other words, a happy clinician makes a more accurate diagnosis. Negotiators who felt good, were more likely to discover solutions in a complex bargaining task (good news for hostages). Links have been discovered between playfulness and gains in physical, social and intellectual resources in monkeys, rats, squirrels, and even humans. When people feel good, their thinking becomes more creative, integrative and flexible. One of the most interesting studies involved interviews with people before and after 9/11 happened. Those with more positive emotions before the attacks felt more positive and less depressed afterwards. The tendency to feel more positive emotions buffers resilient people against depression. Experiencing positive emotion leads to a state of mind and a mode of behavior that prepares an individual for later hard times. They build enduring personal resources. LIVE LONGER Frederickson writes of a study in which young nuns were asked to write about their lives. This was back in the 1930s and the writings were put away and lost for a time. 60 years later the writings were unearthed and scored for positive emotional content. The readers recorded instances of happiness, interest, love and hope. The nuns who expressed the most positive emotions lived up to 10 years longer - better than what you get for quitting smoking.4 Another study looked at the impact of emotions on the heart. You are probably familiar with the idea that stress can damage your body. Recurrent emotion-related cardiovascular activity appears to injure the inner walls of arteries and initiate atherosclerosis. In one experiment the researchers created an anxiety inducing activity. Participants were asked to create a speech in one minute to be taped and evaluated by peers. Participants were then shown a film designed to elicit amusement or contentment, a neutral film or a sad film. Cardiovascular reactions like increased heart rate, peripheral vasoconstriction and increased BP were measured. Those shown the positive films returned to baseline more quickly. Those shown sad films took the longest.3 Joy heals us. Our immune system is constantly listening in on our thoughts and feelings. Joyful people are more productive members of society. They aren't as likely to be absent from work, physically or mentally. They are more able to deal with crisis in the home, workplace or community. Valuing positive emotion is associated with life satisfaction.5 VALUING JOY These are some convincing arguments for the value of joy - it makes us creative, resilient, happier, flexible, and enhances speed, accuracy and development. It's like joy can build the six-million-dollar human. If only we could write a prescription for joy, unfortunately, it's not that easy. Unless you live in Bhutan. Years ago, the Kingdom of Bhutan developed a Gross National Happiness Index and now they measure the GNH instead of the GNP. They have accepted and legislated that human society benefits when material and spiritual development occur side by side to complement and reinforce each other. According to the Kingdom of Bhutan, there are nine components of happiness: Psychological well-being Health Education Cultural diversity and resilience Time use - work/life balance Good governance Community vitality Standard of living Ecological diversity and resilience5 FOCUS INWARD To bring these components into balance in our own lives, we need to focus on individual actions: physical exercise, socializing, hobbies, deliberate changes in perception. The evidence points to changing internal vs. external conditions. There is a quote many attribute to Abraham Lincoln, however I recently learned he didn't say it first, but that doesn't lessen the importance of the saying, "Most people are as happy as they make up their minds to be." The famous British poet, John Milton said it better, "The mind is its own place, and in itself can make a heaven of hell, a hell of heaven." I'm not suggesting that we can all just decide to be happy. For many people, that is not an option. I get that. I am suggesting that small steps can bring more positive emotions into our lives.For me, positive emotions often come from the answer to a question I ask my students when they get frustrated with nursing school - a frequent occurrence. "Would you rather be right, or would you rather be happy?" Now, of course I would rather be both right and happy, but in the end, I choose happiness (though my husband might disagree). For me, happiness is a simple choice because I have the lower ranges of Maslow's hierarchy covered. I have food, shelter, clean drinking water and people who love me - which isn't the case for the majority of the planet. HOW TO GET MORE JOY As nurses, we can always do more to support our patients finding joy. As they find joy, they may also find healing. Our goal as nurses should be to find ways to experience more positive emotions more often. And though I have tried to make you chuckle in this article, the use of humor, laughter and direct attempts aren't always suitable. Instead we need to find other ways to support joy. Researchers suggest that the following ideas support joyful feelings. Look for the silver lining; find benefits within adversity. You had to give meds for a nurse who called in sick? It was hard, but you also looked up a new medication and refreshed your memory on some other meds, meaning you're less likely to make an error in the future. Infuse ordinary events with meaning, like having a special pinning ceremony to celebrate nursing achievements, or bringing a candle, table cloth and some real plates and cups to a lunch meeting. Support mindfulness and spirituality - now's the time to try meditation. Learn how to establish and maintain relationships. Stay in touch after you graduate, get together with coworkers, hang out more often, write a few actual letters. Since serenity comes with feeling competent, search out opportunities to give that feeling to others - find ways to give power to disadvantaged groups. Help others.3, 4, 5 A POSITIVE UPWARD SPIRAL OF JOY I'm giving help others its own paragraph because it is at the center of Fredrickson's research. Gratitude arises from meaningful engagement in activities that benefit other people and the planet as a whole. When we help others, good feelings can also result in community transformation. People who experience positive emotions become more helpful to others. Giving help causes people to feel good about themselves, receiving help causes feelings of gratefulness, witnessing acts of help can also elevate feelings. It's a positive upward spiral. If this is indeed the case, then nurses should be the most joyful people on the planet because we are always helping others.4 Author Tom Bodett said, "a person needs just three things to be truly happy in this world: someone to love, something to do, and something to hope for." If that is true, then I am all set, and I am so grateful to my family, friends, faculty and coworkers for supporting me in having these things. I will keep writing, hoping you will keep reading. References 1. Joy | Definition of Joy by Merriam-Webster 2. How Does Culture Affect Our Happiness? | Psychology Today 3. Fredrickson, B. L. & Joiner, T. (2018). Reflections on positive emotions and upward spirals. Perspectives on Psychological Science, 13(2), 194-199. 4. Fredrickson, B. (2003). The value of positive emotions. American Scientist, 91, 330-335. 5. The Centre for Bhutan Studies and Gross National Happiness. (2017). Happiness: Transforming the development landscape.Retrieved from: HAPPINESS : Transforming the Development Landscape
  10. IT'S A PATIENT SAFETY ISSUE As I stated in Part 1, I just got hired as an assistant professor at the University of South Carolina Upstate (USC-U) in Spartanburg! After seven long years of working on my PhD in nursing, I finished in May of 2018 and have been looking for work since then. During my interview, I asked the dean, Dr. Gibb about the Clinical Nurse Leader Master of Nursing program offered at USC-U.1I had heard of the CNL but didn't know much about it. As a patient safety advocate, I was excited to learn that the CNL role was actually created by the American Association of Colleges of Nursing (AACN) in response to the IOM report that suggested between 44,000 and 98,000 hospitalized patients die each year due to preventable medical errors (I've written about that in several articles: (https://allnurses.com/general-nursing-discussion/can-you-prevent-1177736.html;https://allnurses.com/nursing-issues-patient/why-do-we-1150076.html).2Much research resulted to address this issue and, in that context, the AACN developed a new nursing role, the CNL in 2007. There is a need for leadership at the point of care. CNLs are master's level nurse graduates with the skills and knowledge to create change within complex systems and improve outcomes while they remain direct care providers. This is exciting news! The CNL is the first master's prepared role to be added to the nursing profession in more than 35 years.3 Clinical Nurse Leader The CNL was created to improve the quality of health care systems while controlling costs. In comparison to a nurse administrator or nurse manager, the CNL is a provider of care for individuals at the microsystem level. What does "microsystem" mean? Patients and health care providers interact at four levels: The patient The microsystem: a unit with a care team The organization where the microsystem is housed The environment: policy, payment, regulation, accreditation1 The idea behind the CNL is to retain a master's-level nurse at the clinical bedside. The CNL is an advanced nurse generalist, vs. a specialist. The CNL improves outcomes through coordination and facilitation of care. What they don't do is focus on a specific population like cardiovascular patients or patients with diabetes. Rather they focus on patients with multiple chronic disease, or those with the least financial resources. The CNL is designed to support those who require high levels of care coordination. The CNL is trained to develop, implement and evaluate evidence-based protocols to change processes. CNLs aren't involved in management, but they do play a role in cost containment and financing. The role has been met with varying stages of acceptance, for example the VA has fully implemented the CNL role throughout their system, which includes 1400 facilities.2&3 WHAT DO YOU NEED TO BE A CNL? To begin course work as a CNL, you will need a BSN or you will need to be an RN with a BS in another field. The goal of the CNL is to expand on skills and competencies of BSN programs. Leadership courses teach skills, interpersonal development, understanding of systems, skills in communication, critical thinking. Schools with CNL programs must develop partnerships with practice sites like hospitals and clinics. The partners are actively involved in curriculum design and provide settings for the 500 clinical hours needed for the degree. CNL students are precepted 1-1 for 300-400 clinical hours. This creates a bridge between theory and practice.2&3 Graduation from a CNL program leads to certification. The CNL certification is granted for a period of five years. The CNL certification exam is a computer-based three-hour exam. The AACN website provides study modules and everything you might need to pass the exam. If you take the exam at a school of nursing it is $350, but if you take it at a testing center it costs $425.4 Some popular jobs for CNLs include Clinical liaison, clinical wound specialist and post-acute clinical navigator. The national median annual wage of $84,000. The pay grade for CNLs is much higher than that of registered