Nursing Revolution

The end of the 19th Century closed with infectious diseases unchecked by modern antibiotics. Fighting the scourge of diseases emerged the nurse, whose primary weapons were hygiene and sanitation. The new century has dawned with a new scourge of "superbugs" mutated and resistant to our modern arsenal of antibiotics.

Because of the enormous risk to patients and health care workers, as well as the cost of nosocomial infection, nurses must learn from the past to develop improved isolation, hygiene and education strategies to address the growing spread of MSRA and other anti-infective resistant organisms. The nurse's role as a frontline healthcare provider allows the nurse a number of opportunities and strategies to address the issue. Three low cost nurse strategies to address the issue include 1.the use of single use plates, trays, spoons, serving ware for MSRA/isolation patients. 2. The improved sanitation and documentation of MSRA room cleaning including charts, accucheck machines, and reusable equipment anywhere MSRA patients are located. 3. the creation of a hospital wide educational campaign, focusing on consistent isolation procedures from patient contact to discharge.
Staphylococcus aureus is a common bacteria, Methicillin-resistant Staphylococcus aureus (MSRA) is a strain that has acquired immunity to anti-infective agents. Although MRSA has been around for years, only recently have these infectious “superbugs” come to public attention. The healthcare community reaction to this growing health crisis has largely been one of disinterest (Weigelt , 2004). The motivation to adjust the current nursing and healthcare disinterest are both financial and patient focused. In 2005, the average total patient cost of treatment for one MSRA infected patient was over $9,000 (Weigelt , 2004). Combined with recent federal regulations limiting reimbursement for noscocomal infections, the financial burden for treating MRSA infected patients will shift to the health care facility. The World Health Organization (WHO) has estimated that as many as 60% of hospital acquired infections around the world are caused by drug-resistant microbes (Dragon, 2006). Infections from central venous lines account for up to 40% of hospital-acquired bloodstream infections (Dragon, 2006). The Centers for Disease Control and Prevention monitored more than 1,200 ICUs from 1992 and 2003, while 36% of Staphyloccus aureus isolates found were multi-resistant in 1992, the figure had risen to 64% by 2003 (CDC, 2006).
The first nursing strategy to combat MRSA is to close the loophole in the hospital isolation room in regards to the food tray, dishware and utensils patients eat from. In many hospitals the same food service items are used and reused for isolation patients and the general hospital population. In theory these trays and dinning ware are sanitized between use, however this system relies on minimally trained minimum wage food service staff to insure proper sanitation is achieved and enforced at all times. Although cost and resource intensive, the safest way to ensure the isolation of patients and prevent the spread of MRSA and other super bugs is to limit or eliminate the use of reusable trays and serving ware in isolation rooms.
Improved sanitation and hygiene is the next strategy in eliminating the spread of nosocomial infections within the health care facility. By documenting and verifying the sanitation of susceptible items on hospital floors with isolation patients, the chain of infection can be disrupted. Charts, Accucheck machines, hand washing stations, and anything that could touch those items are possible vectors of transmission. Routine and documented sanitation of these items and any surface they could come in contact with should be cleaned and recorded (CDC, 2007). Increased sanitation training with an emphasis on "superbugs" should be initiated hospital wide. With the profusion of electronic gear at the bedside, all offering hand-touch sites from which MRSA can spread, basic hospital cleaning should take a higher priority for infections like methicillin-resistant Staphylococcus aureus (Dancer, 2007). From nurses and doctors to food service staff and janitors the entire staff needs to be focused on eliminating the threat of nosocomial infection. As managers of patient care and the Health Care providers with the most patient contact, nurses can play a vital role in overseeing the cleaning and sanitation of the healthcare facility.
Lastly, a nurse led educational program needs to be developed to coordinate and ensure that isolation patients are handled properly from first contact to discharge. To often a laise faire attitude develops in regards to isolation procedures and MRSA. Transport personal such as EMT and other first responders need to be notified prior to transport of isolation patients so that proper isolation procedures can be taken while transporting MRSA infected patients. A recent study of a large urban ambulance fleet found 48% of ambulances were positive for MRSA (Roline, 2007). To limit financial liability and improve communication with these pre/post care providers, routine admin and discharge testing should be performed to verify that the receiving and discharged patient did not acquire MRSA while at the hospital. This can also be used as a tool to monitor and aide first responders by alerting them to the need to sanitize their vehicles/gear before and after a particular patient. Furthermore, admin/discharge testing can be used to monitor trends in MRSA infected patients.
The founders of nursing faced unsanitary hospitals without the aide of antibiotics. Today we face a similar scourge of bacterial infections with dwindling options to fight off these infectious agents. The answer to our dilemma lies in the history of nursing. By improving our isolation, sanitation and hygiene procedures, the spread of MRSA and similar “superbugs” can be slowed and even stopped. Let us look to history as we face the modern challenge of antibiotic resistant bacteria. It cannot be necessary to tell a nurse that she should be clean, or that she should keep her patient clean,–seeing that the greater part of nursing consists in preserving cleanliness (Nightengale, 1859). Thru improved hygiene, sanitation, and nursing education, the threat of MRSA and the other "superbugs" can be overcome.


Isolating MRSA infected patients is an effective intervention to prevent the spread of nosocomial MRSA infections within a hospital; however a complete isolation is an expensive proposition.

The first disadvantage is the cost/inadequate insurance coverage of the patient population. Single use disposable plates, trays and serving ware is expensive in relation to the standard reusable hospital trays, plates and serving ware. The added cost of these isolation protocols may not be covered by many current insurers. (Elixhauser, 2007). Ultimately the financial burden is passed on to the health care consumer in the form or higher hospital bills for the uninsured and higher medical insurance rates for the insured.

The second disadvantage is the enormous environmental impact using so many more disposable items will create. Although patient safety is a priority, a hospital does not exist in a vacuum, and faces the same environmental issues as the real world. Disposable plates, trays, and serving ware will need to be disposed of as hazards waste and likely incinerated like most bio-waste. The incineration of this additional waste created will negatively impact the hospitals pollution production. The current political environment of state and federal governments limiting industrial CO2 and other pollutants will impact the hospital of the future and may interfere with the drive to isolate patients from MRSA.

Admissions into US hospitals are generally via 3 routes: transported to the ED via EMS, self transported to the ED (walk ins), and scheduled admissions (non-ED). Patients admitted to the ED via EMS transport face the greatest risk of acquiring a nosocomial MRSA infection. A recent study of a large urban ambulance fleet found 48% of ambulances were positive for MRSA (Roline, 2007). Walk-ins to the ED are the next greatest at risk, as a large number of potentially infected patient mingle in the waiting room and in the ED. This melting pot of patients makes the ED the gateway for MRSA to enter the hospital, and the primary vector of hospital borne MRSA infections. The second intervention to minimize the spread of hospital acquired MRSA is to transform the ED into an isolation unit and assume all patients are carriers of MRSA. By applying MRSA isolation protocols in the ED the spread of MRSA within the ED and throughout the hospital can be reduced.

The primary disadvantage of admission/discharge testing is inadequate insurance coverage / cost. The cost of turning an MRSA testing for every patent that enters and leaves the hospital is significant. (Elixhauser, 2007). ().Who will pay for the additional testing? A large portion of urban hospital patients have little or no insurance and routine MRSA testing may not be covered for insured patients. Further complicating the issue is the cost of success. As more patients are identified as MRSA carriers, more patients will be treated for MRSA increasing costs further. More patients in the general hospital population would be treated with expensive isolation protocols, and expensive anti-infective treatments.

The second disadvantage of admission/discharge testing for all patients is the socioeconiomic impact. Hospitals in high density low socioeconiomic areas will be disproportionally affected by the increase cost of admission / discharge testing. Depressed socioeconomic communities have increased risk factors the spread of MRSA including IV drug use, homeless populations, and a larger percentage population without medical insurance. These large urban hospitals face increased cost with less income to offset those costs. The financial reality is that the hospitals most needing MRSA testing is least able to afford it.

A third disadvantage is shifting the “MRSA blame” to pre/post hospital care providers such as EMS and nursing homes (Roline, 2007). While admission/discharge test may protect the hospital from nosocomial infection related cost increases, pushing the blame on to pre/post hospital care providers such as EMS and nursing homes only shifts the cost to vital partners that can ill afford the additional costs as well. Recent Medicare rule changes that eliminate payments for nosocomial infection place the financial burden of MRSA onto the entire system. It would be a bleak future indeed to have a pristine MRSA free hospital but have no EMS to bring the patients to us and no nursing homes to discharge our patients to. Clearly shifting the financial burden around will only reduce our ability to address the MRSA conundrum.



Centers for Disease Control and Prevention (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Retrieved November 4, 2007 from http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

Centers for Disease Control and Prevention (2006). Management of Multidrug-Resistant Organisms In Healthcare Settings. Retrieved November 4, 2007 from http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

Dragon, N (2006). Fighting today's superbugs: infection control at the forefront. Australian Nursing Journal, 14(2), 16-9. Retrieved October 29, 2007, from Proquest

Forsha B. (2007). Best-practice protocols: Reducing harm from MRSA. Nursing Management, 38(8), 22-27. Retrieved October 29, 2007, from Proquest

Hall, S (2007, February). Infection control: implementing principles in primary care. Practice Nurse, 33(3), 47-51. Retrieved October 29, 2007, from Proquest.

Nightingale, F (1860). Notes on nursing: What it is, and what it is not. New York, NY: D. Appleton and Company.

Roline, C (2007). MRSA colonization in ambulances: Are you taking proper precautions?. Retrieved November 4, 2007, from EMS Responder.com Web site: http://www.emsresponder.com/web/online/EMS-Education-and-Training/MRSA-Colonization-in-Ambulances/5$5711

Weigelt, J, Itani, K, Stevens, D, Lau, W, Dryden, M, & Knirsch, C (2005). Linezolid versus vancomycin in treatment of complicated skin and soft tissue infections. Antimicrobial Agents and Chemotherapy 49, 2260-2266. Retrieved October 29, 2007 from http://aac.asm.org/cgi/content/full/49/6/2260

DeLoach,, C (2007). Pollution prevention workshop for the healthcare industry. Retrieved February 1, 2008, from WRPPN Web site: http://www.wrppn.org/hospital/azhospitalp2.cfm

Steiner, C., Elixhauser, A., Schnaier, J. The Healthcare Cost and Utilization Project: An Overview. Effective Clinical Practice 5(3):143–51, 2002.

Elixhauser, A, Steiner, C.(2007) .Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals, 1993–2005. HCUP Statistical Brief #35. July 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb35.pdf

Cantlon, (2007).Significant pathogens isolated from surgical site infections at a community hospital in the Midwest. . American Journal of Infection Control. Volume 34, Issue 8, Pages 526-529.





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Crohn's Disease

Crohn’s Disease is a life-long, debilitating form of Inflammatory Bowel Disease (IBD) that can cause many complications. Like most autoimmune diseases, these complications and unpleasant symptoms may be unpredictable and difficult to control, which can cause a sense of powerlessness and lead to depression. A. Lei Correa



Because Crohn’s Disease affects mental as well as physical health, the nurse promotes wellness by thoroughly educating the patient on the disease process of Crohn’s Disease, nutrition and pharmacological management, and uses specialty skills to provide care and emotional support using a holistic approach.
The most common and initial indicators of Crohn’s Disease are fatigue, diarrhea, abdominal pain, gastrointestinal bleeding, and weight loss. These symptoms may also be present in patients with other forms of IBD, therefore thorough assessments and specific diagnostic testing is extremely important to avoid misdiagnosis. Since Crohn’s Disease is most often autoimmune (the body tissues attacking itself), patients may experience a multitude of other complications and exacerbations including arthritis, osteoporosis, anemia, malnourishment, fistulas, renal and hepatic disorders, vision problems and sensitive skin, just to name a few. Rayhorn and Rayhorn (2002) explain that this disease does not always effect just the bowel, “Internal organs, the eyes, blood, skin, and the musculoskeletal system are all potential targets for the devastating effects of this disease, known collectively as extraintestinal manifestations, or EMs”.
Gaining knowledge of Crohn’s Disease is the first step to remission. Patient education is one of the most important aspects of nursing; what is told to the patient about the disease and what to expect, and how well that information is understood will determine the patients’ self-perception, self-care, and choices in regards to disease management. The nurse educates the patient according to their learning ability, and (with permission of the patient to protect health information) educates family members who may be taking on the role of care-giver. An individual experiencing the unpleasant signs and symptoms of Crohn’s Disease is not necessarily eager to learn, and the nurse prepares for this by providing resources, pamphlets, and other reading material so it is convenient for the patient when they are ready to soak in more information. The age of the patient is also a factor. The patient should be informed of support groups in their area and can also be referred to the Crohn’s and Colitis Foundation of America (http://www.ccfa.org) (Rayhorn, 2003). Providing information with pictures will of course make it easier to visualize that which cannot be seen. The severity of the patient’s condition should be clearly understood, as well as warnings of potential problems.
Nutrient deficiency is a complication that should constantly be monitored because it can occur during flare-ups or while the patient is in remission. A significant amount of calories and carbohydrates for energy, and adequate hydration every day is absolutely vital in maintaining optimal health. Nutrient absorption is decreased in patients with Crohn’s Disease because the intestines do not function as well as in a healthy individual. Patients will become aware of the type of foods that will irritate their bowels and which foods are well tolerated. According to a webpage created by the New York Methodist Hospital, foods that have irritation potential include raw vegetables, alcohol, simple sugars, and caffeine because they are associated with inflammation. Other inflammatory foods are fruits with a lot of sugar such as grapes, watermelon or pineapple (2002). Sometimes medications can be the culprit for malnutrition. For example, Prednisone is a common drug for Crohn’s Disease patients, but it can cause osteoporosis, and therefore is treated with calcium and Vitamin D supplementation. Iron deficiency is also common, but oral iron supplementation is often not tolerated in patients with Crohn’s Disease and would then iron delivered intravenously or by injection. In extreme cases of the disease, enteral feeding can induce remission, as well as TPN in which bowel rest may be required (Jeejeebhoy, 2002).
Such a debilitating disease can cause the patient to feel powerless and depressed. Being a counselor and an active listener can make a drastic difference in the patient’s self-perception and quality of life. Specialty nurses who have become active participants in gastroenterology have made a huge difference in patients with Crohn’s Disease. Specialty nurses can improve disease management on a whole different level than just a practitioner. There is a motivation for change in the healthcare system as we advance and make new discoveries. Kamm & Norton (2002) agree that, “Changes may also come from a real desire to move the focus of healthcare away from an insensitive technological approach to one based on holistic care” (p. 331). Patients can be taught how to self-medicate when they are having a flare-up; this means utilizing home remedies and adhering to pharmacological measures as instructed. This will increase autonomy and decrease clinic visits. Kamm and Norton (2002) also provide evidence showing, “in a controlled study this reduced clinic visits by 30%, decreased the delay between symptom onset and treatment from 4 days to under 24 hours, increased the quality of life scores, and decreased costs” (p. 334). Patients with Crohn’s disease need a high level of nursing care; one that combines holistic as well as technical approaches.
Crohn’s Disease does not follow a predicted cycle of flare-ups and remissions; rather it can be rollercoaster of unexpected events. Patients are experiencing a total loss of control over their bodies and overall health. Uncontrollable bowels and discomfort can be extremely embarrassing and disheartening. The exacerbation of other problems caused by this disease, adds to this disparity. The pain and discomfort the patient experiences can be managed more effectively through proper education, pharmacological/nutritional management, and emotional support. This is an opportunity for nurses to take advantage of their specialty skills while providing a holistic type of care.






































References

Jeejeebhoy, N. K. (2002). Clinical nutrition: 6. Management of nutritional problems of patients with crohn's disease. Canadian Medical Association Journal, 166(7),
913–918. Retrieved January 29, 2007, from PubMed Central Database.
Norton, C, & Kamm, M.A. (2002). Specialist Nurse in Gastroenterology. Journal of the royal society of Medicine. 95(7): 331-335. Retrieved April 22, 2007, from PubMed Central Database.
Rayhorn, N. (2003). Inflammatory Bowel Disease. Nursing, 33(11), 54. Retrieved November 07, 2007, from Proquest Database.
Rayhorn, N., & Rayhorn, D.J. (2002). An in-depth look at inflammatory bowel disease. Nursing, 32(7), 26-36. Retrieved November 07, 2007, from Proquest Database.
What is the Role of Diet in Crohn’s Disease? (2001). New York Methodist Hospital. Retrieved February 05, 2007, from http://www.nym.org/healthinfo/docs/103/doc103diet.html




Intervention 1: Nutrition therapy along with pharmacological Management
Disadvantage 1: Debilitating side effects from necessary drugs.
The immunosuppressive drugs that are necessary for disease remission are life-long, and produce very unpleasant side effects that although the patient is in a state of “remission”, day-to-day life is still difficult. Remicaid (infliximab) is a drug used for the treatment of rheumatoid arthritis, and is used in Crohn’s patients to keep symptoms at bay, maintain remission, and treat rheumatoid arthritis that gets exacerbated by the disease. However, this drug can cause abdominal pain, nausea, vomiting, fatigue, headache, infusion reactions, and drug-induced lupus (Deglin & Vallerand, 2007, p.642). Azathioprine (Imuran) is another immunosuppressant that can cause the same kind of G.I. upset, along with thrombocytopenia, anemia, and hair loss (Deglin & Vallerand, 2007, p. 180). Methotrexate (Rheumatrex) is a heavy duty immunosuppressant that is actually used on cancer patients, as well as severe Crohn’s Disease. This drug can cause anorexia, G.I. upset, nephropathy, anemia, rashes, malaise, hair loss, and hepatotoxicity (Deglin & Vallerand, 2007, p. 772). In addition to any of the mentioned drugs, prednisone is usually used in addition to a chosen drug therapy. This drug can cause depression, muscle wasting, G.I. upset, peptic ulceration, abnormal fat deposits, and cushingoid appearance (moon face, buffalo hump) (Deglin & Vallerand, 2007, p. 323-327). Unfortunately, the Crohn’s patient will likely go through different therapies such as these before finding one that is effective and somewhat tolerable. Physicians use an algorithm of which drugs to try first, and depending on the reactions, what the next step would be (Knutson, Greenberg, & Cronau, 2003).

Deglin, J, & Vallerand, A. (2007). Davis’s drug guide for nurses. (10th ed.). Philadelphia: F.A. Davis Company.

Knutson, D, Greenberg, G, Cronau, H. (2003). Management of crohn’s disease – a practical approach. American Family Physician. 68(4), 707-14, 717-8, 595-7. (CINAHL Accession No. 2004070944)

Disadvantage 2: Unknown underlying G.I. problems preventing remission.
Some patients with Crohn’s Disease may also have other things going on with their digestive tract even before the onset of their disease. They could have just IBS, and therefore diet will be more selective. There is also a strong possibility of the patient having Celiac Disease (glutten-sensitive enteropathy), which would mean even more diet restrictions to take into consideration. Once Crohn’s Disease has been diagnosed, it seems imperative to also screen for Celiac Disease. It is quite common, affecting 1 in 100 to 1 in 300 (Edwards, 2006). Celiac, like Crohn’s, can cause similar symptoms of G.I. upset, so misdiagnoses can be more common than preceived. If a Crohn’s patient adheres to their drug regimen, and still not feeling well, it is difficult to assess if it is just the wrong drug regimen for them or if they actually have Celiac Disease as well and the glutten ingestion is inhibiting remission.

Edwards, M. (2006). Coeliac Disease – an update. Practice Nurse. 31(7), 42-4. (CINAHL Accession No. 2009176315)


Intervention 2: Specialty nursing
Disadvantage 1: Shortage of specialty nurses.
The field of gastroenterology indeed needs more specialty nurses. However, there is a shortage of nurses in general all around the world, as well as in specialties. It is a huge intervention to attempt to recruit individuals into the nursing field, let alone encouraging nurses to further specialize. The ICN conducted a survery and found some reasons why the number of nurses are declining. Nurses are already dealing with high nurse to patient ratios, long working hours, inadequate compensation, and reduced time with patients due to overburdened administration (“Where”, 2007). The ICN has called on the WHO, but the nursing shortage continues to rise.

(2007). Where are all the nurses. Australian Nursing Journal. 15(1), 19. (CINAHL Accession No. 2009645084).

Disadvantage 2: Not enough. Need communication - team medicine.
Crohn’s Disease can cause extra-intestinal manifestations (rheumatoid arthritis, anemia, osteoporosis, ulcers, malnourishment, renal and hepatic disease, etc.). These other diseases, mean other specializing physicians. One patient with Crohn’s Disease, may be seeing a rheumatologist, gastroenterologist, nephrologist, pharmacist, and dietician, as well as their general physician. If these physicians are not actively and accurately communicating, the patient’s health may be in jeopardy. It is suggested that stress can exacerbate Crohn’s symptoms, and Crohn’s symptoms can exacerbate stress. The need to see so many different doctors can be quite stressful, and may even be detrimental if it is not an efficient team. The patient’s stress level, and means of seeing the necessary specialties are not taken into account as much as it should.

Smith G,D, Watson, R, Roger, D, McRorie, E, Hurst, N, Luman, W, & Palmer K,R. (2002). Impact of a nurse-led counselling service on quality of life in patients with inflammatory bowel disease. Journal of Advanced Nursing. 38(2): 152-60. (CINAHL Accession No. 2002073703).span>

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Preventing Malnutrition in the Elderly.

Clint Webster



Preventing Malnutrition in the Elderly

With the increasing number of baby boomers reaching an older age, malnutrition is a serious problem today. Many of these elderly will end up in nursing homes and up to 85% suffer from malnutrition (Crogen, 2006). This is an alarming number of malnourished patients for the Registered Nurse to take on. However, the knowledgeable nurse can aid elderly patients by providing adequate nutrition in a vulnerable population prone to malnutrition, and prevent the resulting problems. Three nursing strategies can include acquiring knowledge on malnutrition risk factors and signs/ symptoms, in order to identify the problem, know how to improve food consumption via different dining atmosphere, and supplement the types of foods the elderly consume by improving taste and nutrient density.
Malnutrition can be managed, but it requires skilled nurses and medical teams. In understanding that elderly malnutrition is a dramatic problem of epic scale today, this issue is not taken lightly by the medical community. Nursing homes are managed by nurses and this is where malnutrition is extremely prevalent. Mortality and morbidity are correlated with malnutrition (Brownie, 2006). Nutrition plays a large role in the severe problem of pressure sores due to protein loss. Adequate nutrition and protein are necessary in helping prevent and heal these pressure ulcers. Malnutrition makes pressure sores more likely and more difficult to heal (Dambach, 2005). The immune system is also hindered by malnutrition and this at risk population is already more susceptible to communicable diseases (Brownie, 2006). Conditions like pneumonia and bronchitis are much more serious in an elderly patient and malnutrition weakens their defenses. Registered Nurses are key in the fight against elderly malnutrition because they give the most direct care to elderly populations, and hence spend the most time with this high risk population. The nurse working with the elderly population should acquire detailed knowledge of malnutrition in order to identify the problem. The Mini Nutritional Assessment (MNA) is one valuable tool at the Registered Nurse’s disposal to judge malnutrition in the elderly. It consists of a survey of the patient’s level of malnutrition. Depending on the extent or score, it will recommend appropriate interventions that the Registered Nurse will implement (Vellas, 2006). Tools like the MNA incorporate many aspects of nutrition in the elderly to objectively identify who is at risk, but nurses still need to understand the process themselves. Knowing that the elderly client has decreased bodily function related to consuming and absorbing nutrients is important. Diminishing taste and smell senses can make food less appetizing than in the past. Dental problems can make consuming foods difficult. Poor fitting dentures can cause difficulty and pain in chewing and swallowing (Crogen, 2006). Factors such as reduced stomach acid and absorption problems can make garnering nutrients from food difficult. These can be exacerbated by the various medications the elderly take (Eliopoulos, 2005). Motor coordination is sometimes affected by medications. Elderly often already have some motor coordination deterioration. Further impairment by medications can hinder them from adequate consumption in limiting their ability to feed themselves (Crogen, 2006). The nurse should be educated on these issues and understand that they influence the clinical manifestations of malnutrition in the elderly. These can include “weight loss greater than five percent in the past month, weight ten percent below or above ideal range, serum albumin level lower than 3.5g/100mL, hemoglobin level below 12g/dL, and hematocrit value below 35 percent” (Eliopoulos, 2005, 202).
With knowledge on aging changes and identifying who is at risk, nurses should implement appropriate strategies to improve nutrient consumption. Elderly clients in nursing homes can be aided by an environment that is suitable for food consumption. The Registered Nurse in these settings can change lighting and table setting contrast to aid elderly nutrition. In one study, researchers found that placing white plates on blue trays laid out on a green table cloth with more evenly distributed light markedly increased nutrient consumption over three days (Brush, 2007). In those patients who eat in their rooms at the hospital or nursing home, it is especially important that unappetizing objects such as urinals and related items are not near or on the dining area. These objects detract from the dining environment (Calverly, 2007). Promoting a proper dining atmosphere is a valuable tool in nursing care of elderly malnutrition.
Improving the atmosphere of the dining experience can help in the nurse’s ability to manage elderly nutrition, but foods the elderly consume are the most important factor in preventing malnutrition. According to Dunn (2007), many foods and strategies for increasing their consumption do not work. Serving smaller more frequent meals does not improve nutrition. Oral supplements are also not very beneficial and often go wasted or conflict with medications. However, fortified foods (foods with added vitamins and minerals) and nutrient dense foods (foods that naturally have large quantities of vitamins and minerals for the amount of calories they contain) have been found to be effective. Fortified foods work best when they taste like their regular counterparts. Nutrient dense foods have been found to be very effective in promoting nutrition (Dunne, 2007). Improving taste is one of the best and simplest ways of improving nutrition. In some cases it is more important that elderly patients simply consume calories. Elderly patients have the same taste preferences as they have had all of their life, and thus low sodium, low fat meals are not always as appetizing as the normal version of a food with naturally high fat and sodium content (Calverley, 2007).
Malnutrition will always be an issue for the ever growing elderly population. It is important that this issue be dealt with correctly in order to prevent pain and suffering, increased healthcare costs, staff burden, and mortality (Brownie, 2006). A knowledgeable nurse can aid elderly patients by providing adequate nutrition in a vulnerable population prone to malnutrition. Nurses should be aware of the risk factors and signs via greater knowledge and insight, implementing strategies to improve food consumption, and offering different food choices to improve the amount of nutrients ingested. These strategies all help to minimize the devastating effects of malnutrition by promoting nutrition.

References

Brownie, S (2006).Why are elderly individuals at risk of nutritional deficiency?. Journal of Nursing Practice. 2, 115.
Brush, J. A., Meehan, R. A., & Calkins, M. P. (2002). Using the environment to improve intake for people with dementia. Alzheimer's Care Quarterly. 4, 330-339. Retrieved January 9, 2007, from Expanded Academic ASAP database.
Calverley, D (2007).The Food Fighters. Nursing Standard. 22, 20-21.
Crogen, N, & Alvine, C (2006). Testing of the Individual Nutrition Rx assessment process among nursing home residents. Applied Nursing Research. 19, 102-104.
Dunne, J.L., & Dahl, W.J. (2007). A novel solution is needed to correct low nutrient intakes in elderly long-term care residents. Nutrition Reviews. 65. Issue 3, 135-139.
Eliopoulos, C (2005). Gerontological Nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
Vellas, B, Villars, H, Abellan, G, Soto, ME, Rolland, Y, & Guigoz, Y (2006). Overview of the MNA--Its history and challenges. Journal of Nutrition, Health, and Aging. 10, 456-463.

Intervention 1: Improving the dining atmosphere to improve nutrient consumption in elderly.
#1) While it is documented that improving the dining atmosphere will increase nutrition in the elderly, there are obstacles to overcome. One issue is that some elderly in nursing homes are very messy eaters for various health related reasons. This can be a distracting and unappetizing occurrence for the rest of the elderly eating there. Even if the lighting and contrast are adjusted for proper atmosphere, the elderly themselves can end up being a distraction. This can be dealt with by having these individuals in a side room (Andreoli, 2007).
#2) The timing of meals is also important. No matter how nicely laid out the dining atmosphere is, if the meal is during a portion of the day when an individual does not have an appetite, then that person will miss out on a meal until the next one comes around (Jhavari, 2006). This system will prevent a proper dining atmosphere from counting for anything because of poor timing.

Andreoli, N.A., Breuer, L, Marbury, D, Williams, S, & Rosenblut, MN (2007). Serving Culture Change At Mealtimes. MN Nursing Homes: Long Term Care Management. 9, 48.

Jhavari, T. (2006) Enhancing the dining experience in senior living. Nursing Home Magazine. October Issue, 58


Intervention 2: Improving nutrient density of foods, implementing fortified foods, and improving taste will help the elderly improve nutrition.

#1) While these techniques and foods have been shown to work, they do not account for the economic status of the elderly. Some may not have the financial means to afford these services and foods (Holman, 2005). The elderly may have someone else doing the shopping for them if they are not in a home, and this can leave their nutritional options in the hands of the person shopping (Holmes, 2006). Similarly, a common problem can be an elderly person who had a spouse or relative do their shopping for them and they are suddenly no longer capable of shopping. In these instances it leaves those elderly to do shopping on their own or not at all, and if they do end up shopping on their own, their nutritional knowledge could be a new problem.
#2) In other instances the elderly may have a host of issues that deter them from adequate consumption of nutrient. Of these, psychosocial issues such as an elderly person losing a loved one and being lonely can make them disinterested in eating (Holmes, 2006). Many other issues may affect a persons desire to eat as well, limiting nutrition.

Holmes, S. (2006) Barriers to effective nutritional care for older adults. Nursing Standard. 3, 51-54

Holman, R.N., Nicol, M. (2005) Promoting adequate nutrition. Nursing Older People. 17, 31-2



References:


Andreoli, N.A., Breuer, L, Marbury, D, Williams, S, & Rosenblut, MN (2007). Serving Culture Change At Mealtimes. MN Nursing Homes: Long Term Care Management. 9, 48.

Holman, R.N., Nicol, M. (2005) Promoting adequate nutrition. Nursing Older People. 17, 31-2

Holmes, S. (2006) Barriers to effective nutritional care for older adults. Nursing Standard. 3, 51-54

Jhavari, T. (2006) Enhancing the dining experience in senior living. Nursing Home Magazine. October Issue, 58
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Issues challenging obese population.

Many research studies have addressed ways obesity affects the human body biologically, but few have actually highlighted other surrounding issues that affect obese population such as discrimination and lack of accommodation in public places. Therefore, this paper will highlight and address great roles that nurses can play to bring a change in perspective of “other” ignored issues about obesity. Joe Njenga
To make this possible a nurse can implement the following strategies.
1. As health care provider, the nurse can set a good example by not practicing bias and discrimination against obese population.
2. As a manager of a health care organization, the nurse can mobilize resources to ensure equipment like oversized beds, commodes, walkers and wheelchairs are available and ready for use by bariatric patients.
3. A nurse can act as an educator to help in creating public awareness about obesity with the correct perception.
The first strategy is for the nurse to be open-minded, understanding, resourceful and free from bias and discrimination. This can prove to be a big challenge to the body image obsessed society which has done little to help address and solve issues of obesity. Instead, the society has marginalized and labeled obese individuals as lazy, irresponsible and, generally of less worth. As a result, many obese individuals are hesitant to go out in public places like colleges, churches, hospitals and gymnasiums.
A research study found physicians and nurses to be among predominant groups that were most stereotypical about obesity. Physicians associated obesity and other negatively perceived conditions with poor hygiene, noncompliance, hostility, and dishonest. Doctors were less motivated and less optimistic when caring for obese patients because they viewed them as unsuccessful, weak willed and unintelligent. (Puhl & Browell, 2001)Therefore, it is important that nurses set a good example for the rest of the society to follow by caring for obese patients with dignity and an open minded approach. For instance if a bariatric patient requested for bed change and the nurse needed some help to turn the patient she should kindly respond, “Let me get someone to help me” instead of “ You are too heavy I need someone to help me roll you over”.
A second strategy involves the nurse as a manager of a healthcare organization and a patient’s advocate. A nurse can mobilize resources to ensure that facilities and equipment can safely accommodate obese patients. This goal can be achieved by construction of infrastructure that can support the growing obese population such as investing in wider beds that can accommodate weights between 300 and 800 pounds, building wide doorways, purchasing or renting wider wheelchairs, lifts, commodes, gowns, bariatric beds, commodes, and walkers. In addition, hiring more staff to help in safer transfers of obese patients is key to avoid back injuries as, Gallagher (2005) explains “Injuries that result from manual lifting and transferring of patients are among the most frequent causes of nurse related injuries with more than half of strains and sprains being attributed to manual lifting tasks while assisting dependent patients with their mobility needs” (Pg 1). Although this may mean additional expenses, this will serve as a long-term investment as the numbers of overweight patients persistently keep rising.
The third strategy is education of the public. Nurses can change the way the public views obesity through education and enlighten on cause of obesity and surrounding factors. But before the healthcare professionals can educate the public, Maxwell (2005) urges all healthcare professionals to educate themselves and other hospital staff first on ways of being sensitive to the plight of the obese people. In her article Obesity: Pain and Prejudice (2005) she exemplifies, “Don't be like the doctor who told his patient that she would have to be weighed at the zoo” (Pg 4). In comparison to HIV/AIDS epidemic, education about obesity will lead an overall public awareness and change of attitude hence change of behavior. Additionally, early education on obesity is paramount to young children to serve as a preventive measure before they turn into young obese adults by creation of healthy food programs in school such as reduction or eradication of vending machines in schools and promotion of Physical education (Malone, 2005)
After, the nurse sets a good example by not practicing bias and discrimination against obese population, mobilize resources to ensure equipment like oversized beds, commodes, walkers and wheelchairs are available and ready for use by bariatric patients and, educate people to create a public awareness about obesity. This will improve empower and encourage public awareness about obesity with the correct perception and aid obese population to lead healthier lives.
Reference:
Gallagher, S. ((2005)). Caring for the Child Who is Obese: Mobility, Caregiver Safety, Environmental Accommodation, and Legal Concerns. Batriatric Nursing Surgical Patient care , 1.
Malon, S. (2005). Improving Quality of dietary intake in the school setting. Journal of School Nursing , 21, 70-76.
Maxwell, B. (2005). Obesity: Pain and Prejudice. Medscape General Medicine , 7, 3.
Puhl, R., & Browell, D. (2001). Bias, discrimination and obesity. The NOrth American Associaton for the study of Obesity , 9, 788-805.






















Joseph Njenga
NUR 211
John Miller
Research paper
2/4/2008

Intervention 1

As a manager of a health care organization, the nurse can mobilize resources to ensure equipment like oversized beds, commodes, walkers and wheelchairs are available and ready for use by bariatric patients

Disadvantage 1
One major disadvantage of this intervention is lack of enough funds to meet the need of this intervention. Limitation in coverage of most bariatric procedures by insurance has done little to improve the situation at hand. With scarce resources that the facilities have to depend on, tight budget cuts in many healthcare facilities have been enforced leaving no room for expansion in provision of bariatric services and purchase or required equipment. In a research study to find ways of predicting cost by a bariatric clinic, Mosti states, “Although bariatric surgery is highly effective for controlling obesity and its complications, it is uncovered by third-party payers in many countries. High cost and unpredictable expenses account for the lack of coverage”

Disadvantage 2
The second disadvantage is multiple stages of managerial approval in many organizations. The more the stages of approval the hard it becomes to approve any policy in an organization; this is because each stage of a policy approval questions the chances of success in implementation of an idea. Although it is essential to assess the chances of success of any policy before investing, this practice discourages creative employees from coming up with good idea that would in fact help the organization grow. For instance in the Wikipedia encyclopedia (Espo, 2007), the Stem cell research has gone over multiple challenges and yet it has not been approved as illustrated:

The bill passed House of Representatives by a vote of 238 to 194 on May 24, 2005.[1], then passed the Senate by a vote of 63 to 37 on July 18, 2006. President Bush vetoed the bill on July 19, 2006.
The House of Representatives then failed to override the veto (235 to 193) on July 19, 2006. In a second trial The bill passed the Senate on April 11, 2007 by a vote of 63-34, then passed the House on June 7, 2007 by a vote of 247-176. President Bush vetoed the bill on June 19, 2007,[2] and an override was not attempted..

Intervention 2

The second intervention is for nurses to educate the public about obesity through creation of the right perception about obesity and factors that can be employed to reduce it.

Disadvantage 1
As a result of the well known fact about nursing shortage, this phenomenon has affected nursing educators too. Andrea (2007) in her article states, “Of the 2900 nursing doctoral students who enroll each year, only 440 graduate. The average age of a new doctoral graduate in nursing was 45.7 years and 6.5% of the graduates were 55 years or older.” She goes on to say that this demographic has done little to improve the situation of the nursing scholarly culture. In return there is a shortage of faculty that is supposed to teach new nurses and the public in general. The few nurses that graduate from nursing school are hence siphoned to more critical healthcare system like the hospitals. This means that community based care that is meant to be the primary mode of prevention has been left with no educators creating a whole new challenge for public education on issues such as obesity.