nurses (average $65,470) due to their extensive knowledge and the scope of their job. The U.S. Bureau of Labor Statistics has estimated growth for all nursing professions to be 19% by 2022, but most health care facilities are looking for professionals with higher degrees (MSN and Doctorate).5 There are 90 schools of nursing with 192 practice sites in 35 states and Puerto Rico with CNL programs. As of 2011, over 700 nurses obtained CNL, but it isn't known yet how many nurses with CNL degree practice in a designated CNL role.2,3&4 According to the CNL website on the AACN webpage, there are 6,500 CNLs nationwide. The AACN advertises a CNL Summit, Research Symposium, how to get CNL certification, and they even have a CNL day, March 19th.4 The AACN website has resources for how to find a CNL program: American Association of Colleges of Nursing (AACN) > CNL Certification > Apply for the Exam > Eligible CNL Programs OUTCOMES Are outcomes improving? Where CNLs are incorporated into staffing mix, results show that outcomes improve; patient, nurse and physician satisfaction increases; fall rates, pressure ulcers, and nosocomial infections all decrease; there are lower readmission rates, improved financial gains, better communication, improved hand-off care, and decreased nurse turnover.2&3 Paying for a graduate degree can be daunting, however there are multiple resources available, including grants and scholarships at the local, state and national level.6&7 For more information on the CNL degree you can send an email to CNL@aacn.nche.edu REFERENCES 1. Stevenson, J. C. (2017). First master of science nursing degree answers growing need for hospitals. University of South Carolina-Upstate Spartans. Summer, p. 11. Retrieved from: Graduate Programs and Resources: Master of Science in Nursing | USC Upstate 2. Baernholdt, M., & Cottingham, S. (2011). The clinical nurse leader - new nursing role with global implications. International Nursing Review, 58, 74-78. 3. Stanton, M. P., Lamon, C. B., & Williams, E. S. (2011). The clinical nurse leader: a comparative study of the American association of colleges of nursing vision to role implementation. Journal of Professional Nursing, 27(2), 78-83. 4. About CNL 5. What Is The Salary Outlook For Clinical Nurse Leader? - 218 NurseJournal.org218 NurseJournal.org 6. Featured College Scholarships 7. Nursing Scholarships - Scholarships.com
  11. Throughout my career as a nurse, I have advocated for nurses to seek higher degrees. After I obtained my ADN, I converted my previous BS into a BSN, and then got my MSN. Most recently, I finished my PhD and I just got hired as an assistant professor at the University of South Carolina Upstate (USC-U) in Spartanburg (Woot! Go Spartans)! It has always frustrated me that nurses can still graduate with a 2-year degree for entry into practice, not because an ADN doesn't have the requisite skills for patient care, but because patient safety is improved when nurses with higher degrees care for patients. Nurses with higher degrees have an increased interdisciplinary voice, and an increase in job satisfaction as well. ADN PROGRAMS ARE IMPORTANT This article isn't about the debate over what degree is needed for entry into practice. Though the AACN recommends the BSN for entry into practice, that doesn't mean that the ADN nurse isn't well prepared. ADN nurses are needed to address the nursing shortage. The main reason for choosing a BSN is that its focus on general education courses will better prepare a nurse (AACN). Multiple studies have shown improved patient outcomes when BSNs are doing the care. In addition, nurses with higher degrees have a more equitable seat in interdisciplinary settings. When nurses (2 years preparation) are sitting down with Physicians (8 years), Physical Therapists (7 years), Social Workers (4 years), and Pharmacists (8 years) to discuss patient outcomes, there may be a lack of respect from other healthcare practitioners, and the nurse herself may also feel insecurity at the difference in education. Finally, studies have shown that nurses with BSNs make more money, have more career options, and are better situated to earn an advanced degree.1 GET THAT BSN! More ADNs (81,633) received state licenses than those who received BSNs (72,637) in 2016.2 Despite many nurses wanting a BSN, there are barriers, one of which is geography - many potential nurses don't live near where a traditional BSN is available. Another is finances. Tuition at a four-year university isn't something students can afford. Solutions include many community colleges offering bachelor's degree nursing programs. A BSN can be obtained in the traditional manner which is four years at an accredited university or college, there are accelerated programs for those with degrees in other fields, or you can enroll in a wide variety of conversion degrees such as LPN-BSN, RN-BSN and even dual degrees, which allow you to attend community college for two years, followed by enrollment at a four-year institution. Many of these degree programs are offered online and can be done one class at a time. Often the place you work will reimburse you for your educational expenses as well. I already had a BS in biology, so I decided to get my ADN, followed by enrollment in an online RN to BSN program. The hospital where I worked as an ADN offered tuition reimbursement, so I didn't pay a penny for my BSN degree. There are so many things you can do with a BSN, including certification. The list of potential certifications is long and interesting. I was a certified oncology nurse, with chemotherapy certification, now I have certifications in patient safety and holistic nursing. A growing trend is certification in dialysis nursing, but you can get certified in anything from Med. Surg. to Certified Breast Care Nurse to Wound Ostomy and Continence Nurse (WOCN).3You can also be a legal nurse consultant or get involved in travel nursing to spice things up. If you want to be a nurse researcher, an informatics nurse, a critical care nurse, a nurse advocate, or a public health nurse, you'll need your BSN. ADVANCED PRACTICE REGISTERED NURSES Though there is controversy and discussion about which nursing roles are under the APRN umbrella, in actuality, there are only four roles that should be legally designated as APRNs. These roles require regulation above the RN license because they provide care to patients beyond the RN scope of practice. This expansion to scope of practice includes diagnosing, treating, prescribing, and administering anesthesia. Because this expanded scope can put the public at risk, individuals who have APRN status must meet specific qualifications that include education and certification above and beyond the RN role. Boards of nursing legally recognize APRNs to assure public safety.4 An APRN is an RN who has earned a graduate-level degree like a Master of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP). There are four recognized APRN roles: certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS) and nurse practitioner (NP). In addition, nurses can gain specialized knowledge in one of six populations: Family Adult-gerontology Neonatal Pediatrics Women's health Psychiatric-mental health I was surprised to discover that though the US clearly defines these roles, in other countries these titles are not protected. In other words, there is no international agreement about the use of titles to distinguish APN roles. OTHER ADVANCED DEGREES Healthcare terminology is confusing, and nursing is no exception. You can be a registered nurse with an Advanced Degreewithout being an Advanced Practice Registered Nurse! An advanced degree simply means anything beyond a bachelor's degree. An MSN is needed for employment as a case manager, nurse educator (job opportunities are predicted to be up by 19% by 2022!), chief nursing officer, nurse administrator, diabetes nurse and health policy nurse. A new role for nurses is the Clinical Nurse Leader. CNLs are master's level nurse graduates with the skills and knowledge to create change within complex systems and improve outcomes while they remain direct care providers. I'm going to write more about the CNL in Part 2. Becoming a nurse attorney is another option, requiring an RN and a legal degree, which takes three years in addition to an undergraduate degree of some kind. (I wrote an article about nurse attorney Lori Brown. Allnurses has a feature where you can ask nurse attorney Lori Brown any question you like! And what about that PhD (Doctor of Philosophy)? You have to have a Doctorate (either NP or PhD) to teach in MSN, PhD or NP programs, so nurses who want to go the academic route, typically obtain a PhD (I wrote about the difference between NP and PhD here. Nurse researchers and Chief nursing officers in large, well-respected institutions typically have a terminal degree as well. You can get your PhD online or in a traditional, seated environment from a wide variety of schools.5 WHERE TO GO? The National League for Nursing does a survey of nursing schools every two years. In 2014, they reported 1,869 basic RN programs, including 1,092 ADN programs, 710 BSN programs and 67 diploma programs in the U.S.6 Where you get your degree does matter. It's important to choose an accredited school - for example the Veterans Association won't hire graduates from schools that don't have accreditation by ACEN or CCNE.7 Many educational programs offering higher degrees won't accept transfer credits from schools that lack accreditation. In addition, you want to choose a program that fits your lifestyle. Not everyone will want to be in an online program. Consider how often the school admits students - if they only admit every Fall, for example, if you have to drop out for any reason, you'll have to wait a year to rejoin the next class. It's also important to look at NCLEX pass rates. If the school you are considering doesn't have a successful NCLEX pass rate, you have to ask yourself how well they are preparing their students? And schools who fall below NCLEX passing standards for several years can be shut down. Allnurses has a great resource when you are looking for a school - they have peer reviews of nursing schools. Click here for more info. Be careful with sites that advertise! Often those organizations will only present those schools who have paid for advertising. Even articles that look benign, like "A Guide to Become a Registered Nurse" which I found on google, can actually be a hidden advertisement for select nursing schools. It's difficult to find a comprehensive database of nursing schools. One tool I have used is the U.S. News and World Report. They rank colleges each year according to multiple criteria and include tuition, enrollment, and acceptance rates as well as many other details.8To unlock all the features offered by this organization however, you have to pay $40.00 The AACN has a resource page for students to help you find a nursing program. You can search by state or by type: American Association of Colleges of Nursing (AACN) > Students > Find a Nursing Program. They have also included a link to a website that allows you to apply to several nursing schools with one application: American Association of Colleges of Nursing (AACN) > Students Be sure to tune in to Part 2, where I talk specifically about the role of Clinical Nurse Leader. REFERENCES Advantages of a BSN The battle over entry-level degree for nursing continues Credentials and Certifications Advanced Practice Registered Nurse 31 best specialty career choices for nurses Number of Basic RN Programs Veterans Administration Healthcare Application Best Colleges in South Carolina
  12. SafetyNurse1968