Disadvantage 2
Unavailability of health care centers, information coupled with public illiteracy has been a major disadvantage for wellness promotion through community education. Nurses who teach on the community level greatly depend on this resource for their service as educators to be effective. Lack of this resource has lead to an increase in health care cost through Emergency department response and chronic diseases such as diabetes and hypertension. Parker( 2005) states, “Widespread problems with health literacy significantly limit effective dissemination and understanding of relevant health information in society, especially among many vulnerable populations where health literacy challenges are especially pervasive” she goes on to explain that an improvement in community healthcare will reduce disparities, cost and quality of care. Therefore a well furnished community health care center can greatly reduce the cost of health care in the long run (Parker, 2005)


















Bibliography

Andrea L. Smesny, P. J. (2007). Barriers to Scholarship in Dentistry, Medicine, Nursing, and Pharmacy Practice Faculty. American Journal of pharmaceutical education , 5 (71), 91.
Espo, D. (2007, April 12). Stem Cell Research Enhancement Act. Retrieved Feb 5, 2008, from Wikipedia: http://en.wikipedia.org/wiki/Wikipedia:Text_of_the_GNU_Free_Documentation_License
Mosti M, D. G. (2007, nov 27th). Calculating Surgical Costs: How Accurate and Predictable is the Cost of a Laparoscopic Roux-en-Y Gastric Bypass? Obesity surgery , 1555-7.
Parker, L. G. (2005). Library outreach: overcoming health literacy challenges. Journal of the medical library association , 4 Suppl (93), S81- S85.

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Adolescent: Cervical Cancer and Human Papillomavirus

The staggering rate of cervical cancer caused by the Human Papillomavirus (HPV) is chilling. Researchers are learning more about this disease and discovering successful prevention measures to fight it. Having the tools for disease prevention, health care providers are often challenged by real world obstacles. Tove Finch

Lack of public awareness regarding HPV transmission and at risk populations is limited, vaccine controversies surrounding adolescent girls becoming sexually active, and lack of routine screening increases the risk for cervical cancer each year. Targeting the at-risk population, educating HPV prevention, and advocating for cervical cancer screening are essential nursing strategies to reduce the burden of illness caused by HPV.
According to Cox and the CDC (2006), HPV is the most prevailing sexually transmitted infection responsible for cervical cancer. In the United States, 20 million people are currently infected with HPV, an additional six million people become newly diagnosed and nearly four thousand women die from cervical cancer each year (Cox, 2006). Many young women do not know that being sexually active puts them at risk for cervical cancer because HPV can develop undetected and become transmitted unknowingly (Cox, 2006). Fawcett (2007) supports this by stating, “young girls are particularly at risk because some start having sexual intercourse earlier, have higher number of partners, smoke and fail to use barrier methods of contraception” (p.2). Vaccinations to eradicate HPV are underway, but controversial issues continue over personal and religious beliefs. According to Ritchie (2006), there are varied levels of sex education because of religious and cultural beliefs. Therefore, greater preventative steps need to be taken to reduce the incidence of HPV in the younger population.
One nursing strategy on illness prevention is to target the adolescent at risk population. Providing a holistic approach to adolescent health care by including pediatric reproduction health services will benefit public health as a whole and assure access to the at risk population. Roye, Nelson, and Stanis (2003), support this by stating, “nurses should advocate for the provision of comprehensive reproduction health services in all clinical sites that provide primary care to adolescents” (p.4). This type of standardized quality health care will enable goals to eliminate health disparities among adolescents and permit early primary prevention. The national health promotion and disease prevention goals, Healthy People 2010, will also be promoted by strengthening community prevention and protecting the future health of the adolescent population from cervical cancer caused by the Human Papillomavirus, (Potter, 2005).
While targeting the adolescent at risk population, another key strategy must address educating HPV prevention and transmission. Fawcett (2007) states, “educating adolescents about protection against HPV is a vital part of adolescent health care” (p.5). Cox (2006) adds, “At present, HPV is widespread such that most sexually active individuals will be infected in their lifetime” (p.3). Society needs to change their attitude and eliminate political barriers by including an objective nursing focus on educating parents and adolescents about the prevention and transmission of HPV, thus empowering adolescents to participate in disease control. This education may include topics such as risky behaviors, the HPV vaccine, Pap screenings, condom use, and abstinence. Educating on adolescent behavior and giving informed sexual advice permits comprehensive decisions. According to Bartlett, Davis and Belyea, (2007), in any health-related interactions with an adolescent, failure to inquire about an adolescent's involvement in problem behaviors may result in lost opportunities to educate the adolescent, who may have nowhere else to gain such information. Fawcett (2007) supports this by stating, “sexual health education should be aimed at reducing the risk” (p.4). This strategy also supports Healthy People 2010 goals by promoting healthy behaviors and protecting adolescent sexual health, thereby increasing the quality and years to their life.
In addition to education and immunization, screening by Papanicolaou, (Pap) smear, is an essential strategy that contributes to early detection of cervical cancer (Fawcett, 2007). Nurses need to collect comprehensive patient history and advocate screening services in clinical sites that provide primary adolescent care. Cervical screenings have led to a notable decrease in cervical cancer deaths in the middle age population and adolescents alike (Roye, Nelson, and Stanis, 2003). If sexually active adolescents are not regularly screened for HPV they may develop cancer undetected. Fawcett supports this strategy by stating, “We believe that Pap smear screening of sexually active adolescents remains an important preventive health procedure that is clinically justifiable” (p.5).
Evidence exists showing the link between cervical cancer caused by the Human Papillomavirus and the prevalence of this disease on the adolescent population. HPV is like butter, it spreads, making HPV prevention imperative. Many parents are uncomfortable with the idea that the majority of young people are or have had sex by the time they reach early adulthood. Therefore, advocating for adolescent reproductive health services and promoting protective sexual behaviors like HPV prevention and awareness, is an essential step to lessen the burden of disease. It has only recently become a preventable infection. Every effort must be made to further eradicate cervical cancer and provide greater continuity of adolescent health care.



1. Target the At-Risk Population:
A. Failure to Address Adolescent Reproductive Health Issues:
Even though the number of sexual health clinics has increased, it remains difficult to persuade young women to use them. Many young women are sexually active, but very few visit a clinic for advice or treatment. This may be due to feelings of embarrassment or the lack of awareness of the services available. According to Fawcett, nearly half of American teenagers had engaged in sexual intercourse before graduation which suggests that many young people appear oblivious to health promotion messages (2007). Health care providers, such as pediatricians, are often uncomfortable addressing reproductive health issues with adolescent patients and many will fail to do so (Roye, Nelson, & Stanis 2003). Therefore, important adolescent reproductive health information is being overlooked and not getting through from family members or health professionals alike.

B. Lower Socioeconomic Barriers:
Cervical cancer disproportionately affects women of lower socioeconomic status, poor access to health care, and for those who are uninsured (CDC, 2006). Cultural and socioeconomic barriers to cervical cancer screenings have contributed to a distinct health disparity among African American women nation wide. African American women represent a medically underserved population, therefore more likely to be diagnosed with cancer at a later stage when the chance of survival is limited. Additionally, increased rates of cervical cancer have also been found in women in lower socioeconomic groups who may have limited access to basic health care needs. Moore and Seybold (2007) state, “The overall cervical cancer death rate among African American women is six times that among white women” (p.1). The HPV vaccine is new to the market and is not currently covered by most health care plans. While some insurance companies may cover the vaccine costs, others may not. Due to the lag-time after a vaccine is recommended and before it is covered by health plans many young females will miss the opportunity for prevention. The problem of establishing a safety net care for low-income uninsured and underinsured people is national in scope as the number of uninsured has risen past 43 million (Shapiro, Thompson, & Calhoun, 2006).

2. Educating HPV Prevention and Transmission
A. Personal and Cultural Beliefs:
As with any new immunization, controversy exists regarding the ethical use of the HPV vaccine. While it could be argued that routine vaccinations would decrease the numbers of cervical cancer deaths, many may believe that mandatory vaccine programs, currently being proposed in some states, infringe on parental rights to make wise health care decisions for their children. Additionally, some parents believe the HPV vaccine or seeking adolescent reproductive health services promotes sexual promiscuity. Parents are concerned that by consenting to the vaccine they are giving their child unspoken permission to become sexually active. Likewise, groups that promote abstinence until marriage worry that this vaccination will send a message to young women that sexual activity is safe and will undermine the abstinence message (Moore & Seybold, 2007).

B. Lack of Efficacy Data:
According to the CDC, the duration of protection from the HPV vaccine is unclear, however it is believed the vaccine is effective for at least five years (2006). Dawar, Deeks, & Dobson state that, “There are knowledge gaps, especially about the long-term efficacy, this is not unusual at the outset of any new vaccine” (p.7). In 2006 the HPV vaccine became available to the public and so far no adverse effects have been reported and a detailed post-licensure safety monitoring plan is currently in place. Nearly 100% of the study participants developed antibodies after given the HPV vaccination, but at this time there is no data available as to how long the effects of the drug will last or any long term adverse effects directly related to this drug might be.







References:

Bartlett, R., Holditch-Davis, D., & Belyea, M. (2007). Problem behaviors in adolescents. Pediatric Nursing 33(1), 13. Retrieved October 22, 2007 from Proquest database.
Cox, J. (2006). Epidemiology and natural history of HPV. Journal of Family Practice 15(11), 7. Retrieved April 14, 2007 from Expanded Academic ASAP database.
Dawar, M., Deeks, S., & Dobson, S. (2007). Human papillomavirus vaccines launch a new era in cervical cancer prevention. Canadian Medical Association Journal. 177(5), 456. Retrieved February 4, 2007 from Proquest database.
Fawcett, E. (2007). Cervical screening for under 25’s – evaluating the evidence. Journal of Community Nursing, 21(2), 4. Retrieved October 10, 2007 from Proquest database.
Giarratano, G., Carter, C., (2003). Partners in health: Changing cancer screening disparity among underserved african american women. Journal of Multicultural Nursing and Health. 9(1), 40. Retrieved October 22, 2007 from Proquest database.
Moore, S., Seybold, V. (2007). HPV vaccine. Clinician Reviews. 17(1), 35. Retrieved April 14, 2007 from Expanded Academic ASAP database.
Potter, P., Perry, A., (2005). Fundamentals of nursing, 6th edition. (pp.90-91). St. Louis, Missouri: Mosby.
Ritchie, G. (2006). Strategies to promote sexual health. Nursing Standard. 20(48), 35-40. Retrieved October 23, 2007 from PubMed Central database.
Roye, C., Nelson, J., & Stanis, P. (2003). Evidence of the need for cervical cancer screening in adolescents. Pediatric Nursing, 29(3), 224. Retrieved October 10, 2007 from Proquest database.
Shapiro, L., Thompson, D., & Calhoun, E., (2006). Sustaining a safety net breast and cervical cancer detection program. Journal of Health Care for the Poor and Underserved. 17(2), 20. Retrieved October 22, 2007 from Proquest database.

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Incidence of Tuberculosis and Multiple Drug Resistant TB are on the rise. The popular conception is that this disease, as old as humanity, is under control and being eradicated.

However, among certain disenfranchised and underserved populations, such as drug users, prison populations, HIV patients and refugees from high-risk countries, ripe conditions have led to a breeding ground for TB and MDR-TB. Therefore the nursing community must educate everyone they can, identify and be willing to intervene directly with underserved populations and utilize proper techniques and training.
During the first half of the 20th Century, TB was called " white plague " or "consumption" because it seemed to consume and waste a person from within, having traveled from the lungs to other parts of the body. It is a hardy organism spread in aerosol form by coughing, laughing or sneezing. A person can be a carrier, test positive but be non-contagious. They are not be considered to have TB the disease (Selekman 2006). A combination of at least four “front line” anti-TB drugs is used to prevent resistance to the organism (Kidder, 2003). Failing that, subsequent MDR-TB is treated with other more expensive drugs. Just as important as treatment are some nursing strategies that can be very effective at interrupting the spread of the disease.
Nurses must work hard to educate and dispel the many myths that surround TB. The majority of people believe it has been eradicated, at least in the developed countries. People are often shocked when they hear the diagnosis because they believe it leaves them stigmatized and unclean. They believe that only the down & out get TB, yet people from all social strata get TB. Some believe smoking causes it, or that it is hereditary. Effective education by nurses could overcome barriers such as fear and language and cultural differences. One commonly held belief that is true, is that high-risk groups including inmates, homeless, drug users and certain groups of immigrants are more at risk of contracting TB (Boutotte, 2000).
The second nursing strategy is to identify underserved populations and not only go to the source but be prepared to be flexible in implementing nursing interventions. Prisons and jails are a breeding ground for TB due to overcrowding. In addition there are other circumstances that a nurse should know about that contribute to the non-compliance of therapy. In the US, prisons in California and New York have had epidemics of resistant TB. In some prisons, it was discovered that prisoners would sell their medication or deliberately swap sputum samples. Some actually wanted to be sick to stay in the much nicer conditions that the infirmary afforded with no work duty assigned. Conversely, some inmates, believing it would hinder their release dates, bought clean sputum samples, or bribed poorly paid prison medical staff (MacNeil, 2005). In the prisons of Siberia, which are lacking in proper nutrition and appallingly overcrowded, there is a caste system, with Mafia-like bosses, middlemen and abused under castes, who may be beaten if they don’t hand up the valuable drugs to the bosses (Schwalbe, 2002). Of course Mycobacterium tuberculosis does not differentiate between murderers or petty thieves; nor prison guards and their families. It is equally important for the health of the general population that nurses seek out other disenfranchised groups such as the homeless, drug users and immigrants from certain high risk countries.
Fear of immigration authorities, language and cultural barriers, financial restraints, lack of health insurance and inadequate housing are factors that are often compounded by co-infection with other disease processes such as HIV. The only way to obtain compliance is to actually observe each dose administered (known as DOTS-Directly Observed Treatment Short-Course (Kidder, 2003). Compliance in following the drug regimen to its completion is even more difficult when the patient is transient, literally, such as drug users and the homeless population. Further, there is little incentive to continue the therapy when symptoms disperse and more immediate daily needs take prescedence. Dr. Paul Farmer showed that it was necessary to provide assistance with food and shelter to get better results while he worked With TB patients in Haiti (Kidder, 2003). While it requires extra work to bridge cultural, societal and physical barriers, studies also show a direct correlation to the amount of the care provider’s training and the success of implementing prevention and curative strategies (Khan, et.al, 2006).
What training and special protective measures are required by nurses to implement the third nursing strategy? First there are the basics; nurses should be actively on the lookout for patients with signs and symptoms of TB, particularly in high incidence settings. “Nurses should consider a patient to be highly infectious if he has a productive cough, pulmonary cavitation on a chest X-ray, hoarseness, laryngitis, and acid-fast bacillis (AFB) on a sputum smear, and he is not on an anti-tuberculosis drug regimen” (ICN TB Guidelines, 2004). In most cases, it is reportable to a state agency if there is a strong suspicion of infection. The suspected patient should be isolated and started on anti tuberculin drugs before confirmation of lab work. Instruct the patient to cover coughs and sneezes with a tissue or even to wear a mask. It is important that the tuberculosis (Mantoux / PPD) skin test be used as opposed to the older “Tine” test (four pin pricks), which has been deemed unreliable. Chest x-rays are often ordered as a follow-up. This illustrates the need for specialized training and indeed it is possible to become a TB specialist nurse. The work includes contact tracing to find the original carrier and screening close contacts. Being sensitive is also important as the patient may feel responsible for infecting others. The most important aspect of care is ensuring completion of the prescribed therapy. This may require the nursing support to be individualized and flexible.
It is not too hard to see how TB has spread beyond the breeding pools and into the general population and thus this emphasizes the importance of the nurse’s role in treatment and continuous monitoring. Underserved populations present unique challenges outside the classic nurse-patient model. However with diligence toward public education and one’s own education and training, and a little tenacity and flexibility, a nurse can make a difference with overlooked populations.

Bibliography





Boutotte, J., (2000), AFB isolation rounds: What your nurses need to know,
Nursing Management. 31(9), p 49(3), Retrieved October 11, 2007, from ProQuest database.

International Council of Nurses, (2004), TB guidelines for nurses in the care and control of tuberculosis and multi-drug resistant tuberculosis, Retrieved October 10, 2007, from http://www.icn.ch/tb/guide_chap2.htm.

Khan, K., Campbell, A., Wallington, T., Gardam, M., (2006), The impact of physician training and experience on the survival of patients with active tuberculosis, Canadian Medical Association. Journal, 175(7), p 749-753, Retrieved October 09, 2007, from ProQuest database.

Kidder, T. (2003), Mountains beyond mountains: The quest of Dr. Paul Farmer, a man who would cure the world. New York: Random House.

MacNeil, J., Lobato, M., Moore, M., (2005), An unanswered health disparity: tuberculosis among correctional inmates, 1993 through 2003, American Journal of Public Health. 95(10), p 1800-5 (6), Retrieved October 11, 2007, from ProQuest database.

Schwalbe, N., Harrington, P., (2002), HIV and tuberculosis in the former Soviet Union, The Lance, 360, p 19-20, Retrieved October 09, 2007, from ProQuest database.

Selekman, J., (2006), Changes in the screening for tuberculosis in children, Pediatric Nursing, 32(1), p. 73 (3)





New Verbiage


There are often barriers to any educational nursing intervention but specifically in the realm of teaching about Tuberculosis, several disadvantages are the misinformation that exists and the discrimination experienced. Effective education by nurses must over come myths such as the belief that TB has been eradicated, at least in the developed countries. People are often shocked when they hear the diagnosis because they believe it leaves them stigmatized and unclean. They believe that only the down & out get TB, yet people from all social strata get TB. Some believe smoking causes it, or that it is hereditary. The second disadvantage to education is the fear of immigration authorities, language and cultural barriers, financial restraints, lack of health insurance and inadequate housing are factors that are often compounded by co-infection with other disease processes such as HIV. Dr. Paul Farmer found that education about compliance was highly affected whether you had adequate shelter and food, or to put it another way when you are starving you aren’t so concerned about a missed dose even if it’s free (Kidder, 2003).
In Africa TB rates are high and effectiveness of treatment low. A lot has to do with the linking of TB to AIDS and inherit problems with teaching about that disease process. “Limited funding, governmental indifference or opposition, AIDS stigma, and social discomfort discussing sex were often cited as barriers.
It is not just enough to identify at risk populationsas a nursing invervention. The factors that make them hard to find, diagnose & treat are also factors that make them non-complainant with their treatments. Patients with or at risk for TB face discrimination, often because of its association with AIDS. Also, prison inmates homeless, drug users and immigrants from certain high risk countries are not often policy makers first priorities, if indeed, they are on the radar at all.
In Africa, the stigma of AIDS prevents people from readily seeking help until other disease processes including TB are well entrenched. Additionally wars and famine make a shambles of health care systems the populations become transient.
Prisoners face several of these problems. Often there is little staffing and little sympathy for the care of inmates. With limited resources it is hard to convince policy makers that $ and drugs should be used on this lowest caste of society. There are additional compliance/containment problems that typical nursing interventions are not geared toward. In some prisons, it was discovered that prisoners would sell their medication or deliberately swap sputum samples. Some actually wanted to be sick to stay in the much nicer conditions that the infirmary afforded with no work duty assigned. Conversely, some inmates, believing it would hinder their release dates, bought clean sputum samples, or bribed poorly paid prison medical staff (MacNeil, 2005).

Another problem is that government officials may not wish to acknowledge problems with treatment programs. Conversely government officials may have their own idea of what their own treatment program should look like and be dismissive of foreign intervention or non-profits whom they may feel are “irrelevant or even a nuisance.” (Naidoo, 2001)






Bibliography – New Research



Kelly, C., (2006) Psychological and socio - medical aspects of AIDS/HIV (Programs, resources, and needs of HIV-prevention nongovernmental organizations (NGOs) in Africa, Central/Eastern Europe and Central Asia, Latin America and the Caribbean. AIDS Care, 18(1), p. 12- 21, Retrieved from Proquest database January 30, 2008


Naidoo, K. (2001), The role of the nonprofit sector. In C. E. Koop, C. Pearson & M. Schwarz (Eds.), Critical issues in global health (pp. 406-415). San Francisco: Jossey-Bass.

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Reducing Medication Errors With Technology

Providing patient safety is one of the primary responsibilities within the nursing profession. Medication errors not only threaten the patient, they threaten the nursing profession. Roy Simpson (2005) brings to light that nurses are associated with more patient deaths and injuries than any other healthcare profession. This is related to the total time spent with the patient, a shortage in the workforce and weaknesses in operational practices and protocols (Simpson, 2005). Today’s nurse needs to be able to navigate through these obstacles and rely on other resources beyond the “five rights”. Bar code and point-of-care technologies contribute to verification of the five rights, improve workflow and allow for communication between different disciplines. Studies, such as those by Paoletti, Suess, Lesko, Feroli, Kennel, Mahler and Saunders (2007), show a substantial reduction in medication errors in clinical settings that have employed such technology. Information technology provides the means by which a nurse can reduce medication errors, insure patient safety and safeguard the nursing profession in today’s clinical setting.
The nursing shortage has a direct impact on medication errors in the clinical setting. The shortage has led to longer hours and frequent shifts resulting in additional stress and fatigue. As a result, nurses have been associated with an increase in medication errors within the clinical setting (Simpson, 2005). The five rights of right dose, route, drug, time and patient are dependent on the nurse’s ability to identify inaccuracies at the patient bedside. This system becomes compromised when the user is drained and unfocused. Bar code and point of care technology addresses the human error factor by automating the five rights (Wolf, 2007). The process involves scanning the identifying bar codes of the nurse, patient and the medication to be administered. Information is processed through various software systems accessing the patient’s medical profile and comparing it to physician orders and pharmacy protocol. A contradiction of any of the five rights results in an alert, prompting the nurse to further investigate before administering the medication and preventing a possible error.
As technology grows so has the capability of the nurse to go beyond the five rights. Enhancements are capable of alerting nurses to medications that are contraindicated due to vital signs, allergies and/or lab values. This is especially beneficial when giving cardio glycosides and electrolyte supplements. Indicators can caution nurses when using high-risk drugs, such as insulin and heparin, preventing lethal dosing. Errors associated with look-alike/sound-alike drugs can be avoided with customized comments and warnings (Grissinger & Globus, 2004). Information technology allows healthcare providers to customize systems to address the specific needs and barriers of the clinical setting.
In addition to notifying the nurse of potential problems, point of care technology broadens a nurse’s knowledge base by allowing access to the most up to date information at the patient’s bedside (Simpson, 2005). Medicine is constantly advancing and medications are constantly being introduced, updated or, in some cases, taken off the market. Systems can access data regarding new medications, medication/herbal supplement reactions, and signs and symptoms of adverse reactions. This allows nurses to make more informed decisions, faster, resulting in better patient care (Simpson, 2005).
Errors in charting have contributed to the rise medication errors and patient injuries. Patient care and medication administration is dependant on the accuracy, detail and up to date documentation by all team members. Staffing shortages and unpredictable workflow often require nurses to chart at the end of their shift increasing the potential for error (Simpson, 2005). Bar code, point of care technology allows for the nurses to electronically chart patient care and medication administration in real time at the patients bedside. This reduces the risk of errors associated with handwriting, omission and transcription (Paoletti, et al., 2007). Additionally, the time that is spent charting during a shift (which is projected to consume 13%-28% of a nurses total shift) can be focused back toward direct patient care (Braswell & Duggar, 2006).
Data collected from bar code, point of care technology allows nursing managers and pharmacist to generate reports identifying factors that can lead to medication errors. Nurse managers are able to track compliance and address training or other issues as necessary (Braswell & Duggar, 2006, p.14). Pharmacist can use the data to identify opportunities for improvement in storage strategies for medications in nursing-unit decentralized cabinets, separation of look-alike products and formulation differences within the pharmacy department (Paoletti et al., 2007, p 540). The ability to identify the origin of error is the first step and a proactive resource in bringing about positive change. This results in opening lines of communications between the disciplines in the effort to resolve obstacles that might result in error.
The need to incorporate information technology in the clinical setting can be observed in the Paoletti et al. (2007) study at Lancaster General Hospital. Medical observers reported 188 errors related to medication administration prior to the implementation of electronic medical administration records and bar-code medication administration. The errors included wrong time, wrong technique, wrong dose, extra dose, wrong medication and wrong formulation. It was found that errors were more likely to occur at the point of medication administration because safety nets relied on nurses to remember, identify and resolve discrepancies at bedside (Paoletti et al., 2007, p.538). Moreover, of the 188 errors observed, none of them were reported or identified by staff members. Paoletti et al. (2007) assert that the reporting of errors is dependant on the willingness of the provider to file a report. Many of theses errors may be unknowingly committed or go unnoticed by the provider. One can therefore conclude that the prevalence of medication errors is much higher and a greater threat than once understood.
Facilities that have implemented information technology into their medication administration protocol have seen positive results. Lancaster General Hospital had a 54% reduction in medication errors after implementation (Paoletti et al., 2007). Braswell and Duggar (2006) report that the Spartanburg Regional Health System had error rate reductions as high as 78% after implementing bar code, point of care technology systems. Paoletti et al. (2007) write that subsequent to implementation reports were generated identifying possible and prevented errors. Nursing managers were able to use the data to implement training programs to address areas of opportunity. Pharmacy and nursing communication and collaboration during the implementation phase resulted in improved interdepartmental relationships. The commitment to a safer environment has not only been appreciated by patients and nurses, but has served as a recruiting tool for new nurses.
In summary, information technology has a place at the patient’s bedside and within the nursing profession. As the number of qualified nurses begins to diminish, the reliance on technology becomes greater. Wolf (2007) declares that errors will be reduced with the assistance of technology. Technology complements the way a nurse works by supporting the five rights, improving workflow and enhancing communication. The end result is a safer environment for both the patient and the nursing profession.


a. Intervention #1 Bar-coded medication administration
i. Disadvantage 1. Automation of the five rights leads to a decline in nursing diligence.
In its efforts to make the process safer, the administration of medication with the use of bar code technology can lead to a reliance on the system alone (McDonald, 2006). A nurse must still rely on his or her knowledge base as the primary source for decision-making. Automation can lead to a knowledge deficits in different aspects of the nursing profession. With the demands put on today’s nurse (in terms of staffing issues, patient to nurse ratios and high patient demands), nurses are more tempted to look for shortcuts. Bar coding systems are set in place to support the current protocol of addressing the five rights before administrating medication to a patient. McDonald (2006) asserts that systems can create new kinds of errors if not accompanied by well-designed, well-implemented crosscheck processes and a culture of safety.

McDonald, C. (2006, April 4) Computerization can create safety hazards: a bar-coding near miss. Annals of Internal Medicine, 144(7), 510-516. Retrieved February 1, 2008 from Academic Search Premier database.

ii. Disadvantage 2. Hardware and software systems associated with bar coded medication administration are susceptible to technical issues.
Bar-coded medication administration and its users rely on a wireless apparatus capable of connecting to the main system. When hardware and software systems are unable to communicate, the system, as a whole, becomes ineffective. Elizabeth Mims, nurse consultant for the Veterans Health Administration National Bar Code Medication Administration Joint Program Office, noted that problems with wireless transmission can occur due to steel beams in older buildings, rooms with lead shielding, and closed doors (Traynor, 2004). Additional issues include slow response/download times, equipment problems, missing armbands, and illegible barcodes (Heinen, 2003). Technical issues, and the lack of experience and expertise to overcome them, can be costly, frustrate users, disturb workflow, and jeopardize patient safety.

Heinn, M., Coyle, G., & Hamilton, A. (2003, October). Barcoding makes its mark on daily practice. Nursing Management, 34(10), 18-20. Retrieved February 1, 2008 from Academic Search Premier database.

Traynor, K. (2004, October 1). Details matter in beside barcode scanning. American Journal of Health- System Pharmacy, 61(19), 1987-1988. Retrieved February 1, 2008 from Academic Search Premier database.

b. Intervention 2. Point of care technology and electronic patient charting
i. Disadvantage 1. Although point of care technologies and electronic patient charting can provide great benefits, it is also susceptible to infringement on ones medical condition and/or history. Leah Curtin (2005) stresses that the information contained in these databases offers enormous opportunities for prejudice and financial gain. A patient’s medical record, both past and present, is vulnerable to anyone with ability to bypass the safeguards put in place to protect those records (Curtin, 2005). A patients right to confidentiality, and the process put in place by HIPPA to protect that confidentiality, can all be threatened as information is more readily available to a larger number of people. As Curtin (2005, p 352) asserts, healthcare informatics involves healthcare, ethics and informatics – and its practioners must, for the public’s good, be bound by additional ethical, moral and legal responsibilities.

Curtin, L. (2005, October). Ethics in nursing administration. Ethics in informatics: the intersection of nursing, ethics, and information technology. Nursing Administration Quarterly, 29(4), 349-352. Retrieved February 1, 2008 from CINAHL database.

ii. Disadvantage 2. Access to patients’ charts and medical history is dependant on the compatibility of the systems being used.
It was thought that the information maintained on electronic patient charting and patient data would be easily accessible. Philip Darbyshire (2004) states that the basic function of systems being able to “talk to each other” has been one if its shortcomings. Clinicians get little benefit in a system that cannot communicate and/or integrate with other patient care data bases located in various clinics, hospitals, and labs (Darbyshire, 2004). Information entered in point of care systems and electronic patient charts can only be useful if obtainable. Access to a patient’s complete medical history leads to more informative decision making and better patient outcomes.

Darbyshire, P. (2004). ‘Rage against the machine?’: nurses’ and midwives experiences of using computerized patient information systems for clinical information. Journal of Clinical Nursing, 13(1), 17-25. . Retrieved February 1, 2008 from CINAHL database.





References


Braswell, A., & Duggar, S. (2006, October). The new look of beside technology. Nursing Management, 37, 14-32. Retrieved November 7, 2007, from Academic Search Premier database.


Curtin, L. (2005, October). Ethics in nursing administration. Ethics in informatics: the intersection of nursing, ethics, and information technology. Nursing Administration Quarterly, 29(4), 349-352. Retrieved February 1, 2008 from CINAHL database.


Darbyshire, P. (2004). ‘Rage against the machine?’: nurses’ and midwives experiences of using computerized patient information systems for clinical information. Journal of Clinical Nursing, 13(1), 17-25. . Retrieved February 1, 2008 from CINAHL database.


Grissinger, M., & Globus, N. (2004, January). How technology affects your risk of medication errors. Nursing, 34(1), 36-42. Retrieved October 31, 2007, from CINAHL database.


Heinn, M., Coyle, G., & Hamilton, A. (2003, October). Barcoding makes its mark on daily practice. Nursing Management, 34(10), 18-20. Retrieved February 1, 2008 from Academic Search Premier database.


McDonald, C. (2006, April 4) Computerization can create safety hazards: a bar-coding near miss. Annals of Internal Medicine, 144(7), 510-516. Retrieved February 1, 2008 from Academic Search Premier database.


Paoletti, R., Suess, T., Lesko, M., Feroli, A., Kennel, J., Mahler, M., et al., (2007, March 1). Using bar- code technology and medication observation methodology for a safer medication administration. American Journal of Health-System Pharmacy, 64(5), 536-543. Retrieved November 3, 2007, from CINAHL database.


Simpson, R. (2005, January). Patient and nurse safety. Nursing Administration Quarterly, 29(1), 97-101. Retrieved November 3, 2007, from CINAHL database.


Traynor, K. (2004, October 1). Details matter in beside barcode scanning. American Journal of Health- System Pharmacy, 61(19), 1987-1988. Retrieved February 1, 2008 from Academic Search Premier database.


Wolf, Z. (April, 2007). Pursuing safe medication use and the promise of technology. MEDSURG Nursing, 16(2), 92-100. Retrieved November 3, 2007, from CINAHL
Database.

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Final Research Paper for Megan Dempsey

Measles, also known as rubeola, is a highly contagious, airborne disease transmitted by infected people. Most people live in parts of the world where vaccinations and immunity are a way of life. In six countries, including the United States, measles deaths are at near zero today (Otten, Okwo-Bele, Kezaala, & Brellick, 2003).

A Continuing Need

The Measles Initiative, A Continuing Need

Measles, also known as rubeola, is a highly contagious, airborne disease transmitted by infected people. Most people live in parts of the world where vaccinations and immunity are a way of life. In six countries, including the United States, measles deaths are at near zero today (Otten, Okwo-Bele, Kezaala, & Brellick, 2003). Still, many people around the world do not have access to these vaccinations, and are therefore susceptible to many diseases that have nearly been eradicated in first world countries, such as the United States. The World Health Organization recognized a need to create a new vaccination program to immunize African children and adults against the number one killer of preventable disease in their country, measles. As a united front, the World Health Organization, The American Red Cross, The United Nations Foundation, The Bill Gates Foundation, and The United States Center for Disease Control and Prevention created The Measles Initiative, as a solution for the measles epidemic in effected regions of the world. The Measles Initiative was put in motion to prevent unnecessary deaths of innocent children and adults by the simple use of a $1.00 vaccination. In addition to saving lives, this global vaccination program will help stop the spread of a highly contagious disease, in hopes of eradicating the measles virus for good.
The measles vaccine has been in use for forty years, but it was not until 1974 that global measles vaccination programs were put into effect (Wolfson, 2007). These programs have since been categorized into three phases. The first phase began in 1974, with high hopes of introducing routine measles vaccinations to almost every country in the world. UNICEF then led a universal childhood vaccination program that started the second phase. The second phase started in the 1990’s and continued to 1999 with the administration of one vaccination at 9 months old to children in 47 countries (Elliman & Bedford, 2007). The second phase found failure when school age children were found to contract the disease, due to not responding well to the vaccination at 9 months old. It was in 1999, when the WHO, UNICEF, The Bill Gates Foundation, and The American Red Cross united to create The Measles Initiative to vaccinate children age 9 months to 14 years old. The third phase would involve two vaccinations, at least three years apart, with scientific research showing that two vaccines are more effective than one (Elliman & Bedford, 2007).
The partnership of each group involved in The Measles Initiative is crucial because each group bears a different responsibility. The WHO designs the policies and health guidelines for each country to ensure proper, safe steps are taken during immunization campaigns. UNICEF is the only organization allowed to import the vaccine into most developing countries and has a sophisticated logistics capacity as well as great stature in the country. The CDC provides funding and the technical and scientific information to the campaign. The UN Foundation provides a substantial amount of funding as well as the financial mechanisms necessary to move funds between agencies and to countries. The American Red Cross provides funding and has the network of Red Cross volunteers to do the work, ensuring each child has a chance to be vaccinated. The Bill Gates Foundation provides funding (Measles Initiative, 2006).
With all of these groups coming together, the vaccination of over 80 million children started in Sub-Saharan Africa, an area of the world that was responsible for over half of the worlds measles deaths, causing 45% of vaccine preventable deaths (Otten, Okwo-Bele, Kezaala, & Brellik, 2003). The Measles Initiative would continue all over the world and wherever there was a need, there would be a vaccine against measles. The Measles Initiative set a goal to cut global measles deaths by 90% by 2010 (Measles Initiative, 2006).
In 2005 Otten, Kezaala, Fall, Maresha, Caimes, & Eggers (2005) found that between December, 2000- June of 2003, the average decline in the number of reported cases was 91%. The total estimated deaths averted in 2003 were 90,043. The initiative has been wildly successful and is still in progress. In 2005 the number of reported measles-related deaths around the world was at 345,000, which is a 60% decrease from 1999’s reported number of deaths of 873,000 (Irby, 2005). In continuing with this success, The Red Cross wants to ensure that The Measles Initiative steadily moves across the globe to vulnerable regions like Asia, where measles deaths are the highest outside of Sub-Saharan Africa and to smaller countries such as Pakistan, and Uzbekistan. With theses programs, health workers provide not only measles vaccines, but also insecticide-treated nets for malaria prevention, vitamin A, de-worming medication and polio vaccines (Irby, 2005).
The follow up campaigns have proven to be successful all over the world. And it has even been suggested that receiving the measles vaccine could act as a non-specific immune boost to give added protection against other diseases, but further research is needed to confirm this (Salama, Mcfarland, & Mulholland, 2003). There is still a need to continue with vaccination campaigns in Africa. Between 2003-2005, citizens of Mozambique were ravaged with a measles outbreak. There were 1,676 confirmed cases in just three years (Nshimirimana, et all, 2006). This was from failure to vaccinate enough of the population to prevent the endemic proving the absolute importance that even those in remote areas of the world must be vaccinated due to the virus’s airborne ability to infect. In 2004 and 2005, there were several large outbreaks in the European Region. The outbreaks in Romania and the Ukraine were the source of measles outbreaks in a number of EU countries, countries in which the government had reported that measles were under control (Spika, 2006). This exemplifies that measles can still effect vulnerable and non-vulnerable populations alike.
The necessity to eradicate vaccine-preventable diseases is overwhelming. Many of these diseases are highly contagious and there are no walls to protect us from the infected. Everyday people travel from region to region carrying unknown diseases. Diseases, such as measles, are capable of wiping out at-risk populations where treatment and medications are remote. We are fortunate to have access to vaccines that our bodies respond to with immunity. The measles vaccine, when given in two doses, is nearly 100% effective against the virus, but whether we can totally eradicate the virus with global vaccination is debatable. Eradication is possible due to the fact the virus in monotypic and unable to mutate (Spika, 2006). The lack of an animal reservoir and the fact that this is an acute, not chronic, illness makes eradication possible. The problem still remains that measles is a highly contagious disease, making it necessary to vaccinate every child, including those in remote areas of the world (Spika, 2006).
With continuing measles vaccination programs and with the united support of major health organizations such as UNICEF, the WHO, The American Red Cross, and the CDC, eradicating measles becomes more of a possibility every time a child is vaccinated. The measles vaccination has been shown to save tens of thousands of lives and the need to vaccinate against measles will continue until the final goal of measles eradication is met.
a. Intervention 1 Immunize every child in Africa against Measles
i. Disadvantage 1 It is extremely unlikely that every child in Sub-Saharan Africa will be found by members of the Measles Initiative due to the topography of the country
1. Sub-Saharan Africa’s climate and topography make it extremely difficult to account for its total population. “Despite colonialism, African remains powerfully itself, moulded by its hard environment” (Otten,2003). The problems of finding those in need of medical care are usually compounded by a collapse in basic infrastructure; broken roads and bridges, and continued insecurity (Otten, 2003).. It is difficult to maneuver through the terrain to find tribal groups that are “hidden” from society. The measles initiative would like to vaccinate every child in Africa, but this seems unlikely due to the fact that there are people unaccounted for in a country that is divided by desert, mountains, vast forest and war.