    Oh The Places You'll Go: The Why, How and What of Higher Education

    Thank you for clarifying! I so appreciate it. You are so right.
  13. SafetyNurse1968

    What Do You Want to Be When You Grow Up? Try Clinical Nurse Leader

    Are you a CNL???
  14. BE A DETECTIVE I'm teaching nursing fundamentals right now, and one of the things I tell my students over and over again is the importance of observation. Assessment and inspection are two of the fundamentals of Fundamentals. I tell them the job of nursing will never get boring if you think of each patient as a mystery. "Try to be like Sherlock Holmes (yes, they still know who that is, much to my joy) or House (from the TV show) and solve the mystery". No matter what your patient says, I want you to think, "What's really going on here?" I'm going to tell you a true story (names and relationships have been changed to protect the innocent). It has a beginning, a middle, and an end, but I am leaving off the end, for now. Because I believe you can solve this mystery, I really do. So read on, and see if you can unravel the Mystery of The Dog in a Fedora. Ruth It's been a few years since this happened, and it concerns my cousin Ruth. I hadn't seen her in a few years - we live on opposite ends of the country, but out of the blue she called to ask if she could come to live with us for a few months. She was 18 and living a vagabond life, driving around the country in a PT cruiser with her dog, Mavis, exploring, meeting weird people, and working odd jobs. She had just finished picked oranges in Florida, and was looking for a break from living rough until a job opened up for her on the west coast picking apples. We weren't happy with our nanny, and I loved the idea of connecting with actual family, so we agreed she would stay for a few months and keep and eye on our four children, taking them places, keeping them safe, and bonding. The version of Ruth who showed up on our doorstep was thin for her 5'9" frame. She had cropped her hair short and dyed it purple. She has piercings and tattoos in odd places, but is a smart and very funny girl. I've known her all her life, and I trust her, despite her appearance. You might think from the description that Ruth is into drugs and alcohol, but I believe her when she adamantly denies using any mind-altering substances, because she lost her father at a very young age to suicide. Ruth is my cousin by a second marriage, and before her mom married my uncle, her dad had been an addict with a diagnosis of manic depression. When she found out he had killed himself, she hadn't seen him in years, but she had memories of him coming home drunk and high. The kids adored her, probably because at the time she was staying with us she was just a really big kid herself. One of their favorite things to do was take a fresh pack of markers and draw all over each other. I would come home from work and find Ruth with a pink mustache, lovingly drawn on by my 5 year-old daughter. I never knew what each of my four kids would have on their arms, backs, legs and tummies when I arrived home. One day it would be cartoons of dogs and cats, another day it would be an entire Shell Silverstein poem. We all thought it was hilarious, and it washed off in the bath. Ruth did a great job entertaining my kids, but a less than great job with the other duties of a nanny. She didn't wash the dishes, the guest room looked like a bomb had gone off in her suitcase, and the kids toys were always everywhere but in the toy box. You make exceptions for family members because you love them. SOMETHING ISN'T RIGHT As time went on however, I began to notice how tired RUTH seemed to be. She would sleep until 5 minutes before I needed her to watch the kids. She would go to bed the moment I got home. The kids started talking about how she was too tired to play. A neighbor called me one day to report my 2 year-old son was wandering in the front yard, alone, without any pants on. I called Ruth, who answered promptly, saying in a quiet voice that she was sitting down, leaning up against the front door frame, too tired to walk around with the little guy. His lower extremity situation was normal for him - he was a staunch nudist. It would have surprised me if his pants had been ON, but I was worried that the kids weren't getting the care they needed to be safe. That evening, after the kids went to bed, I knocked on Ruth's bedroom door. A faint murmur let me know she was awake and I entered the guest room. After moving aside a pile of clothing, I sat on the bed and said, "Ruth, what's going on?" She was quiet for a long time. Finally she mumbled "I'm just so tired...all the time." "Are you not sleeping?" "I feel like all I do is sleep, but it's never enough." I know teenagers need a lot of rest and sleep, but when it interferes with activities of daily living, my nurse radar goes up. I did a visual scan of Ruth and the room. She looked tired, with dark smudges under her eyes, and her skin was pale, but she was always pale, favoring the goth lifestyle of no sun at any time. I observed no signs of drug or alcohol use, but those could easily be hidden. "Is this normal for you? I mean, I haven't seen you in a few years, maybe this is how it is all the time?" She started chewing her lip, and looking at her chewed fingernails she said, "I feel like it's been for the last few months. I used to do stuff. I used to ride horses. I picked all that fruit." That was a good piece of evidence. She had successfully picked fruit all spring - keeping a very physical job that was probably based on quotas. "What's changed?" I was trying not to pry too much, but it had to be done. "I went off the pill a while a go, and I've been bleeding a lot, on and off for a while now." Now we were getting somewhere! Sexually active, recently stopped birth control. "Are you bleeding a lot?" She shrugged and looked away. I could tell she was embarrassed. She shook her head indicating a negative. "Well you could be a little anemic, maybe you could try eating some spinach or broccoli. Heck, I could fry you up some chicken livers." She smiled at that, which was nice to see. "I'm a vegetarian, remember?" "We've got to figure something out - you have to be able to keep the kids safe, right? Do you need a few days off?" "No, I'll be ok. Sorry. I've probably just got a cold or something." "Keep me posted ok? Let me know if you feel worse, and just keep talking to me, ok?" "Sure." I left her then, sure that she went right back to sleep. I was worried about her. Her voice seemed flat and she didn't look like her usual cheerful self. Since depression runs in her family I wanted to keep an eye on her mood as well. "Ruth is her own person, as I am sure you know. Once she left home, she didn't want any more mothering. You know about as much as I do at this point." My aunt Nancy said in response to my phone call that evening. No insight was going to come from Ruth's mom, then. HALLUCINATIONS A few weeks went by, and I could tell Ruth was really trying, but I could also see that she wasn't feeling any better. She seemed listless, and tired, and had even stopped coloring my children. She was never one to chat much, but now she was practically silent. I decided to head into her room for another fact-finding mission. "So it seems like you aren't feeling any better. I see how hard you are trying. I'm worried about you. Are you feeling down?" As before, there was a long silence before the answer. "I'm having some weird thoughts." "What kinds of thoughts?" "I don't know. Just bad thoughts." "Ruth, you have to tell me what's going on. It's my job as someone who loves you to get you to open up. Please talk to me." Ruth took a deep breath and then said in a voice so quiet I could hardly hear her, "I'm seeing things." That wasn't what I was expecting. "How do you mean?" "When I lie down to go to sleep, I see lights on the ceiling. They move around. It's actually pretty cool." I didn't agree with that statement. "You're not taking anything, no drugs, no alcohol?" "Gross, no!" finally she showed a little spirit.She continued, with a small laugh in her voice. "There's a gray cat." "A grey cat." I repeated stupidly. We don't have a cat, much less a grey cat. "You've seen a grey cat around the property? "No, it just appears in my room, or in the kitchen sometimes." My whole body was tingling with this information. I was running through a list of things that could cause hallucinations, and none of them were good. Schizophrenia, tumors, brain injury, the list was not anything I wanted for my cousin. "I'm not sure I understand, Ruth. Are you saying you are seeing things that you know aren't really there?" I could see tears in her eyes as she looked away at the wall. "Yeah, I know it sounds crazy. Sometimes your dog comes in and sits down and she has a hat on. She's wearing a black fedora on her head." I sucked in some air and tried to get a handle on my thoughts. ETIOLOGY OF HALLUCINATIONS After doing some research, I was surprised that hallucinations in children are more common than