Otten, J. The suffering of millions. (2003, June). New African,(419), 59. Retrieved February 4, 2008, from Platinum Full Text Periodicals database.


ii. Disadvantage 2 There is knowledge deficit amongst some of Africa’s population that the immunization is necessary.
1. Many people In Africa are more concerned with short-term survival than minded to take risks for long-term development. Tribal people in the Congo region live in a warring county, their primary concern is to survive the day. These people have more eminent concerns such as what they are going to eat and drink for the day rather than the need for vaccinations. Knowledge deficit is a problem because they are surviving, but their children are dying from diseases like measles, that could have been prevented from a simple vaccine. It is important to teach the need of vaccinations, not only individually, but also globally, as measles cannot be eradicated unless every individual is immune (Culligan & Welsh, 2001).

Tim Cullinan, James Welsh. (2001). The problems of medical relief agencies. The Lancet, 357(9257), 713-4. Retrieved February 4, 2008, from Platinum Full Text Periodicals database

Intervention 2 Give a booster shot of the measles vaccine to the same children at least three years apart from the time it was first given,
i. Disadvantage 1 Record keeping if Africa is modest due to the socioeconomic status of certain rural parts of the country.
1. Immunization records have been lost or never documented due to the fact that there is little access to computers where most records are stored safely. Paper charting has been lost. especially in tribes where travel is a way of life. This problem has led to errors in documentation of school age children who have or have not received a second booster shot to discourage a measles outbreak during early education. The booster shot is necessary to prevent further outbreaks and spread of such a highly contagious disease. As the child gets older, vaccination records have become more and more obscure (Alan,Lifton,Thai,Kaying, & Hang, 2001), This potentiates the need to vaccinate school age children against measles and other threatening diseased where there are either no documents of incorrect document of the child’s past medical history. In Sub-Saharan Africa, there are few computers and even fewer dollars to provide accurate accounts of medical history (Alan et all, 2001).

.Alan R. Lifson, Dzung Thai, Kaying Hang. (2001). Lack of Immunization Documentation in Minnesota Refugees: Challenges for Refugee Preventive Health Care. Journal of Immigrant Health,3(1), 47-52. Retrieved February 4, 2008, from Research Library database..


ii. Disadvantage 2 African tribes travel due to political unrest, making it difficult to find the children who are in need of a booster shot.
1. Political unrest and a warring state have caused people to leave their homes and communities. . Some of these people go into hiding to escape the consequences of war. This makes it extremely difficult to find those children in need of a second measles shot as well as other vaccinations. The reality of this has shown that the measles epidemic is still a problem in Africa because school age children need a booster to keep them immune from the disease. Aid workers cannot find these displaced children to give them the immunization that are necessary
(Dowden,2005).


Richard Dowden (2005, March). To save Africa we must listen to it. New Statesman, 18 (850), 18-20. Retrieved February 4, 2008, from Platinum Full Text Periodicals database.






























References



Alan R. Lifson, Dzung Thai, Kaying Hang. (2001). Lack of Immunization Documentation in Minnesota Refugees: Challenges for Refugee Preventive Health Care. Journal of Immigrant Health, 3(1), 47-52. Retrieved February 4, 2008, from Research Library database. (Document ID: 352546391)
Carlson, L. (2007, March). Immunization update: neonates to adolescents. Nurse Practitioner, 32(3), 49-57.

Fitzpatrick, M. (2007, May 24). An End to the MMR guilt trip for blameless parents. Community Care, Community Care 1674, 23.


Nshimirimana, D., Masresha, B.G., & Maumbe, T. . (2006, September 22). Effects of measles-control activities--African region, 1999-2005 MMWR: Morbidity & Mortality Weekly Reportt
55, 1017-1021.


Otten, M. W., Okwo-Bele, J. M., & Kazaala, R. (2003, May 15). Impact of Alternative Approaches to Accelerated Measles Control: Experience in the African Region. Journal of Infectious Diseases 187, 36-43.
.Richard Dowden (2005, March). To save Africa we must listen to it. New Statesman, 18(850), 18-20. Retrieved February 4, 2008, from Platinum Full Text Periodicals database. (Document ID: 810330381).
Tim Cullinan, James Welsh. (2001). The problems of medical relief agencies. The Lancet, 357(9257), 713-4. Retrieved February 4, 2008, from Platinum Full Text Periodicals database. (Document ID: 69559122).

The suffering of millions. (2003, June). New African,(419), 59. Retrieved February 4, 2008, from Platinum Full Text Periodicals database. (Document ID: 349264441).

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The Cultural Diversity of Patients and the Importance of Providing Culturally Competent Care

The 21st century has been an era of multiculturalism and diversity. With this increase in our ethically diverse population, the nurses’ ability to deliver appropriate care for all people is extremely important. Jennifer McBride

There are a number of barriers that separate people of different backgrounds, but unless those barriers are discovered and overcome the people in this world will never receive the healthcare that they need and deserve. Cultural competence in the nursing field is imperative in providing successful care to clients of different ethnic or cultural backgrounds. Nurses can accomplish this by first evaluating their own personal beliefs, educating themselves and others on skills needed to do cultural assessment, and by collaborating with a multidisciplinary team.
Lacking cultural competence is a huge problem in the health care industry. Cultural competence is knowing how to communicate with people of different backgrounds. It is knowing what biologic variations can present. Cultural competence is knowing about the client’s world view and how they view life, illness, medicine, gender and health care. Without this knowledge it is virtually impossible to provide people with adequate care. Communication is key in providing the healthcare provider with vital information about the client. Cultural competence by no means calls for the nurse to be fluent in all languages, rather to know how to get around these barriers. By not knowing how a client feels about medicine or women, for example, the nurse could very easily offend the client, which could cause the client to have a negative experience. Lacking cultural competence is a problem because of our ever growing diverse country. It is a problem because without it, people will not receive the care nor education that they need.
Becoming culturally competent is an ongoing process and the nurse must bring the willingness and commitment to change. Every person is to an extent, ethnocentric. Dennis and Small (2003) recognized that clarifying one’s own values is one of the most important steps in being culturally competent. Learning how to reduce our ethnocentrism is enhanced by realizing that there are many other cultures out there. Some of these cultures are similar to our own and some are very different. Some have practices that we like or dislike, but having an awareness to this helps us to treat our clients as individuals.
In order to achieve cultural competence the nurse must yearn for the following characteristics: cultural desire, cultural awareness, cultural knowledge, cultural skill and cultural encounters. (Potter and Perry, 2005) Cultural awareness is the examination of one’s own cultural background. This process involves the recognition of one’s biases, prejudices, and assumptions about individuals who are different. Cultural knowledge is the process of seeking and obtaining educational information about diverse cultural and ethnic groups. (Purnell, 2005) Obtaining cultural knowledge about the patient’s health related beliefs and values involves understanding their world view. Understanding the patient’s world view will help the nurse to interpret how the patient views their illness. Nurses can obtain this knowledge by doing research on different cultures on the internet or at the library. Cultural skill involves being able to accurately perform a culturally based, physical assessment. The nurse needs to know about biologic differences in cultural groups, whether that is skin color or metabolic differences. The nurse also needs to be educated on cultural beliefs about medicine, illness and healthcare. This will refine or modify one’s existing beliefs about a cultural group and will prevent stereotyping. Although it may not be an actual skill, cultural desire is the pivotal and key construct of cultural competence, for it is the nurse’s desire that evokes the entire process of cultural competence. Cultural desire includes a genuine passion to be open and flexible with others, to accept differences and build on similarities, and to be willing to learn from others.
During the assessment phase it is very important to take into account things such as variations between groups. Skin color is one of the most easily observable. Many skin conditions manifest differently in light and dark skin; anemia, erythema and jaundice are just a few (Dennis and Small, 2003) Nurses need to take into account the different biologic variations of clients while performing their assessments and developing a plan of care. Because of African American’s dark skin tone it may be difficult to diagnose inflammation, jaundice and cyanosis. Clients of Asian background have a high incidence of lactose intolerance. Some variations are not biological, but are still extremely important to recognize. For instance, Native Americans sometimes wear a ceremonial patch that keeps evil spirits away; these patches should never be removed by a health care professional. Because of their religious beliefs, Muslim men may not want to be touched by a woman, even in a health care setting. Knowing these variations ensures that the nurse will be able to provide the appropriate care and treatment.
Using a formally trained medical interpreter is sometimes necessary to facilitate accurate communication during the nurse-client encounter. The use of untrained interpreters, friends or family members may pose a problem due to their lack of knowledge regarding medical terminology and disease entities. This situation is heightened when children are used as interpreters. (Campinha-Bacote, 2003) Nurses can learn just a few phrases in the most common languages and this will help with being able to communicate with clients. Usually when a health care professional attempts to communicate with a client in their own language it makes them feel more cared for and can lower the communication barriers. Nurses need to have at least a minimal amount of knowledge about the culture and background of the client they are dealing with. Collaborating with multiple health care team members is also sometimes helpful in receiving new ideas and, or receiving help in dealing with clients. Another person may have a different perspective than the nurse, and this can sometimes be a good thing.
According to Servonsky and Gibbons (2005) some assessment strategies that demonstrate how nurses can deliver culturally competent care include knowing what questions to ask and how to ask them in a nonjudgmental way, being able to empower the family and its members and acting as a mentor so that the family is more involved in the health care process. All of these things point to having a therapeutic nurse-client relationship. Working on and implementing these strategies will help the client and family to feel comfortable. Empowering the family will allow them to trust their nurse. Servonsky and Gibbons (2005) define cultural competence as:
An understanding not only of one’s own culture, values, and beliefs, but the awareness and acceptance of cultural differences among groups and the recognition that diverse groups have their own way of communicating, behaving, problem solving and interpreting health and illness. (2)
This country is growing and becoming more culturally diverse every day.

Providing successful care to clients is ensuring that the world not only survives, but advances. Nurses need to have the skills and competence to care for these clients. There will always be barriers that attempt to separate people of different backgrounds, but there are ways to overtake them. By evaluating their own personal beliefs, educating themselves and others on skills needed to do cultural assessment, and by developing collaborating with team members, the nurse can and will be able to provide culturally competent care to clients of different cultural and ethnic background.

A. Evaluating one’s own personal beliefs.
i. Viewing own personal beliefs as superior to all others.
1. Narrative: In order to provide culturally congruent care it is first necessary to examine one’s own personal beliefs. This step is essential in becoming culturally competent due to its ability to allow one to recognize that there are many different cultures with many different views on everything from life, gender, illness and medicine. Although it is a vital step, it can have a harmful outcome. In knowing and understanding one’s own cultural beliefs, it is possible to view only those as right, and all other beliefs as wrong. The attitude that one’s own ethnic group, world view or culture is superior to all others is termed ethnocentrism (Taylor, 1998). This has a harmful affiliation with viewing all other differences as negative.
1. Journal citation: Taylor, Rosemarie. (1998) Check Your Cultural Competence. Nursing Management. 29 (8) 30. Retrieved February 2, 2008 from Proquest Database.
ii. Assumed similarity or stereotyping.
2. Narrative: Another possible fallout of being in touch with one’s own cultural beliefs is believing that all other cultural groups are similar. The assumption that every culture has similar beliefs and values can lead to staff conflict as well as poor outcomes for patients. In the American culture for example, it is common courtesy to have direct eye contact with whomever one is speaking to. To believe that all cultures feel this way can lead to negative client experiences. Some Asian cultures believe direct eye contact with superiors is disrespectful. To become multicultural is to realize that one’s values and beliefs simply reflect a single set of options among many (Taylor, 1998). Stereotyping is another possible outcome. It is possible to make assumptions and perceptions about people based on their ethnicity and cultural background. For example, just because it is known that many Asian cultures use medical practices such as cupping, burning and pinching, it would be inappropriate to assume that your Asian-American client also uses these practices. It is critical to know and understand practices among different cultures, but is wrong to assume that because someone is from a certain ethnic background that these practices are used in everyday life.
3. Taylor, Rosemarie. (1998) Check Your Cultural Competence. Nursing Management. 29 (8) 30. Retrieved February 2, 2008 from Proquest Database.
B. Educating self and others on skills needed to do accurate cultural assessment.
i. Not dedicating self to the process of life-long learning and research for the purpose of assessment findings.
1. Narrative: Knowledge about cultures and its impact on interactions with health care is essential for nurses, whether one is practicing in a clinical setting, education, research or administration. Culturally congruent care can only be achieved through the process of learning cultural competence. Therefore, one must become an empowered, active learner. Cultural competence is an ongoing process in which one is always attempting to become more culturally competent. (Campinha-Bacote, 2003) The problem with this life-long learning process is that many nurses believe that there is not enough time in the day. Yes, one may be exhausted after a twelve hour shift at the hospital; however, this commitment will result in high quality, culturally congruent care.
2. Journal citation: Campinha-Bacote, J. (2003) Many Faces: Addressing Diversity in Health Care. Journal if Issues in Nursing. 8, 1. Retrieved Jan 19,2007 from Proquest Database.
ii. Not providing an assessment individualized to the clients race or culture.
1. Narrative: Providing individualized care to each and every client is dependent on having knowledge about different cultural practices, beliefs and world views. However, providing individualized care also means that every person is unique and that one must take into account their cultural background without assuming that because that client is Muslim, Indian or Asian, that they have certain religious or cultural practices. Nurses sometimes have a tendency to make generalizations about clients based on their background. This goes hand in hand with assuming similarities and stereotyping. There is always a fallout to every good intervention, but knowing that these problems exist is what allows us to acknowledge it and not make the mistake.
References:
Campinha-Bacote, J. (2003) Many Faces: Addressing Diversity in Health Care. Journal if Issues in Nursing. 8, 1. Retrieved Jan 19,2007 from Proquest Database.
Dennis, B.P. & Small, E.B. (2003). Incorporating cultural diversity in nursing care: An action plan. ABNF Journal, 14 (9), 17-26. Retrieved February 8, 2007, from Proquest Database.
Hernandez, C.G., Quinn, A.A., Vitale, S.D., Falkenstern, S.K., & Ellis, T.J. (2004). Making nursing care culturally competent. Journal of Holistic Nursing Practice. 18, 215-218. Retrieved January 19, 2007, from Proquest database.
Potter, P. & Perry, A. (2005). Culture and Ethnicity. In S. Epstein (Ed.), Fundamentals of Nursing (pp. 120-133). St. Louis, Missouri: Mosby
Purnell, L. (2005). The Purnell model for cultural competence. Journal of Multicultural Nursing and Health, 11 (2) 7-15. Retrieved February 4, 2007, from Proquest Database.
Servonsky, J.E. & Gibbons, M.E. (2005). Family nursing: Assessment strategies for implementing culturally competent care. Journal of Multicultural Nursing and Health, 11, 51-56. Retrieved January 19, 2007, from Proquest database.

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Postpartum Depression

Postpartum depression (PPD) is feelings of failure, guilt, loneliness and low self esteem lasting longer than two weeks or beginning two weeks or more after delivery. 50-80% of women experience the “baby blues,” a period characterized by feelings of restlessness, anxiousness, fatigue and loneliness which usually subside by the 10th postpartum day. This condition is mild and transient (Wong, 2006). 10-15% of women experience postpartum depression, typically with the classic symptoms of depression, sadness, crying, withdrawal and sleep disorders.


The woman may fear harming her baby or have thoughts of suicide. PPD is one of the most commonly undiagnosed conditions after childbirth. Approximately 40% of cases go unnoticed. Generally this is due to the mother’s embarrassment, guilt or fear of the feelings she is having and more often than not, she will not voluntarily admit to this kind of emotional distress (Wong, 2006). Recently the public has become aware of this ailment due largely to celebrities coming forward about their experiences with PPD. This publicity is helping women suffering from PPD to understand it and seek treatment. The nurse’s role in educating patients to prevent PPD, recognizing signs and symptoms of PPD and successful care of women suffering from PPD is essential to the health of the mother and her baby.
Nurses can educate new mothers and their families to help prevent postpartum depression in a number of ways. The precise cause has not been identified but is a combination of biochemical, psychological, social and cultural factors. Changes in hormone levels, fatigue due to childbirth, demands of the newborn, feelings of loss when separated from the newborn and cultural norms regarding the mother’s behavior are just some of the contributing causes of PPD. Informing clients of the predisposing characteristics and circumstances that place them at risk is the first key step. Issues such as prenatal depression, maternal history of depression, lack of social support, life stress, child care stress, maternal blues, marital dissatisfaction and prenatal anxiety should all be considered during conversation with the mother during both prenatal and postnatal visits. Another significant aspect is that at childbirth, the focus of attention transfers from the pregnant mother to the newborn. Continuing to support and care for the mother would help to reduce depression as well as help family members recognize symptoms of PPD. Flexible, mother-focused support from community providers may decrease the prevalence of PPD (Watt, 2002). Educating the mother and family on signs and symptoms is an important tool. These include feelings of distress, not being able to identify the source of the distress, and expressing undue concern about the health of their infant or themselves. Signs and symptoms of PPD are similar to any depressive state and consist of feelings of disappointment or apathy, sadness, insomnia, headache and anger for no justifiable reason.
Postpartum depression can interfere with maternal role attainment and may result in delayed maternal infant bonding. Because of this, nurses should seek education to better recognize early signs and symptoms of PPD and should include knowledge on assessing patients who are at risk. Risk factors for PPD are increased anxiety during pregnancy, ambivalence about pregnancy, previous postpartum depression, previous mental health disorders, previous problems with premenstrual syndrome, marital discord, poor extended family support, low socioeconomic level and a history of abuse, neglect or alcoholism. Screening tools such as the Edinburgh Postnatal Depression Scale and Beck’s Postpartum Depression Checklist may be used (Creehan, 2007). A nurse who identifies and addresses these issues early on is able to assist the new mother with seeking treatment, supporting her and being empathetic to her feelings (Castine, 2007).
Nurses play a crucial role in providing interventions and treatment for postpartum depression, beginning with identification. Screening for risk factors is the first crucial step to discovering PPD. Next, assessing the mother’s mood and affect as well as the interactions between the mother and infant is critical. The mother is very vulnerable during this immediate postpartum period so the nurse must focus on showing support and caring. Informing the mother of strategies for feeling rested are napping when the baby does and letting someone else take care of the household chores. Discuss planning self care with the mother, such as taking a walk, reading a book, having a date with her significant other and spending time with friends. Encouraging the mother to share her feelings will also improve her well being. Encouraging breast feeding is an important role the nurse can play at this time. It can help the mother bond with her newborn and results in the mother feeling pleased. Crying is also beneficial to the postpartum woman. Psychologically, it is expressive, and physiologically, it rids the body of toxins and hormones (Fooladi, 2006). This can alleviate some of the depressive feelings the new mother has. The nurse can also promote support within the family by discussing the condition and ways they are able to help the new mother. The nurse can also help the mother get in touch with support groups and programs in the community that would be beneficial to her. When depressive symptoms continue beyond the “baby blues” period, it is important to assist women in seeking medical treatment. Medical management of PPD includes pharmacological intervention. Antidepressants such as Tegretol or Depakote are necessary in most cases. Psychotherapy is another important step in the treatment process and is focused on her fears and concerns regarding her new responsibilities and roles as well as monitoring for suicidal or homicidal thoughts (Wong). Possible alternative or complimentary therapies include acupuncture, acupressure, aromatherapy, herbs, healing or therapeutic touch, massage, relaxation techniques, reflexology and yoga.
Postpartum depression is a condition that is treatable, however it is commonly undiagnosed. Nurses are able to offer much support, guidance and knowledge to these mothers. Their role is essential in the education, recognition and successful care of women suffering from PPD.

A. Intervention 1: Focus on diagnosing postpartum depression
a. Disadvantage 1: It is difficult to assess for postpartum depression due to several factors.
The length of stay in the hospital after a vaginal delivery is forty eight hours and for a cesarean section it is ninety six hours. (Datar & Sood, 2006) This amount of time allows primary care providers to ensure the physical health of the mother and newborn as well as keeping the cost of childbirth reasonable. This amount of time does not, however, allow sufficient time to monitor mental health conditions. The first postpartum check-up takes place six weeks after birth during which the provider will perform a physical examination and discuss any concerns the new mother is having. Many women suffering from postpartum depression feel embarrassed and choose not to share their feelings. After the six-week check-up, the focus turns to the infant, without further follow up for the mother (Gjerdingen & Center, 2003). With so few opportunities to assess for PPD, it’s difficult to diagnose every case.
b. Disadvantage 2: Embarrassment may hold women back from sharing feelings.
Women are expecting a period of adjustment during the postpartum period and may not realize that what they are experiencing is abnormal. (Epperson, 1999) The period directly after giving birth is very new to first time mothers. There is a feeling of pressure to be a “good mother”. If and when depressive feelings come about, she doesn’t know how to handle it during a time that is supposed to be the happiest in her life. Because of this, it is less likely that she will seek professional assistance. Denial of the classic depressive symptoms of postpartum depression delays treatment and ultimately delays normal mother-child bonding as well. Due to the very few opportunities the primary care provider has to diagnose PPD, it is important that women be educated about PPD. This will likely help them understand their feelings and seek treatment.

B. Intervention 2: Continuing to support and care for the mother postpartum
a. Disadvantage 1: Taking the time to do self care
The demands of motherhood can be overwhelming, especially if there is also strain on the mother’s relationship with her significant other or their finances. Everything is new, and taking care of your own child is exciting and frightening at the same time. These women often have responsibilities they feel that they must do on their own including cooking, cleaning and caring for the infant while trying to recover from giving birth. In order to relieve everyday stresses incurred by the new mother, she must learn to perform self-care (Cheng, 2006). The new mother needs to take time for herself. Things such as resting and exercising will help with her physical health. But self-care is so much more than that. She must let her family and friends help her with household chores and remember that she doesn’t have to do everything by herself. The new mother also needs to take care of her emotional needs by having a date with her partner and spending time with friends. Getting out of the house to go for a walk can do wonders for stress. Talking about feelings with a significant other, family and friends will help the new mother identify any depressive symptoms she may be having as well as improve her emotional health overall (Cheng, 2006).
b. Disadvantage 2: Finding the time, energy, courage and resources to get involved in support groups.
New mothers are overwhelmed with their new duties and lifestyle. There are some strategies for coping with the stress that goes along with this such as asking for help, setting daily goals, and discovering new activities. There are support groups available for just about any condition and postpartum depression is no different. It is usually difficult for women to discuss their feelings, especially if they are embarrassed of those feelings. Talking about them with a group of strangers can be quite intimidating. There are many resources available on the internet, such as Postpartum Support International (http://www.postpartum.net/index.html) . Providing information about support groups during well child check-ups may help new mothers realize that support is out there and will hopefully seek it out if she is not comfortable discussing her feelings with her provider yet (Cheng, 2006).

Resources

Castine, J. & Walton, J. (2007, March 14-20). Postpartum depression negatively impacts child development. Michigan Chronicle, p. B8.

Cheng, C., Fowles, E., & Walker, L. (2006). Postpartum maternal health care in the United States: A critical review. Journal or Perinatal Education, 15(3). Retrieved February 4, 2008 from PubMedCentral database.

Creehan, P. & Simpson, K. (2007). Perinatal Nursing (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 492-512.

Epperson, C. (1999). Postpartum major depression: Detection and treatment. American Family Physician, 59(8). Retrieved February 4, 2008 from American Academy of Family Physicians News and Publications database.

Fooladi, M. (2006). Therapeutic tears and postpartum blues. Holistic Nursing Practice, 20(4), 204-. Retrieved January 3, 2007 from Expanded Academic ASAP database.

Gjerdingen, D., & Center, B. (2003). First-time prenatal to postpartum changes in health, and the relation of postpartum health to work and partner characteristics. Journal of the American Board of Family Medicine, 16. Retrieved February 4, 2008 from Journal of the American Board of Family Medicine database.

Hendrick, V. (2003). Treatment of postnatal depression: Effective interventions are available, but the condition remains underdiagnosed. British Medical Journal, 327(7422). Retrieved January 3, 2007 from PubMedCentral database.

Lieu, T., Braveman, P., Escobar, G., Fischer, A., Jensvold, N. & Capra, A. (2000). A randomized comparison of home and clinic follow-up visits after early postpartum hospital discharge. Pediatrics. 1058. Retrieved January 3, 2007 from Expanded Academic ASAP database.

Watt, S., Sword, W., Krueger, P., & Sheehan, D. (2002). A cross-sectional study of early identification of postpartum depression: Implications for primary care providers from The Ontario Mother & Infant Survey. Journal of BioMed Central Family Practice, 3. Retrieved February 20, 2007 from PubMedCentral database.

Wong, D., Perry, S., Hockenberry, M., Lowdermilk, D.L. & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St.Louis: Mosby, Inc. pp. 619-621, 638-9, 674-9.

The Role of the Nurse in Postpartum Depression. (n.d.). Retrieved February 5, 2007, from http://www.awhonn.org/awhonn/?pg=873-6230-7000-4730-4770

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Best Practices in the Prevention and Treatment of Pressure Ulcers

With health care reform, staff downsizing, and the lengths of hospital stays decreasing, it is inevitable that the incidence of wounds will increase. The Joint Commission of Accreditation of Hospital Organizations (JACHO) suggests the appearance of a pressure ulcer may indicate the quality of care provided by a hospital. Of course the patient’s complex condition must be viewed before it can be related to inferior quality-of-care (Hall, Schumann, 2001).
Best Practices in the Prevention and Treatment of Pressure Ulcers

With health care reform, staff downsizing, and the lengths of hospital stays decreasing, it is inevitable that the incidence of wounds will increase. The Joint Commission of Accreditation of Hospital Organizations (JACHO) suggests the appearance of a pressure ulcer may indicate the quality of care provided by a hospital. Of course the patient’s complex condition must be viewed before it can be related to inferior quality-of-care (Hall, Schumann, 2001).
Preventing the incidence of a wound is one of the most important responsibilities that nurses have. Recognizing the stages of a pressure ulcer is a basic competency for nurses, however the National Pressure Ulcer Advisory Panel (NPUAP) identified, based on research, that nurses did not have the skills to identify even stage 1 pressure ulcers (Ayello, Baronoski, Salati, 2006). Regulatory bodies set guidance for staging pressure ulcers, depending on the care setting, which may determine how the same pressure ulcer is staged. Providing the best possible nursing care means staying current with the development of better products and prevention techniques that support better healing (Ayello, et. al., 2006).
The quality of wound care education received in school affects the knowledge and competence of the clinician’s wound care management. The contents of many textbooks are either incomplete or inaccurate and only provide a brief description of wound care and prevention of pressure ulcers. The caregiver’s ability in providing wound care and their knowledge about the skills needed in preventing wounds may be shown to have greater importance even than assessing the patient’s risk factors. Medical and physical conditions, environmental sources and iatrogenic causes are the three major risk factors that contribute to the failure of wound healing. Pressure ulcer development may now be determined not by how sick the patient is, but by the clinician’s knowledge and abilities which can have direct impact on outcome of healing (Hall, et. al., 2001).
The Centers for Medicare and Medicaid Services (CMS) track pressure ulcers in acute care as medical errors through the Medicare Patient Safety Monitory System (MPSMS) (Ayello, et. al., 2006). In their sister publication, Nursing 2006, Ayello set out to examine if the latest nursing wound care practices reflected the current best practice standards. According to the results of the survey, older nurses with many years of experience knew a lot about wound care where as the newer, younger and less experienced nurses needed more wound care education.
Identifying patients at risk for pressure ulcers led to the development of The Braden risk assessment tool. Overemphasis on documenting risk based on The Braden scale is important upon admission and or when the patient’s condition begins to change no matter the location of the care setting. The implementation of prevention protocols at any of the six subscales must be done rather that relying to the total risk score (18 or below) (Ayello, et. al., 2006).
In providing guidance and clinical decision making, algorithms, guidelines and clinical pathways are tools that should be used along with clinical expertise in preventing delays and enhancing appropriate treatments. The United States Department of Health and Human Services (USDHHS) has provided a list of six areas that are used to develop pressure ulcer treatment plans such as 1) a complete history and physical, 2) identification of complications and comorbid conditions, 3) nutritional assessment, 4) pain assessment, 5) psychosocial assessment, and 6) evaluation of the individual’s risk for the development of additional pressure ulcers (Hall, et. al., 2001).
Lewis, Pearson, and Ward (2003) recognize the need for straightforward guidelines for treatment and prevention of pressure ulcers. It is believed that the duration and magnitude of pressure exertion on a particular body part or region can increase the variations of pressure ulcers making it difficult to be successful with treatment.
However, practices in staging of pressure ulcers may vary from care setting to care setting; wound prevention and treatment has evolved over the years. Benbow (2006) indicates that an ‘all-in-one’ guideline on pressure ulcer prevention and management was published by the National Institute for Health and Clinical Excellence (NICE) in 2005. It is published in two parts The Management of Pressure Ulcers in Primary and Secondary Care is the first part and the second part is on risk assessment and prevention which also includes the use of pressure-relieving devices. The guideline highlights what healthcare professionals should do to prevent and treat pressure ulcers using evidence-based best practice (Benbow, 2006).

a. Intervention 1 - Continuing education for nurses in the prevention of pressure ulcers
i. Disadvantage 1 – knowledge deficit
1. Although not all pressure ulcers are preventable. Patients
with multisystem failure are particularly at risk despite the aggressiveness of
interventions. Knowledge deficit amongst nurses is a key factor in the
prevalence of pressure ulcers.
2. Education and training of healthcare professionals must be an
interdisciplinary approach. With technological and therapeutic advances
systematic implementation and updates systematic implementation needs
to be adaptable. Ultimately this education should be easily accessible to
both nurses and patients in the form of resource manuals and brochures
and easily comprehended.
Source: Lewis, M., Pearson, A., & Ward, C. (2003, April). Pressure ulcer
prevention and treatment: transforming research findings into
consensus based clinical guidelines. International Journal of
Nursing Practice, 9(2), 92-102. Retrieved November 14, 2007,
from CINAHL database.

ii. Disadvantage 2 – Not keeping up with current standards and technology
1. Management of wound care is constantly evolving. As technology
advances keeping up with the changes plays a major role in wound
healing.
2. If clinicians do not keep current with the standards and
guidelines as they become updated even the most aggressive interventions
may not be useful in preventing pressure ulcers. Knowledgeable staff
performing the initial assessment and accurate staging is essential.
Source: Caliann, C. (2007, May). Pressure ulcers a quality issue. Nursing
Management, 38(5), 42-51. Retrieved February 6, 2008, from
Academic Search Premier database.
b. Intervention 2 – Treatment options for already existing pressure ulcers
i. Disadvantage 1 – Socioeconomic status
1. Socioeconomic status affects both healthcare institutions as well as the
patients. It is important to be aware of the costs involved in treatment of
pressure ulcers which should be a good motivator for reducing the
incidence.
2. Hall and Schumann state that only one half of 1% of the aggregate health
care dollar is spent on wound care in the United States. A total national
cost of treatment has been estimated to exceed $1.36 billion dollars per
year. The average cost to heal a single pressure ulcer ranges from $1,951
for a leg ulcer to $29,373 for a diabetic ulcer. An independent study of
Medicare claims data shows that more than $20,000 is spent per patient,
per ulcer episode.
Source: Hall, P., & Schumann, L. (2001, June). Wound care: Meeting the
challenge. Journal of the American Academy of Nurse
Practitioners, 13(6), 258-268. Retrieved November 4, 2007,
from CINAHL database.

References:


Ayello, E., Baranoski, S., & Salati, D. (2006, September). Best practices in wound care
prevention and treatment. Nursing Management, 37(9), 42-48. Retrieved November
4, 2007, from CINAHL database.

Benbow, M. (2006, September 6). Guidelines for the prevention and treatment
of pressure ulcers. Nursing Standard, 20(52), 42-44. Retrieved November 4, 2007,
from CINAHL database.

Hall, P., & Schumann, L. (2001, June). Wound care: Meeting the challenge. Journal of
the American Academy of Nurse Practitioners, 13(6), 258-268. Retrieved November
4, 2007, from CINAHL database.

Lewis, M., Pearson, A., & Ward, C. (2003, April). Pressure ulcer prevention and
treatment: transforming research findings into consensus based clinical guidelines.
International Journal of Nursing Practice, 9(2), 92-102. Retrieved November 14,
2007, from CINAHL database.

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Pediatric Oncology Nursing: Support for an Uncertain Journey

Uncertainty—this is an every day occurrence for pediatric oncology patients and their families. The fear and anxiety experienced from the time a child is diagnosed throughout their long journey of treatments and tests needs to be eased by a familiar role: nurses. Jaime Giampapa

Since the very nature of cancer creates an atmosphere of unpredictability and unfamiliarity, pediatric oncology patients and their families need support from nurses who can provide care to meet not only their physical needs, but also their psychological and at times emotional needs. Nurses can make a difference to a family dealing with this illness by providing supportive care. This can be accomplished by nurses using creatively to care for these children, educating their parents, and developing therapeutic relationships along the way.
Cancer can tear a family apart. When a child is diagnosed with cancer, the family is “suddenly placed in the position of coping with a wide array of new situations, such as painful and frightening symptoms, uncertainty of prognoses, and changes in social relationships” (Suzuki& Kato, 2003, p 159). Not only does this foreboding situation put stress on the patient, but the whole family unit, which can be catastrophic. Parents describe the diagnosis and treatment of their child afflicted with cancer as one of the most stressful times of their lives (Kerr, et al., 2007), and this stress can cause a family to become ineffective. Through this tumultuous time, it is vital for the patient and his family to come together in support, and the nurse can aid in this effort.
Firstly, a nurse needs to creatively provide care to their pediatric oncology patients. By using creativity, the nurse may reduce the anxiety experienced by the patient during treatment and procedures, while also meeting physical needs. This is also a more efficient way of providing care. For example, many pediatric oncology patients have aichmophobia (fear of needles or pointed objects). A researched method of reducing this fear is utilizing simple stress reducing medical devices, defined as medical equipment, such as winged needles and syringes, with simple visual stimulation on its surface, such as stickers demonstrated by the picture(Kettwich, et al., 2007) . By using these stress reducing measures, it “has been demonstrated to markedly suppress anxiety, fear and aversion” (Kettwich, et al., 2007, p 21), which will allow the nurse to effectively and efficiently provide care to these patients.
Another creative method for treatment of pediatric oncology patients is beaded bracelets. The John Hunter Children’s Hospital introduced a Bravery Bead program in which patients receive beads spelling their name upon diagnosis and are awarded beads for completing treatments or procedures (Cotterell, 2005). This program provides children going through treatments to look forward to the fun reward of the beads after completion. Although research has not been conducted on how the beads have affected the children collecting them, one can conclude that the bracelets are symbolic of the journey they have traveled thus far. Nurses can play an integral role in implementing this program for their patients.
In addition to providing care to the patient, the nurse needs to be supportive of their parents. Parents are often overlooked when focusing on the patient’s needs, but the parents are dealing with feelings of anxiety and fear as well. Nurses need to recognize that parents “have to cope with the distress [of their child being diagnosed] along with their responsibilities as their child’s primary source of physical and psychosocial support” (Suzuki& Kato, 2003, p 160). If nurses help provide parents with the right tools to cope with their child’s illness, the child will most likely cope effectively as well. The most important tool, as identified by parents of pediatric oncology patients in a conducted study, was basic information about their child’s illness (Kerr, et al. 2007), which the nurse can address by answering questions parents may have about their child’s cancer. By locating some reliable resources (such as pamphlets, booklets and internet sites) for parents, as well as referring them to various support groups or information sessions, the nurse can attempt to fulfill the parent’s needs. In addition, 84% of the same “parent need” study revealed that emotional needs were also important for the nurse to address (Kerr, et al., 2007).
Finally, nurses need to develop a therapeutic relationship with the pediatric oncology patients and their families. The ideal therapeutic relationship is described as “the nurse combin[ing] the basics of everyday care with the human touch” (Hawes, 2005, p16), which allows the parents to feel their child is in the right hands. Trust is of utmost importance among the patient, his parents and his nurse. The relationship should be connected, but not to the point of over-involvement. This may be characterized as the nurse “tak[ing] on the role of ‘omnipotent rescuer’” (Hawes, 2005, p 15) in which the nurse has become controlling within the relationship overstepping necessary boundaries. Care should be shared between families, and the nursing staff in complete balance.
In conclusion, nurses can make the difference in pediatric oncology by providing complete supportive care for the patients and their parents. For years, nurses have been known as the “caring role” in our society, and nurses fill that role with pediatric oncology patients by establishing a care plan that involves a holistic approach to nursing. This can be accomplished by nurses creatively providing care to these children, educating their parents, and developing therapeutic relationships during their journey to recovery. The nurse develops a professional, but compassionate, relationship with the patient and the family to give complete care that will meet all their needs, physiological and psychological.


Disadvantages

A. Nurses develop therapeutic relationships with pediatric oncology patients and their families.
I. Nurses can become too involved with the patients and their families.
A nurse can become the “omnipotent rescuer” for a particular family, which can develop into an unhealthy relationship for the nurse and the family involved. This relationship usually occurs when the nurse is inexperienced and does not know how to set boundaries between themselves, the patients and their families, indicating over-involvement. Common behaviors for blurred boundaries include the nurse-patient relationship transforms into social context, also the nurse can become controlling in the patient’s care at the expense of the patient. Nurses who fall into this type of therapeutic relationship need to develop boundaries to care for the patient, but not escalate the situation to the point that it is unhealthy for the pediatric oncology patient and the nurse providing the care. By learning from mistakes and listening to experiences of mentor nurses, pediatric oncology nurses can learn to develop positive therapeutic relationships

Hawes, R. (2005). Therapeutic relationships with children and families. Paediatric Nursing, 17(6), p15-18. Retrieved October 12, 2007, from Expanded Academic at http://web.ebscohost.com.

II. Culture, ethnicity and race can reduce the effectiveness of a therapeutic relationship between the nurse and pediatric oncology patients and their family.
Some families of patients with cancer have different beliefs and practices due to their culture, ethnicity and race. This can prove to be a barrier in developing a positive therapeutic relationship with the nurses providing care. If the nurse is not thoroughly informed of the family’s individual culture, communication may be very difficult to achieve. This is especially true when the patient and their family speak a different language. In this situation, an interpreter may not always be available for the nurse to keep the family involved in their child’s care. It is often difficult to use children, family members and friends of the family to translate because this form of communication may not allow the patient’s family to speak openly about the care of their child. The barrier of communication continues if the nurse fails to incorporate traditional cultural beliefs of a family into treatment plans which can cause the family to not trust the nurse and staff to effectively care for their child. A nurse in this situation must learn to effectively communicate with the family in order to provide the optimum care for the pediatric oncology patient and develop the vital therapeutic relationship.

Wong, D.L., Perry, S.E, Hockenberry, M.J., Lowdermilk, D.L., Wilson, D. (2006) Maternal child nursing care: 3rd ed. St. Louis, Missouri: Mosby Elsevier. p 1219-1220

B. Nurses educate parents of pediatric oncology patients
I. Parents are stressed due to their child’s status and may not retain the information taught.
Parents of pediatric oncology patients are not retaining the essential information taught because of their stress at the time of education and minimal opportunity to have proper education. Due to the increase in ambulatory care and short hospital stays, the available time to properly educate parents has decreased, and therefore, so has the absorption of information. Important aspects to the patient’s care, such as “the signs that should cause alarm and long-term implications of a disease” can contribute to ignorance of how to adequately care for their child (Fox, Smith, 2003). Not only is short hospital time reason for poor digestion of information, but also their stress levels are not conducive to learning. According to Fox and Smith, most parents need additional information after their child has been discharged and cannot recall the information provided at the hospital. Therefore, because of the parent’s heightened stress level, they forget the instructions about their child’s care. Nurses must use different forms of providing information, such as pamphlets and resourceful internet sites, to enforce information learned in the hospital and prevent parent confusion.

Fox, A., Smith, P. (2003) Parents and the internet. Internet journal of pediatrics & neonatology. 3(1), p 110-116.

II. Parents that have lower socioeconomic status and education may not be able to comprehend the education regarding their child’s illness.
When parents of pediatric oncology patients have a lower socioeconomic status and have lower levels of education, the understanding of their child’s treatment may not be fully comprehended. These parents are not able to process and make sense of the information given by nurses, and may lead to misunderstandings and confusion. This is not conducive to an acceptable ability to provide knowledgeable care to their child. Parents in this group also cannot understand distressing aspects of their child’s illness because they do not understand the process behind the cancer. Although there is not sufficient data to fully support the correlation between lower education and uncertainty, one can conclude that these two topics are related. In order to combat confusion and uncertainty in these situations, the nurse must use understandable information for these parents to comprehend, and then check their knowledge after education.

Santacroce, S. (2002) Uncertainty, anxiety and symptoms of posttraumatic stress in parents of children recently diagnosed with cancer. Journal of pediatric oncology nursing. 19, p 104-111

Resources

Cotterell, D. (2005). Beads for a brave journey. Australian Nursing Journal, 13(3), p31-32. Retrieved October 12, 2007, from Expanded Academic at http://web.ebscohost.com.

Fox, A., Smith, P. (2003) Parents and the internet. Internet journal of pediatrics & neonatology. 3(1), p 110-116.

Hawes, R. (2005). Therapeutic relationships with children and families. Paediatric Nursing, 17(6), p15-18. Retrieved October 12, 2007, from Expanded Academic at http://web.ebscohost.com.

Kerr, L., Harrison, M., Medves, J., Tranmer, J., & Fitch, M. (2007) Understanding the supportive care needs of parents of children with cancer: An approach to local needs assessment. Journal of Pediatric Oncology Nursing, 24, 279-293.

Kettwich, S., Sibbitt, Jr., W., Brandt, J., Johnson, C., Wong, C., & Bankhurst, A. (2007) Needle phobia and stress-reducing medical devises in pediatric and adult chemotherapy patients. Journal of Pediatric Oncology Nursing, 24, p 20-28.

Santacroce, S. (2002) Uncertainty, anxiety and symptoms of posttraumatic stress in parents of children recently diagnosed with cancer. Journal of pediatric oncology nursing. 19, p 104-111

Suzuki, L. & Kato, P. (2003) Psychosocial support for patients in pediatric oncology: The influences of parents, schools, peers and technology. Journal of Pediatric Oncology Nursing, 20, p 159-174.

Wong, D.L., Perry, S.E, Hockenberry, M.J., Lowdermilk, D.L., Wilson, D. (2006) Maternal child nursing care: 3rd ed. St. Louis, Missouri: Mosby Elsevier. p 1219-1220

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best nursing practice for gastric bypass surgery

According to the Centers for Disease Control (CDC), statistics show that of adults in the United States, 20 years of age and older, over 60 million people are obese(Marquerite, 2006, p.1-2).Options to resolve this problem include preventative medicine, diet, exercise, and education. Yoon- heui coffman

Nursing best practice:
Post-op care for the gastric bypass patient
According to the Centers for Disease Control (CDC), statistics show that of adults in the United States, 20 years of age and older, over 60 million people are obese (Marquerite, 2006, p.1-2). Options to resolve this problem include preventative medicine, diet, exercise, and education. After all of these options have been exhausted with a health care professional, gastric bypass surgery should be considered. According to Marquerite, Roux-en-Y gastric bypass (RYGB), Biliopancreatic diversion (BPD), and Laparoscopic adjustable gastric banding (LAGB) are the three main types of gastric bypass surgery (Marquerite, 2006, p.3). Short-term complications include marginal ulcers and stenosis at the gastrojejunal anastomosis necessitating dilatation, anastomotic leakage, and gastrointestinal hemorrhage. Other complications are wound infection, incision hernia, pneumonia, pulmonary embolus, and prolonged nausea or vomiting. Long-term complications include regained weight or inadequate weight loss and nutritional deficiencies (Marquerite, 2006, p.3-4). Most morbidly obese patients report experiences of humiliation, embarrassment, insults, and blatant verbal abuse regarding their weight from their treating physicians. Obesity promotes incredible feelings of worthlessness, powerlessness, and a poor quality of life (Reto, 2003, p. 140-141). Therefore, in order for gastric bypass surgery to be successful, post-operative nursing intervention must integrate the following three approaches: physiological, psychosocial, and educational restoration.
Physiological facts
There are several important physiological facts when considering gastric bypass surgery. In obese patients, the increased size of normal structures and fat deposits interferes with the mechanics of numerous body functions. Fat deposits in the diaphragm and intercostals muscle cause decreased functional residual capacity, expiratory reserve volume, and forced expiratory volume. Sleep apnea also occurs due to airway narrowing (Hurst, Blanco, Boyle, Douglass, & Wikas, 2004, p. 77). Research has shown that prophylactic use of biphasic positive airway pressure (BiPAP) at a level of 12/4 postoperatively reduces pulmonary dysfunction and accelerates preoperative pulmonary function in obese patients (Davidson, Kruse, Cox, & Duncan, 2003, p. 110). Continuous positive airway pressure (CPAP) helps to prevent atelectasis by improving tidal volume during sleep (Davidson et al., 2003, p. 107). Therefore, it is necessary for proper respiratory care such as CPAP and BiPAP to prevent obesity hypoventilation syndrome.
If we consider wound infection, adipose tissue is poorly vascularized and may cause delayed healing of open wounds, so infection control and daily inspection of skin are needed (Hurst et al., 2004, p. 78-80). Obese patients are at risk for developing pressure ulcers and yeast infection. With each turning, skin folds are assessed, cleansed, and dried as needed. All lines and tubes are visually inspected to make sure they are not trapped in a skin fold (Hurst et al., 2003, p. 113). Monitoring for cellulitis, frequent turning and repositioning are all helpful (Hurst et al., 2004, p. 80). Difficulty getting out of bed in the early postoperative period may worsen the situation. Nurses can help with personal hygiene performance and need to encourage the patient to begin early ambulation.
Another important physiological issue is blood clotting. The morbidly obese are at higher risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) because of immobility stasis in addition to polycythemia related to chronic respiratory insufficiency (Davidson et al., 2003, p. 109). Low molecular weight Heparin such as Dalteparin (Fragmin) injection with careful monitoring of prothrombin time (PT) and partial prothrombin time (PTT) is needed to help prevent clot formation (Davidson et al., 2003, p. 111). Use of a sequential compression device and early ambulation can be helpful to decrease pain and enhance recovery (Hurst et al., 2004, p. 80).
Psychosocial facts
Empathetic nursing care is also needed. Studies show that patterns of eating connect to mood, anxiety, stress, and other hidden reasons (Reto, 2003, p. 140- 142). Overeating and obsessions with food allow for the redirecting and narrowing of thoughts, attention, and affect as well as shutting out thoughts (Reto, 2003, p.145). At the time of bariatric surgery, patients may deem themselves as taking “desperate, last resort measures” and hence becomes self-loathing, shameful, and even express suicidal ideation (Hurst et al., 2004, p. 78). Nonjudgmental, supportive, and sensitive staffs are important to promoting partnership with patients (Hurst et al, 2004, p. 79). These patients may believe that it is impossible for others to understand their life. Negative stereotype regarding the morbidly obese patient can interfere with professionalism. Regardless of how a nurse feels about obesity, one should not allow personal attitudes to influence the way care is delivered to an obese client.
Cultural influences also need to be considered. Sociocultural factors that promote thinness and self-concept relating to beauty cause binge eating disorder. The combination of a growing fast food business, multibillion dollar fashion industry, and diet programs lead to unhealthy eating habits (Reto, 2003, p.140-142). Cultural factors such as forced feeding where young children required cleaning their plates contribute obese society (Reto, 2003, p.144). Parents lacking in parenting skill may succumb to their children’s insistent request in unhealthy food (Reto, 2003, p.145). Some patients may compensate for past psychological trauma by developing a very strong personality, while others have low self- esteem. Nursing staff need to discuss fat bias openly and try to understand each patient personally.
Educational facts
Obesity can alter the pharmacokinetic properties of medications. Highly lipophylic drugs require dose calculations based on actual weight, while minimally lipophylic drugs require dosage calculations based on a patient’s ideal weight (Hurst et al., 2004, p. 77). Diabetics, for example, may need insulin dose and or oral hypoglycemic medications adjusted frequently to match the caloric intake and weight loss of the patient. It is important to identify the changing form of medication, dosage alteration, and new medication administration with the patient. Patients also should be encouraged to share any side effects of medications due to polypharmacy.
Patients are at risk for developing deficiencies of iron, B12, folate, and calcium because ingested food bypasses the duodenum, the primary site of absorption of theses nutrients (Elliot, 2003, p. 134). Patients need to take multivitamins on a life-long basis and will address the changes in dietary intake as well as in vitamin and mineral absorption (Marquerite, 2006, p.5). When sugar is consumed, it can cause dumping syndrome which consists of hypoglycemia, bloated sensation, and watery diarrhea. Patients should avoid sugar, caffeine, carbonated drinks and consume high- protein supplements or shakes (Elliot, 2003, p. 136). Diet modification can help restore fluid/ electrolyte balance, prevent dumping syndrome, and ensure the nutritional balance. Therefore, all weight loss patients should have a dietary consultation prior to discharge.
Planning exercise as conditions permit with help from physical therapist (PT)/ occupational therapist (OT) will bring a maximum effect after surgery. According to Marquerite, many well- known medical associations recommend a minimum of 150 minutes of physical activity per week over three to seven days (Marquerite, 2006, p.4). Many morbidly obese individuals, due to size, energy limitations, and/ or co- morbid conditions, may benefit from a planned and monitored, exercise program. Short and long term goals should be set to achieve optimal levels of activity (Marquerite, 2006, p.4-5). Regular physical activity promotes physical and psychological health. It can enhance cardiopulmonary functioning, musculoskeletal fitness, weight control, and psychological well- being.
Conclusion
Gastric bypass surgery is a complicated procedure that involves many risk factors to consider. Weight loss maintenance will not be achieved if we neglect these considerations. Physiologic developmental changes, behavioral aspects, family and social support, cultural origin, and environmental issues are important things for each patient and must be incorporated into the plan of care. Nurses are effective in providing postoperative care for gastric bypass patients when they provide holistic, physical, and psychological care, while collaborating in patient education.


References

Davidson, E., Kruse, W., Cox, H. & Duncan, R. (2003, Apr). Critical care of the morbidly obese. Nursing Quarterly, 26(2), 105- 116. Retrieved October 25, 2007 from Ebsco database.


Marquerite, S. (2006, Oct). Breaking through obesity with gastric bypass surgery. The Nurse Practitioner, 31(10), 12-23. Retrieved October 25, 2007 from CINHL database.


Hurst, S., Blanco, K., Boyle, D., Douglass, L., & Wikas, A. (2004, Mar). Bariatric implications of critical care nursing. Dimensions of Critical Care Nursing, 23(2), 76-83. Retrieved Oct 27, 2007 from Ebsco database.


Reto, C. (2003, June). Psychological aspects of delivering nursing care to the bariatric patient. Critical Care Nursing Quarterly, 26(2), 139-149. Retrieved Nov 1, 2007 from Proquest database.


Elliot, K. (2003, Apr). Nutritional considerations after bariatric surgery. Critical Care Nursing Quarterly, 26 (2), 133-138. Retrieved Nov 9, 2007 from CINHL database.








Nur 211

Intervention 1

Non judgmental and non- stereotypical nursing attitudes are needed with dealing with patients. Regardless of how a nurse feels about obesity, one should not allow personal attitudes to influence the way care is delivered to an obese client.

Disadvantage1;
Obesity seems still seen as somebody’s fault.

In modern societies, slenderness generally is associated with social acceptability, success, and beauty. One study found that individuals who were obese who underwent simulated job interviews were rated less qualified for jobs and viewed as having poorer work habits, as well as more emotional and interpersonal problems than participants in a control group (Murray, 2003, p. 990). The problem is health care providers often have negative perceptions of people who are obese. According to Brownnell, a study of over 400 physicians identified patient characteristics that aroused feelings of discomfort or dislike(Brownell, 2001, p.789- 792). So, there is a stereotype that obese people ought to just pull themselves together and stop eating so much and exercising more. As a nurse, one should be aware of this unconscious prejudice and discrimination towards obese patients.

Murray, D. (2003, Dec). Morbid obesity-psychosocial aspects and surgical interventions. Association of Operating Room Nurses, 78(6), 990-995. Retrieved Jan 1, 2008 from Ebsco database.

Brownwell, K. & Puhl, R. (2001, Dec). Bias, discrimination, and obesity. Obesity Research, 9(12), 788-805. Retrieved Jan 1, 2008 from Pubmed database.


Disadvantage 2;

There is minimum protection of obese individuals’ civil rights, to include the potential lack of insurance coverage.

Many reimbursement systems do not categorize obesity as a disease so physicians often have difficulties getting reimbursement for their services for the gastric bypass surgery. No federal laws exist to prohibit discrimination against obese individuals, and only a few states prohibit employment discrimination on the basis of weight. While many courts do not recognize obesity as an actual impairment, obese individuals must often use impairment claims (Brownell, 2001, p.793- 794). Whether it is advantageous for obesity to be considered a disability is a matter of debate, but it is important to consider patient’s rights and treat equally as a nurse.



Brownwell, K. & Puhl, R. (2001, Dec). Bias, discrimination, and obesity. Obesity Research, 9(12), 788-805. Retrieved Jan 1, 2008 from Pubmed database.


Intervention2

Diet modification and a plan of exercise are needed for post-op gastric bypass surgery patient to maintain weight loss.


Disadvantage1;
Lack of education opportunity and resources are common in many obese patients.

According to Najman, being overweight or obese is highly associated with lower socioeconomic status (Najman, 2006, p.977-980). Low socioeconomic status may influence a variety of factors including health insurance, local schools and their resources, local food stores and the extent to which they carry healthful foods, the price of food, tendency to watch television and participate in other sedentary activities, and access to gyms and health clubs (Vieweg, 2007, p.1-7). Education strategies considering specific population like SES (socioeconomic status) to reduce health inequalities can help solve this problem.

Najman, J. (2006, Dec). Socioeconomic disadvantage and changes in health risk behaviors in Australia: 1989-90 to 2001. Bulletin of the World Health Organization, 84(12), 976-979. Retrieved Jan 1, 2008 from Ebsco database.

Viewer, V., Johnston, C., Lanier, J., Fernandez, A., & Pandurangi. A.(2007, Jan). Correlation between High Risk Obesity Groups and Low Socioeconomic Status in School Children. Southern Medical Journal, 100(1), 8-13. Retrieved Jan1, 2008 from Proquest database.


Disadvantage 2
Patients who do not comply with prescribed health instructions are a common problem that can cause frustration for health care providers.

Compliance with behavior and lifestyle changes, that are needed to lose weight and maintain weight loss, can be extremely difficult because of genetic background, environmental pressures, and ingrained, life-long behaviors (Vieweg, 2007, p.1-7). Nurse should have realistic expectations and be aware of the considerable barriers. Nurses can help patients identify barriers, explore how these can be removed, and devise new strategies to achieve the same objectives.

Viewer, V., Johnston, C., Lanier, J., Fernandez, A., & Pandurangi. A.(2007, Jan). Correlation between High Risk Obesity Groups and Low Socioeconomic Status in School Children. Southern Medical Journal, 100(1), 8-13. Retrieved Jan1, 2008 from Proquest database.

Brown, I. (2006, Jan). Nurses’ attitudes towards adult patients who are obese. Journal of Advanced Nursing, 53(2), 221-232. Retrieved Jan1, 2008 from CINHL database.

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Education: Key To A Satisfying Birth Experience

Caesarean births and the use of anesthetics to cope with the pains of labor are on an upward trend across the US (Wong & Perry, 2006). They are becoming more prevalent daily. The RN plays an integral role in educating a pregnant woman toward her best labor and birthing experience because in many instances the RN may be the primary source of information during prenatal care. The pregnant mother should be very well informed on what her body will be going through. The nurse can be detrimental in assessing her fears of labor and childbirth and in turn do something to calm and ease those fears. The pregnant woman should also be educated by the RN on all her choices ranging from when and where the birth is going to take place, birth support systems, options for pain and discomfort management, prenatal, birthing and parenting classes, and also options to include spirituality as part of her birthing experience. The mother should know that this is her experience and she has the right and influence to make it what she wants it to be.
The first nursing strategy is to assess the pregnant woman’s knowledge and fears of pregnancy, labor and delivery. The RN’s education of the client as to the process of a normal pregnancy and birth can be started early in the months before the baby is born giving her increased confidence. “A study by Nancy Lowe, associate professor of nursing, Ohio State University, Columbus, found that, among first-time mothers, less-confident women had a greater fear of labor and birth than did those who scored high on confidence and self-esteem tests,” (Unknown, 2001). By teaching and educating an expectant mother what her body will be undergoing in the following months you are empowering her to make decisions based on fact rather than based on horror stories or myths that may have been told to her throughout her years as a woman. Lowe maintains, “Western women are bombarded with messages that undermine their beliefs in the ability of their bodies to give birth successfully, as well as their beliefs in their personal ability to exercise control over their birth experience,” (Unknown, 2001). Pregnancy and birth are natural processes with which women have been blessed to be the partakers of. In an uncomplicated pregnancy there should be no need for fear or anxiety. In order to help a woman overcome any possible fears or anxieties the RN can use this opportunity to completely and truthfully inform the mother about the process of birth. She can also inform her on what complications can happen because preparedness in both situations is a necessity. “The goals for all childbearing women are safe, esteem-building, satisfying birth experiences that launch them into motherhood with a sense of competence and self-confidence,” (Ballen & Fulcher, 2006, p. 305). The expectant mother should be encouraged to enroll in classes on the birthing process as well as classes on care for a newborn after birth. The RN should also encourage the mother to ask any necessary questions that she may have. Books, websites, magazine articles, and any other information can be suggested, and if needed, support services should be put into place.
One of the most effective ways to have a great outcome in the birthing experience is to have the right support. Midwives and/or doulas are alternatives to a doctor and may be more apt to understand and handle this in a satisfying way. The midwife is trained for delivery in low risk situations and refers to a physician for high-risk deliveries. In contrast a doula would be one who is supportive in the hospital environment. She is not trained to handle the birth on her own but rather to be the main support for the laboring woman. In this type of situation the RN and the doula can work together. “The goal of the nurse is to ensure a safe outcome. The goal of the doula is to ensure that the woman feels safe and confident,” (Ballen & Fulcher, 2006, p.305). The doula knows beforehand the woman's wishes and is prepared to carry them out as an advocate when the woman may not be thinking straight in the heat of the moment. "A woman's satisfaction with childbirth is influenced more by the quality of support she receives, feeling in control of herself, and feeling that she was actively involved in decisions than by her degree of pain, the number of interventions she experiences, or even the medical outcomes," (Ballen & Fulcher, 2006, p. 304-305). By working as a team, a doula and an RN can help produce an environment where the laboring woman and her needs are the number one priority. In order for this to be effective the roles of the RN and doula need to be strictly followed as to not cause tension or confusion between the caregivers. Where an RN cannot be involved a doula can. "The hallmark of doula care is her continuous, rather than intermittent presence." At times when the RN is doing paperwork or out in other rooms, the doula can stay at the woman's side. "The doula's care includes direct hand-on physical care and comfort . . . She keeps the laboring woman informed about her progress in labor . . . She helps explain medical terminology used by healthcare staff. If the plan of care changes, the doula facilitates the mother's adjustment to the new plan." (Ballen & Fulcher, 2006, p.305) By working together and understanding the woman's needs this can be a great time for empowerment and satisfaction for the woman and her long-term self-esteem.
If a woman decides it would be best to include pain relief into her birthing experience, the nurse can educate beforehand on what, when and how each option is used. She should be informed on both the positive and negative outcomes of different pain relief choices including affects on herself and the yet unborn baby. Pain relief comes in many different forms, from narcotics, parenteral opioids and analgesics, to hydrotherapy, breathing techniques, and spiritual components like prayer or just belief. The most common pain relief choice for women right now is the epidural. “More than half of women giving birth choose to have an epidural and some labor and delivery units report 85-90% epidural rate,” (Wong & Perry, 2006). For some women the epidural is a lifesaver. The unfortunate thing about epidurals though is that they can cause the woman to have a fever, which in turn can be potentially harmful to the fetus. “The need for oxygen therapy in the nursery was 6 times higher among infants whose mothers had a temperature,” and “most fever during term labor is not, in fact, related to infection but rather to the use of epidural,” (Lieberman, et al, 2000) “In a study of 1,218 women in labor, 123 developed a fever. Ninety-seven percent of these women had received epidural anesthesia for pain relief. Babies born to these women were more likely to have a low Apgar score, to be inactive after delivery, and to require resuscitation and oxygen therapy. They were also more likely to have a seizure,” (Lieberman, et al, 2000). Other drugs, such as opioid drugs like meperedine (Demerol) and fentanyl (Sublimaze) are commonly used but researchers have found that they “are associated with neonatal respiratory depression, decreased alertness, inhibition of sucking, lower neurobehavioral scores, and a delay in effective feeding,” (Leeman, 2003).
However, there are many options of pain relief that are not drug related. These options are more along the lines of relaxation and focus techniques, as well as the woman’s knowledge of what her body is going through, giving her increased self-confidence. Many women when looking for a place to give birth look for a hospital or birth center that includes a tub for hydrotherapy. Other options include acupuncture, breathing techniques such as Lamaze or Bradley methods, continuous labor support, maternal positioning and touch and massage techniques. Some women use spirituality to help them through the birth experience because they may feel that women’s bodies are supposed to carry and bear children, they may believe that is what women were specifically created for. In the Bible the first woman’s name is “Eve” which means “life” or “life producer,” which may give the pregnant woman added self-confidence if that is her belief. The woman should be told of all the options available to her and make the choice which best fits her view of what the labor, delivery and birth experience should entail.
Overall, being fully informed of any decision to be made in life causes the best outcome to be brought forth. The RN’s role is to assess the knowledge and fear/anxiety levels of the expecting woman and then determine the best method to overcome this. She also has a responsibility to communicate with and educate the pregnant woman on a variety of issues like what pregnancy and labor are, possible birthplace, support of mom, pain relief, etc. Of course there will be times when things outside of the plan may happen, but in the event that were to happen the RN can help the mother to be prepared. The RN is a critical component in advocating for mother and making one of the most important events in a woman’s or families life something to be looked back upon and only think of it as a wonderful experience and cherished memories. Overall the experience includes many facets, which when working together can create a beautiful outcome for mother, baby and family.



Intervention 1 – Having Labor Support That Is In The Best Interest Of The Mother & Baby

Disadvantage 1 – RN & doula not understanding each other’s role and not working together toward the best outcome and same goal.
- It is critical that an RN and doula understand which role each other serves as to not become a hinderance for the mother and baby outcome. Some RN’s see the doula as a threat but it does not need to be seen this way because the two professions serve different purposes. If an RN understands the doula’s role she can be more relaxed in her role as a nurse and less stressed and more able to give competent patient care.(Ballen & Fulcher, 2006)


Disadvantage 2 – Having a midwife who is not properly trained! Make sure to check them out!
- State suspends midwife for unprofessional conduct, she was suspected of “putting a patient’s fetus at risk by failing to provide prenatal attention, not adequately managing her labor and failing to transport the patient during an emergency, the child was stillborn.” The midwife is also suspected of not consulting with a doctor when it appeared another baby’s condition was “significantly abnormal, the child ended up on life support for four days and died after being removed from a respirator.” There is always a bad one out there. (Esposito, 2003)






Intervention 2 – Pain Relief Options For Example The Epidural

Disadvantage 1 – Loss of bodily control
- Although epidural analgesia is the most effective form of pain relief during labor it is associated with increased rates of instrumental vaginal delivery, prolonged labor and oxytocin augmentation. This results from dense paralysis of motor function from the epidural. Some of the adverse events might be related to this motor paralysis because it affects the mothers pelvic floor tone, mobility, and ability to push during labor. (MacArthur, 2001)


Disadvantage 2 – Harmful effects on baby
- Intrapartum maternal fever is a great concern to doctors because it may indicate negative effects on the newborn. Recent studies have demonstrated that for women of term pregnancy, much of fever developing during labor may not be infectious in origin but a consequence of the use of epidural analgesia. Even when the fever is not infectious in origin it is still a cause for concern in regard to the fetus. In primate studies it has been directly associated with the development of fetal hypoxia, metabolic acidosis, and hypotension. (Lieberman, 2000)


References

Ballen, L.E., & Fulcher, A.J. (2006). Nurses and doulas: Complementary roles to provide optimal maternity care. Journal of Obstetric, Gynecologic, and Neo-Natal Nursing, 35(2), 304-311.

Esposito, S. (2003) “State suspends midwife for unprofessional conduct.” The News Tribune. B02. Retrieved February 6, 2008 from ProQuest. Tacoma Community College.

Florence, D.J., & Palmer, D.G. (2003). Therapeutic choices for the discomforts of labor. Journal of Perinatal & Neonatal Nursing. 17(4), 238-252.

Leeman, L., Fontaine, P., King, V., Klein, M.C., & Ratcliffe, S. (2003). The nature and management of labor pain: Part II. Pharmacologic pain relief. American Family Physician 68 (6), 1115. Retrieved January 22, 2007 from Expanded Academic ASAP database. A108993892

Lieberman, E., Lang, J., Richardson, D.K., Frigoletto, F.D., Heffner, L.J., & Cohen, A. (2000). "Intrapartum Maternal Fever and Neonatal Outcome." Pediatrics 105(1). Retrieved January, 22, 2007 from Expanded Academic ASAP. Thomson Gale. Tacoma Community College.

MacArthur, C., Shennan, A., May, A., Whyte, J., et al. (2001) “Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: A randomized controlled trial.” The Lancet. 358(9275). Retrieved February 6, 2008 from ProQuest. Tacoma Community College

Unknown Author. (2001). Self-confidence key to easier childbirth. USA Today Magazine. 10. Retrieved 22 Jan. 2007 Expanded Academic ASAP. A79340037

Wong, D.L., Perry, S.E., Hockenberry, M.J., Lowdermilk, D.L., & Wilson, D. (2006) Maternal Child Nursing Care. 3rd. ed. (pp.455).China: Mosby.


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Motherhood and the war on AIDS

In the United States, since the beginning of the epidemic, AIDS has been diagnosed for an estimated 8,460 children who were infected perinatally. Of those, an estimated 4,800 (57%)have died.
Perinatal HIV transmission is the most common route of HIV infection in childrenand is now the source of almost all AIDS cases in children in the United States (CDC 2007 p.1). Having HIV does not need to end people’s lives, mothers can still have happy, healthy families.Preventing mother-to-child transmission (MTCT) of HIV can be done with antiretroviral therapy (ART) medications, cesarean section (CS), and bottle feeding instead of breast feeding. These three strategies will greatly reduce the risk of transmission of HIV to the infants. The CDC states, ART administered to the mother during pregnancy, labor and delivery, and then to the newborn, as well as elective CS, can reduce the rate of perinatal HIV transmission to 2% or less (2007 p.1). This paper first will explain the need for antiretroviral medication. Also, it will show the need for cesarean section. Last it explains the need to bottle feed to help reduce the risk of HIV transmission.
Giving antiretroviral therapy medications to mothers before and during pregnancy and to the infant after birth reduces the risks of transmitting HIV. Pregnant mothers, who are HIV-positive, should begin to take ART medication as soon as they find out they are pregnant. Also, they need to have it given intravenously while giving birth, and the infant needs to take ART medication for 6 weeks to help reduce the risk of transmission. ZDV is started orally at 14 to 34 weeks gestation, given intravenously to the mother during labor and administered to the infant for six weeks. In the United States, taking prophylactic medication during pregnancy can dramatically reduce, but not eliminate, the risk of vertical transmission. The reported rates of MTCT of HIV are less than 2% for women who begin treatment early in pregnancy, 12-13% among women who do not initiate treatment until labor, delivery, or after birth (Kirshenbaum 2004 p.106). One common ART medication is Zidovudine (ZDV). Kirshenbaum states, four out of five women pregnant at diagnosis of HIV reported taking ZDV as a vertical transmission risk reduction strategy. Women voiced trust in the medication and seemed to contemplate a wide array of vertical transmission risk reduction strategies (2004 p.110). After 2000, in the United States, when ART became widely used in pregnant women, 1,839 infant infections were averted (Walensky 2006 p.16). One of the major achievements in HIV research was the demonstration that administration of ZDV to the pregnant women and her infant can reduce the risk of perinatal transmission by nearly 70%. In the United States, without ART approximately 25% of pregnant women infected with HIV will transmit the virus to their child (CDC 2007 p.1&2).
Another way to reduce mother to child transmission of HIV is to have an elective cesarean section. Children who are vaginally delivered have a high risk of becoming infected with HIV due to the vaginal secretions and bleeding during delivery. Vaginal delivery is associated with increased risk of MTCT, this increased risk is ascribed to increased exposure to infected genital secretions and micro trauma during birth (Mohlala 2005 p.488-490). The greatest benefit in preventing transmission is associated with cesarean delivery performed before the rupture of membranes or to the onset of labor in conjunction with ART prophylaxis (CDC 2007 p.4). The most potent predictors of perinatal HIV transmission are prolonged rupture of the amniotic membranes, and mode of delivery. Several studies done in South Africa have demonstrated that delivery by CS reduces MTCT significantly. Recruited into the study were 26 HIV-positive pregnant mothers. For 23 of the 26 fetuses, fetal cord blood samples obtained at birth were negative for HIV RNA. Their findings demonstrated that women with healthy pregnancies who underwent elective CS before labor, at 38-40 weeks of gestation, almost all gave birth to HIV free children (2005 p.488).
The last thing to do to prevent mother to child transmission of HIV is to bottle feed and to not breast feed. There is a high risk of transmission of HIV through breast milk. Though it is healthy for mothers to give their child the first milk, which is colostrum, with HIV-positive mothers the risks outweigh the benefits. Since HIV can pass through breast milk, it is safest for HIV-positive mothers not to breast feed (Boston Women’s Health Book Collective 2005 p.304). More than one-third of all MTCT of HIV in breast-feeding population is estimated to occur via breast milk (Rousseau 2004 p.1880). During 1992-1998, a randomized clinical trial was conducted of breast feeding versus formula feeding in infants of HIV-infected mothers in Nairobi, Kenya, and found the frequency of breast milk transmission to be 16%. MTCT of HIV through breast feeding led to 44% of infants being infected (Richardson 2003 p.736). In 1998, United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) revised their guidelines on feeding infants of HIV-positive mothers in developing countries. Previously breast feeding was recommended for all mothers including HIV-positive mothers. Now with more understanding of disease HIV the revised guidelines recommend “avoidance of breast feeding” to prevent MTCT of HIV even in the developing countries (Whitney 2001 p.244).
In the absence of interventions, the rate of mother to child transmission of HIV is 15-25% in Europe and the United States and 25-40% in Africa and Asia. WHO estimated that, in 2002, HIV-infected children accounted for 10% of the infections in developing countries. Perinatal transmission accounts for more than 90% of HIV infections in infants and children, and it is also responsible for almost all new HIV infections in preadolescent children (Mohlala 2005 p.488). MTCT of HIV is a complex process that can occur while the fetus is in utero, during
delivery of the infant, or through breast feeding (Richardson 2003 p.736). The first thing to do to reduce the risk of mother to child transmission of the disease pregnant mothers should take antiretroviral medications. Second, pregnant mothers need to have a cesarean section delivery. Last, mothers should bottle feed their babies and not breast feed.

Reference Page
Center for Disease Control and Prevention. (October 2007). Mother-to-child (perinatal)HIV transmission and prevention. CDC HIV/AIDS Fact sheet. Retrieved November 17, 2007 from http//:www.cdc.gov.
Kirshenbaum, S., Hirky, E., Correale, J., Goldstein, R., Johnson, M., Rotheramborus, J., et al. (2004). Throwing the dice: Pregnancy decision-making among HIV-positive women in four U.S. cities. Perspectives on Sexual and Reproductive Health, 36 (4), 106-113. Retrieved on November 12, 2007 from CINAHL database.
Mohlala, B., Tucker, T., Besser, M., Williamson, C., Yeats, J., Smit, L., et al. (August 2005). Investigation of HIV in amniotic fluid from HIV-infected pregnant women at full term. The Journal of Infectious Diseases, 192, 488-491. Retrieved on October 28, 2007 from CINAHL database.

Richardson, B., John-Stewart, G., Hughes, J., Nduati, R., Mbori-Ngacha, D., Overbaugh, J., et al. (March 2003). Breast-milk infectivity in human immunodeficiency virus type1-infected mothers. The Journal of Infectious Diseases, 187, 736-740. Retrieved on November 20, 2007 from CINAHL database.

Rousseau, C., Nduati, R., Richardson, B., John-Stewart, G., Mbori-Ngacha, D., Kreiss, J., et al. (November 2004). Association of levels of HIV-1-infected breast milk cells and risk of mother-to-child transmission. The Journal of Infectious Diseases, 190, 1880-1888. Retrieved on November 2, 2007 from CINAHL database.

The Boston Women’s Health Book Collective. (2005). Our bodies, ourselves. New York: Simon & Schuster.

Walensky, R., Paltiel, A., Losina, E., Mercincavage, L., Schackman, B., Sax, P., et al. (July 2006). The survival benefits of AIDS treatment in the United States. The Journal of Infectious Diseases, 194, 11-19. Retrieved on November 2, 2007 from CINAHL database.
Whitney, E., Cataldo, C., DeBruyne, L., Rolfes, S..(2001). Nutrition for health and health care. California: Peter Marshall
Socioeconomic status is a barrier to bottle feeding instead of breast feeding. Baby formula is very expensive and many low income mothers can not afford it. Instead it is very cost effective for them to breast feed because it doesn’t cost anything and it is easy to access. Also, in many third world countries, like Africa they do not have access to clean water and using the water they have with formula will make their child very sick. In America we have running water to almost every building but in other countries the women have to walk miles to just get water. Walking to get water is not feasible when you have a crying child. Cesarean sections(c-section) are very expensive and if you don’t have insurance most people can’t afford it. In many third world countries there is no choice but to have the baby vaginally because they have very limited resources when it comes to doctors and nurses.