you might think. An article I read states that most children ages 9-11 have had at least one psychotic-like experience, including hallucinations. There is an eight percent hallucination prevalence rate in children, however they tend to be transient and resolve spontaneously. In 50-95% of cases, after a few weeks or months.1 Causes of hallucinations include many organic problems, which I list below, but there are also some environmental factors I was unaware of including stress and anxiety, as well as childhood trauma. A positive relationship exists between hallucinations and sexual, physical and emotional abuse, but not parental death.2 Hallucinations are also related to drug use3 (LSD, psilocybin/mushrooms, mescalin/peyote), and a link has even been found between cannabis use and schizophrenia. Those who smoke cannabis are five times or more are more likely to develop schizophrenia, and researchers have found that if you are prone to schizophrenia, you are more likely to try cannabbis.4 Organic causes of hallucinations Schizophrenia Dementia Delirium Charles Bonnet Syndrome and Anton's syndrome (both involve vision issues.) Seizures (small, brightly colored spots or shapes that flash.) Migraines Peduncular hallucinosis (infarct of midbrain,) Sleep disturbances Tumors Inborn errors of metabolism Creutzfeldt-Jakob disease (a fatal, progressive neurodegenerative illness from prions.) Mood disorders (a significant relationship between hallucinations and suicidal behavior, those with MDD, and psychotic experience 14-fold increase in suicide plans or attempts.) HEADING TO THE EMERGENCY ROOM I will admit that I've seen things in the woods that I know weren't really there. I occasionally see things out of the corner of my eye after I've been running or biking for a long time. Once during an endurance race, I saw the little black dog I adored in college. She died many years ago, but we spent so many happy hours in the woods together. I don't think a trip to the ER is needed when I see things after pushing my body to its physical limits. Ruth, however needed to go. I questioned her further, "You said you are having bad thoughts. Is that what you meant, the hallucinations? Or is there something else? Are you having thoughts of harming yourself?" I know she's a cutter - I had seen the marks on her thighs under the very short dresses she wears, but the marks looked old and I hadn't brought it up, not wanting to pry into her private life at the beginning of the summer. Now it was time to pry. Ruth replied, "I don't know." "Well I don't know either." I said with exasperation. I got up, went around to her side of the bed and gave her an awkward hug. She obviously didn't want it, but I was in full mom mode. "Can you promise me you won't hurt yourself?" Another long silence as I held her, and she did soften a little bit into the hug. She finally whispered, "No." Ok then. I have never had to take anyone to the Emergency Room before. I called first, and they said to just drive up and bring Ruth inside, through the same doors that people with open head wounds, gunshots, and overdose travel. I called Ruth's mom while I was on the way, and she agreed I was doing the right thing. We didn't talk long because Nancy wanted to get moving on buying a plane ticket to come be with her daughter. Taking Ruth to the ER, not knowing if she would be admitted to the "psych ward" was one of the worst experiences of my life. Watching them wheel her away, not being able to protect her or keep her safe, and having to trust that the hospital would do the right thing - that was incredibly hard. SHE'S OK! Lucky for all of us, it all turned out ok. They kept her for four, long days. After her mom arrived, she went and camped out at the hospital so she could be there for each and every visiting hour. I begged Nancy to bring me copies of all the lab reports. I wanted to get as much information as possible. We talked at least three times a day. I kept telling her what to ask, and imploring her to take copious notes. "If they see you taking notes, they'll take better care of her!" I shouted into the phone. I love my profession, and I love being a nurse, but I know how easy it is for well intentioned, highly trained healthcare workers to make an error. I was determined to keep Ruth as safe as she could be. I'm going to stop here for a little while. I wonder what you think was going on with Ruth? I've given you the same information I had. I still feel so guilty for not figuring it out sooner. Why was my dog wearing a fedora? The rest of the story will be in part 2. References 1. Hallucinations in Children, Adolescents: Psychiatric, Medical Causes, Assessments and Treatment | Psych Central Professional 2. Visual Hallucinations: Differential Diagnosis and Treatment 3. Common Hallucinogens and Dissociative Drugs | National Institute on Drug Abuse (NIDA) 4. Marijuana use and schizophrenia: New evidence suggests link
  15. BACK STORY Read the full story HERE. A few years ago, my cousin Ruth came to live with us for the summer and be a nanny to my four kids. While she was living with us she presented with increasing fatigue and listlessness. Eventually she admitted to having hallucinations, describing lights flashing on the ceiling as she tried to sleep, and of seeing our family dog wearing a grey fedora. She had always been pale and thin, she was a vegetarian, and she had recently stopped taking her birth control pills, which had led to intermittent bleeding for several months. In addition, she had a family history of suicide and manic depression. I suggested she try to eat more iron rich foods, and keep me posted on her fatigue level, but she didn't tell me much - typical of a teenager. Finally, we ended up taking her to the ER when she admitted to having thoughts of harming herself. I had considered anemia as the source of her fatigue, but when I questioned her about the amount of bleeding she was having, she had denied that it was excessive. In my experience anemia doesn't cause hallucinations, so when she started telling me about seeing our dog in a hat, given her family history, I started worrying about a mental health disorder, especially schizophrenia, which typically presents in early adult-hood.1 NOT THE USUAL SUSPECTS Ruth was in the psych ward for four days, and during that time they did a full history and physical, including a psychological evaluation, medication reconciliation and a wide panel of lab tests. Though they found signs of depression, that didn't explain seeing my dog in a fedora. What they did find was severe iron deficiency anemia. She had been bleeding longer and more heavily than she had previously admitted, and I could have kicked myself for not taking her to see a doctor sooner. This article is my penance for not picking up on it sooner. I review risk factors, signs and symptoms of the various types of anemia, as well as diagnostic tests and treatments, and there are great resources for further learning. I still don't think I would have put iron deficiency anemia with hallucinations - I have looked far and wide for case studies or research discussing a link between the two. I Googled anemia and hallucinations multiple ways and got nothing. I tried hypoxia and hallucinations as well. I looked on Google Scholar, PubMed and hematological websites, but found very little linking the two. There is an article about a woman with very low iron who thought she was infested with spider eggs (Delusional parasitosis secondary to severe iron deficiency anemaia).2I also found a link between mountain climbing and psychosis, but the authors haven't found a direct link between hypoxiafrom mountain climbing and hallucinations.3 There's also a link between Vitamin B-12 deficiency caused anemia and hallucinations. Some people diagnosed with dementia or Alzheimer's are actually suffering from B12 deficiency.4 Ruth wasn't a mountain climber, she wasn't vegan or lacking intrinsic factor or producing inadequate stomach acid. She was slowly bleeding to death. ANEMIA Anemia is common and affects one-third of the world's population, and more than 3 million Americans. Anemia is defined as any pathological condition leading to significant decrease in total body erythrocyte (Red Blood Cell) mass. Red blood cells (RBCs) carry hemoglobin, an iron-rich protein that binds and carries oxygen to tissues in the body. Anemia occurs when you don't have enough red blood cells or when your red blood cells don't work correctly.5 SAFETY Given the prevalence of anemia, you would think it would be easy to get all the information you need to know on the internet, but not so. I found myself longing for my old nursing school Med/Surg textbook. I found a lot of information for the layperson, describing signs and symptoms, but very little information on diagnostic lab values, and how to do a work-up on someone suspected of having anemia. As a patient safety specialist, I know that multiple organizations recommend up-to-date, easily accessible information be available to healthcare providers. It is often nurses who spot