A. Cesarean delivery instead of vaginal delivery

I. Infection of the abdominal incision.
1. Being a mother brings many obstacles and is life changing. Just to take care of the baby is an all day job but then if you have a c-section you have a huge abdominal incision. The incision is painful and requires you to not lift heavy things like the baby and to not twist your body. This makes it very difficult to take care of the babies day-to-day needs. Also, the incision has many potential problems like infection. Taken care of properly the incision can heal nicely but taken care of in an unclean way is very dangerous and will cause an infection which will cause a delay in healing.
2. “Numerous factors have the potential to delay healing and cause infection. These should be identified as early as possible, ideally pre-operatively, to optimize post-op care and recovery. Over a period of 35 weeks, data was collected from 715 women undergoing c-section. Of these 80 developed surgical incision infections and for 57 symptoms were not identified until after discharged(Gould 2007).”

II. Obesity
1. A major problem in America is obesity. Being obese and pregnant puts you at high risk for surgical site infections after c-sections. Due to the excess belly fat it is hard for the incision site to heal due to the extra fat and weight.
2. “Obesity has been associated with a higher rate of infections after c-sections. It puts greater mechanical stress on the wound and this delays healing, even when there is no sign of infection(Gould 2007).”


B. Bottle feeding instead of breast feeding

I. No weight reduction
1. Breast feeding helps mothers to take off the weight they gained to conceive the baby. Many women fear getting pregnant just because they do not want to gain weight. Let’s face it we live in a world where beautiful means being a size 0-5 so many women have a hard time choosing to have a baby so if they do they want to breast feed right away to help lose the weight.
2. “Believing that breast feeding allow mothers to get back their figure more easily and protects from breast cancer is linked to the choice to breast feed. Indeed, mothers that breast feed return faster to pre-pregnancy weights and may be protected from developing breast cancer (Chabrol etal).”

II. Bad, unmoral mothers
1. Breast feeding is a healthy, bonding experience for mother to child. So mothers who do not breast feed are seen as depriving their child what they need. Many mothers are seen as uncaring and lazy if they don’t breast feed. The first day of colostrum is very boosting to the babies immune system but beyond that there a very few differences with bottle or breast feeding.
2. “The relationship between the moral reasoning factor and bottle feeding may reflect guilt in the mother if she doesn’t breast feed. It was found that many mothers associate bottle feeding with feelings of guilt and failure. Many mothers feel an obligation to breast feed or to be a perfect mother. They also may feel inadequate or fear of failure to breast feed (Chabrol etal).”

References
Chabrol, H., Walburg, V., Teissedre, F., Armitage, J., & Santrisse, K. (2004) Influence of Mother’s Perceptions on the Choice to Breast Feed or Bottle Feed: Perceptions and feeding choice. Journal of reproductive and infant psychology 22:3 August 2004 pgs.189-198. Retrieved Jan. 30, 2008 from cinahl database

Gould, D. (2007) Cesarean Section, Surgical Site Infection and Wound Management. Nursing Standard 21:32 April 2007 pgs.57-66. Retrieved Jan. 30, 2008 from cinahl database

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Pain Management in Cancer Patients

No cancer patient should needlessly suffer due to inadequacies in pain management. Nurses should continually strive to improve pain relief for cancer patients. Holly Cope

Best Practices for Pain Management in Cancer Patients
No cancer patient should needlessly suffer due to inadequacies in pain management. Nurses should continually strive to improve pain relief for cancer patients. Ideally the goal is to equip nurses with the capability of providing consistent, improved pain management for all patients. Throughout this paper, best nursing practices for pain management in cancer patients will be illustrated.
There is no question that cancer causes pain, and constant, unrelieved pain, can be torturous. Unrelieved pain has profound effects, including decreased quality of life, impaired functionality, and reduced productivity (Woodward, 2005, p.261). Several sources address the process of developing pain management programs using various improvement strategies. These combined sources acknowledge the effects of unrelieved pain, while shedding light on how improvement practices should be implemented. Through the course of this paper, three aspects of pain management will be examined: nurse assessment, documentation and patient education. Identification of key processes and barriers for effective pain management is paramount to improving pain relief (Woodward, 2005 p. 263). Every nurse that cares for a cancer patient should be asking, “Is there more that can be done to alleviate this patient’s pain?” By creating a pain management program, nurses are taking proactive measures in their patient care as well as creating an allowance for patients to be involved in their own healthcare. However none of this can be put into practice if nurses themselves are not instituting proper pain assessment. The first step in improving pain for cancer patients is to have proper, thorough and consistent nurse assessment of pain.
Support for this is given through research showing that poor staff assessment and reassessment practices impede pain relief for patients (Idell, Grant, &Kirk, 2007, p.661). Nursing efforts geared towards proper assessment are essential to maintaining successful pain management planning. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates not only pain assessment in all patients but also pain reassessment in response to interventions. Unfortunately, compliance with JCAHO standards remains problematic for many institutions (Idell, et al., 2007). However, barriers that impede proper assessment can be removed.
Research indicates that by increasing the frequency with which a patient’s pain is evaluated, interventions to reduce pain are implemented earlier. Analyzing nurse competency regarding assessment practices, and providing a team leader that holds nurses accountable has proven to be effective in increasing compliance with JCAHO standards (Idell, Grant, & Kirk, 2007, p. 662). Enhancing nurse availability and accessibility to assessment tools via a unit based educator that oversees all activities to ensure consistent implementation of said tools, has also increased compliance within institutions (Woodward, 2005, p.265). When pain assessment for all patients becomes consistent, management of pain increases and patient pain is better relieved.
Assessment can also be effectively executed with the implementation of pain management rounds. These rounds would include nurses evaluating each patient’s pain level and pain frequency trends on set days of the week. Those patients with pain would then be discussed by the interdisciplinary team and proper changes made to their pain management regimen if appropriate. Studies have shown that institutions using this assessment format have 70% of patients reporting being very satisfied with nurses’ treatment of their pain. Prior to the initiation of this assessment program, no patients rated themselves as very satisfied (Sterman, Gauker, & Krieger, 2003, p.860).
Documentation is a key factor in creating an effective pain program to aid in the relief of cancer pain for patients. An example of problematic documentation is explained in Woodward’s article. While conducting chart reviews, discrepancies in pain level documentation were revealed. The patient’s numerical pain rating was documented 60% of the time before medicating while only 12% of the time was a patient’s pain reevaluated and documented within 2 hours after a pain medication was administered (Woodward, 2005, p.263). These statistics illustrate that without proper documentation there is no record of patient care and therefore no way of addressing how to improve said care. Improper or zero documentation will result in inconsistent pain management (Sterman, Gauker, & Krieger, 2003, p. 859).
Lack of documenting a patient’s pain level is in direct opposition to best nursing practices. Various strategies to attend to this problem include the creation of better suited accountability measures for nurses, as well as the standardization of both basic and ongoing pain education for all members of the nursing care team relevant to their scope of practice (Woodward, 2005, p.265). With proper documentation, a patient’s pain level can be tracked and their pain treated without delay. Continuous accountability for documenting and follow up care pertaining to said documentation is a key element in successful pain management (Idell, Grant, & Kirk, 2007, p. 670).
Aside from nursing assessment and documentation, patient education plays a vital role in pain management. One valuable tool involves patients tracking their daily pain progress. Nurses can teach patients how to develop and use a pain management diary. The diary will provide the nurse with valuable information about their patient’s pain issues. Studies have stated the importance of patients documenting daily accounts of their pain level, the medications taken to relieve their pain and their response to the medications (Kim et al., 2004, p.1138). This strategy, coupled with nursing documentation, will provide nurses with more information with which to treat their patient’s pain.
One way to enhance a patient education strategy is through a tool called the Pain Experience Scale. This is a scale that measures patient’s knowledge regarding cancer pain management. These surveys are then evaluated to determine an effective patient education program. Most patient education programs focus on these basic principles: personalized pain management, how to better communicate with healthcare providers, and how to contact a provider. After experimentation with education programs such as these, patients demonstrated a 12% increase in knowledge when compared to patients who had not undergone such programs (Kim, et. al., 2004, 1138).
By determining where a patient’s knowledge deficit exists, a nurse will be better equipped to educate on cancer pain. A nurse can then expand and reinforce a patient’s knowledge base with information designed to facilitate pain relief (Kim, et al., 2004, p. 1142). Through education, patients are encouraged to be involved in their own pain management (Woodward, 2005, p. 261). The patient has expert knowledge about their pain level. A nurse has the obligation to teach and listen to the patient regarding what the patient is feeling and how specific interventions are working to relieve pain (Sterman, Gauker & Krieger, 2003, p.861). Patients need to be taught to use their voice in order to enable the nursing staff to better help alleviate their pain.
In summary, the overall goal for developing a pain management program is to provide consistent, improved pain management for cancer patients. This goal has been shown to be attainable through the best nursing practices of assessment, documentation and patient education. These three key elements are interrelated and work together to provide nurses with the assurance that they are doing everything in their power to alleviate their patient’s pain.











References

Aubin, M., Vezina, L., Parent, R., Fillion, L., Allard, P., & Bergeron, R., et al. (2006, November). Impact of an educational program on pain management in patients with cancer living at home. Oncology Nursing Forum, 33(6), 1183-1188. Retrieved February 1, 2008 from CINAHL database.
Harper, K., Bell, S. (2006, August). A pain assessment tool for patients with limited communication ability. Nursing Standard, 20(51), 40-44. Retrieved February 2, 2008 from CINAHL database.
Idell, C., Grant, M., & Kirk, C. (2007, May). Alignment of pain reassessment practices and national comprehensive cancer network guidelines. Oncology Nursing Forum, 34(3), 661-671. Retrieved October 30, 2007 from CINAHL database.
Kim, J., Dodd, M., West, C., Paul, S., Facione, N., & Schumacher, et al. (2004, November). The PRO-SELF pain control program improves patients’ knowledge of cancer pain management. Oncology Nursing Forum, 31(6), 1137-1143. Retrieved November 1, 2007 from CINAHL database.
Michales, T., Hubbartt, E., Carroll, S., Hudson-Barr, D. (2007, July-September). Evaluating an educational approach to improve pain assessment in hospitalized patients. Journal of Nursing Care Quality, 22(3), 260-265. Retrieved February 3, 2008 from CINAHL database.
Sterman, E., Gauker, S., & Krieger, J. (2003, September-October). A comprehensive approach to improving cancer pain management and patient satisfaction. Oncology Nursing Forum, 30(5), 857 – 864. Retrieved October 28, 2007 from CINAHL database.
Woodward, D. (2005, July-September). Developing a pain management program through continuous improvement strategies. Journal of Nursing Care Quality, 20(3), 261-267. Retrieved October 10, 2007 from CINAHL database.
a. Intervention 1: Instituting proper pain assessment is critical to cancer pain management
i. Disadvantage 1: Thorough education regarding proper pain assessment may not be readily available to many nurses.
Knowledge deficits in pain assessment practices among nurses are some of the most common contributing factors to under treatment of cancer pain in adults. Many health care institutions rely solely on the education the nurse received in school and provide no additional training. Proper Assessment is a key factor in pain management but lack of education for nursing staff will undermine this critical intervention. Common assumption is that all nurses have the same baseline knowledge about pain. Nurses have varied experiences in education and pain management.
Michales, T., Hubbartt, E., Carroll, S., Hudson-Barr, D. (2007, July-September). Evaluating an educational approach to improve pain assessment in hospitalized patients. Journal of Nursing Care Quality, 22(3), 260-265. Retrieved February 3, 2008 from CINAHL database.

ii. Disadvantage 2: Some patients may not be able to participate in the assessment process.
Every patient is different and assessing pain varies from patient to patient.Assessment of pain in patients with impaired communication due to the severity or progression of their cancer or even cognitive impairment, represents one of the most significant challenges in pain management. Nurses have difficulty knowing when these patients are in pain and when they are experiencing pain relief. This makes the patient vulnerable to under and over treatment.

Harper, K., Bell, S. (2006, August). A pain assessment tool for patients with limited communication ability. Nursing Standard, 20(51), 40-44. Retrieved February 2, 2008 from CINAHL database.

b. Intervention 2: Patient education plays a vital role in pain management
i. Disadvantage 1: Patients may not have the willingness or desire to participate in their pain relief plan depending on the severity of their cancer.
Patient education and participation is important in order to help the nurse better treat a patient’s pain, but should not replace the nurse’s role of providing a plan of care for pain relief. Unfortunately, not all patients want to participate in this aspect of their care. Some are too sick and just want their pain relieved, while others look to the nurse to provide the expert care. Patients may participate in a pain control plan if they are not consumed with illness and pain. Studies have indicated that many patients want to be taken care of when faced with a terminal illness and are not focused on learning about their pain. Many patients just want their pain relieved by the nurse that is providing care for them.
Kim, J., Dodd, M., West, C., Paul, S., Facione, N., & Schumacher, et al. (2004, November). The PRO-SELF pain control program improves patients’ knowledge of cancer pain management. Oncology Nursing Forum, 31(6), 1137-1143. Retrieved November 1, 2007 from CINAHL database.


ii. Disadvantage 2: Nursing staff may put too much responsibility on the patient to report their pain issues.
Nurses may rely too heavily on the patient to report their need for pain relief. By putting an emphasis on educating the patient regarding their pain, some nurses may depend entirely on the patient to tell them what they need. There needs to be a balance and partnership between the patient and the nurse that is providing care. Educational interventions to modify patient’s attitudes and misbeliefs, coupled with consistent nursing follow through, contribute to improved pain management in patients living with cancer. Nurses should not put the burden of pain relief on the patient and many will.
Aubin, M., Vezina, L., Parent, R., Fillion, L., Allard, P., & Bergeron, R., et al. (2006, November). Impact of an educational program on pain management in patients with cancer living at home. Oncology Nursing Forum, 33(6), 1183-1188. Retrieved February 1, 2008 from CINAHL database.


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Obesity During Pregnancy

Pregnancy, even for “healthy” women, can be difficult. Being overweight or obese adds another risk factor to this complex process.


Pregnancy, even for “healthy” women, can be difficult. Being overweight or obese adds another risk factor to this complex process. In a 2003-2004 National Health and Nutrition Examination Survey, it was estimated that 66% of adults in the United States were either overweight or obese, a figure that is expected to increase (Centers for Disease Control). Individual health risks of being overweight or obese include high blood pressure, coronary heart disease and the potential development of Type II diabetes. Coupled with pregnancy, weight issues carry harmful effects not only for the mother, but they can also impact fetal development. Given the current rise in obesity rates, not only in the United States, but worldwide, nurses need to be aware of pregnancy risks with maternal obesity and should educate women about safe weight gain, nutrition, and pre-pregnancy considerations, to prevent unwanted pregnancy outcomes that can develop from maternal weight issues.
Obesity is associated with numerous health risks for women in all stages of life. During pregnancy, this condition carries with it increased risks of pregnancy induced hypertension, pre-eclampsia, and gestational diabetes mellitus (GDM) (Villamor and Cnattinguis, 2006). During the second half of pregnancy, increased fetal nutrient demands and maternal nutrient ingestion result in higher levels of maternal blood glucose which in turn can lead to maternal insulin resistance (Wong, Perry, Hockenberry, Lowdermilk, Wilson, 2006). During a “normal” pregnancy maternal insulin production increases to compensate for this resistance. When the pancreas is unable to produce sufficient insulin or there is ineffective insulin use, gestational diabetes may result. Obesity increases insulin resistance leading to an even greater risk of GDM. GDM not only affects pregnancy but can result in increased trauma during labor and delivery (Wood, 2004). Macrosomia (large for gestational age), resulting from insulin resistance, puts a woman at an increased risk of perennial lacerations and the need for episiotomy (Wong et al, 2006). Many LGA infants require a cesarean section to be born, placing the mother at increased risk of infection due to impaired skin integrity. Shoulder dystocia is a common birth trauma for the LGA infant delivered vaginally. Educating women on the risks they will face during pregnancy is the first strategy nurses should use.
The next strategy is to educate parents about the risks of obesity to the fetus. Maternal obesity not only affects maternal health, but may also affect the development of the fetus. Maternal obesity before birth has an increased correlation with unwanted pregnancy outcomes, especially neural tube defects such as spina bifida (Watkins, Rasmussen, & Honein, 2003). An association is also indicated between obesity and a risk for omphlocele, heart defects like left ventricular outflow, and infants with multiple anomalies (two or more unrelated birth defects). Metabolic changes, such as hyperglycemia or increased hormone levels, impact fetal growth and development. Furthermore, prepregnancy and prebirth nutrition in obese and overweight woman may be deficient compared to average weight women. Overweight woman have increased requirements for certain nutrients including folic acid, which protects against birth defects. Lack of folic acid increases the risk for neural tube defects. Neonates born to mothers with gestational diabetes have an increased risk for hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome (Wong et al, 2006).
In an effort to further prevent unwanted pregnancy outcomes, education of reproductive age women about nutrition and healthy weight gain should be another strategy used by nurses and other health care providers. It is recommended that weight gain is approximately 3 to 6 pounds during the first trimester and 6 to 12 pounds for both the second and third trimesters (Wood, 2004). Weight loss during pregnancy is not advised, as woman, even those who are overweight or obese, need to gain at least enough weight to equal the products of conception (Wong et al, 2006). Furthermore, limiting caloric intake during pregnancy also limits nutrient intake. It should be stressed to pregnant women that they should not eat more than they feel they need to despite the fact that they are told they are “eating for two.” Pregnant women have a recommended intake of 60 grams of dietary protein per day and should eat plenty of fruits and vegetables, which are low in calories but satiate the appetite for longer periods of time. When choosing grain products they should try to eat whole grain products and avoid high glycemic foods such as white bread, cookies, sugary cereals, and other empty calories. Moderate exercise, recommended to control weight during pregnancy, can also lower blood sugar levels and should be an intervention for women with GDM.
Obesity may increase birth complications up to 200% (Villamor and Cnattingius, 2006). Along with interventions for obese women who are pregnant, a final, but perhaps the most important strategy, if for nurses to encourage woman to achieve a healthy weight before becoming pregnant (Watkins, Rasmussen, & Honein, 2003). A study in the American Journal of Perinatology found that prepregnancy obesity and weight gain of more than 34 pounds both significantly increase the risk of adverse pregnancy outcomes. The results of the study support other reports by the Institute of Medicine, which recommend education during preconception with regard to the importance of optimal BMI at the start of pregnancy (Obesity Risk Factors, 2007).
Through education and encouragement of healthy lifestyles, nurses can improve the outcomes of pregnancy for all women, especially those at increased risk, such as women with obesity. By reducing negative outcomes, nurses not only improve the future well being of infants but they are also improving the quality of life of mothers, insuring a healthier life with their new child. Lastly, family life altogether will be improved as the cost of health care for both mothers and children will be reduced due to their improved health status and their reduced risks for other complications in life.


Centers for Disease Control (2007) Overweight and Obesity Trends Among Adults. Retrieved October 23, 2007, from http://www.cdc.gov/nccdphp/dnpa/obesity/trend/index.htm

Obesity Risk Factors; New Obesity risk factors findings from N.J. Jain and co-researchers published. (2007, August). Women’s Health Weekly, 171. Retrieved November 26, 2007, from Proquest database.

Villamor, E. and Cnattingius, S. (2006). Interpregnancy weight change and risk of adverse pregnancy outcomes: a population-based study. The Lancet 368(9542), 1164-1170. Retrieved April 12, 2007, from Expanded Academic ASAP database.

Watkins, M., Rasmussen, S., Honein, M. et al (2003).Maternal obesity and risk for birth defects. Pediatrics, 111(5), 1152-1158. Retrieved April 21, 2007, from Expanded Academic ASAP database.

Wong D., Perry S., Hockenberry, M., Lowdermilk, D., and Wilson, D. (2006) Maternal Child Care Nursing Third Edition. St. Louis, Missouri: Mosby Elsevier.

Wood, S. (2004). A weighty issue. Baby Talk, 69(3), 54-58. Retrieved April 12, 2007, from Proquest database.


Intervention 1: Educate women about the risks of obesity on fetal development
Disadvantage 1: Not all women seek prenatal care.
Despite increased access to prenatal health care, several factors including; socio-economic status, language barriers, and knowledge deficits, prevent many woman from seeking prenatal health care. In a 2002 study only 68% of black non-Hispanic and Hispanic women received early and adequate prenatal care compared with 79% of white non-Hispanic women. A study specific to pregnant women on Medicaid found that only 20% to 42% of minority women received private care, where as 52% of white women did. The ability to find prenatal care also varies based on proximity to health care providers. Generally, fewer health care providers are found in rural areas, requiring that pregnant women in rural areas travel outside their county to obtain needed services. Limited access to private health care decreases the likelihood of women following up with a health care provider (Adams, Gavin, And Benedict, 2005).
Adams, E., Gavin, N, and Benedict, M. (2005). Access for Pregnant Women on Medicaid: Variation by Race and Ethnicity. Journal of Health Care for the Poor and Underserved, 16(1), 74-95. Retrieved February 5, 2008 from Proquest database.

Disadvantage 2: Education alone does not guarantee change.
Despite an increasing awareness of the growing obesity epidemic and its causes, promoting public health requires more than simply educating the public about the risks of obesity. Educating about risk factors does not guarantee that women will be motivated to make life-style changes that can reduce the risks associated with obesity and pregnancy. Furthermore, while it is important that woman know the risks of obesity and their pregnancy, this information can result in increased psychological stress. Rather than educate about risks, the focus should be on promoting small life-style changes that can improve the health of pregnant women, such as a healthy diet and physical activity (Obesity research, 2007)

Obesity Research; Getting people to move is one of the challenges in promoting physical activity (2007, January 13). Obesity, Fitness & Wellness Week, 6. Retrieved February 4, 2008, from Proquest database.






Intervention 2: Encourage women to achieve a healthy preconception weight.
Disadvantage 1: Conception is not planned in all cases.
The time before a woman becomes pregnant is crucial to reducing the risk of birth defects, however, nearly half of all pregnancies are unintended. Limited access by many women to health care prevents regular access to a health care provider prior to conception. Furthermore, as advanced prenatal care has improved maternal and infant health, preconception care has slowed (Prenatal Care; Preconception, 2006).
Prenatal Care; Preconception care crucial to improving maternal and infant health (2006, October 22). Medical Letter on the CDC & FDA, 86. Retrieved February 4, 2008, from Proquest database.

Disadvantage 2: Delaying pregnancy may place women at other risks for future pregnancy.
In the developed world, an increasing proportion of births are attributable to women of advanced maternal age. Advanced maternal age has been associated with an increased risk for stillbirth. For women who are obese and of an advanced maternal age, delaying pregnancy to achieve a healthy preconception weight may negate the beneficial effects of weight loss. “Prepregnancy counseling for patients who delay childbearing into their late 30s may be too late to inform decisions about preventing pregnancy risks” (Benzies, 2008).

Benzies, K. (2008). Advanced maternal age: Are decisions about the timing of child-bearing a failure to understand the risks? Canadian Medical Association Journal, 178(2) 183-184. Retrieved February 5, 2008, from Proquest database.

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Managing Oral Mucositis

Oral mucositis is an inflammatory process of the oral cavity caused by damage of the epithelium (Cawley, 2005, p.584). It is a common side effect that affects approximately 40%-100% of patients who undergo specific cancer treatments (Cawley, 2005, p.584; Eilers, 2004, p.13). Crystal Seto.

Oral mucositis may result in complications such as pain, infection, malnutrition, treatment delays and dosage reductions in cancer therapy, and decreased functional status and quality of life (Cawley & Benson, 2005, p. 584; Eilers, 2004, p. 13; Sadler et al., 2003, p. 28-29). Thus, proper management of oral mucositis is paramount in patients treated for specific cancer therapies. Nurses interact with patients during all phases of treatment, which gives them the advantage of playing a pivotal role in the proper management of oral mucositis. Cawley & Benson (2005) and Sadler et al. (2003) review the significance of nurse education and training, patient teaching, and the promotion of self-care by patients. In support, Eiliers (2004) points out that ongoing assessment and monitoring, and utilization of interventions with an evidence-based approach are efficacious and important in managing oral mucositis. Furthermore, Potting’s empirical study may prove to be a novel approach to assessing oral mucositis in daily nursing practice. Collectively, knowledge, proper and sufficient oral assessment skills and tools, and the delivery of adequate evidence-based palliative care by the nursing staff prove to be essential components of managing oral mucositis in cancer patients.
In order for nurses to properly manage oral mucositis they must first be knowledgeable about the pathophysiology. The oral mucosa is composed of rapidly-dividing epithelial cells, which are replaced approximately every two weeks from stem cells of the submucosa. Therefore, the integrity of the mucosa is dependent on the continuous reproduction of the submucosal stem cells (Cawley & Benson, 2005, p. 585).
Cawley and Benson (2005) use Sonis’ model to describe the five phases that occur with the process of oral mucositis. It begins with phase one (0-2 days), initiation, when epithelial cells are damaged by the effects of radiotherapy and chemotherapy. Next, phase two (2-3 days), upregulation and message generation, occurs. It involves increased tissue injury and cell death by inflammatory cytokines. Clinically, patients may begin to present with erythema as the mucosa starts to thin. Then, the third phase is signaling and amplification (2-10 days) in which there is cell damage below the mucosal layer. Next is ulceration (10-15 days), the fourth and most clinically observable phase. Ulcers appear deep (extends from epithelium into the submucosa) and are irregularly-shaped. The ulcers are often coated with a pseudomembrane of fibrinous exudate, which is ideal for bacterial colonization. Furthermore, nurses should recognize that nerve endings are exposed at this point. Thus, patients begin to experience pain during this phase. The final phase, phase five is healing (14-21 days). Cell proliferation begins and new tissue layers form. Although healing occurs, patients will continue to have an increased risk for developing oral mucositis because cells below the surface are permanently damaged.
Furthermore, nurses must be knowledgeable about the risk factors associated with the development of oral mucositis. This will help nurses identify high-risk patients, allow nurses to promote oral health care in high-risk patients, and assist nurses in prioritizing their care (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15; Sadler et al., 2003, p. 30). There are treatment related risk factors including chemotherapy, radiotherapy, and bone marrow transplantation (Cawley & Benson, 2005, p. 585). In addition, patient-related risk factors include age, periodontal disease and oral health, diet, tobacco and alcohol use, medications, oxygen therapy, and changes in breathing (Eilers, 2004, p. 15). Young children are at risk due to their higher epithelial cell proliferation rate, and their higher rate of hematologic malignancies which produces prolonged and intensive myelosuppression; older individuals are at risk due to physiologic declines in renal function and healing capabilities (Eilers, 2004, p. 15). Periodontal disease and alterations in oral health impair the permeability of the oral mucosa, reduces oral pH, causes tooth decay and gingivitis, and increases infection rates (Eilers, 2004, p. 15). Nurses should encourage patients to complete a comprehensive dental evaluation prior to receiving their cancer treatment (Sadler et al., 2003, p. 30). Moreover, diet is another factor that places patients at risk. Excessive sugar consumption or inadequate protein and calories to the diet contribute to tooth decay and irritation of the oral mucosa, which prolongs healing time (Eilers, 2004, p. 15). Patients should be counseled about the effects of their diet so they can actively minimize their risk. Furthermore, tobacco and alcohol use exacerbates periodontal disease and irritates and alters the oral mucosa (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15). Medications that may cause xerostomia (e.g. opioids, antidepressants, antihypertensives, antihistamines, diuretics, sedatives, phenothiazines) also promote periodontal disease and create a favorable environment for bacterial and fungal overgrowth (Eilers, 2004, p. 15). Lastly, patients who are subjected to oxygen therapy and/or have changes in their breathing (e.g. tachypnea and mouth breathing) are at an increased risk for developing mucositis because of the dry environment created in the oral cavity (Eilers, 2004, p. 15).
In addition to knowledge, nurses require proper assessment skills and tools to adequately manage oral mucositis. It is essential for nurses to incorporate thorough and ongoing assessment and monitoring throughout the treatment period so that interventions can be modified accordingly (Eilers, 2004, p. 14; Sadler et al., 2003, p. 31). Assessment of the oral cavity should begin before cancer treatment. Nurses play a key role in teaching patients the rationale and benefits of ongoing assessments. During nursing assessments, a thorough examination of the oral cavity should be implemented with appropriate lighting (Eilers, 2004, p. 17). Oral cavity assessments should include visualization of the lips, tongue, gingivae, and all other surfaces within the cavity; palpation of visible lesions; and evaluation of function (Eilers, 2004, p. 17). Interaction with patients for subjective assessment data is also important (Eilers, 2004, p. 17). Nurses should inquire about problems that patients may be experiencing, and they should also inquire about patients’ opinions about current interventions. If current interventions are dissatisfying to patients, or if patients do not understand how to adequately provide self-care, it can cause delays in the healing process and/or may cause the patient to discontinue treatment. Moreover, nurses must accurately document all observable findings gathered from each assessment. Observable findings in the oral cavity that could indicate impending complications include color changes, moisture changes, change in mucosal integrity, and edema of the lips and tongue (Eilers, 2004, p. 17).
It is critical for all nurses involved with a patient to use an assessment tool that is effective, to use the same assessment tool, and to be properly trained in using the assessment tool (Cawley & Benson, 2005, p. 587; Potting et al., 2005, p. 233). An ideal tool for evaluating the oral cavity should be: reliable, valid, objective, and usable in all clinical and research situations (Cawley & Benson, 2005, p. 586; Potting, Blijlevens, Donnelly, Feuth, & Van Achterberg, 2005, p. 229). Some of the instruments utilized in practice for scoring oral mucositis include the Oral Assessment Guide (OAG), Oral Mucositis Assessment Scale, Oral Exam Guide, World Health Organization Scale, and the National Cancer Institute Common Toxicity Criteria Scale for Mucositis and Stomatitis (Cawley & Benson, 2005, p. 587; Potting et al.; 2005, p. 229). Potting et al. (2005) argue that current instruments lack inter-rater reliability, practicality, and usability in daily nursing practice. Thus, Potting et al. (2005) developed a new instrument called the Nijmegen Nursing Mucositis Scoring System (NNMSS), which was tested and found to have favorable results. The goal of developing the NNMSS was to create an assessment instrument that was reliable, valid, and usable in daily nursing practice (Potting et al., 2005, p. 233). The NNMSS measures both objective (erythema, oedema, lesions) and subjective (pain, dryness of mouth, viscosity of saliva) characteristics of the oral cavity (Potting et al., 2005, p. 232). The NNMSS is still a newly developed instrument that needs further testing, but proves to be a promising assessment tool for the future.
The final component nurses should incorporate in their management of oral mucositis is the delivery of adequate evidence-based care. Nursing implementation of an oral care protocol is the key to preventing or minimizing oral mucositis and its complications (Cawley & Benson, 2005, p. 588; Eilers, 2004, p. 15). For patients who undergo cancer therapies, good oral hygiene is the most basic element in the oral care protocol (Cawley & Benson, 2005, p. 588; Eilers, 2004, p. 16). Nurses should always include patient teaching of how and when to care for the mouth to promote self-care. Nurses need to educate patients on topics such as toothbrushes (use soft-bristled/foam brushes, brush at lease twice daily, when to replace ); daily flossing; mouth rinses (avoid alcohol-based mouthwash); foods to avoid (coarse, spicy, acidic, alcohol, extremely hot or cold); ways to deal with dry mouth (rinses, sugar-free candy/gum, increase fluid intake); denture-care instructions (remove when performing oral care, avoid use except when eating, importance of regular cleaning); products to use for dry lips (water-based moisturizers); and how to examine and note changes in their oral cavity (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 16).
In addition to oral care protocol, there are various treatment therapies to manage oral mucositis (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). A common therapy to prevent and treat oral mucositis is mouth rinses (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). It helps to clean the debris, keep the oral cavity soft and moist, and offers pain relief (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). Recommended rinsing solutions include 0.9% saline solution, sodium bicarbonate, and a 0.9%/sodium bicarbonate mixture (Eilers, 2004, p. 18). There are also some rinses that can offer pain relief such as Magic mouthwash (lidocaine, diphenhydramine, magnesium or aluminum hydroxide), and Gelcair Bioadherent Oral Gel (polyvinylpyrrolidone, sodium hyaluronate, and glycyrrhetinic acid) (Cawley & Benson, 2005, p. 589). Nurses must teach patients about various rinses and instruct patients on its proper use.
Another treatment for oral mucositis is cryotherapy (Eilers, 2004, p. 18; Nikoletti, Hyde, Shaw, Myers, Kristjanson, 2005, p. 751). Cryotherapy is based on the principle of vasoconstriction, which reduces epithelial exposure (Eilers, 2004, p. 18). It is an ideal treatment for patients who receive a bolus of chemotherapy (especially with 5-fluorouracil), but it is not practical for those receiving prolonged chemotherapy infusions (Eilers, 2004, p. 18). Nikoletti et al. (2005) conducted a study of cryotherapy, using ice chips, and found that it significantly reduces the effects of oral mucositis.
Furthermore, there are various other agents that patients can use including mucosal protectants like sucralfate suspension and hydroxypropyl cellulose film; antiseptic agents; anti-inflammatory agents; topical analgesics; and growth factors (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 19-20). Mucosal protectants promote mucosal healing and cell regeneration (Eilers, 2004, p. 18). According to Eilers (2004), growth factors assist with the regeneration and healing of the oral mucosa (p. 21). In addition, recombinant human keratinocyte growth factor is instrumental in treating mucositis because, it stimulates the replication and maturation of epithelial cells (Cawley & Benson, 2005, p. 589).
To conclude, it is crucial for nurses to be self-directed in seeking knowledge deficits, updating their knowledge base and skills, and utilizing evidence-based interventions to provide optimal patient care and effective management of oral mucositis. Knowledge enables nurses to anticipate the occurrence of oral mucositis and be proactive in the management of its process (Cawley & Benson, 2005, p. 585). Although visual signs of mucositis typically only appear after seven to ten days of treatment initiation, damage begins the day of treatment (Cawley & Benson, 2005, p. 585-586). Initiating patient care prior to therapeutic cancer regimens will minimize the debilitating effects of oral mucositis. Furthermore, adequately maintaining or minimizing oral mucositis will increase the likelihood for completion of therapy and improve patient outcome.

a. Intervention 1- Proper Oral Assessment

i. Disadvantage 1- Current assessment tools lack inter-rater reliability, practicality, and usability in daily nursing practice.
Some of the common scoring instruments used for the assessment of the oral cavity in cancer patients lack validity, reliability, and/or usability (Cawley & Benson, 2005, p. 586; Potting et al., 2005, p.228). A few current scoring instruments used in practice include the Oral Cavity Assessment Form (OCAF), the Oral Assessment Guide (OAG), the Oral Mucositis Index (OMI), and the Western Consortium for Cancer Nursing Research Stomatitis Staging System (WCCNR). Potting et al. (2005) revealed that some instruments base their validity on consensus statements from cooperative groups or a small number of experts in the field, and that only a few instruments were evaluated for reliability during the study of the instrument. In addition, Potting et al. (2005) state that some instruments require the assessment of several items or symptoms on specific locations in the oral cavity, which require patients with severe pain to open their mouths for prolonged periods. Various instruments require different tools to correctly inspect the oral cavity, which can be too complicated for daily nursing practice and requires a significant amount of training to be used accurately (Potting et al., 2005, p. 231). Moreover, some of the scoring instruments were developed for various purposes and from the perspective of a specialized field (e.g., dentistry, radiotherapy, oncology) (Jaroneski, 2006, p. 1086; Potting et al., 2005, p. 229). Most of these instruments focused on evaluating a particular intervention and were not developed with an emphasis on inter-rater reliability because they were only used by a few researchers (Potting et al., 2005, p.229). The lack of inter-rater reliability in these instruments is incompatible with daily nursing practice, which requires a reliable and validated instrument that offers consistency with the changing of staff during every shift (Potting et al., 2005, p. 229).

Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.
Potting, C.M.J., Blijevens, N.A.M., Donnelly, J.P., Feuth, T., & Van Achterberg, T. (2006, July). A scoring system for the assessment of oral mucositis in daily nursing practice. European Journal of Cancer Care 15(3), 228-234. Retrieved October 18, 2007 from CINAHL database.

ii. Disadvantage 2- Lack of universal standards of practice regarding oral care for cancer patients.
According to Jaroneski (2006) there are no universal standards of oral care for patients with cancer. Moreover, Eilers (2004) notes that not only are standards of oral care used inconsistently in patients who undergo cancer therapy, but standards of oral care do not even exist in many institutions. Literature regarding the frequency of performing oral assessment is inconsistent, and experts fail to agree upon the use of assessment tools in the management of oral mucositis (Jaroneski, 2006, p. 1089). Current clinical guidelines, and evidence-based guidelines developed by organizations such as the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology, for the prevention and treatment of cancer therapy fail to address the use of grading scales in the assessment phase (Jaroneski, 2006, p. 1089). Chemotherapy and biotherapy guidelines and recommendations by the Oncology Nursing Society addresses the use of an assessment tool, but does not provide a specific protocol for its use (Jaroneski, 2006, p. 1089). The lack of standards of practice in the use of assessment tools and in the frequency of performing oral assessments lead to the use of inconsistent assessment tools, inadequate documentation, and absent or inconsistent oral evaluations. Adequate and proper assessment of oral mucositis is necessary to guide clinical practice for positive outcomes.

Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.

b. Intervention 2- Delivery of adequate evidenced-based care.

i. Disadvantage 1- Knowledge gaps in the pathophysiology of oral mucositis, and identification of at-risk patients.
Oncology nurses must be aware of and become familiar with the current five-stage model of mucositis developed by Sonis. Before Sonis’ research, mucositis was believed to be a result of epithelial damage caused by radiotherapy and chemotherapy (Cawley & Benson, 2005, p. 585). Sonis’ research has helped us better understand the process of oral mucositis, which targets the submucosa, as opposed to the previously believed epithelium (Cawley & Benson, 2005, p. 585).
A review of Sonis’ five-stage model is included above. An understanding of this model can help guide clinical practice for more positive outcomes (Cawley & Benson, 2005, p. 586; Jaroneski, 2006, p. 1089). Nurses who are knowledgeable about the five stages can better anticipate the occurrence of oral mucositis and therefore, can better manage oral mucositis. An understanding of the occurrence and stages of events involved with the process of oral mucositis allows nurses to be proactive with their interventions. In addition to being knowledgeable about the pathophysiology, nurses should also be able to identify at-risk populations. This knowledge will help nurses reduce patients’ risk, implement early interventions, and provide supportive care to patients who are at-risk from suffering the effects of cancer therapy (Cawley & Benson, 2005, p. 584). Cawley & Benson (2005) acknowledge differing views based on age as a risk factor, which includes both the older populations and the younger populations. Other risk factors that nurses should be aware of include gender (women more likely than men to develop oral mucositis), certain chemotherapeutic agents (5-FU, etoposide, methotraxate, antimetabolites, cyclophosphamide, bulsulfan), medications (opioids, antidepressants, phenothiazines, antihypertensives, antihistamines, diuretics, sedative), tobacco and alcohol use/abuse, oxygen therapy, poor oral health or periodontal disease, diet (high sugar intake, protein/calorie malnutrition), and changes in breathing (tachypnea, mouth breathing) (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15).

Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.

Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.

ii. Disadvantage 2- Lack of an efficacious management strategy.
According to Eilers (2004) there is a widespread interest in the prevention and treatment of mucositis, but limited progress toward finding an efficacious management strategy. Eilers (2004) states that there are few well-designed studies demonstrating the effectiveness of various treatments, but the studies are inconsistent. Thus, different institutions are using diverse regimens and are forced to make incomplete informed treatment decisions (Eilers, 2004, p. 17). In addition, although there are a variety of agents available for reducing the severity of mucositis, oral complications remain a significant source of morbidity for patients who undergo cancer therapy (Eilers, 2004, p. 17). Current treatment strategies are targeted at providing symptomatic relief, reducing the severity of mucositis, and using systemic agents that work against multiple targets (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18).

Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.

References
Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Nikoletti, S., Hyde, S., Shaw, T., Myers, H., & Kristjanson, L. (2005, July). Comparison of plain ice and flavoured ice for preventing oral mucositis associated with the use of 5 fluorouracil. Journal of Clinical Nursing14(6), 750-753. Retrieved October 18, 2007 from CINAHL database.
Potting, C.M.J., Blijevens, N.A.M., Donnelly, J.P., Feuth, T., & Van Achterberg, T. (2006 July). A scoring system for the assessment of oral mucositis in daily nursing practice. European Journal of Cancer Care 15(3), 228-234. Retrieved October 18, 2007 from CINAHL database.
Sadler, G., Stoudt, A., Fullerton, J., Oberle-Edwards, L., Nguyen, Q., & Epstein, J. (2003, February). Managing the oral sequelae of cancer therapy. MEDSURG Nursing, 12(1), 28-36. Retrieved October 18, 2007 from CINAHL database.

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Medication Errors

Administration of medications is an important nursing function and one that if not properly carried out, can lead to a host of problems for the patient and nurse. It is estimated that over 1.5 million preventable medication errors occur annually in the United States (Neal, 2006), leading to death, patient disability, increased length of hospital stays and costs.

Cause and Prevention: Medication Errors
Administration of medications is an important nursing function and one that if not properly carried out, can lead to a host of problems for the patient and nurse. It is estimated that over 1.5 million preventable medication errors occur annually in the United States (Neal, 2006), leading to death, patient disability, increased length of hospital stays and costs. According to Abudato (2004), medical errors (including medication administration errors and others) kill approximately 44,000 people yearly costing hospitals up to $30 billion annually. Medication errors can result in consequences for both the patient and the nurse; death for the patient and legal troubles for the nurse. By following some basic strategies, nurses play an important role in the reduction of such errors. These strategies include following established safety procedures, utilizing team communication to ensure safety, and using technology to reduce errors.
There are many factors that contribute to medication errors resulting in consequences to both patient and nurse. Factors that can contribute to errors include illegible handwritten drug orders, confusing drug names, and the use of nonstandard or unclear abbreviations (Neal, 2006). For the patient, the effect of drug errors can range from no side effects to death. For the nurse who commits a medication error the consequences can range from additional training and supervision to lawsuits and revocation of licensure. Medication errors can occur at any stage in the process of delivering medications to patients, from the originating prescriber to the pharmacy, but the majority of medication errors occur during administration.
Adherence to established safety procedures by all healthcare professionals can help to reduce medication errors. Errors occurring during the administration process are likely due to one of the steps of the five rights of medication administration being omitted: the right patient, medication, dose, route, and time, with the most frequent errors resulting from omission, wrong dose, and wrong medication (Davidhizar & Lonzer, 2003). Factors that can exacerbate errors include problems with the drug distribution system, inadequate staffing levels, environmental factors (e.g., distraction), nurses working in unfamiliar units, and not following standard policy and procedure. According to Davidhizar and Lonzer (2003), the following strategies are useful in addressing safety issues that revolve around medication errors: 1) reporting and analyzing errors using a multidisciplinary approach; 2) providing adequate staffing and training; 3) establishing and monitoring policies and procedures to ensure effectiveness and safety; and 4) all members of the healthcare team should have an awareness of how medication errors occur and be conscientious when administering medications. Attention to safe drug administration and safety guidelines is of particular importance in efforts to reduce medication errors and increase patient safety; it is an issue that is of concern across the various healthcare disciplines and nurses are essentially the final check and balance in the system.
Communication is a key function for nurses in providing safe and effective healthcare to their patients, and includes communicating effectively with patients and other healthcare team members. Abudato (2004) states that 90% of errors that occur within the healthcare industry are due to communication that breaks down at the nurse-physician level. Often, dysfunctional communication patterns between professionals in healthcare entities results from the organizational structure which determines how professionals interact with each other, who has the power (individual and group), and the cultural norms of the organization. RN’s are accountable to provide safe care to the point of questioning physician orders in order to fulfill the role of patient advocate. This can lead to dysfunctional communication because it represents a challenge to the authority and power of the physician, especially those who feel that they are where the “buck stops” when deciding what is and is not appropriate patient care (Arford, 2005).
Johns Hopkins has adopted a three-step model that focuses on assertiveness as a strategy for communication. This model advocates that when nurses communicate it is appropriate to use the first name of the person they are addressing in order to get their attention. The model further stresses that it is important to not only present the problem, but also present a solution and seek agreement to what has been proposed. Finally, the model suggests that if satisfactory resolution is not attained, move the problem up to the next level of authority (Abudato, 2004). Organizational structure often dictates the way communications occur and it is important to remember that no matter the situation, mutual respect must be maintained. Effective communication among all team members is an important aspect of delivering appropriate patient care and advocating for the patient, and is an area where things can often go wrong.
There is no substitute for common sense and diligence, but technological advances may be of use in helping to prevent medication errors. Technological measures include automated medication dispensing machines, computerized IV administration, and the bar coding of both patients and drugs. A research study conducted among a select group of nursing students at a suburban New York university was designed to answer the question: Does the use of PDAs (personal digital assistants) with drug and medication calculation software improve the accuracy and efficiency of medication administration (Greenfield, 2007)? Results of this study upheld the hypothesis that the use of PDAs and medical software did, overall, improve the accuracy and efficiency of medication administration. The author of the study recommends that all nursing students be required to have PDAs with drug and calculation software on them. There is evidence to suggest that use of technology is helpful in reducing medication errors, nonetheless, a strong human component remains and does not replace the need for carefulness and good judgment.
Medication errors represent a serious issue for the healthcare community as a whole. Errors can result for a variety of reasons; however, the majority of errors occur during administration of the medications. Because the nurse is the final link in the process of administering medications, it is the responsibility of the nurse to ensure accurate delivery of medications to patients. Strategies that the nurse can use to accomplish this include attention to policies and procedures, effective communication with other healthcare team members, and using available technological resources to complement other safeguards and individual competence.
a. Staffing and reporting
i. Staffing
1. Because of the high acuity of patients in the hospital setting today, adequate staffing levels are critical to providing safe patient care. With repeated interruptions nurses may find it difficult to establish and maintain a routine that may be critical to the delivery of appropriate and timely medications. In addition to disruptions in the work flow, the complexity of the work performed by nurses as they balance their workload, along with managing the goals of the organization and goals of patient care, contributes to the problem.
2. Aebersold, M., Kalish, B.J. (May/June 2006). Overcoming barriers to patient safety. Nursing Economics 24(3), pp. 143-155. Retrieved from ProQuest on February 2, 2008.
ii. Reporting of errors
1. Reporting of errors relies on voluntary reporting. Traditionally, the nursing profession has operated based on a culture of fear and blame that focuses on individual culpability rather than looking at problems from a system-wide perspective. There can also be some ambiguity with regards to what actually constitutes a medication error (e.g., is late delivery of a dose a medication error?) and there is often reluctance to report errors that do not result in patient harm. Often nurses feel that reporting medication errors will be personally and professional damaging and are also reluctant to report errors made by others such as physicians, pharmacists and other nurses.
2. Groves, M., Pafford, L., Stetina, P. (June 2005). Managing medication errors – a qualitative study. MEDSURG Nursing 14(3), pp 174-178. Retrieved from Expanded Academic ASAP on April 6, 2007.
j. Communication & organizational structure
i. Interpersonal communication
1. Historically, health care has been organized in a hierarchical fashion with physicians at the top of the hierarchy being seen as the ultimate authority when it comes to patient care. This type of culture has become so ingrained in our health care system that we don’t even question it. According to Abudato (2004), the acceptance of this culture can result in physicians subconsciously ignoring important information provided by nurses because they view them as subordinate. When this type of response is the norm, nurses may feel irrelevant and stop communicating, which only serves to further dysfunctional communication styles and may have an impact on the quality of patient care, including medication administration.
2. Abudato, S. (2004, September). Making the communication connection: To minimize miscommunication with colleagues and patients, get assertive. Nursing Management 35(9), pp. 33-35. Retrieved from ProQuest on October 24, 2007.
ii. Organizational structure
1. While each nurse should have accountability in delivering safe and competent care including medication administration, often the organization itself which creates problems. It is the organization that provides the context in which nurses and physicians communicate because it directs the behavioral norms and determines how nurses and physicians communicate with each other. Conflict can arise in the context of nurses performing their roles as independent practitioners resulting in dysfunctional nurse-physician communication when individual authorities are challenged. Organizations often do not provide environments that are conducive to fostering teamwork and collaborative communication between nurses and physicians.
2. Arford, P.H. (2005, March-April). Nurse-physician communication: An organizational accountability. Nursing Economics 23(2), pp. 72-77. Retrieved from Expanded Academic ASAP on April 6, 2007.

 
References
Abudato, S. (2004, September). Making the communication connection: To minimize miscommunication with colleagues and patients, get assertive. Nursing Management 35(9), pp. 33-35. Retrieved from ProQuest on October 24, 2007.
Aebersold, M., Kalish, B.J. (May/June 2006). Overcoming barriers to patient safety. Nursing Economics 24(3), pp. 143-155. Retrieved from ProQuest on February 2, 2008.
Arford, P.H. (2005, March-April). Nurse-physician communication: An organizational accountability. Nursing Economics 23(2), pp. 72-77. Retrieved from Expanded Academic ASAP on April 6, 2007.
Davidhizar, R., Lonser, G. (2003, July-September). Strategies to decrease medication errors. Health Care Manager 22(3), pp. 211-218. Retrieved from Expanded Academic ASAP on April 6, 2007.
Greenfield, S. (2007, March). Medication error reduction and the use of PDA technology. Journal of Nursing Education 46(3), pp.127-131. Retrieved from ProQuest on April 6, 2007.
Groves, M., Pafford, L., Stetina, P. (June 2005). Managing medication errors – a qualitative study. MEDSURG Nursing 14(3), pp 174-178. Retrieved from Expanded Academic ASAP on April 6, 2007.
Harrington, S., Lilley, L., and Snyder, J. (2007). Pharmacology and the nursing process (5th ed.). St. Louis: Elsevier Saunders.
Neal, T. (2006, September 19). Preventing medication errors. The Seattle Times. Downloaded from seattletimes.nwsource.com on April 6, 2007.

Leave the following text intact.

Cause and Prevention: Medication Errors
Administration of medications is an important nursing function and one that if not properly carried out, can lead to a host of problems for the patient and nurse. It is estimated that over 1.5 million preventable medication errors occur annually in the United States (Neal, 2006), leading to death, patient disability, increased length of hospital stays and costs. According to Abudato (2004), medical errors (including medication administration errors and others) kill approximately 44,000 people yearly costing hospitals up to $30 billion annually. Medication errors can result in consequences for both the patient and the nurse; death for the patient and legal troubles for the nurse. By following some basic strategies, nurses play an important role in the reduction of such errors. These strategies include following established safety procedures, utilizing team communication to ensure safety, and using technology to reduce errors.
There are many factors that contribute to medication errors resulting in consequences to both patient and nurse. Factors that can contribute to errors include illegible handwritten drug orders, confusing drug names, and the use of nonstandard or unclear abbreviations (Neal, 2006). For the patient, the effect of drug errors can range from no side effects to death. For the nurse who commits a medication error the consequences can range from additional training and supervision to lawsuits and revocation of licensure. Medication errors can occur at any stage in the process of delivering medications to patients, from the originating prescriber to the pharmacy, but the majority of medication errors occur during administration.
Adherence to established safety procedures by all healthcare professionals can help to reduce medication errors. Errors occurring during the administration process are likely due to one of the steps of the five rights of medication administration being omitted: the right patient, medication, dose, route, and time, with the most frequent errors resulting from omission, wrong dose, and wrong medication (Davidhizar & Lonzer, 2003). Factors that can exacerbate errors include problems with the drug distribution system, inadequate staffing levels, environmental factors (e.g., distraction), nurses working in unfamiliar units, and not following standard policy and procedure. According to Davidhizar and Lonzer (2003), the following strategies are useful in addressing safety issues that revolve around medication errors: 1) reporting and analyzing errors using a multidisciplinary approach; 2) providing adequate staffing and training; 3) establishing and monitoring policies and procedures to ensure effectiveness and safety; and 4) all members of the healthcare team should have an awareness of how medication errors occur and be conscientious when administering medications. Attention to safe drug administration and safety guidelines is of particular importance in efforts to reduce medication errors and increase patient safety; it is an issue that is of concern across the various healthcare disciplines and nurses are essentially the final check and balance in the system.
Communication is a key function for nurses in providing safe and effective healthcare to their patients, and includes communicating effectively with patients and other healthcare team members. Abudato (2004) states that 90% of errors that occur within the healthcare industry are due to communication that breaks down at the nurse-physician level. Often, dysfunctional communication patterns between professionals in healthcare entities results from the organizational structure which determines how professionals interact with each other, who has the power (individual and group), and the cultural norms of the organization. RN’s are accountable to provide safe care to the point of questioning physician orders in order to fulfill the role of patient advocate. This can lead to dysfunctional communication because it represents a challenge to the authority and power of the physician, especially those who feel that they are where the “buck stops” when deciding what is and is not appropriate patient care (Arford, 2005).
Johns Hopkins has adopted a three-step model that focuses on assertiveness as a strategy for communication. This model advocates that when nurses communicate it is appropriate to use the first name of the person they are addressing in order to get their attention. The model further stresses that it is important to not only present the problem, but also present a solution and seek agreement to what has been proposed. Finally, the model suggests that if satisfactory resolution is not attained, move the problem up to the next level of authority (Abudato, 2004). Organizational structure often dictates the way communications occur and it is important to remember that no matter the situation, mutual respect must be maintained. Effective communication among all team members is an important aspect of delivering appropriate patient care and advocating for the patient, and is an area where things can often go wrong.
There is no substitute for common sense and diligence, but technological advances may be of use in helping to prevent medication errors. Technological measures include automated medication dispensing machines, computerized IV administration, and the bar coding of both patients and drugs. A research study conducted among a select group of nursing students at a suburban New York university was designed to answer the question: Does the use of PDAs (personal digital assistants) with drug and medication calculation software improve the accuracy and efficiency of medication administration (Greenfield, 2007)? Results of this study upheld the hypothesis that the use of PDAs and medical software did, overall, improve the accuracy and efficiency of medication administration. The author of the study recommends that all nursing students be required to have PDAs with drug and calculation software on them. There is evidence to suggest that use of technology is helpful in reducing medication errors, nonetheless, a strong human component remains and does not replace the need for carefulness and good judgment.
Medication errors represent a serious issue for the healthcare community as a whole. Errors can result for a variety of reasons; however, the majority of errors occur during administration of the medications. Because the nurse is the final link in the process of administering medications, it is the responsibility of the nurse to ensure accurate delivery of medications to patients. Strategies that the nurse can use to accomplish this include attention to policies and procedures, effective communication with other healthcare team members, and using available technological resources to complement other safeguards and individual competence.
a. Staffing and reporting
i. Staffing
1. Because of the high acuity of patients in the hospital setting today, adequate staffing levels are critical to providing safe patient care. With repeated interruptions nurses may find it difficult to establish and maintain a routine that may be critical to the delivery of appropriate and timely medications. In addition to disruptions in the work flow, the complexity of the work performed by nurses as they balance their workload, along with managing the goals of the organization and goals of patient care, contributes to the problem.
2. Aebersold, M., Kalish, B.J. (May/June 2006). Overcoming barriers to patient safety. Nursing Economics 24(3), pp. 143-155. Retrieved from ProQuest on February 2, 2008.
ii. Reporting of errors
1. Reporting of errors relies on voluntary reporting. Traditionally, the nursing profession has operated based on a culture of fear and blame that focuses on individual culpability rather than looking at problems from a system-wide perspective. There can also be some ambiguity with regards to what actually constitutes a medication error (e.g., is late delivery of a dose a medication error?) and there is often reluctance to report errors that do not result in patient harm. Often nurses feel that reporting medication errors will be personally and professional damaging and are also reluctant to report errors made by others such as physicians, pharmacists and other nurses.
2. Groves, M., Pafford, L., Stetina, P. (June 2005). Managing medication errors – a qualitative study. MEDSURG Nursing 14(3), pp 174-178. Retrieved from Expanded Academic ASAP on April 6, 2007.
j. Communication & organizational structure
i. Interpersonal communication
1. Historically, health care has been organized in a hierarchical fashion with physicians at the top of the hierarchy being seen as the ultimate authority when it comes to patient care. This type of culture has become so ingrained in our health care system that we don’t even question it. According to Abudato (2004), the acceptance of this culture can result in physicians subconsciously ignoring important information provided by nurses because they view them as subordinate. When this type of response is the norm, nurses may feel irrelevant and stop communicating, which only serves to further dysfunctional communication styles and may have an impact on the quality of patient care, including medication administration.
2. Abudato, S. (2004, September). Making the communication connection: To minimize miscommunication with colleagues and patients, get assertive. Nursing Management 35(9), pp. 33-35. Retrieved from ProQuest on October 24, 2007.
ii. Organizational structure
1. While each nurse should have accountability in delivering safe and competent care including medication administration, often the organization itself which creates problems. It is the organization that provides the context in which nurses and physicians communicate because it directs the behavioral norms and determines how nurses and physicians communicate with each other. Conflict can arise in the context of nurses performing their roles as independent practitioners resulting in dysfunctional nurse-physician communication when individual authorities are challenged. Organizations often do not provide environments that are conducive to fostering teamwork and collaborative communication between nurses and physicians.
2. Arford, P.H. (2005, March-April). Nurse-physician communication: An organizational accountability. Nursing Economics 23(2), pp. 72-77. Retrieved from Expanded Academic ASAP on April 6, 2007.

 
References
Abudato, S. (2004, September). Making the communication connection: To minimize miscommunication with colleagues and patients, get assertive. Nursing Management 35(9), pp. 33-35. Retrieved from ProQuest on October 24, 2007.
Aebersold, M., Kalish, B.J. (May/June 2006). Overcoming barriers to patient safety. Nursing Economics 24(3), pp. 143-155. Retrieved from ProQuest on February 2, 2008.
Arford, P.H. (2005, March-April). Nurse-physician communication: An organizational accountability. Nursing Economics 23(2), pp. 72-77. Retrieved from Expanded Academic ASAP on April 6, 2007.
Davidhizar, R., Lonser, G. (2003, July-September). Strategies to decrease medication errors. Health Care Manager 22(3), pp. 211-218. Retrieved from Expanded Academic ASAP on April 6, 2007.
Greenfield, S. (2007, March). Medication error reduction and the use of PDA technology. Journal of Nursing Education 46(3), pp.127-131. Retrieved from ProQuest on April 6, 2007.
Groves, M., Pafford, L., Stetina, P. (June 2005). Managing medication errors – a qualitative study. MEDSURG Nursing 14(3), pp 174-178. Retrieved from Expanded Academic ASAP on April 6, 2007.
Harrington, S., Lilley, L., and Snyder, J. (2007). Pharmacology and the nursing process (5th ed.). St. Louis: Elsevier Saunders.
Neal, T. (2006, September 19). Preventing medication errors. The Seattle Times. Downloaded from seattletimes.nwsource.com on April 6, 2007.

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Substance abuse among nurses

The prevalence of substance abuse among nurses is rising and continues to rise. The American Nurses' Association (ANA, 2002) estimates that six to eight percent of nurses use alcohol or other drugs to the extent that they impair their professional performance (ANA, 2002). Because of the incidence of drug abuse among nurses, it is important all nurses to be aware that drug abuse exists among nurses and should know the proper steps to assist their co-worker get the support they need.

Some startling recent statistics show that in the United States, the problems in productivity and employment among individuals with substance abuse problems cost the American economy $80.9 billion. Of this, $66.7 billion was attributed to alcohol and $14.2 billion to other drugs (NIH, 2007). Of course, this does not include the emotional costs to families and individuals such as divorce, alcohol, and drug-related domestic and child abuse, automobile injuries, etc. One out of every ten nurses has engaged in substance abuse and this is a defiant problem for the nursing community. A great strategy for combating substance abuse is being aware of the signs of drug abuse; new nurses can be better equipped to take action against an ever growing issue. An additional strategy is knowledge of factors that contribute to drug abuse among nurses. Finally, learning early on how to manage one’s own stress level can greatly decrease the pervasiveness of drug abuse in the nursing community.
The majority of nurses who receive treatment for problems related to chemical abuse became addicted as students, and were academically in the top third of their class. A majority also hold advanced degrees. It has been estimated that approximately ten percent of nurses are chemically impaired and most disciplinary problems that are addressed by Boards of Nursing are related to nurses in this ten percent (Uris, 2002). Nurses should be educated on the signs and symptoms of substance abuse among their peers. It is important for all nurses to be aware of signs and symptoms of substance abuse, such as, mood swings, diminished alertness, increasing forgetfulness, defensiveness, decreased concentration. Additionally signs of withdrawal, impaired cognition, isolation or withdrawal from colleagues. Substance abuse issues in nursing usually are first noted by staff members. Whether a staff nurse acts on his or her knowledge or chooses to remain silent, directly affects patient care, safety and the reputation of the institution. It also ultimately affects the impaired colleague's level of functioning (Dunn, 2005). By the time a nurse demonstrates negative or inappropriate work habits, the problem already has reached a serious stage. It is advantageous for institutions to create systems that allow for reporting and tracking substance-abuse incidents and provide education and support to help nurses participate in rehabilitation and avoid placing patients in harm's way (Blair, 2003).
Being aware of signs and symptoms is important; however being aware of factors that contribute to substance abuse is another important step in understanding its prevalence. Some of the factors that have been identified as contributing to substance abuse are: psychological or physical pain, emotional problems, a demanding high-pressure and stressful work environment, and family problems. Additional factors that have been known to contribute are previous emotional or mental health problems, family members with chemical dependency, depression, anxiety, or mental, emotional, or sexual abuse (George, 2003). Some recent studies have shown that nurses who work in oncology have overall high substance use rates. One theory for this behavior is that controlled substances serve as a coping mechanism to help nurses distance themselves from the emotional pain they may experience while working with dying patients (Dunn, 2005). Psychiatric nurses also experience high levels of substance use. Nurses working in psychiatric areas may consider self-medication more acceptable because they work in a culture that accepts using psychotropic medications to cope with life (Anderson, 2004). Additionally, psychiatric nurses may be more willing to report their use of substances than other specialty nurses because they perceive this as an acceptable form of treatment. Pediatric and women's health nurses report the lowest use of addictive substances. This could be due to the lack of availability of these substances on their units, or it could be that this population of nurses is emotionally expressive (NIH, 2003). People who are able to express their feelings may have less need for substance use.
Learning about the signs and symptoms and knowledge about contributing factors are great ways to decrease the prevalence of substance abuse Furthermore, increasing education about management of stress levels is another strategy that can help reduces substance abuse in the workplace. Stress provides another explanation for why some nurses abuse substances. Increased workloads, decreased staffing, double shifts, mandatory overtime, rotating shifts, and floating to unfamiliar units all contribute to feelings of isolation, fatigue, and, ultimately, stress (Ponech, 2005). Each person feels stress and handles it in different ways; learning early on how to effectively manage stress can be extremely beneficial in finding alternative ways to decrease stress. Chronic stress can result in increased sensitivity to stress and cause more susceptible to the effects of stress. Research indicates that increased sensitivity to stress actually alters physical patterns in our brain, thus if stress is uncontrolled it can lead to emergency measure to decrease it, and thus leading to the use of substance abuse (Anderson, 2004). To aid in learning how to decrease stress here are a few strategies for decreasing stress: learning to take time out for self care, regular exercise, good communication with family, friends and co-workers, planning productive solutions to problems, ask for support when feeling stressed out, and learning to set clear limits.
To actively combat this issue of substance abuse that imperils patients and gives rise to a bad reputation toward nurses, all nurses should be aware of the signs and symptoms of substance abuse; to strive for better communication in their homes and within the work place. To find out what helps them manage their stress levels and to fervently practice self care that will aid in the decrease of physical, emotional, and psychological stress. By being aware of the signs and symptoms nurses’ know what signs may point to the need for intervention for their co-worker. By being knowledgeable about factors that contribute to substance abuse nurse can identify those factors if present in their own lives and can get help before those issues become uncontrolled. Understanding how stress correlates with substance abuse nurses’ can utilize alternative means to reduce stress in their life, ultimately reducing the prevalence of substance among the nursing community.

“Helping the impaired nurse is difficult, but not impossible. The choices for action are varied. The only choice that is clearly wrong is to do nothing.”
National Council of State Board of Nursing








Intervention # 1 Being aware of signs & symptoms of substance abuse.
Intervention # 2 Knowledge of factors that contribute.

Intervention #1
~ Disadvantages
a.) If nurses are aware of signs and symptoms they may be better able to hide there problem. Nurses may become more capable of masking there substance abuse by being more cautions not to exhibit the signs and symptoms that they were taught are associated with substance abuse in the workplace (Dunn). Examples of signs and symptoms that are taught are as follows, and being aware of these can contribute to the ability to facade the issue in a nurse set on not getting caught. Attendance. Look for sporadic absences, a day at a time and usually on a Friday or Monday. Appearance. Take note of a nurse who shows a sudden dramatic change in her personal grooming. Affect. Watch for disturbing shifts in a nurse's personal traits-her facial expressions, voice, posture, and gestures. For example, an outgoing nurse may suddenly become stone-faced and uncommunicative. Attitude. Pay attention to any changes in a nurse's attitude toward work. A staff member noted for her efficiency may suddenly begin taking longer to complete tasks. And listen closely to patients' complaints: A neglectful nurse may have a drug or alcohol problem.

b.) While researching this paper it became unambiguous to see all the many different, well thought out, techniques nurses use to steal medications. It is outlined in many different articles step-by-step how nurses go about obtaining controlled substances. By merely researching the signs and symptoms it could potential lead to an open door for someone who might be interested in obtaining medication to be aware of techniques that others have tried (NIH). Below is an example of how knowledgeable impaired nurses are about their addiction habits.

More than 15 years of my life are a blur I remember only a few landmarks through the fog of alcohol, cocaine. Dilaudid, Demerol, heroin, and other drugs. I was in and out of psychiatric units and drug treatment programs. I cycled through a dozen or so boyfriends. For extra money, I waited on tables or tended bar. But mostly I worked in hospitals-as a nurse. Yes, I took vital signs, changed dressings, gave medications, charted-the same things you do
every day. Many of the drugs I used came from the medication cabinets of some very well run hospitals.
But no one ever confronted me about my addiction. It's easy for an impaired nurse to "hide." I preferred to work the night shift, when staffing was minimal and there were no supervisors or visitors around. I also liked neurosurgery units; patients with head or spinal cord injuries were less likely to complain about taking a p.r,n medication. The final turn of events came one night when I told a patient with a spinal cord injury he needed medication he didn't want, I gave myself the Demerol, and then tried to give him sterile water. He refused it, so I put the syringe back in the drawer. Apparently, my nurse-manager suspected me because as soon as I put the syringe in the drawer, she confiscated it. I knew she'd fire me once she found out it contained only water, so I quit. I participated in group meetings with other recovering doctors and nurses. That was one of the toughest parts of treatment. I told them I felt good about the work I'd done as a nurse. Immediately, they confronted me, pointing out that 1 couldn't be an addicted nurse and a good nurse at the same time. I was surprised by their frankness. They knew about lying to yourself. And they knew that only friends who cared enough to be tough and honest could break through that denial. My recovery hasn't been easy. I haven't made it without stumbling but I wanted to live my life without taking drugs-and I've reached that goal. Today, I counsel adolescents at the treatment center that helped me recover. It's the best job I've ever had. Now I'm grateful that I have the chance to give back some of what I've been given. That's one reason I'm telling my story. If you have a problem with drugs or alcohol, you can get help. Recovery isn't easy, but it's worth the price.
(Alexander).


Intervention # 2
~ Disadvantages
a) By being aware of the all the contributing factors, nurses might tend to think that anyone that has some of these factors are suspicious of substance abuse. Therefore, being untrusting of their colleague, and constantly watching over there back, which in turn may bring down the units trust and moral (Ponech). Nurses are at risk for drug abuse because of the availability of medications in the workplace and the cultural acceptance within nursing that pharmacologie agents provide a desirable method to cure one's ills. Health care provides a permissible climate in which to use exogenous substances to correct internal feelings or illnesses. Nurses have been taught that medications solve problems. They have seen medications alleviate pain, cure infections, and diminish anxiety. Not only are prescription medications accessible, but nurses also have a mistaken belief about their personal skills and level of knowledge to self-medicate without becoming addicted. Self-medicating behaviors may only be viewed as inappropriate when the magnitude and regularity of these behaviors increases. Access creates a familiarity with controlled substances that can increase the likelihood that nurses will use them on their own. Nurses may erroneously believe that they have the ability to control and monitor their own use of medications because of their experience with administering medications and observing their effects on patients Some nurses "believe that they are immune to the negative consequences of drug use because they are so familiar with drugs." (Dunn).


b.) Nurses that may have contributing factors, or who are at high risk for substance abuse may feel that they are being targeted or looked down on by their nursing peers. Thereby, discouraging them form asking for help if needed, or feel un-apart of the team because they don’t feel comfortable discussing their personal life with any of their co-workers; which may lead to depression and feelings of inadequacy in their careers (ANA). Recognizing that substance abuse is a medical illness that requires treatment is the first step in removing the stigma associated with it. Current philosophies of the ANA and boards of nursing support helping addicted nurses seek treatment and rehabilitation to become productive members of society and nurses again. Certainly, communication and information sharing are paramount for this process to be effective.
It is only logical that a nurse who is suspected of abusing substances should be reported. It is the emotional aspect that undermines the reporting process. Being fearful that a colleague may lose his or her job or terminate a friendship are powerful motivators to withhold or dismiss anecdotal or subjective information. As social beings, people are motivated by emotions; the ability of nurses to report a colleague would be less hampered, however, if one of their loved ones was being cared for by a nurse who was impaired. As patient advocates, this is the level of nursing at which all nurses should practice.


 

References:


Alexander, D. (2005). When nurses are addicted to drugs. Nursing. (2) 50-58 Retrieved for Proquest February 29th 2008.

American Nurses Association (2002). ANA code of ethics for nurses. Washington DC.


Anderson, J. (2004). Treatment considerations for the addicted nurse. Behavioral Health Management. (14) 22-26. Retrieved from Proquest September 30, 2007


Blair, P. (2003). Report impaired practice-stat. Nursing management. (33) 23-25. Retrieved from Proquest October 12, 2007


Dunn, D. (2005). Substance abuse among nurses-defining the issue. Association of operating room nurses. (82) 592-596. Retrieved from Proquest October 1, 2007.


George, M. (2003). Substance abuse among healthcare professionals. Nursing Ethics. (14) 843-849. Retrieved from Proquest October 9, 2007


National Institute of Health (2007) www.drugabuse.gov/infofacts/costs.html


Ponech, S. (2005). Telltale signs. Nursing Management. (31) 32-37. Retrieved from Proquest October 12, 2007


Uris, P. (2002). Chemical dependency handbook for nurse managers. National Council of State
Boards of Nursing. Retrieved from www.dora.state.co.us/nursing October 12, 2007

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Autoethnography and Mental Health Nursing

It is no secret that it takes a special kind of person to be a mental health nurse. Qualities and abilities such as well-developed self-awareness, acceptance of self and others’ feelings, an understanding of the complexity of the human experience, an ability to accept ambiguity and uncertainty, willingness to take responsibility for self, and provision of trust and respect are crucial for the effective psychiatric mental health nurse (Foster, McAllister & O’Brien, 2006).

But how does one integrate all these qualities effectively in practice? How does one become an effective mental health nurse? Foster, McAllister & O’Brien, 2006, state that autoethnography is the answer. According to them, autoethnography, the study of "self" should be an integral part of every mental health nurse's practice to ensure the highest level of care.

There has been little research, and little literature has been written on the topic of autoethnography, and its use. Foster, McAllister & O’Brien, 2006, in their article “Extending the Boundaries: Autoethnography as an Emergent Method in Mental Health Research”, talk about the use of autoethnography as a new approach to caring for the mentally ill, as well as a research method, with the emphasis on mental health nursing research.

The same authors, in an article published in December 2006, talk about the experiences of a doctoral student whose mother is mentally ill, and the process through which she used autoethnography to generate new research in the field, and relate to other mentally ill patients.

Other articles such as “Nursing Student Attitudes to Psychiatric Nursing and Psychiatric Disorders in New Zealand” (Surgenor, Dunn & Horn, 2005) and “A Survey of Mental Health Nurses’ Experiences of Stalking” (Ashmore, Jones & Jackson, 2006) talk about the different experiences that nurses have with mental health patients. These articles show how different interactions with mental health patients change nurses’ attitudes, and the way that they interact with their patients thereafter.

It is a well known fact that attitudes, beliefs, values, life experiences and even religious practices greatly impact nurses’ ability to care. In most areas of nursing practice, attitudes and beliefs are mostly positive. When it comes to mental health however, nurses attitudes and beliefs may be less positive. This in turn, may negatively impact the level of care that mental health patients receive.

Research by Reed & Fitzgerald, 2005, found that attitudes were found to be linked to issues that influence nurses’ ability to provide care. Dislike was also apparent from nurses who suggested mental health care was not their role. One of the most prevailing feelings however was fear, which caused avoidance. James & Cowman, 2007, identified attitudes towards clients with bipolar disorder to be less then favorable. The authors recognize that mental health patients are more difficult to care for than other patients. As a result, these patients receive care that is inadequate.

Autoethnography has been defined as “the study of self” (Foster, McAllister & O’Brien, 2006). A process through which a nurse looks at herself and identifies her own attitudes, beliefs and values about mental health, and issues that are involved in mental health nursing in order to improve their care of the mentally ill. This way, psychiatric mental health nursing is seen as being directed by the nurse’s own characteristics, who is working together with the client to create a therapeutic relationship and to improve or maintain the client’s health.

In order for the nurse to effectively interact with the client, the nurse needs to first be able to understand that her character has been constructed by a set of experiences that is different from the patient’s. Social constructivism is a perspective that maintains that people develop a sense of what is real through conversation with, and observations of others (Foster, McAllister & O’Brien, 2006). This means that whatever the nurse holds to be real, might not be real for the patient, because his experiences have been different. Thus a nurse cannot impose her perception of reality onto the patient because of her different experiences. A nurse cannot be therapeutic until she realizes that what is real, and what makes sense to her, might not be real, or not make sense to a patient. Autoethnography works by having the nurse look at what her reality is, takes note of what the patients’ reality is, and only then, can the nurse make a final judgment.

“Psychiatric mental health nursing research literature also recognizes the importance of the quality of engagement between nurse and the client as being integral to the nurses effective use of self” (Foster, McAllister & O’Brien, 2006). The way that a nurse interacts with the patient, and the quality of their relationship, is crucial for a therapeutic environment. Foster, McAllister & O’Brien, 2006, also state that clients themselves have reported that provision of respect, security, confirmation, and companionship are some of the most valuable aspects of the nurse-client relationship. How can nurses provide these to the patients, when the nurses are afraid of patients, avoid patients and or believe that it is not their role to take care of these patients? It is impossible for the nurse to provide security for these patients when they themselves are scared. It is impossible for the nurse to provide companionship to these patients when the nurse avoids them. If the nurse cannot effectively talk to, listen to, and empathize with the patient, there is no therapeutic relationship.