valuable details: patterns in vital signs, low lab values, patient behaviors, family stories, empty vitamin bottles found in a purse (can you hear the patient's voice? "oh, I didn't think it was important to tell the doctor about my vitamins!") When we have access to knowledge, we are better detectives, and have a better chance of keeping our patients safe. TYPES OF ANEMIA 5,6,7 Ruth had iron deficiency anemia, the most common type of anemia worldwide, affecting 10-30% of world population; in the U.S. 11% of women and of 4% men have iron deficiency anemia, but there are many other types of anemia.6 Iron deficiency anemia caused by a shortage of iron in your body. Your bone marrow needs iron to make hemoglobin. Without adequate iron, your body can't produce enough hemoglobin for red blood cells. It occurs in many pregnant women, and is also caused by blood loss - like Ruth's, from heavy bleeding. Ulcers, cancer and regular use of aspirin can cause it as well. Vitamin B12 Deficiency caused by a lack of folate and vitamin B-12.Both are needed to produce health red blood cells. A diet lacking in these nutrients can cause decreased RBC production. In addition, if your body doesn't make intrinsic factor, you can't process the vitamin - leading to pernicious anemia. Chronic diseases Cancer, HIV/AIDS, rheumatoid arthritis, kidney disease and Crohn's can interfere with production of red blood cells. Aplastic anemia Caused by underproduction of red blood cells due to infection, medication, autoimmune disease and exposure to toxic chemicals. Bone Marrow Diseases leukemia and myelofibrosis can cause anemia by affecting blood production in the bone marrow Hemolytic Anemia when RBCs are destroyed faster than bone marrow can replace them. It can be inherited or develop later in life, includes Sickle cell Anemia which is an inherited defective form of hemoglobin that causes RBCs to form a crescent or sickle shape - they die prematurely. Thalassemia A rare inherited blood disorder in which the body makes an abnormal form of hemoglobin SYMPTOMS 5,6,7 When you have anemia, your body tissues lack oxygen, so you may have one or more of the following symptoms: Tiredness Dizziness Weakness Headaches Pale skin Fast heartbeat Shortness of breath Pounding or whooshing in ears Craving for ice or clay (picophagia) Sore or smooth tongue Brittle nails Hair loss Difficulty concentrating Grumpiness Poor cold tolerance Decline in renal function Osteoporosis Sarcopenia (loss of muscle tissue) RISK FACTORS5,6,7 There are many risk factors for anemia: major surgery or trauma, menstruation (especially if periods are heavy) recently given birth, pregnant or breast feeding, GI disease like celiac, IBD, ulcerative colitis or Crohn disease, peptic ulcer, bariatric or gastric bypass, vegetarians, people who don't each iron-rich foods. DIAGNOSIS5,6,7,8 Diagnosis of anemia involves asking many questions. You will want to know: severity; rate of onset; the patient's overall health and oxygen demand; past medical history (menstruation, duration, frequency, flow, pregnancy, blood in stool, blood loss - acute vs. chronic); family history. You will also do a complete physical exam (Pallor, conjunctiva, oral mucosa, nail beds, palmar creases, orthostatic BP changes - intravascular volume shift), lab workup and medication reconciliation. LAB VALUES8,9 Diagnosing iron deficiency anemia is simple. Start with the CBC and look at the RBC count, and Hematocrit and Hemoglobin levels. If those are low, get an order for TIBC, iron and ferritin. A comprehensive list of lab values related to anemia is included, and where it's applicable I have included Ruth's values as well as normal values in parenthesis. Red blood cell size and color: with iron deficiency anemia, RBCs are smaller and paler in color Red Blood Cell count: how many RBCs you have. It's also known as an erythrocyte count. The test is important because RBCs contain hemoglobin, which carries oxygen to your body's tissues. Your tissues need oxygen to function. Ruth: 3.1x1012/L (3.9-5.2x1012/L) Hematocrit: the percentage of blood volume made up by RBCs. Ruth: 23.1% (34.9-44.5 % women; 38.8 - 50.0 % men). Hemoglobin: the oxygen carrying molecule found in RBCs. Lower than normal hemoglobin levels indicate anemia. Ruth: 7.0 g/dL (13.5-17.5 g/dL men; 12.0-15.5 g/dL women). Mean corpuscular volume(MCV): the average volume of red cells. It can be directly measured by automated hematology analyzer, or it can be calculated from hematocrit (Hct) and the red blood cell count (RBC) as follows: MCV in fl = (Hct [in L/L]/RBC [in x1012/L]) x 1000. Ruth 73 fL (78-102fL) Ferritin: a protein that contains iron and is the primary form of iron stored inside cells. The amount released and circulating in the blood reflects the amount of iron stored in the body. When your iron level is low, your body will pull iron out of storage to use it. A low level of ferritin usually indicates a low level of stored iron. Ruth: 4 ng/mL (12-156 ng/mL) Total iron binding capacity (TIBC): tells how much transferrin (a protein) is free to carry iron through the blood. If TIBC is high, more transferrin is free because there is less iron. Ruth: 550 mcg/dL (200-450 ng/mL). Serum Iron: The amount of iron in your blood may be normal, even if the total amount of iron in your body is low - which is why other tests are needed (like the TIBC and Ferritin levels). Ruth: 10 umol/L (10-30 umol/L)7 If it's not iron deficiency anemia, further tests are needed. Click on THIS link for more lab values and images of blood smears.9And check out this Powerpoint based on Hazzard's Geriatric Medicine and Gerontology.8It has flow charts for diagnosis, case studies, and a discussion of microcytic vs. macrocytic anemia (too much for this article!) TREATMENT5,6,7,8 Iron deficiency anemia: taking iron supplements (take on an empty stomach to increase absorption, don't take with antacids, take with Vitamin C, watch out for constipation) and making changes to your diet (red meats, leafy-dark green vegetables, beans, molasses, liver, grains). If the underlying cause of iron deficiency is loss of blood, the source of the bleeding must be located and stopped. In Ruth's case, she had to get back on contraceptives to lighten her heavy menstrual flow. She also had to take iron, and it takes a long time to get iron levels up to normal, unfortunately they can't be corrected overnight, and may take months to replenish. Vitamin deficiency anemia: dietary supplements and increasing these nutrients in your diet. If your digestive system has trouble absorbing vitamin B-12 from the food you eat, you may need vitamin B-12 shots. At first, you may receive the shots every other day. Eventually, you'll need shots just once a month, which may continue for life, depending on your situation. Anemia of chronic disease:no specific treatment for this type of anemia. You have to treat the underlying disease. If symptoms become severe, a blood transfusion or injections of synthetic erythropoietin, a hormone normally produced by your kidneys, may help stimulate red blood cell production and ease fatigue. Aplastic anemia:blood transfusions to boost levels of red blood cells. You may need a bone marrow transplant if your bone marrow is diseased and can't make healthy blood cells. Anemia associated with bone marrow disease:medication, chemotherapy or bone marrow transplantation. Hemolytic anemias:avoiding suspect medications, treating related infections and taking drugs that suppress your immune system, which may be attacking your red blood cells. Depending on the severity of your anemia, a blood transfusion or plasmapheresis may be necessary. Plasmapheresis is a type of blood-filtering procedure. In certain cases, removal of the spleen can be helpful. Sickle cell anemia:administration of oxygen, pain-relieving drugs, and oral and intravenous fluids to reduce pain and prevent complications. Doctors also may recommend blood transfusions, folic acid supplements and antibiotics. A bone marrow transplant may be an effective treatment in some circumstances. A cancer drug called hydroxyurea (Droxia, Hydrea) also is used to treat sickle cell anemia. Thalassemia:blood transfusions, folic acid supplements, medication, removal of the spleen (splenectomy), or a blood and bone marrow stem cell transplant. REFERENCES 1. Schizophrenia Facts and Statistics 2. Delusional parasitosis secondary to severe iron deficiency anemia 3. Mountain Climbing Can Actually Cause Psychosis, And We Don't Know Why 4. https://www.hsph.harvard.edu/nutritionsource/b-12-deficiency/ 5. Anemia 6. Iron deficiency anemia - Diagnosis and treatment - Mayo Clinic 7. Iron-Deficiency Anemia | National Heart, Lung, and Blood Institute (NHLBI) 8. Halter, J.B., Ouslander, J. G., Tinetti, M. E., Studenski, S., High, K. P., and Asthana, S. (2009). Hazzard's Geriatric Medicine and Gerontology, 6thedition: McGraw-Hill: https://www.kansashealthsystem.com/~/media/Files/KUMED/pdf/BM%20Presentation/Differentiation%20of%20Anemia.ashx 9. http://pitt.edu/~mazst19/leoa.html
  16. SafetyNurse1968