Using autoethnography, the nurse first needs to understand that she dislikes these patients, is afraid of these patients, and avoids these patients. The nurse than must think and identify the reasons for these behaviors. Why is it that the nurse fears and avoids these patients? Then she must remedy the problem By doing so, the nurse just went from a nurse who fears and avoids a patient, to a caring nurse who can develop a healthy therapeutic relationship with the patient. By doing so, the nurse becomes a caring nurse who can develop a healthy therapeutic relationship with the patient.

Autoethnography is the process through which nurses evaluate their own attitudes and beliefs towards mental health. This way they can correct any misconceptions or false beliefs about mental health patients they might have. In this manner they can provide the best care possible. It is a process which should be applied by every nurse that has a mental health patient in her care.

INTERVENTION 1

The nurse will identify her own thoughts, feelings and perceptions about the mentally ill client and the disease process that can interfere with the quality of care provided and set them aside while caring for the mentally ill client.

Disadvantage 1

Knowledge deficit

Knowledge deficit is a big problem in mental health nursing. Many research studies have concluded that most nurses are undereducated about how to care for mentally ill patients. Because of the limited amount of education, nurses rely on their own beliefs, perceptions and values when setting standards in their care for the mentally ill clients (Reed & Fitzgerald, 2005). A lot of nurses have their preset beliefs that mentally ill patients are difficult to take care of, assaultive and non cooperative and simply hard to take care of. A lot of times nurses attribute these qualities to all mentally ill patients (Reed & Fitzgerald, 2005). It is hard for them to understand that this is not necessarily true and that she needs to set these feelings aside. Because of the lack of education in caring for these clients, these nurses make further mistakes in their care which in turn reinforces their false beliefs. The nurse goes on attribute these qualities to the patient’s condition and does not perceive them as their own beliefs and perceptions. This makes it even harder for the nurse to implement this nursing intervention while caring for the mentally ill client.

Reed F. & Fitzgerald L. (2005, December). The mixed attitudes of nurse’s to caring for people with mental illness in a rural general hospital. International Journal of Mental Health Nursing, 14, 249-257. Retrieved November 1, 2007 from CINAHL database.

Disadvantage 2

Pt. discrimination/dislike.

Dislike and discrimination of mentally ill clients has been thoroughly studied and documented. Most of the time, this attitude stems as a result of the choices the patients make. Choices which make it more difficult for the nurse to provide care (Reed & Fitzgerald, 2005). Mentally ill clients can become easily agitated, non cooperative, resistive and paranoid (Reed & Fitzgerald, 2005). They also make poor choices and judgment calls. In most cased hygiene standards are usually very low also. This leads the nurse to develop a sense of dislike towards these patients. This attitude makes the nurse more reluctant to identify her own attitude as a barrier in quality care. As a result, there is a further increase in the nurses' anxiety, dislike and avoidance of the patients. This type of attitude also increases the use of medical and mechanical restraints which can be very detrimental to the patient.

Reed F. & Fitzgerald L. (2005, December). The mixed attitudes of nurse’s to caring for people with mental illness in a rural general hospital. International Journal of Mental Health Nursing, 14, 249-257. Retrieved November 1, 2007 from CINAHL database.

INTERVENTION 2

The nurse will sit with the mentally ill pt. for at least 20 minutes to listen to the pt’s “story”, identify the pt’s belief system, thoughts, perceptions and degree of cooperativeness to help nurse better understand patient and increase comfort level with patient.

Disadvantage 1

NEGATIVE PAST EXPERIENCES.

Past experiences with mentally ill clients can either strengthen or ruin the perception of these clients to the nurse. Negative experiences heavily influence the nurses’ perception of these patients, the care they deserve, and even the nurses own perspective on her ability to provide care for these patients (Ashmore, Jones & Jackson, 2006). Nurses who had negative experiences with mentally ill clients experienced an increase in their level of anxiety, increased feelings of unhappiness and anger. They also said they felt less relaxed, outgoing, happy and competent in their care (Ashmore, Jones & Jackson, 2006). The same article stated that 37.5 percent of nurses who had a stalking experience ignored the patient afterwards, 14.3 percent of nurses yelled at the person, and 19.6 percent pleaded the person to stop (Ashmore, Jones & Jackson, 2006). Experiences as such, can make the nurse avoid a situation where she has to sit and talk with the mentally ill client. She will also be reluctant to develop nursing interventions in which the nurse has to spend time with the patient. This can make the relationship even worse and have a negative outcome on the plan of care.

Ashmore R., Jones J., Jackson A. & Smoyak S. (2006, March). A survey of mental health nurses’ experiences of stalking. Journal of Psychiatric and Mental Health Nursing, 13, 562-569. Retrieved November 1, 2007 from CINAHL database

Disadvantage 2

FEAR.

Fear is the biggest barrier in providing quality care for the mentally ill patient. The nurses are worried about their physical safety and the safety of other coworkers on the ward. They also feel vulnerable professionally, ethically and legally about the action they might have to take to avoid harm if such action should be necessary (Reed & Fitzgerald, 2005). This can cause a gap in between the nurse and the patient. As a result, the nurse can end up avoiding the patient, keep their distance and take shortcuts when interviewing them. For communication to be effective in the nurse/mentally ill client relationship, the nurse has to show empathy, warmth, respect, patience and trustworthiness (Foster, McAllister & O’Brien, 2006). When the nurse fears these patients, she can’t show any of these qualities to these patients, thus making it hard to implement this intervention.

Foster K., McAllister M. & O’Brien L. (2006, March). Extending the boundries: Autoethnography as an emergent method in mental health nursing research. International Journal of Mental Health Nursing,15, 44-53. Retrieved October 4, 2007 from CINAHL database

References:

Foster K., McAllister M. & O’Brien L. (2006, March). Extending the boundries: Autoethnography as an emergent method in mental health nursing research. International Journal of Mental Health Nursing,15, 44-53. Retrieved October 4, 2007 from CINAHL database.

Surgenor, L., Dunn, J. & Horn, J. (2005, June). Nursing student attitudes to psychiatric nursing and psychiatric disorders in New Zealand. International Journal of Mental Health Nursing, 14, 103-108. Retrieved October 20, 2007 from CINAHL database.

Reed F. & Fitzgerald L. (2005, December). The mixed attitudes of nurse’s to caring for people with mental illness in a rural general hospital. International Journal of Mental Health Nursing, 14, 249-257. Retrieved November 1, 2007 from CINAHL database.

Ashmore R., Jones J., Jackson A. & Smoyak S. (2006, March). A survey of mental health nurses’ experiences of stalking. Journal of Psychiatric and Mental Health Nursing, 13, 562-569. Retrieved November 1, 2007 from CINAHL database.

James P. & Cowman S. (2007 October). Psychiatric nurses' knowledge, experience and attitudes towards clients with borderline personality disorder. Journal of Psychiatric and Mental Health Nursing, 14, 670-678. Retrieved November 1, 2007 from CINAHL database.

Foster K., McAllister M. & O’Brien L. (2005 December). Coming to Autoethnography: A mental health nurse’s experience. International Journal of Qualitative Methods, 1-13. Retrieved November 1, 2007 from CINAHL database.

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Nurses and Breastfeeding

The American Dietetic Association [ADA] (2005) recommends that all infants be breastfed for the first 12 months of life with the addition of complimentary foods after 6 months of age (Spear, 2005). Yet in the United States, the percent of infants being breastfed for the first 12 months is only 17% to 20%. (ADA, 2005).

Nurses are often the people entrusted to provide lactation education and support to new mothers. Despite this, lactation education can be and often is lacking. More thorough breastfeeding education in nursing schools can help to better equip nurses for providing effective breastfeeding counsel and support (Spear, 2005). Nurses employed in hospitals should advocate for the development of a hospital wide policy regarding breastfeeding (Wallis & Harper, 2007). In addition, nurses involved in caring for new mothers should receive continual training on breastfeeding counseling and lactation through continuing education coursework, clinical experiences and in-service training (US Department of Health and Human Services [USDHHS], 2000). When these strategies are implemented, the nurse, as a client educator, will be effective in increasing exclusivity and duration of breastfeeding, thereby promoting wellness in both mother and infant.

Breastfeeding provides many benefits to both mother and child. Maternal benefits can include reduced postpartum bleeding, decreased uterine involution time, improved bone density and reduced risk of breast and ovarian cancer. Some of the numerous benefits for the child are protection against infectious and non-infectious diseases, decreased risk of childhood obesity, reduced risk for heart disease, enhanced immune system, and decreased risk of diarrhea and respiratory infections (ADA, 2005). Breastfeeding also offers an economic way to provide optimal nutrition to the baby (ADA, 2005). Notwithstanding, there are many barriers to breastfeeding among all populations. Many women do not breastfeed because they lack a full understanding of its benefits. Others refrain because of embarrassment and social disapproval, especially when it comes to breastfeeding in public. Some feel that breastfeeding will make them less attractive, and others feel they cannot breastfeed due to work or school responsibilities (ADA, 2005).

A nurse who has been prepared can help a woman overcome these barriers with information, resources and counsel on breastfeeding. Unfortunately, many nurses do not have the education necessary to be able to educate others on breastfeeding. This is evidenced by a survey done on students who had successfully completed their obstetric nursing courses. Only 22% of surveyed students knew that breast milk has antibacterial properties, 85% did not know that breastfeeding is recommended for the first year of life. Forty-one percent thought that formula and breast milk were nutritionally equivalent (Spear, 2005). In order to correct this educational deficit, students interested in working in obstetrics or pediatrics can be offered breastfeeding and human lactation seminars. These seminars can help students learn to identify and overcome barriers to breastfeeding. Possible seminar supplements include a maternal breastfeeding panel to help students see the mother’s perspective on breastfeeding initiation, and participating in clinical experiences with lactation specialists (Spatz, 2005).

After thorough education on lactation in nursing school, a nurse in the hospital setting can continue to improve breastfeeding success rates by advocating for the development of an effective hospital policy on breastfeeding. All staff should be aware of and follow this breastfeeding policy (Wallis & Harper, 2007). Appropriate policies should address a number of topics including, staff training in the skills needed to implement the policy, early initiation of breastfeeding, education of pregnant women about the benefits of breastfeeding, education of mothers on how to breastfeed and maintain lactation, limited use of any food or drink other than human breast milk, rooming-in, breastfeeding on demand, limited use of pacifiers and artificial nipples, and fostering of breastfeeding support groups and services (USDHHS, 2000).

Once a breastfeeding policy is in place, all involved staff members should receive the necessary training to enable them to follow that policy. Many nurses on staff in maternal and newborn units lack experience, and therefore confidence, in helping a new mother breastfeed. This anxiety can inadvertently be communicated to the mother and be detrimental to the breastfeeding process (Wallis & Harper 2007). One option for this training is through the requirement of continuing education coursework on human lactation and breastfeeding (USDHHS, 2000). Wallis and Harper (2007) reference a hospital that holds three breastfeeding workshops a year; which all employees are encouraged to attend. These workshops focus on practical management of breastfeeding, advantages of breastfeeding, and initiating and maintaining lactation. In addition, a new mother always attends to share her experience with breastfeeding. New staff should receive immediate training on breastfeeding and human lactation as well as on the hospital breastfeeding policy (Wallis & Harper, 2007). This will allow for hospital staff to provide continuity of care to the woman and child.

Breastfeeding is not “popular” in the United States. The nurse, as a client educator, can increase exclusivity and duration of breastfeeding, thus reversing this trend. This will result in improved wellness in both mothers and infants. When nurses receive adequate education on lactation in nursing schools, help develop hospital policy on breastfeeding, and participate in continuous on-the-job training to improve their skill and knowledge in helping women breastfeed, they become more effective at their role in helping mothers initiate and maintain breastfeeding.


a. Intervention 1 -More thorough breastfeeding education in nursing schools.


i. Disadvantage 1 - Offering extra classes will not provide enough education to change the current trends.
Providing extra courses and seminars for those students who plan on going into fields that involve mother and baby will be beneficial to these particular students, if they choose to take them. However, many nurses do not have a specific are of nursing in mind while still in school, but later on will switch to maternal and newborn nursing. Breastfeeding information and training must become a larger part of basic nursing curricula (Spear, 2005). This will help to provide all nurses with the skills and current information to provide support to the breastfeeding mother. If the general nurse is prepared to support mothers in breastfeeding, outcomes for exclusivity and duration will likely improve.

Spear, H. J., (2005). Baccalaureate nursing students’ breastfeeding knowledge: A descriptive survey. Nurse Education Today, 26, 332-337. Retrieved January 3, 2007 from Expanded Academic ASAP database.


ii. Disadvantage 2 - Incorporating more breastfeeding education into the basic curricula will be ineffective with the current general nursing textbooks.
Nursing students have several textbooks that might contain information on breastfeeding such as a maternal and child or nursing fundamentals textbook. Trying to improve students’ knowledge of breastfeeding best practices could be very ineffective with these texts. Phillipp, McMahon, Davies, Santos and Jean-Marie (2007) discovered upon analyzing the breastfeeding information in six maternal newborn nursing textbooks, that many textbooks are deficient in the area of breastfeeding. All of the books that were reviewed had important breastfeeding information that was inaccurate, inconsistent, or omitted. In order for incorporating breastfeeding education in to the basic curricula to be effective, new textbooks with accurate and complete information will need to be used.

Phillipp, B.L., McMahon, M.J., Davies, S., Santos, T., & Jean-Marie, S. (2007). Breastfeeding information in nursing textbooks needs improvement. Journal of Human Lactation, 23(4), 345-349.


b. Intervention 2 –Nurses in hospitals should advocate for a hospital-wide breastfeeding policy.


i. Disadvantage 1 –A policy to give no other food and drinks to newborns besides human milk unless medically necessary is discriminatory.
Contemporary evidence has shown that initiating breastfeeding within the first hour of birth is beneficial to both mother and child. The first days of life for the newborn is when many babies receive colostrum from their mothers. This colostrum is the source of maternal antibodies for the babies and is beneficial to them in many other ways as well. Conversely, in many Asian cultures, colostrums is viewed as old milk and not good for the babies health (Kaeswarn, Moyle, & Creedy, 2003). This cultural conflict can cause difficulty for both the nurse and the new mother who share these cultural beliefs about colostrums. The nurse must put her beliefs aside and do as the hospital policy states. The new mother can be put in a vary uncomfortable situation where she can choose to confirm to hospital rules or defy them and stay true to her beliefs and perhaps be labeled as a difficult patient (Kaeswarm et al., 2003). An effective policy would also need to address the cultural issues surrounding breastfeeding.

Kaeswarn, P., Moyle, W., & Creedy, D. (2003). Thai nurses’ beliefs about breastfeeding and postpartum practices. Journal of Clinical Nursing, 12, 467-475. Retrieved January 31, 2008 from Expanded Academic ASAP database.


ii. Disadvantage 2 –Mothers who choose not to breastfeed can be labeled as poor mothers.
There is much research stating that breast milk is the optimal food for a newborn. Despite this, there are many reasons for which a mother might choose to not breastfeed her child. Even though breastfeeding is best for the child in most cases, the mother still has the right to choose whether she will breastfeed the child. Strict policy against using formula in hospitals can alienated the mothers who do not want to breastfeed. Nurses and doctors, in some instances, have tried to convince the mother to change her mind using tactics that border on coercion. These mothers can be made to think that death will be eminent for her child if she does not breastfeed. All mothers should be educated on the benefits of breastfeeding, but if they choose to use formula they should be provided with information on how to choose formula and successfully nourish her baby. Not providing any type of formula education could actually cause harm to some children (Kent, 2006).

Gerorge, K. (2006). Child feeding and human rights. International Breastfeeding Journal, 1(27).


References
American Dietetic Association. Promoting and supporting breastfeeding (2005). Journal of the American Dietetic Association, 105, 810-818.
Spatz, D.L. (2005) The breastfeeding case study: a model for educating nursing students. Journal of Nursing Education 44(9), 432-437. Retrieved September 24, 2007 from Proquest database.
Spear, H. J., (2005). Baccalaureate nursing students’ breastfeeding knowledge: A descriptive survey. Nurse Education Today, 26, 332-337. Retrieved January 3, 2007 from Expanded Academic ASAP database.
US Department of Health and Human Services. (2000). HSS blueprint for action on breastfeeding. Washington, DC: Author. Retrieved January 19, 2007 from www.4women.gov/breastfeeding/bluprntbk2.pdf
Wallis, M. & Harper, M. (2007) Supporting breastfeeding mothers in hospital: part 1. Paediatric Nursing. 19(7), 48-52. Retrieved September24, 2007 from EBSCO Host database.

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Family Centered Care in the NICU

Roughly 12.5% of all babies born in the United States each year are premature (Archibald, 2006). That is a about half a million children being born before the 37th week of gestation is complete.

While in the hospital, new parents need an advocate. That advocate can be the registered nurse. The role of the RN is that of a care provider for the neonate. However, it is also one of an educator and facilitator of communication for the needs of the family. Too often families are made to feel like visitors in special areas of the hospital like the NICU (neonatal intensive care unit). By implementing the three strategies of incorporating a family centered care plan, unrestricted access to the child and treatment participation, and developing good communication skills with full information sharing, the RN can help the families become contributors, rather than spectators, in the care of their neonate.
When a newborn and parents are separated, the necessary bonding time is greatly diminished. According to Wong (2006), infants begin to develop a sense of trust as they learn the feel, sound, and smell of their parents. When their parents are gone, the neonate must learn to trust the nurses. However, the nurse is also associated with pain as well as comfort. It is important for the parents to be enveloped in the care of their child so that the neonate does not begin to associate pain with their care provider. During this time, the parents also discover the personality of their infant and how to recognize their needs by the behavioral cues displayed. When their time is limited in the NICU, the personalities go undiscovered and these cues go unlearned. When the previously mentioned strategies are put into practice, these developmental tasks can be completed successfully.
The first strategy is to create a family centered care plan (FCC). By incorporating family centered care into the unit, those stresses can be alleviated tremendously. FCC is creating a partnership between the parents and the hospital staff. There are four main concepts to FCC. They are dignity and respect, information sharing, family participation, and family collaboration (Cisneros, 2003). Though implementing family centered care can be difficult, it brings positive outcomes for both the family and the child. There is not a single way that all neonatal units must operate their family centered care. Each location is different depending on the needs of the staff and patients. The facility begins with a vision and a philosophy. It is suggested that the staff in the neonatal unit participate in developing these documents. Sharing of ideas and reviewing all feedback allows for a clear and well developed vision to emerge. Families are also an integral part of developing FCC. Those who have the experience of having a child in the neonatal intensive care unit are a valuable resource to consult when making changes to the program.
The second strategy is finding ways to involve parents in the care of their child. Parents are no longer seen as visitors but as critical components in the care plan of the child. Unlimited access to their baby at any time of the day is essential. It is important for the parents to be able to be there to comfort their child and learn ways to ease their tensions and pain. The nurse is the educator for the parents. He or she provides the information and guidance to help the parents through this difficult time. Two important areas that the nurse needs to help the mother in are kangaroo holding and breastfeeding. Kangaroo holding is skin to skin contact between mother and baby. These things are necessary, not only for the development of the infant, but also as a way for the mother and child to bond. Parents are encouraged to participate in the care of their child while they are in the NICU. Physical contact, especially kangaroo holding, has been shown to help the baby thrive as well as promote bonding between child and parent (Johnson, 2005). They show the parents how to take part in the infants care so that they may spend as much time as they wish with their baby. Many infants in the NICU have feeding problems or are unable to digest properly. The NICU nurse aids the mothers in breast and bottle feeding. The nurse takes time to show the parents how to read monitors, adjust equipment, and explain difficult medical jargon so that they are comfortable and understand clearly. Parents leave the NICU with a bond to the staff that cared for their child. Some even bring the baby back to show that they are thriving. “It’s a great reminder that the NICU isn’t a horrible place. Most babies leave here and grow into happy, healthy kids. You’d never know that they ever had a health problem” (American Baby, 2007).
The third strategy is developing good communication with the families. The largest contribution to family-centered care is the participation of the families. The NICU nurse is not only a caregiver and educator, but he or she must be an excellent communicator. As a result of being informed of every detail, the parents feel a sense of involvement and control in their decision making. By providing explanations and honest answers, the nurse helps the parents to build confidence in their abilities. Being this close allows the parents to make better decisions regarding the care of their baby and gives them the opportunity to become more connected to the child. Daily communication between the nurse, the other hospital staff, and the parents keeps the flow of family centered care moving. If the parents do not feel included in their infants care plan, then family centered care has not been achieved. “To support the philosophy of FCC, attention must be paid to teaching and supporting nurses’ communication skills, and relationship building with self, peers, and families” (Griffin, 2006).
While taking care of the half a million children born prematurely each year, the role of the RN is that of a care provider for the neonate and an educator and facilitator of communication for the needs of the family. The purpose of FCC is to provide the parents with a greater role in the care of their infant. By implementing the three strategies of incorporating a family centered care plan, unrestricted access to the child and treatment participation, and developing good communication skills with full information sharing, the RN can help the families become contributors, rather than spectators, in the care of their neonate.
Archibald, C. (2006, Mar-Apr) Job satisfaction among neonatal nurses.
Pediatric Nursing. Pitman: Vol. 32, Iss. 2, p. 162, 176-179.

Cisneros-Moore, K., Coker, K., DuBuisson, A. & Swett, B. (2003, April) Implementing potentially better practices for improving family-centered care in neonatal intensive care units: success and challenges. Pediatrics 111. Retrieved Apr. 22, 2007 from www.pediatrics.org.

Griffin, T. (2006, Jan-Mar) Family-centered care in the NICU. Journal of Perinatal & Neonatal Nursing 20. Retrieved Jan. 3, 2007 from Expanded Academic ASAP database.

Johnson-Nagorski, A. (2005, Jan-Feb) Kangaroo holding beyond the NICU. (Updates & Kidbits)(neonatal intensive care unit). Pediatric Nursing 31. Retrieved Jan. 3, 2007 from Expanded Academic ASAP database.

Special babies, special care. American Baby. Retrieved April 13th, 2007 from http://www.americanbaby.com.

Wong, D., Perry, S., Hockenberry, M., Lowdermilk, D., Wilson, D. Maternal Child Nursing Care. St. Louis: Mosby, 2006.
a. Intervention 1 –Incorporating a family-centered care plan
i. Disadvantage 1 – The family-centered care plan that the facility has adopted may not fulfill the needs of each individual family.
Unrestricted access to their infant and treatment participation only may not fulfill the emotional and psychiatric needs of the family. It takes more than just family-centered care to assist the parents. Hospitals that offered a combination of formats for support services: group support, one-to-one support, and telephone support were more effective at meeting the needs of the infant’s parents. (Hurst, 2006). The family-centered care ideology is all too often “cookie-cutter” and not adaptable to the individual family needs.
Hurst, Irene (2006). One size does not fit all: parents' evaluations of a support program in a newborn intensive care nursery. Journal of Perinatal & Neonatal Nursing, 3, 252. Retrieved February 3, 2008 from ProQuest database.
ii. Disadvantage 2 – Support groups are more effective than family-centered care.
Parents often become frustrated when they have a child in the NICU. The unknown environment and language can be overwhelming. Though family-centered care tries to alleviate these issues, it has several hang-ups. It does not leave the parents with an outlet for frustrations. Group support offered more opportunities for families to problem-solve communication issues with nursery personnel and provide information that assisted parents' involvement in their babies' care. Parent support programs offer an important mechanism to assess provider approaches to facilitate family-centered care (Hurst, 2006). By having others to talk with who are going through the same experiences, the families can become more connected and have a place to discuss their fears and concerns.
Hurst, Irene (2006). One size does not fit all: parents' evaluations of a support program in a newborn intensive care nursery. Journal of Perinatal & Neonatal Nursing, 3, 252-255. Retrieved February 3, 2008 from ProQuest database.
b. Intervention 2 –NICU nurses need to develop good communication skills and fully share care information with the family.
i. Disadvantage 1 – Years of experience and clinical work setting influenced both perceptions and practices of family-centered care.
A recent study of sixty-two licensed registered nurses looked at the level of implementation of family-centered care. It covered the necessity of family-centered care and current nurse practices. According to Peterson, Cohen, and Parsons, 2004, scores representing current nursing practice of family-centered care were significantly lower than those representing its necessity (p = .000). Nurses with 10 years or fewer of neonatal or pediatric experience scored significantly higher on both the total Necessary Scale (p = .02) and total Current Scale (p = .017) than did those with 11 years or more. Nurses who work in the NICU scored significantly lower on the total Necessary Scale (p = .013) than did nurses who work in pediatrics or PICU. Although nurses agree the identified elements of family-centered care are necessary, they do not consistently apply those elements in their everyday practice.
Peterson, M., Cohen, J., & Parsons, V. (2004). Family-centered care: do we practice what we preach?. Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN., 4, 421-424. Retrieved January 31, 2008 from ProQuest database.
ii. Disadvantage 2 – The fear of the unknown and a lack in trust of the healthcare provider can lead the mother to feel trapped. Heermann, Wilson, and Wilhelm (2005) reported that mothers "struggled to mother" because nursing interactions pushed the mothers to the sidelines and left the mothers feeling unimportant in the life of their child. The power struggles between the mothers and the nurses with each trying to position herself as the 'expert' on the infant. Heermann, Wilson, and Wilhelm (2005) found that mothers attempted to negotiate partnership relationships with professional caregivers but that their actions were frequently misunderstood or unrecognized. Thus, the primary focus in this study was the mother's developing relationship with the infant and ways in which that relationship was affected by interactions with the nurses.
Heermann,J., Wilson,M., Wilhelm, P. (2005). Mothers in the NICU: outsider to partner Pediatric Nursing, 3, 176-183. Retrieved January 31, 2008 from ProQuest database.

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Preventing Heart Disease

Travis Cox

As of 2007, heart disease is the leading cause of death in the United States and it includes a variety of diseases relating to the heart (AHA, 2007). Heart disease is very costly and creates quite a burden for the patients affected as well as their families.

As of 2007, heart disease is the leading cause of death in the United States and it includes a variety of diseases relating to the heart (AHA, 2007). Heart disease is very costly and creates quite a burden for the patients affected as well as their families. With nursing education, heart disease can be reduced. It can also help maintain the health of patients at risk or those who have been diagnosed with heart disease. Nurses have the proper training and are more cost effective than using physicians for educational means. With proper nurse education and intervention through nurse led clinics, clients who either have heart disease or are at risk for heart disease will have significantly better quality of life. Heart disease targets people who are with hypercholesterolemia, have hypertension, hyperglycemia, which are smokers or, TABP (Type A Behavior Patterns) which has been recently added to the list (AHA, 2007). Because these problems are very prominently found in today’s society, heart disease is common and hard to avoid. In 2005, it was estimated that the cost of heart disease in America was $394 billion (CDC, 2005). This ever-increasing problem can be avoided or managed by maintaining basic day to day activities which include: decreasing cholesterol in daily diet, avoiding obesity by regular exercise, avoiding a sedentary lifestyle, smoking cessation, controlling diabetes and having regular check ups and health screenings. (CDC, 2005) As a nurse, strategies such as education, screenings in outpatient clinics and community screening can lead to a decrease in heart disease and better lives for those with heart disease.

There are many techniques that a nurse can utilize when educating people on the importance of preventing heart disease. Diet, exercise and smoking are three main categories that ought to be addressed. The American Heart Association has many pamphlets and brochures that talk about strategies and methods to prevent this disease (AHA, 2007). Education should focus on the methods used to prevent heart disease such as reducing cholesterol, lowering salt intake and avoiding obesity. Avoiding foods high in saturated and trans fat can help reduce cholesterol. One of the biggest obstacles for this issue is educating those in poverty who find it easier and cheaper to eat a ninety-nine cent high fat cheeseburger then to buy fresh fruits and vegetables from the grocery store (Wright, 2007). Preventative diets include ones high in vegetables and fruits as well as avoiding large quantities of red meat and foods high in Omega-3 fatty acids (found in many seafood products). One of the most common preventative diets is the Mediterranean style diet which consists mainly of olive oil, bread, abundant fruit and vegetables, a moderate amount of wine, and animal products such as lamb, sausage and goat cheese (Wright, 2007). Exercising regularly can also help to reduce the risk of heart disease. It is recommended that the average adult get 30 minutes of moderate exercise 5 times a week (AHA, 2007). Nurses should also promote smoking cessation programs or products that can help people to stop smoking such as nicotine gum or patches. There are nearly 135,000 smoking-related cardiovascular disease deaths per year (AHA, 2007). Education on this matter can be the first step to promoting a healthy lifestyle and reducing the occurrence of heart disease.

Along with education, people screened early and screened often have a better chance of avoiding or fighting heart disease. Nurse led clinics have been a proven resource in reducing the number of people with heart disease as well as improving the lifestyle of those with heart disease (CDC, 2005). Studies involving three different styles of outpatient teaching methods and screenings were done and compared in 2001. These studies showed that people responded to and were more apt to attending nurse led clinics. The study compared hospital screening, physician run clinics and nurse led clinics. The results showed that the nurse run clinics had more visitors with a better rate of identifying patients at risk. They also had better follow up care and better education retention with an overall 85% success rate and a 33% better overall experience according to patients (Campbell, 2005). Nurse led clinics also were more cost effective per patient with better success rates according to a 2005 study which showed that nurse led clinics can thrive financially in a community while serving a valuable purpose (Berg, 2007). Clients at these clinics receive advanced screenings based on their predisposition to heart disease. They will receive proper education, screening for blood pressure and cholesterol and monitoring for patients with heart disease to help them get on track (Berg, 2007).

Besides nurse led clinics, nurses can help educate and screen in the community. Mobile operation centers such as school and office screenings can be set up with correspondence to the American Heart Association (AHA, 2007). These mobile screenings can have a significant impact in catching people pre disposed or those who may have early signs of heart disease but have not yet been diagnosed. These early tests (education, cholesterol and blood pressure screening) can save a life as well as start someone down the right path in getting well. These early warning stations can also be a very helpful resource for preventative education.

Strategies such as education and early detection are the absolute key to preventing heart disease. Nurses can be a valuable tool in all these venues. Nurses can help people pre disposed to heart disease to stay healthy and treat people with heart disease so that the quality of life for these people becomes better rather then declining into a state where the disease process takes over and eventually ends in death. Overall nurses can educate, prevent and sustain people’s health regarding heart disease. Nurses are cost effective, properly trained and caring enough to get the job done.

INTERVENTION DISADVANTAGES:

Disadvantage A)
Mobile operation centers such as school and office screenings can be set up with correspondence to the American Heart Association (AHA, 2007). These mobile screenings can have a significant impact in catching people pre disposed or those who may have early signs of heart disease but have not yet been diagnosed.

Reason Number 1:
The cost of running and maintaining these mobile operation centers would be to costly to justify their use.

To make this option work well, the city would be required to make an investment to a fleet of vehicles, man power to operate and maintaining those vehicles, man power to work out of those vehicles and screen patients, the cost of supplies, advertising the location of screening clinics and possible paying for temporary housing for the vehicles. According to an article from Children’s Advocate, the cost of running a mobile health center can be over $500,000 in the first year and then $250,000 every year after that to maintain the program. This money would need to come from taxes, fund raisers or private funding which is not practical (Santana, 2005).



Reason Number 2:
Pre screening of patients does not determine that those people at risk or currently living with heart disease will have the motivation or means to seek out regular professional medical help.

The range of people who would be screened in this system is to vague to guarantee that people would follow up with primary care providers or seek out providers if they currently do not receive care. With our current health care system those uninsured would not benefit from this except by gaining some understanding of a disease that they may have. They do not have the insurance or money to seek out routine care to guarantee their future health. Those with insurance or means to seek out care may not follow up with their doctors. We can not be sure that the costs will not out way the benefits. In a research article published in PHN, who screened 222 people for ongoing visits to the mobile centers and follow up exams 3 in 10 people screened did not seek further medical expertise. 8 in 10 of these people could not afford the cost of medical exams, further treatment or transportation to medical facilities (Betty, 1998).

Disavantage B)
Nurse led clinics have been a proven resource in reducing the number of people with heart disease as well as improving the lifestyle of those with heart disease

Reasons number 1:
Nurse led clinics cost more per individual then medical facilities that can meet all of their needs.

The cost of running a nurse lead clinic is astronomical, without MD support the services provided are limited and patients still have to be referred to other medical facilities. Although they may be able to screen and educate they can not do numerous treatments needed to help patients. Patients would much rather be seen in an all encompassing site where all there needs can be met. In a study of 19 nurse led clinics that dissected the willingness of patients to pay for the amount of services rendered for heart disease the cost was (on average) $254 higher in the nurse clinics providing intervention then in just assessing and educating. This extra cost per individual would make it very hard for a nurse led clinic to compete with other medical centers (Campbell, 2005).

Reason number 2:
Nurse led clinics do not have the resources to effectively treat and manage people with heart disease.

Nurse led clinics lack the resources available to treat heart disease patients. They must be referred to treatment centers and hospitals for continuous care. Although nurse led clinics can help educate and prevent heart disease they still lack this essential tool to treat people with heart disease. In my research for this article I found that a majority of clinics that were nurse led failed because of the feeling that they were not giving adequate care to their patients (Campbell, 2005).

References

American Heart Association (AHA). (2007). Exercise and Fitness. Retrieved October.
17, 2007 from http://www.americanheart.org/presenter.jhtml?identifier=1200013

Berg, S., Hertz, P.. (2007). Outpatient Nursing Clinic for Congenital Heart Disease Patients: Copenhagen Transition Program. Journal of Cardiovascular Nursing, 22, 488-492. Retrieved November. 17, 2007 from http://www.jcnjournal.com.

Betty, A., Elnitsky, C. (1998). Rural Mobile Health Units: Outcomes. Public Health Nursing. Vol. 15 (1), 3-11. Retrieved January. 31, 2008 from http://www.blackwell-synergy.com/doi/abs/10.1111/j.1525-1446.1998.tb00314.x?cookieSet=1&journalCode=phn

Campbell, N.C., Murchie, P., Ritchie, L.D., & Thain. J. (2005). Running nurse-led secondary prevention clinics for coronary heart disease in primary clinics: Qualitative study of health professionals’ perspectives. British Journal of General Practice, 55, 522-528. Retrieved April. 12, 2007 from PubMed Central database.

Campbell, N., Murchie, P., Raferty, J. (2005) Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomised controlled trial. BMJ, 707. Retrieved January. 31, 2008 from http://www.bmj.com/cgi/content/full/330/7493/707

National Center for Chronic Disease Prevention and Health Promotion (CDC). (2005). Preventing Heart Disease and Stroke. Retrieved October. 17, 2007 from http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/cvh.htm

Santana, J. (2005). Going Out to the Community, Mobile Clinics Bring Health Care to Families. Childrens Advocate, 12, 96 – 100. Retrieved January. 31, 2008 from http://www.mobilehealthclinicsnetwork.org/featured.html

Wright, J. (2007). Nutritional Spices of Life. Journal of Community Nursing, Vol. 21 (10), 10-16. Retrieved November. 21, 2007 from http://www.jcn.co.uk/index.html


Travis Cox

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Adolescent HIV Prevention and Education

Sexually active young people in the United States are at persistent risk for HIV infection. This risk is especially notable for youth of minority races and ethnicities.

Continual prevention outreach and education efforts are required in order for adolescents to receive clear and accurate information. Approximately 4,842cases of HIV are diagnosed yearly among people ages 15-24 years (Eaton et al., 2006). With this rate of HIV infections among adolescents it is clear that additional efforts are required as new generations replace the generations that benefited from earlier prevention strategies. Adolescents are receiving mixed messages regarding HIV due to the medications that are now available and longer life expectancy of those living with the disease. Nurses working with adolescents can be pivotal in reaching youth before high-risk behaviors are established by identifying high risk adolescent populations, promoting education, and eliminating barriers to testing.

The Centers for Disease Control and Prevention (CDC) has conducted biennial Youth Risk Behavior Surveillance (YRBS) studies since 1991 in order to identify priority risk behaviors among youth. The results for the YRBS are obtained from students in grades 9-12 who participate in national, state, or local surveys. Of the students surveyed, 46.8% had engaged in sexual intercourse at least once in their life (Eaton et al., 2006). Male students were consistently ranked higher in risk taking behaviors than female students. Minority students (African American and Hispanic) predominately had more risk behaviors than Caucasian males or Caucasian females. These behaviors included multiple sexual partners, unprotected intercourse, and injection drug use (Eaton et al., 2006). Although most students receive some form of preventative health care annually, few discuss STD, HIV, or pregnancy prevention at those visits (Burstein, Lowry, Klein, & Santelli, 2003).

Understanding and identifying adolescent populations that are statistically at higher risk for HIV is a key strategy for nurses. Beedy-Morrison, Nelson, and Volpe (2005) provide evidence that Caucasian adolescent girls engage in higher HIV risk behaviors and receive less HIV testing compared with African American adolescent girls. Although HIV prevalence is higher among African American adolescents, the authors emphasize the implications the result of this study has on health care professionals. According to the findings, if Caucasian girls are more likely to engage in risky sexual behaviors and yet are less likely to be tested, there may be many undiagnosed HIV cases. In addition to the undetected HIV cases, the information health care professionals utilize to identify high risk groups may be inaccurate. Authors Goodenow, Netherland, and Szalacha (2002) found significantly high rates of HIV risk behaviors among bisexual adolescents. A study conducted in Seattle and British Columbia supports the previous research but also found a higher likelihood of HIV risk behaviors among sexually abused students in all sexual orientation categories (Saewyc et al., 2006). Nurses must promote greater community awareness of at-risk adolescents and seek to educate those populations. Education can occur through street outreach, pamphlets with referrals, posters, and classes where youth are located such as the YMCA or Boys and Girls Clubs of America.