    Can You Prevent This Medical Error?

    CASE STUDY Ms. Grant (not her real name), 68-year-old woman, recent cardiac bypass Postoperative for elective cardiac bypass with significant complications: ventilator acquired pneumonia, right-hemispheric stroke, clinically significant GI bleeding, acute tubular necrosis requiring hemodialysis Stated on morning of event: "I feel good for the first time in a long time." Morning of planned transfer to step-down patient was observed coughing and moving head and extremities in uncontrolled manner. BP 220/95 mmHg. No history of seizure or seizure medications Blood was drawn, patient taken for a CT to rule out stroke or cerebral hemorrhage Serum glucose came back 0 during transport to CT lab Patient died after being in coma on life support for 7 weeks. What happened here? A woman well on her way to recovery from a difficult postoperative course was about to be transferred form the ICU to a step-down unit. What caused the seizures? Keep reading to find out (Link to full article is at the end of this blog post)1. MEDICAL ERROR The Institute of Medicine published a report in 2000 called "To Err is Human"2. This report is based on thousands of chart reviews from various hospitals in the late 80"s and 90's. Americans were shocked to find out that medical error kills the same number of people as if a jumbo jet full of passengers crashed every week, with no survivors - approximately 44,000-98,000 deaths per year. These numbers are likely a gross underestimate, with the true number being closer to 400,000 deaths per year.3Recent research suggests medical error is the third leading cause of death in the US. In a report from the British Journal of Medicine in 2016, the authors analyze how medical error fits in with the leading causes of death (heart disease and cancer are still 1 & 2) with lower respiratory disease being 3rdand accident 4th..4 I think it's safe to say that almost no one in healthcare wants to make an error. Despite our best efforts, we continue to harm patients (I talk about this in another blog post. This list shows the most common medical errors. MEDICAL ERRORS Adverse Drug Events6 Catheter-Associated Urinary Tract Infection Central Line-Associated Blood Stream Infection Injury from falls and immobility Obstetrics Pressure ulcers Surgical site infections Venous thrombosis Ventilator-Associated Pneumonia The National Patient Safety Foundation has a Vision Statement: Creating a world where patients and those who care for them are free from harm.5 We can also most likely agree that our goal is for patients to be free of harm - specifically preventable accidental harm. We cannot eradicate human error, but we can build safeguards where we know error is likely, thereby decreasing the impact of errors and potential for harm. TIME LINE Back to the case study. Have you come up with some ideas for what happened to Ms. Grant? Take a look at this time line from the actual incident to give you some additional information. Time Event 0430 Nurse draws blood for routine morning laboratory tests: serum glucose level is 6.72 mmol/L (121 mg/dL) 0600 Medical student visits patient before team rounds. Patient is stable 0610 Cardiothoracic ICU team visits; no new issues are noted. Patient is showing much improvement; team has every expectation that she will make a complete recovery 0620 Patient drinks small amount of orange juice; note in chart indicates patient is stable 0635 Nurses uses straight urinary catheter to drain patient's bladder per standing order. Patient appears well by tired; expresses desire to nap 0645 Alarm goes off, alerting nurse to occlusion of patient arterial line; nurse flushed line with 2 mL of heparin lock flush. 0735 Day nurse receives shift change report from night nurse and assumes care of patient 0745 Night nurse completes shift. Patient is reported to be sleeping soundly 0815 Day nurse discovers patient having seizure activity. Labetalol is given by day nurse for systolic BP >200 mm Hg. Patient physician is called. 0820 1 mg lorazepam given IV by nurse for apparent seizure 0835 Neurology is called for abrupt change in LOC 0842 Emergent CT whos no evidence of intracranial hemorrhage, mass or mass effect. Lab notifies ICU that serum glucose is undetectable. 1 ampule 50% dextrose in water given IV 0855 1 mg lorazepam IV 0905 1 mg midazolam given IV push, patient intubated Where in this time like could an error have occurred that cause Ms. Grant's death? I want to emphasize that she didn't die from any of her multiple post-operative complications. Ms. Grant died as a direct result of an unintended, preventable medical error that occurred between 0430 and 0815. Here is the rest of the timeline, and the piece of information that will most likely lead you to the most obvious cause of her seizure. 0915 Day nurse discovers bottle of regular human insulin on medication cart immediately outside patient room 0920 1 mg midazolam IV push 0945 10 mg chlorpromazine, 6 mg morphine, 2 mg midazolam IV push 0950 1 ampule 50% dextrose in water given 1005 Glucose level of 1.3 mmol/dL (24 mg/dL) reported from lab 1015 1 ampule 50% dextrose in water given 1100 2 ampules 50% dextrose in water given 1245 5 mg labetalol given IV push for systolic BP of 195 mmHg 1315 1 ampule 50% dextrose in water given for serum glucose of 3.1 mmol/L (55 mg/dL) Remainder Blood glucose level difficult to maintain, patient comatose After a thorough investigation of this sentinel event, it was discovered that at 0645, the nurse flushed the patient arterial line with insulin instead of heparin. Due to the presence of insulin on the medication cart, there is no way to determine if this was the first time this had happened. NURSING ROLE I'm teaching fundamentals of nursing right now to brand new BSN nursing students. What follows is a description of what we teach them. The nursing role is to administer medication as prescribed while preventing error and patient harm. What goes into "administering medication as prescribed"? In addition to being aware of federal, state, and institutional regulations, nurses also need to know the nurse practice act and their scope of practice. NURSE KNOWLEDGE OF MEDICATIONS: Generic- given by the original manufacturer which becomes the drugs official name, vs. Trade- name under which the drug is marketed. Look-alike/sound-alike drugs- list produced by the Institute for Safe Medication Practices and the Joint Commission. Classification- indicates the effect of the drug on the body/site of action. Medication Form- the form the medication comes in such as tablet, elixir, powder inhalation, often effects absorption and metabolism Pharmacokinetics describes how a medication enters the body, reach and active state for action, metabolized, and excreted when their effects have been obtained Therapeutic Effect- the expected, desired effect of taking a medication vs. Side effect- expected, unavoidable effects, at therapeutic doses. Adverse effect-undesirable/unpredictable side effects, often severe, Toxic effect- may be a result of prolonged exposure to drug or excessively high dosage, accumulation in the blood, may be lethal in their results Idiosyncratic reactions- unpredictable over or under reaction of a patient to a medication i.e. Benadryl making a child climb the walls when it should really make them sleepy. Allergic reaction- an immune response is elicited, release of antibodies by the body -Anaphylactic- life-threatening, reaction constriction of bronchiolar muscles, edema of the pharynx/larynx, severe wheezing, ShOB Timing: onset, peak, trough, duration, half-life, Route: Parenteral, SQ, IM, IV, Non-parenteral, Oral, Sublingual- under the tongue, Buccal-mucous membranes of the cheek, Topical, Inhalation, Intraocular Measurement: Metric- mL, mg, g, L, Household- drop, cup, tbsp., tsp. , oz. THE FIVE RIGHTS In addition, since 1893, we have been taught the 5 rights as the number one process for safe medication administration. The five rights were first seen in The Nursing Sister: A Manual for Candidates and Novices of Hospital Communities.7 Nursing sisters taught five rights to prevent error: right patient, medication, dosage, route and time. Since then, there have been an increasing number of rights: client education, documentation, client right to refuse, assessment, and evaluation of the client after the medication is administered.8The number of rights increases, but error rates do not change. I have tried to find research to support use of the 5 rights - there isn't much out there - no randomized clinical trials showing that using the 5 (or 6, 7, 8, 9) rights improves patient safety when compared to some other method of safe medication administration. Below you will see safety guidelines from a fundamentals of nursing clinical packet. It's what we are teaching new nursing students to do to prevent medical error. Safety Maintains medical asepsis, sterile technique and standard precautions Maintains proper body alignment and personal safety Demonstrates appropriate use of equipment provided Provides nursing care that maintains the emotional and physical safety of patients and other members of the healthcare team Demonstrates knowledge and identification of national patient safety goals Communicates observations or concerns related to hazards and errors to patient, Families and the health care team, and faculty Organize multiple responsibilities and provide care in a timely manner while using clinical reasoning skills to prioritize care Safe Accurate (each time) Affect (each time) With occasional or with supporting cues And here is a clinical check-off sheet for a return demonstration for safe medication administration BLAME THE NURSE It's obvious that the nurse who gave the patient insulin instead of heparin made a mistake. That nurse gave the wrong drug. That nurse didn't follow the five rights. If we stop with these statements, is it possible this error could happen again to another patient? The answer is YES. We have to go deeper if we want to prevent error. "The single greatest impediment to error prevention...is that we punish people for making mistakes" Dr. Lucian Leape9 GETTING TO THE ROOT OF THE MATTER Doing a root cause analysis is required by the Joint Commission for sentinel events (I wrote about RCA in another blog. Below is the causal tree from the RCA for Ms. Grants death. SOLUTIONS The causal tree shows that multiple factors contributed to the patient receiving the wrong drug. The committee that investigated the death came up with the following solutions: Insulin was added to automated dispensing device Staff were educated to keep medications secured and not on drug cart Nurses were reminded to keep med carts locked Use of multi-dose vials of insulin and heparin prohibited Use of saline flushes to restore patency of arterial lines required instead of heparin Interdisciplinary team to examine how to expedite delivery of medications to patients At the end of every Root Cause Analysis (I have lead many as a former Patient Safety Officer) we always ask, "If these interventions had been in place at the time of the event, could the error have occurred?" If the answer is "yes" then we get back to work. What do you think? Are there any other ideas you have for preventing this type of error? What experiences have you had with medical error? SECOND VICTIMS A "second victim" is a healthcare worker who has been involved in a medical error. Second victims often experience emotional trauma, stress, financial strain, loss of job and loss of peer respect after being involved in an error. Unfortunately, I've been there (yet another blog) If you, or someone you know has been involved in a medical error, please send them to one of these sites to get support and help: ProPublica Patient Safety Action Network Community: Patient Safety Action Network Community Public Group | Facebook Medically Induced Trauma Support System: Home - MITSS REFERENCES 1. Bates, D. W. (2002). Unexpected hypoglycemia in a cricitally ill patient. Annals of Internal Medicine, 137(2), 110-116. Retrieved from: Unexpected Hypoglycemia in a Critically Ill Patient | Annals of Internal Medicine | American College of Physicians 2. Kohn, L., Corrigan, J., & Donaldson, M. (2000). (Editors). To err is human: Building a safer health system.Washington DC: National Academy Press. 3. Classen, D., Resar, R., Griffin, F. (2011). Global "trigger tool" shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30, 581-9. doi: 10.1377/hlthaff.2011.0190. 4. Makary, M. & Daniel, M. (2016). Medical error - the third leading cause of death in the US. British Medical Journal, 353, 1-5. doi: 10.1136/bmj.i2139 5. Institute for Healthcare Improvement 6. Wachter, R. M. (2012). Understanding patient safety. 2nd ed. China: McGraw Hill. 7. Wall, B. (2001). Definite lines of influence: Catholic sisters and nurse training schools. Nursing Research, 50(5), 314-321. 8. Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2013). Fundamentals of nursing (8th ed.). Philadelphia, PA: Elsevier. 9. Leape, L., Epstein, A. M., & Hamel, M. B. (2002). A series on patient safety. Journal of the American Medical Association, 288(4), 501-508. 10. Patient Safety Action Network Community Public Group | Facebook 11. Home - MITSS
  17. SafetyNurse1968

    Can You Prevent This Medical Error?

    I have a course you can take for 1 CE (no charge!) that will answer your question: Safe Medication Administration: Everything You Need to Know to Improve Your Practice – COURSE for 1 CE – Safety First Nursing but to give you the short answer: med errors, Cauti, Clabsi, wrong patient/site in surgery. It really depends on how you define the term "Error". These errors are so hard to capture because we rely on self-report. Falls, chaotic discharge...there are so many! To learn more, you can take a look at this article from Becker's review on the 9 most common med errors: 9 Most Common Medical Errors
  18. SafetyNurse1968

    Can You Prevent This Medical Error?

    If you PM me I will send you the full text article. The case I presented is from the Annals of Internal Medicine. It was published back in 2002, and describes a case that went to the JC for review as a sentinel event. "You can't make this stuff up!"
  19. SafetyNurse1968

    Can You Prevent This Medical Error?

    SO true - this happened back in 2002, and best practice has certainly changed a lot since then!
  20. SafetyNurse1968

    Can You Prevent This Medical Error?

    It used to be, the article was published in 2002.
  21. SafetyNurse1968

    Can You Prevent This Medical Error?

    I appreciate your comments, and I am wondering how just blaming the nurse prevents the problem from happening again?
  22. SafetyNurse1968

    Can You Prevent This Medical Error?

    I agree - but this is the check-off sheet that is used for seniors - it isn't up to me to make changes - I am showing you what I was given. Someday maybe I will be faculty and can advocate for check-offs that are based more on real world nursing.
  23. BACKGROUND ON TYPE I DIABETES In 1910, english physiologist Sir Edward Albert Sharpey-Schafer discovered that Insulin is secreted from the pancreas, but until commercial production of insulin began in 1923, Type I Diabetes (DMI) was a "death sentence". Gary's experience with type I diabetes begins in 1957, when urine glucose was the standard, and synthetic insulin and insulin pumps were still years away from first production.1 TYPE I OR TYPE II? People with diabetes either have a total lack of insulin or too little insulin. Type I used to be called juvenile-onset, and is also called insulin-dependent diabetes affects only 5-15% of all diabetics. The body's immune system destroys all insulin producing cells in the pancreas - without insulin the cells in the body can't absorb glucose (sugar), which is needed for energy. Type II (formerly called adult-onset or non-insulin dependent diabetes) can develop at any age. It commonly appears during adulthood, but can affect children and teens. Type 2 is found I 90-95% of people with diabetes. In type 2, the body can't use insulin correctly - having insulin resistance. As type 2 worsens, the pancreas may make less insulin, causing insulin deficiency. SYMPTOMS Type 1 diabetics commonly experience low blood sugar (hypoglycemia) whereas those with type II won't have hypoglycemia unless they are on insulin or other diabetic medications. Type I cannot be prevented, whereas type 2 can be prevented or delayed with a healthy lifestyle, including weight loss, eating well and exercising regularly. Complications of both include blindness, kidney failure, and increased risk of heart disease, stroke, foot and leg amputations. TREATMENT Treatment for type I includes infusion of insulin with a syringe, pen or pump, and blood sugars need to be checked 4-10 times daily. Type 2 can be treated with weight loss, bariatric surgery, controlling carbohydrate intake and physical activity, as well as oral diabetic medications. Type 2 changes over time and may mean more medication is needed to maintain control of blood glucose. Not everyone with Type 2 needs to check CBGs. THE FIRST INSULIN INJECTION Treatment of diabetes has come a LONG way! Consider the story of the first insulin injection. Leonard Thomson, age 14, arrived at Toronto General Hospital on December 2, 1921 weighing only 65 lbs. He had been diagnosed with diabetes 2 years earlier. He was put on a 450 calorie per day diet and his blood glucose was usually around 504 mg/dl, and he was always acidotic. Doctors only expected him to live a few days. On January 11, 1922, Leonard was injected with insulin isolated from dog pancreas. The next day, his blood glucose was tested and had fallen from 441 to 320.4 but there was still a lot of sugar in his urine. Twelve days later, after working on purification techniques, they repeated the injection and Leonard's blood glucose dropped from 520.2 to 120.6, with practically no sugar in his urine. In the following weeks he continued to get daily injections, with subsequent weight gain and strength. By February six other patients with diabetes had experienced positive results. DISCOVERY OF INSULIN The biggest breakthrough in treatment was the discovery of insulin in 1921, but hypoglycemia continued to be an issue since monitoring was by urine testing, and was crude at best. Allergic reactions to insulin were common (impurities often were 80,000 parts per million - 8%). Modern insulin by comparison is less than 10 parts per million. Major improvements in the tools to manage Type I were developed in late 70s and early 80s with purified insulin in 1982, and the invention of pumps. Improvements in monitoring also helped. Self-monitoring of blood glucose and the introduction of hemoglobin A1c around the same time, allowed measurement of long term control.2 THE INTERVIEW Gary was diagnosed with DMI on April Fools day in 1957 when he suddenly slipped into a coma. "My grandfather was almost aware of what was going on - the symptoms - everything and he rushed me to a hospital. I vaguely remember being put in the backseat of his car. After that what I remember is waking up in an oxygen tent." DIABETES IN THE 1950s Gary said his parents were with him night and day, but that he wasn't really aware of what DMI was at the time. He was too busy enjoying the huge box of toys that he received! When he was discharged, his routine involved a daily shot, which his dad gave him. "Back then there were needles that dad would sharpen on an emery board we had to sterilize and keep [them] in alcohol. We didn't sterilize them every day, we would boil them in distilled water maybe twice a week. Before too long I was practicing on an orange, I learned how to give myself a shot." When I asked Gary about checking his blood sugars he started laughing. "Back then it was urinalysis and the problem with that is what you're seeing is 5 hours before, so when they came out with actually testing blood sugar, and I could find out what my blood sugar was at the time. I would say I probably didn't start testing blood sugar until 1980-ish" GROWING UP WITH DIABETES I asked Gary what it was like growing up with DMI. "When I was younger it was embarrassing when I had to go into the restroom to give myself a shot. I remember one of my first years at camp I had to keep my insulin in the refrigerator in the kitchen of the dining room, so I had to go there in the morning after I got dressed and get my insulin out, and one morning at camp the camp directors daughter was real curious and wanted to see how I gave myself a shot, well I was wearing pants that day, which means I had to take my pants down to do it and I'm going nope, this ain't working (laughter) so I found a restroom." THE STATE OF THINGS Currently Gary sees an endocrinologist once or twice a year, as well as twice-yearly visits to his regular doctor. He also sees an ophthalmologist and a podiatrist. I asked him about his current health and he said, "My current doctor has called me the poster child for type I diabetes. He gave examples of people who were 20 years younger than I was doing terrible, losing eyesight, kidney failure, terrible stuff." He says his goal is to check his blood sugar 5-6 times daily, counts carbohydrates by reading food labels, stay away from sugar and exercise, however he and I both agreed he isn't perfect (I've seen him put away some birthday cake!). I asked Gary if he has always taken such good care of himself. Again he laughed. "When I was younger, see I grew up with four brothers and they were normal, and my dad liked sweets too, and I would sneak, steal, whatever - sweets all the time. I also went trick or treating because the folks wanted to keep me as normal as possible. So I would get bags of regular sugar candy, and as I was trick or treating (mimes eating candy) so my blood sugar was probably just way off the rack. When I was in college, I went to my doctor, he took a blood sugar on me and it was over 700 and he looked at me going 'I don't understand why you're still standing here'. He also talked about how his driver's license was revoked several years ago, and how that was the prime motivator for him to take better care of himself. "I was on the highway and I was not going side to side, but I was going off on the shoulder, and then I got on the side street and I was hitting curbs. Not only that, I passed out right before a red light, and luckily I was not going that fast at that point and almost coasted into the back of an SUV, which stopped. I scratched the bumper of the SUV and kinda smashed my front end." Finally, I asked Gary about how it feels to be a "patient" and if he had any advice for nurses or those who care for patients with DMI. "I wish they wouldn't be so demanding. I feel like they [family members] are always saying, you need to take something. If my blood sugar is low, I'm in a confused state. But I have been there by myself before and was able to react to it. It takes me a little more time to analyze things, so suggesting things calmly, saying you know, you look like you have low blood sugar, can I get you something instead of telling me what to do." He mentioned how difficult it was to get Medicare to pay for him to check his blood sugar 6 times daily, the standard is three times a day. I asked him if he had ever considered an insulin pump to simplify his routine. "I think because I am so active, I honestly feel it would be cumbersome, and because of the fact that I am doing pretty well, I don't want anything to do with it, but that's me. I know Doctors that have them that are Type I." We've been working on him to get a pump, but so far, we haven't had any luck! His advice for those with DMI: check blood sugars frequently, read food labels and exercise! "It's a lifestyle change, and once you get at it and realize how much better you feel and look, you have more energy and you can deal with emotional and psychological things better, it's all good." MOTIVATIONAL INTERVIEWING While I was doing this interview, I thought about all the patients I have talked to who are like Gary in that they know what they are supposed to be doing, they know the right thing to do, but they continue to make choices that don't necessarily support optimal health. With Gary, he is aware that he eats too much sugar, and that he could be more consistent with checking his blood sugars, and with exercise. One thing we do know as nurses, is that simply telling a patient to do something doesn't usually work. There are many techniques for getting a patient, loved one, family member to realize that they need to make changes, and to support them in making those changes. One of my favorite techniques is motivational interviewing, or MI. MI has been used successfully to help people change addictive behaviors - it's a style of counseling that can help resolve the mixed feelings that prevents clients from realizing personal goals. "Motivational interviewing is a way of being with a client, not just a set of techniques for doing counseling."3 I am not an experience practitioner of MI, but I try to remember to use some of the principles when I see a person struggling with something they actually want to do, but can't seem to find a way to do it. It's normal to have mixed feelings about illness, and presenting acceptance of those feelings is the first step of MI - don't judge (easy to say, hard to do!). MI operates under the assumption that an empathetic, supportive, yet directive style provides conditions under which change can occur. When you argue or get aggressive, the confrontation can increase defensiveness and reduce the likelihood of behavioral change. The 5 basics of MI4 Express empathy through reflective listening. Develop discrepancy between clients' goals or values and their current behavior. Avoid argument and direct confrontation. Adjust to client resistance rather than opposing it directly. Support self-efficacy and optimism. The biggest tool is the readiness ruler5-where you try to move the client from talking about reasons "why not", to reasons "why" they should make a change. You can use the readiness ruler by asking, "How ready are you to make a change?" On a scale of 1-10, with 10 being the most ready and 1 being not at all ready. You can then follow up with, "How could you move from this number to a higher number?" and, "Why didn't you rate yourself lower?". The client is coming up with the answers and solutions, not you - making it much easier for the client to be open to change. A final question before finishing the session is, "On scale of 1-10, how confident are you that you can make a change?" When you meet the client again, you can follow up on these questions to see how effective the client's ideas have been, and make modifications as needed. Gary admitted to me that despite knowing sugar is bad for him, he still craves it, and occasionally eats candy, cake or a small bowl of ice-cream. I decided to try a little MI on him. ME: So on a scale of 1-10, 10 being the best self-care - someone who follows every single rule for Type I diabetes, and 1 being the worst - the person who doesn't do anything they are supposed to do, where do you think you would fall? G: Seven and a half. ME: What would it take to get you to an 8 or 8.5? G: (Laughs) Consciously decide that sugar is really bad, although it's good because Stevia has been around for a while, even coconut sugar metabolizes so much better for a diabetic than regular processed stuff. If I want sweet stuff, I should bake it myself and put the right stuff in it. ME: Yeah, you can make a lot of stuff with erithrytol, xylitol -the sugar alcohols that don't affect your blood sugar and Stevia As you can see, motivational interviewing is a tool that focuses on building motivation for and reducing resistance to behavior change. And as you can see, my father-in-law, just like anyone else who has dealt with health issues, wants to do the right thing. Sometimes using the right tools can support people in accomplishing what they know they need to do, and sometimes not. Gary still hasn't got that insulin pump! I've included some videos on how to do MI in the references, please check them out and consider using this tool to support positive change in your patients with chronic illness.6.7.8 REFERENCES 1. History of Diabetes: American Diabetes Association® 2. https://www.karger.com/ProdukteDB/Katalogteile/isbn3_8055/_83/_53/Insulin_02.pdf 3. Miller W. R., Rollnick S. (2013). Motivational Interviewing: Preparing People for Change, 3rd Edn. New York, NY: Guildford Press. 4. Welcome to the Motivational Interviewing Website! | Motivational Interviewing Network of Trainers (MINT) 5. Tools for MI: Page not found - ADEPT Two - Motivational Interviewing - Tools and Techniques.pdf 6. Finding Your Way to Change: How the Power of Motivational Interviewing Can Reveal What You Want and Help You Get There 7. 8.
  24. SafetyNurse1968

    Sick And Tired, Seeing Things? You Might Have Anemia

    It's so much more debilitating than I ever realized. I think the stories of those who have been there really help it hit home - anemia is a big deal.
  25. SafetyNurse1968

    Why Is She Having Hallucinations? The Mystery of The Dog in A Fedora

    Here it is, the answer to all your questions! https://allnurses.com/general-nursing-discussion/sick-and-tired-1175300.html
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