Another key strategy for nursing professionals is to provide reality based education. HIV education should include “skills in negotiation, conflict resolution, critical thinking, decision-making and communication, which improves their self-confidence and ability to make informed choices such as postponing sex until they are mature enough to protect themselves from HIV, other STIs and unwanted pregnancies” (Unicef, 2002, p.26). Rew, Whittaker, Taylor-Seehafer, and Smith (2005) suggest that nurses must make sure confidentiality boundaries are established in order to build trust. Adolescents are more receptive to nurses that are open and direct and move from less sensitive topics to more sensitive topics during an assessment. Nurses must assist youth in establishing clear goals for preventing HIV and focus on specific health behaviors related to those goals. Adolescents need to be encouraged to talk with their parents and delay sexual intercourse. If delaying sexual intercourse is not an option adolescents must be taught about the risks and effective contraception methods that will protect against pregnancy, STD’s, and HIV.

An additional strategy nurses need to utilize is to eliminate barriers to sexual health promotion in order to provide effective HIV education. Barriers such as embarrassment, worries about confidentiality, previously bad experiences, and access problems can prevent an adolescent from seeking care. Lindberg, Lewis-Spruill, and Crownover (2006) found that African American adolescents “viewed available healthcare systems as formidable and unwelcoming and healthcare providers as judgmental and disrespectful” (p.85). The adolescents pointed to lack of privacy, having to discuss the problem with multiple personnel including the receptionists, and long waiting times as major barriers. In order to target adolescents, they need a place where they can receive competent care in a relaxing, private, and adolescent focused environment. A teen health clinic with a non-medical environment and open staff is one solution to this problem. Other options include private entrances for teens or a prescribing nurse available at schools.

Currently, we do not yet have a cure or vaccine to prevent HIV. This disease is still winning the war but there is an arsenal of weapons at our command. Nurses must have the know-how and the ability to utilize the resources available. The key to making a difference for adolescents is the adoption of successful HIV prevention interventions, paired with ongoing evaluation of their effectiveness in reducing risky behaviors or increasing safer behaviors. The key strategies addressed provide a foundation to prevent adolescent HIV infection rates. However, many more strategies will be required in order to find success. Young people need the tools to protect themselves from HIV infection and it is going to require a community collaborative effort.

Intervention I- Provide Reality Based Education

Disadvantage I- Limited and Inconsistent HIV Education

HIV prevention work cannot take place without certain ‘tools’ – things that can be used by those at risk of HIV to prevent infection. Ongoing discrimination against HIV positive people and a high number of annual infections suggest that AIDS education in the US is not as effective or as widespread as it could be. A 2006 survey for example found that 10% of Americans thought that there were drugs that could cure HIV, and 29% thought HIV could be transmitted through kissing. Although comprehensive sex education in schools is generally considered the best context in which to teach about AIDS, only around 60% of teachers report using a comprehensive (or abstinence-plus) system. About 34% teach strict abstinence-only programs, while at least 6% teach absolutely nothing at all. The exact content of what is taught can also vary considerably, and many have reported that even in schools where comprehensive education is theoretically taught, a lot of important information can be missed out or glossed over.

UNICEF (2002). Young people and HIV/AIDS: Opportunity in crisis. New York, NY: Author. Retrieved October 2, 2007, from http://www.unicef.org/publications/files/pub_youngpeople_hivaids_en.pdf

Disadvantage II – Outside Variables Can Affect HIV Curriculum Success

Important factors other than curriculum characteristics may dramatically affect their success. In general, at least three groups of factors may affect whether a curriculum-based program produce behavior change: 1) the characteristics of the curriculum and its implementation; 2) the needs, deficits (and assets) of the youth being served by the program; and 3) the characteristics of the youths’ environment, especially the prominence of AIDS, other STDs or teen pregnancy. In some communities in the United States where few young people hear messages to delay sex until older and where HIV is a salient issue, programs that encourage young people to delay sex in order to avoid HIV may be effective, whereas they might not be effective in other communities where youth already hear those messages or where HIV is not a salient issue.

Kirby, D., Laris, B.A., & Rolleri, L. (2006). Sex and HIV education programs for youth: Their impact and important characteristics. Family Health International, 1-76. Retrieved from www.etr.org on January 28, 2008

Intervention II – Eliminating Barriers to HIV Prevention Education

Disadvantage I – Health Care Access and Poverty Prevent Youth From Seeking Care

Studies have found that young people face a host of barriers to health care, including limited access to transportation, lack of confidentiality and youth-friendly service delivery environments, fear about seeking care, and lack of information about services available. Nearly 1 in 4 African Americans and 1 in 5 Hispanics live in poverty. The socioeconomic problems associated with poverty, including lack of access to high-quality health care, can directly or indirectly increase the risk for HIV infection.

Burstein, G.R., Lowry, R., Klein, J.D., & Santelli, J.S. (2003). Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics, 111(5), 996-1002. Retrieved January 3, 2007, from Expanded Academic ASAP database.

Disadvantage II- Less Effort to Reaching “Other” At-Risk Populations

There is a need to pay more attention to the needs of specific groups of young people like young parents, young lesbian, gay and bisexual people, as well as those who may be out of touch with services and schools and socially vulnerable, like young refugees and asylum-seekers, young people in care, young people in prisons, and also those living on the street. Young people who drop out of school are more likely to become sexually active at younger ages and to fail to use contraception.

Rew, L., Whittaker, T.A., Taylor-Seehafer, M.A., & Smith, L.R. (2005). Sexual health risks and protective resources in gay, lesbian, bisexual, and heterosexual homeless youth. Journal for Specialists in Pediatric Nursing, 10(1), 11-19. Retrieved October 2, 2007, from EBSCO Research database.

References

Beedy-Morrison, D., Nelson, L.E., & Volpe, E. (2005). HIV risk behaviors and testing rates in adolescent girls: Evidence to guide clinical practice. Pediatric Nursing, 31(6), 508-513. Retrieved January 14, 2007 from Expanded Academic ASAP database.

Burstein, G.R., Lowry, R., Klein, J.D., & Santelli, J.S. (2003). Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics, 111(5), 996-1002. Retrieved January 3, 2007, from Expanded Academic ASAP database.

Eaton, D.K., Kann, L., Kinchen, S., Ross, J., Hawkins, J., Harris, W.A., & et al. (2006). Youth risk behavior surveillance-United States 2005. Morbidity and Mortality Weekly Report, 55(SS-5), 1-112. Retrieved January 31, 2007, from http://www.cdc.gov/mmwr

Goodenow, C., Netherland, J., & Szalacha, L. (2002). AIDS-related risk among adolescent males who have sex with males, females, or both: Evidence from a statewide survey. American Journal of Public Health, 92(2), 203-210. Retrieved January 9, 2007, from PubMed central database.

Kirby, D., Laris, B.A., & Rolleri, L. (2006). Sex and HIV education programs for youth:Their impact and important characteristics. Family Health International, 1-76Retrieved from www.etr.org on January 28, 2008.

Lindberg, C., Lewis-Spruill, C., Crownover, R. (2006). Barriers to sexual and reproductive health care: Urban male adolescents speak out. Issues in Comprehensive Pediatric Nursing, 29(2), 73-88. Retrieved October 2, 2007, from EBSCO Research database.

Rew, L., Whittaker, T.A., Taylor-Seehafer, M.A., & Smith, L.R. (2005). Sexual health risks and protective resources in gay, lesbian, bisexual, and heterosexual homeless youth. Journal for Specialists in Pediatric Nursing, 10(1), 11-19. Retrieved October 2, 2007, from EBSCO Research database.

Saewyc, E., Pooh, C., Murphy, A., Skay, C., Richens, K., Reis, E. (2006). Sexual orientation, sexual abuse, and HIV risk behaviors among adolescents in the pacific northwest. American Journal of Public Health, 96(6), 1104-1110. Retrieved October 2, 2007, from EBSCO Research database.

UNICEF (2002). Young people and HIV/AIDS: Opportunity in crisis. New York, NY: Author. Retrieved October 2, 2007, from http://www.unicef.org/publications/files/pub_youngpeople_hivaids_en.pdf

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Smoking Cessation and the Role of the Nurse

Habitual smoking is a worldwide health crisis that can shorten life expectancies by over 20 years and create fatal illnesses such as lung cancer, emphysema and heart disease (Whyte,2007).Because smoking can lead to chronic and acute illnesses, nurses can have and impact on their clients health by educationg them on the importance of smoking cessation.


Paste the rest of your old paper plus the new part and all the references over these words. Leave the following text intact.Nursing strategies for this are to act as role models by not smoking themselves, promoting smoking cessation in the adult clients, and educating children and adolescents on the dangers of taking up smoking.
The International Council of Nurses believes that nurses can be very helpful in the prevention of smoking and smoking cessation. Nurses can help to reinforce this influence on their client’s by not smoking themselves since they are regarded by the public as important health role models. Just as important, or even more so is to provide a good example for their own children in order to safeguard the nurses health and that of their family. Children of smokers have an increased risk of sudden infant death syndrome, respiratory infections, lung cancer and ear infections (Kellogg, 2002).
Smoking and the willingness to try a smoking cessation program should be assessed with clients. Nurses working in Dr’s offices who see the same clients on a regular basis are in an optimal position to do this. Cost should not be a deterrent since the clients’ employer may offer programs or their insurance benefits may cover the cost of smoking cessation programs. While some clients may not be ready to quit, the nurse may follow an approach called the “transtheorhetical model of change.” This method is a way to help clients move through stages such as: precontemplation, contemplation, preparation, action and maintenance in order to prepare them for smoking cessation. During precontemplation, the client has no intent on quitting smoking in the next six months. The contemplation stage is the time that the client has an intention to quit during the next six months time. Preparation is the stage that the client has planned to quit in the next 30 days and has taken behavioral action toward action. The stage that follows preparation is the action stage which includes clients who have quit for less than six months. Lastly, is the maintenance stage in which the client has remained free of smoking for more than six months.
Another approach for the nurse to use with smoking cessation is the intervention steps known as the five A’s which include: ask, assess, advise, assist and arrange (Whyte, 2007). Asking clients about their smoking is always the first step. For the younger person asking about what their friends do is also important. Assessing includes whether or not the client is ready to make a change within the next 30 days. Advising pertains to providing help and motivation for the smoker to quit. Assisting the client could include many options such as: setting a quit date, recommending smoking cessation pharmacotherapy, removing all tobacco items from the clients’ environment, individual or group therapy, expecting challenges and enlisting help from friends and family. Lastly, arranging follow up contact by either in-person or telephone conversations to keep track of the client and continue with support.
Nurses can also help support their clients by educating them on the available pharmacotherapy treatments for smoking cessation. There are six currently available treatments approved by the Food and Drug Administration (FDA) for smoking cessation: one nonnicotine treatment and five nicotine replacement products that differ based on delivery mechanism (Ford, 2006). The nicotine replacement products include the nicotine inhaler and nasal spray which are available by prescription and the nicotine gum, lozenge and patch which are available over the counter. Clients should be advised to completely stop smoking before using nicotine replacement product to increase their chance of success. Sustained-release bupropion (bupropion SR) is approved by the FDA for smoking cessation, is available by prescription in tablet form and should be started before the client stops smoking. It is believed to ad smoking cessation through the inhibition of various neuro chemicals normally activated in the brain by smoking (Scanlon, 2006). Bupropion SR Bupropion SR and the nicotine patch can be combined for another alternative.
While interventions and pharmacotherapy’s can be effective in smoking cessation with the adult population, smoking prevention among children and adolescents is better than the cure. The younger a person begins to smoke, the greater their risk of smoking-induced diseases such as cancer or heart disease (Whyte, 2002). For this age group, peer lead prevention programs can be very effective. These can include videos or films which highlight the social consequences such as: smelly clothing, bad breath, financial cost and decreased athletic ability. Nurses working in schools can help by promoting smoke-free environments and reinforce the dangers of smoking.
Smoking has many adverse effects on health and contributes greatly to morbidity and mortality. Because smoking can lead to chronic and acute illness, nurses can have an impact on their clients’ health by educating them on the importance of smoking cessation and the avoidance of smoking in children and adolescents. Nurses can also set a healthy example by not smoking themselves. These strategies can help to increase abstinence rates and decrease tobacco-related mortality and morbidity which can help to improve their client’s lives.
Intervention #1- Promoting smoking cessation in adult clients.
Disadvantage #1- The high addictiveness of cigarettes.
Due to the high addictiveness of tobacco, clients participating in smoking cessation treatments do not always respond as readily as many healthcare professionals would like. It is the complex neurobiology of tobacco that is likely to be responsible for the development of tobacco dependence. The nicotine is the principal addictive component of tobacco smoke and shares many of the pharmacological characteristics of a psychostimulant drug such as amphetamine and cocaine.
Balfour, D., (2002). The Neurobiology of Tobacco Dependence: A Commentary. Respiration. 69, (1). 7-11. Retrieved February 4, 2008, from Proquest database (677604631).
Disadvantage #2- The financial costs of smoking cessation treatments.
Smoking cessation medications can range in price from $3.50 to $11.00 per day. Medicare does not cover smoking cessation treatments and private insurers have been reluctant to cover these costs as well. Their lack of coverage comes even as the healthcare savings has been estimated to be $1,623 a year for each person that quits smoking. Fortunately, tobacco cessation treatments are available and effective, and more medications are being developed to treat tobacco dependence. However, the inability of tobacco users to afford these treatments remains a barrier to reducing smoking cessation.
Solberg, L., (2005, June). Impact of insurance coverage on the use and effects of smoking cessation medications. Disease and Management Health Outcomes. (3). 151-58. Retrieved February 5, 2008, from EBSCO database (1173-8790).

Intervention #2-Educating children and adolescents on the dangers of taking up smoking.
Disadvantage #1-Peer pressure and the smoking behavior of their closest friends.
Research findings show that adolescent peer relationships contribute to adolescent cigarette smoking. Youth who are friends with smokers have been found to be more likely to smoke themselves than those with only nonsmokers as friends. Best friends, romantic partners, peer groups and social crowds all have been found to contribute to the smoking or non-smoking behavior of teenagers. Rather than coercive pressures, the decision to smoke has been found to be more about trying to fit in, social approval and popularity.
Castrucci, B.C., Gerlach, K.K., Kaufman, N.J., Orleans, C.T., (2002, September). The association among adolescents’ tobacco use, their beliefs and attitudes, and friends’ and parents’ opinions of smoking. Maternal and Child Health Journal. 6(3). 159-67. Retrieved from EBSCO database February 5, 2008.
Disadvantage #2- Advertising and promotion of smoking that appeal to adolescents.
Despite tobacco industry claims, researchers have consistently implicated cigarette marketing activities as an important catalyst in the initiation of smoking in adolescents. Due to advertising, studies show and increase in smoking rates among population subgroups specifically targeted by marketing campaigns.
Biener, L., (2000, March). Tobacco marketing and adolescent smoking: more support for a casual inference. American Journal of Public Health, 90(3). 407-11. Retrieved February 5, 2008, from EBSCO database (0090-0036).


References

Kellogg, John Harvey, (2002, June). Tobaccoism. American Journal of Public Health, 92 (6). 932-934. Retrieved October 12, 2007, from EBSCO database (0090-0036).

Potts, Lisa A., (2007, August 15). Emerging psychotherapies for smoking cessation. American Journal of Health-System Pharmacy, 64 (16). 1693-1698. Retrieved October 12, 2007 from EBSCO database (1079-2082).

Saarman, L., Daugherty, J, & Riegel, B. (2002, June). Teaching staff cognitive-behavioral intervention. MedSurg Nursing, 11(3). 144-151. Retrieved January 7, 2007, from Expanded Academic ASAP database (A87509029).

Scanlon, A. (2006, November). “Nursing and the 5A’s guideline to smoking cessation interventions”. Australian Nursing Journal, 25(4), 14- . Retrieved January 7, 2007, from Expanded Academic ASAP database (A154562471).

Whyte, F., & Kearney, N. (n.d.). Enhancing the nurse’s role in tobacco control. Retrieved February 4, 2007, from http://www.tobacco-control.org/tcrc_Web_Site/Pages_tcrc/Resources/Factsheets/enhancenursesrole.pdf

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Anaphylaxis

Anaphylaxis and its treatment
Gary Darley

Anaphylaxis is a rising threat to the lives of many people. Recent increases in the number of serious reactions seen in emergency rooms, have led to the need for an increased awareness of the causes and treatment of anaphylaxis (Sampson, 1601). The intent of this paper is to explain what is happening during an anaphylactic reaction and what the protocol is to correct it. The science of treating anaphylaxis is relatively well understood, and when established protocols are followed, treatment of anaphylaxis is highly successful.

Anaphylaxis and its treatment
Anaphylaxis is a rising threat to the lives of many people. Recent increases in the number of serious reactions seen in emergency rooms, have led to the need for an increased awareness of the causes and treatment of anaphylaxis (Sampson, 1601). The intent of this paper is to explain what is happening during an anaphylactic reaction and what the protocol is to correct it. The science of treating anaphylaxis is relatively well understood, and when established protocols are followed, treatment of anaphylaxis is highly successful.
To start, anaphylaxis is defined by Brown as, a severe, life-threatening generalized or systemic hypersensitivity reaction (157). Finney states that, anaphylaxis is a severe allergic reaction, where the body’s immune system over-reacts to a harmless substance. The reaction becomes so strong that it threatens imminent death through hypotension, bronco-constriction and hypovolemia, if no action is taken to negate the effect (50).
While anaphylaxis can be mistaken for other conditions such as, an asthma attack, arrhythmia, myocardial infarction, pulmonary embolism, insulin reaction or vaso-vagal response, it is important to note, that most anaphylactic reactions occur within minutes of exposure to an antigen (Finney, 52). Signs and symptoms include pallor, hypotension, anxiety, respiratory distress, pulmonary edema, angio-edema, stridor, tachycardia, urticaria, wheezing and tightness of the chest (53).
Among the chief causes of anaphylaxis are food-induced causes, namely peanuts, tree nuts, fish and shellfish (Sampson, 1601). It is important to note that these are the major foods that cause anaphylaxis, but not the only ones. Other causes include exercise induced, venom reactions or reactions to therapeutic drugs (Brown, 158). In 15-32% of reactions according to Brown, no causative agent was identified. This makes preventing reactions from reoccurring more difficult (157).
There are two major parts of the immune system which are responsible for anaphylactic reactions. First are basophils and second are mast cells. Basophils are a type of white blood cell that carries histamine, heparin and other inflammatory factors. They are found in the blood stream. Mast cells are basophils that have left the blood stream for body tissues, such as loose connective tissue, gastrointestinal mucosa, lungs and the area around blood vessels. In addition to histamine, heparin and inflammatory factors, mast cells also carry spasmogens (Bryant, 24). When working properly these two cell types effectively aid your body in combating invading organisms and keep you healthy. They do this by working with lymphocytes and memory cells. As lymphocytes react to an antigen they produce antibodies and memory cells. The antibody attaches to the antigen inactivating it. Memory cells stay in the vascular system, ready to rapidly produce antibodies, so as to put a quick stop to any identical antigens that may invade. The combination of antigen and antibody attaches to the basophil or mast cell, which then releases chemical signals, primarily histamine. The release of these chemicals attracts another type of white blood cell, an eosinophil for phagocytosis (Bryant, 24-25).
In an individual who is prone to anaphylaxis the basophils and mast cells over produce histamine and other inflammatory factors, or degranulate releasing their entire chemical stores (Bryant, 25). This causes a cascade of events to occur. Vessels dilate and become more permeable to fluids, causing third spacing of fluid and edema. A decrease of up to 35% of blood volume can occur in ten minuets or less, resulting in hypotension and hypovolemia. Airway constriction due to direct histamine action on smooth muscle and edema in the airway decrease a patient’s ability to effectively breathe. Without immediate intervention, most patients will asphyxiate or go into cardiac arrest (Brown, 159).
Several factors exist which predispose an individual to having an anaphylactic reaction, a history of asthma, food allergy (especially to nuts and sea food), history of anaphylaxis, pubescent patients and patients on beta-blockers or angiotensin-converting enzyme inhibitors. As the majority of reactions come from a foreign substance entering the body, the keystone to anaphylactic therapy is prevention (Sampson, 1606). On those occasions when a reaction does occur, treatment must be immediate.
Treatment of anaphylaxis follows the airway, breathing and circulation rule. Epinephrine is the cornerstone of initial treatment for anaphylaxis. Formerly called adrenaline, epinephrine counter-acts the anaphylactic reaction by relaxing the smooth muscles of the airway, constricting blood vessels and suppressing the release of histamine (Finney, 54). 0.15mg for children and 0.3mg of epinephrine for adults can be carried in an easy to use auto-injector called an Epi-pen. The longer it takes to treat the patient with epinephrine, the greater the incidence of complications and fatal reactions. Once initial treatment is performed, an assessment of the patient’s oxygen saturation, overall perfusion and cardiac output must be performed (Sampson, 1604-1605). While epinephrine does a good job initially, additional therapy may be needed in the form of oxygen, to maintain adequate blood saturation, and IV fluids to combat circulatory fluid loss (Brown, 161). Oxygen via mask or nasal canula maybe used, or if necessary artificial ventilation can be used (Brown, 164). Albuterol is sometimes employed to aide in opening the airway. While normal saline may be used, the preferred fluid replacement is an isotonic crystalloid such as Lactated Ringers (Bryant, 161). After treatment has been successful, a four hour observation period is recommended. This is to ensure the reaction does not recur after the epinephrine wears off (Brown, 163). The figure on the following page is a step by step process taken from Brown, showing anaphylactic treatment (164).
Once a patient has been diagnosed with an anaphylactic reaction, education on what to do is essential. A trigger needs to be isolated by an allergist, so that avoidance is possible. The patient needs to be taught the signs and symptoms of an anaphylactic reaction. They then need to understand how to use a portable epinephrine injector, such as the Epi-Pen. Once the Epi-Pen has been used, transport to an emergency room needs to follow, even if the patient seems to recover, as they may still have the antigen in their system. A medical bracelet should be worn, advising any emergency personnel of the patient’s allergy. It must be reiterated, especially to young patients and their care givers, that avoidance of the antigen is vital, but that a normal life is possible.
In conclusion, anaphylaxis is a treatable condition that all medical personnel need to be aware of. It is being seen on a more frequent basis throughout the United States. The reactions are primarily caused by severe food allergies, which can be controlled through avoidance. The cornerstone of treatment is epinephrine, with other therapeutic measures taken as needed. While anaphylaxis complicates a patient’s life, it does not have to stop it. Medical personnel everywhere should be prepared to successfully combat anaphylaxis when it comes knocking at the door.

Intervention #1: Epinephrine Use
While epinephrine is often considered a miracle drug in the treatment of anaphylaxis, there are several disadvantages that surround it. Two of these disadvantages will be discussed. The first is education for patients who use Epi-Pens. In an article by Kumar et al, the authors cited a study that found that in 90% of fatal anaphylactic reactions, patients were not carrying their epinephrine injectors (Epi-Pens). Another cited study showed that some patients had prescriptions for Epi-Pens but never carried them, some carried them but didn’t know how to use them and others carried and used expired equipment, which failed to perform when needed (284). These studies show that patient education is at least as valuable as having the needed supplies to treat an anaphylactic reaction.
Kumar, A., Teuber, S., & Gershwin, M. (2005, December). Why do people die of anaphylaxis: A clinical review. Clinical & Developmental Immunology, 12(4), 281-287. Retrieved February 3, 2008, from Academic Search Premier database.

The second problem found was in the availability of trained staff to recognize an anaphylactic reaction and use epinephrine appropriately. Rankin and Sheikh conducted a survey in the UK that found that epinephrine was available in 97% of schools surveyed. Of those schools with an identified at risk child 80% had staff trained to use epinephrine, while only 48% of schools without an at risk child had staff trained to use epinephrine. 59% of all the schools surveyed did not feel confident in their ability to properly treat and manage an anaphylactic reaction. These numbers become significant when you realize that the highest incidence of anaphylaxis occur due to food sensitivity reactions and those reactions become known when a person is in the primary to high school levels of schooling (1429).
Rankin, K., & Sheikh, A. (2006, August). Serious Shortcomings in the Management of Children with Anaphylaxis in Scottish Schools. PLoS Medicine, 3(7), e326. Retrieved February 3, 2008, from Academic Search Premier database.

Intervention #2: Allergen Avoidance
Another problem with treating anaphylaxis is avoiding the trigger to a reaction. Two difficulties regarding avoidance will be discussed here as well. The first is in non-patient education. One of the major causes of anaphylaxis is an allergy to peanuts (Munoz-Furlong, 33). It seems like such a harmless thing, a peanut. But to some it is deadly.
The Grecos understand because they saw it almost happen to Colby over Labor Day weekend. The toddler, who had safely eaten peanuts before, got three peanut M&Ms as a potty-training reward. "Within 20 minutes, he was sick to his stomach," his grandmother says. "Then he started swelling up and developing hives." Then Colby started struggling to breathe; his face turned pale and his lips turned blue from lack of oxygen. "They did arrive at the hospital in time to save his life," Maureen Greco says. Doctors said Colby had suffered a severe allergic reaction. It could happen again, they said, if he ever touched or ate something containing peanuts. (Even children who have had mild reactions in the past are at risk for severe incidents.) So, Julie Greco has done what any mother would do: She has asked the parents at Colby's preschool to avoid sending in snacks made with peanuts -- and taken him home from one class birthday party because the cake contained them anyway (Painter).
As people who live in this world with others, education is needed so that we can be good neighbors and citizens. Believing a child when they say, “I can’t have that” maybe the difference between attending that child’s funeral or not (Painter).
Munoz-Furlong, A. (2006, February). Going Nuts Over Allergies. Education Digest, 71(6), 33- 34. Retrieved February 3, 2008, from Academic Search Premier database.

Painter, K. (n.d.). In the shadow of the peanut. USA Today, Retrieved February 3, 2008,from Academic Search Premier database.

The second difficulty lies in patient education. In a world where we eat what comes in a box, we have no idea what may have been used in the manufacturing process for that food. Label reading becomes imperative for someone with a known allergic reaction. The food item in question may not even contain the ingredient needing to be avoided, but the plant where it was made can have a risk for cross contamination with other products that do. Labels contain warnings that need to be headed in order to avoid a reaction (Schmit).
Schmit, J. (n.d.). More food labels take an ominous tone on allergens. USA Today, Retrieved February 3, 2008, from Academic Search Premier database.

In summary, anaphylaxis can be treated successfully, but that success rests largely on education. Epinephrine can save a patients life, when used appropriately or it can also cause death when not used or used inappropriately. Avoidance of an allergen is essential to living a wonderful life. When not avoided, allergens can cause a loss of quality of life in the short term as well as the long term in the form of death. Understanding these things becomes a vital necessity to those of use living here on this blue rock we call Earth.


References


Brown, S. (2006, April). Anaphylaxis: Clinical concepts and research priorities. Emergency Medicine Australasia, 18(2), 155-169. Retrieved November 5, 2007, from CINAHL database.

Bryant, H. (2007, May). Anaphylaxis: Recognition, treatment and education. Emergency Nurse, 15(2), 24-28. Retrieved November 5, 2007, from CINAHL database.

Finney, A., & Rushton, C. (2007, May 23). Recognition and management of patients with anaphylaxis. Nursing Standard, 21(37), 50. Retrieved November 5, 2007, from CINAHL database.

Kumar, A., Teuber, S., & Gershwin, M. (2005, December). Why do people die of anaphylaxis: A clinical review. Clinical & Developmental Immunology, 12(4), 281-287. Retrieved February 3, 2008, from Academic Search Premier database.

Munoz-Furlong, A. (2006, February). Going Nuts Over Allergies. Education Digest, 71(6), 33-34. Retrieved February 3, 2008, from Academic Search Premier database.

Painter, K. (n.d.). In the shadow of the peanut. USA Today, Retrieved February 3, 2008, from Academic Search Premier database.

Rankin, K., & Sheikh, A. (2006, August). Serious Shortcomings in the Management of Children with Anaphylaxis in Scottish Schools. PLoS Medicine, 3(7), e326. Retrieved February 3, 2008, from Academic Search Premier database.

Sampson, H. (2003, June). Anaphylaxis and emergency treatment. Pediatrics, 111(6), 1601-1608. Retrieved November 5, 2007, from CINAHL database.

Schmit, J. (n.d.). More food labels take an ominous tone on allergens. USA Today, Retrieved February 3, 2008, from Academic Search Premier database.

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The nurses’ role in providing holistic care for a patient should include a spiritual assessment upon hospitalization. The question is, are nurses given the proper training on when to use an assessment tool and if so, how to plan care based on the results for a more holistic healing?

Providing spiritual care for patients becomes more complicated for the nurse as the definition of religion and spirituality seems to blend together. Addressing key nursing strategies, such as educating nurses on how to properly use a spiritual assessment tool, identifying what spiritual therapies are provided or available to patients, and what therapies nurses have found to be beneficial during the healing process are essential in allowing nurses to provide a plan of care that is focused on the overall holistic healing of the patient.
Nurses are in an excellent position to provide spiritual care to patients that can positively impact their healing process. Recognizing the patient’s spirituality may also help to enhance the nurse-patient relationship. Spiritual or holistic nursing is an area that has been neglected within nursing education. Concern over conflicting spiritual values between nurse educators, students, and patients may cause educators and students to avoid these difficult areas of care. (Lovanio & Wallace 2007). When approaching a patient about their spirituality, the nurse must be sensitive and cautious. Spiritual assessment and care should be based on a relationship of trust between patient and nurse. It will involve awareness of the person's culture, social and spiritual preferences, as well as a respect for their beliefs and religious practices. Spirituality is a core component of holistic healing as it provides the foundation for hope and faith that life will continue on through their sickness. When spirituality and emotional needs are not addressed, a patient’s hope can quickly turn to depression, their faith to disbelief, and their will to live can fade. Nurses are in an ideal position to provide spiritual care to patients but many are hesitant to because they lack the experience and education to do so.
Educating nurses on how to properly use a spiritual assessment tool to address patient’s needs is a crucial part of the solution. According to Power (2006), one problem nurses run into in America is that spirituality is often linked to religion. With spirituality being such an important part of the health assessment, nurses are struggling with ways to integrate any assessment tool that is acceptable for everyone. There are several different tools used but the most effective tool is simply using general observation and encouraging patients to talk about their spirituality. Power (2006) states that for nurses to be more sensitive to a patient’s culture and religious practices, a nurse might simply ask what a patients’ belief system is and if there is a pressing concern. Nurses might also consider taking a simple spiritual history. This history should address the patient's spiritual attitudes and value system, spiritual development, and sense of meaning and purpose spirituality may play in the patient's life. The biggest problem found in hospitals is nurses admit they need more education in conducting a spiritual assessment and feel they would be better prepared if there was a way to combine an informal assessment with a more specific assessment tool such as a spiritual history (Power 2006). No matter when, how, or what assessment tool is used, nurses agree that by gaining valuable information about the patients spirituality can be vital to their healing.
While educating nurses is important, another key strategy is identifying what spiritual therapies are available to the patient. Since many nurses feel they are undereducated when it comes to spiritually assessing their patients, Grant (2004) says that nurses are equally unaware of the different interventions and therapies available to their patients. Spiritual interventions should not be limited to services provided by a chaplain or priest but should also include more basic human needs. Some simple therapies that could be given to patients include things such as touch, therapeutic conversation, listening, prayer or meditation, or a referral to other resources inside or outside of the hospital.
Many patients do not think to ask nurses for spiritual support. But if nurses provide simple therapies, then patients develop a bond with their nurse that will make it easier to seek the support they need. Other interventions that patients should be made aware of are alternative therapies such a biofeedback and acupuncture. No matter which therapies or interventions patients choose, nurses should make all options available and encourage patients to seek out what fits their needs and beliefs best.
Knowing what therapies are available is important, but also knowing what therapies and interventions other nurses have found beneficial can greatly impact nurse’s ability to make the biggest difference. Dembner (2005) concludes that many people use prayer as an acceptable belief or tool for healing their loved ones. The difference that prayer makes is to the patient’s spirit and the level of hope they have during their healing process. Other nurses say that their patients do not pray but like to meditate or take quiet moments to reflect on the past and future. Adopting a nursing philosophy that routinely includes therapeutic touch, active listening, appropriate humor, referral to a spiritual counselor and understanding can keep hope alive in patients when physical healing is not taking place. Healing of the soul can give the patient the peace they need to deal with the physical stress of the illness.
Educating nurses on how to approach a patient with spiritual needs is crucial if a patient’s hope is going to be kept alive. Holistic healing can only take place if the whole body is healing as one. Recognizing a nurses own limitations and knowing when to make a referral, or utilizing other members of the team is as important for spiritual care as it is for other aspects of care. Implementation of key nursing strategies such as educating nurses on how to properly use a spiritual assessment tool to address the patients needs, identifying what spiritual therapies are available, and what therapies nurses have found to be beneficial during the healing process are essential in allowing nurses to provide a plan of care that is focused on the overall holistic healing of the patient.


a. Intervention 1 – Educating nurses on how to properly use a spiritual assessment tool to address patient’s needs is crucial part of healing

i. disadvantage 1 – Nurses do not receive enough education in school to be able to use the spiritual assessment tool correctly
1. Nurses may lack the confidence to broach spiritual issues with patients and their families owing to limited dialogue on spirituality in education and practice.(Cavendish 2005) Most educational experience is limited in assessments practiced in nursing school or during a school’s clinical setting, with spiritual care inconsistently or infrequently addressed.
2.Cavendish, R., DiJoseph, J. (2005 July/Aug). Expanding the Dialogue on Prayer Relevant to Holistic Care. Holistic Nursing Practice. 19(4), 147-154. Retrieved February 4, 2008 from EBSOC Research Database.


ii. disadvantage 2 –Spirituality is difficult to teach to a wide range of people
1. There may be as many different spiritual values and beliefs as there are individuals. Varying spiritual values may make the range of spiritual interventions difficult
for nurses. The lack of emphasis on spiritual assessments and care in nursing school may be because some educators believe that spirituality cannot be taught, but must be modeled by nurse educators in order for students to learn to address the spiritual needs of patients. Nursing educators often lack spiritual education and are consequently ill-prepared to teach spiritual assessment and interventions to students.(Lovanio (2007) Plus, concern for conflicting spiritual values between nurse educators, students and patients, may cause nurse-educators to avoid these difficult areas.
2. Lovanio, K., & Wallace, M. (2007 Jan/Feb). Promoting Spiritual Knowledge and Attitudes: a student nurse education project. Holistic Nursing Practice, 21(1), 42-48. Retrieved January 3, 2007 from Expanded Academic ASAP database.



b. Intervention 2 –Identifying what spiritual therapies & interventions other nurses have found beneficial can greatly impact nurse’s ability to make the biggest difference

i. disadvantage 1 – Spiritual care is not clearly defined
1. Nurses are often not comfortable providing spiritual care and they may not be able to distinguish spiritual needs from religious needs. Cavendish found that spiritual care activities are not clearly defined in the nursing education, and few spiritual care interventions are outlined in nursing care books to guide nurses with their care. The private nature of spirituality may be another reason that spiritual interventions are not initiated.
2. Cavendish, R., Konecny, L., Mitzeloitis, C., Russo, D. (2003 Oct-Dec). Spiritual Care Activities of Nurses Using Nursing Interventions Classification (NIC) Labels. International Journal of Nursing Terminologies and Classifications. Retrieved February 4, 2008 from http://findarticles.com/p/articles/mi_qa4065/is_200310/ai_n9312174/pg_7

ii. disadvantage 2 – Many time spiritual care and interventions are not notated in the patients charts
1. Spiritual care activities (eg, praying with patients or supporting their prayer activities) are rarely found in nursing notes. If nurses are providing spiritual care, many times it is not being documented correctly. In a 2004 study some nurses claim the reason they do not document the type of spiritual care they provided is because they do not know how to document it. Typically, the only reference to spirituality in acute care settings relates to asking if patients would like to visit with a chaplain.
2. Grant, Don. (2004 Jan/Feb). Spiritual interventions: How, when, and why nurses use them. Holistic Nursing Practice, 18 (1), 36 – 42. Retrieved January 3, 2007 from Expanded Academic ASAP database.


References

Cavendish, R., Konecny, L., Naradovy, L., Kraynyak Luise, B., Como, B.,Okumakpeyi, P., Mitzeliotis, C., & Lanza, M. (2006 Jan/Feb). Patients' perceptions of spirituality and the nurse as a spiritual care provider. Holistic Nursing Practice, 20(1), 41-48. Retrieved January 3, 2007 from Expanded Academic ASAP database.

Cavendish, R., DiJoseph, J. (2005 July/Aug). Expanding the Dialogue on Prayer Relevant to Holistic Care. Holistic Nursing Practice. 19(4), 147-154. Retrieved February 4, 2008 from EBSOC Research Database.

Cavendish, R., Konecny, L., Mitzeloitis, C., Russo, D. (2003 Oct-Dec). Spiritual Care Activities of Nurses Using Nursing Interventions Classification (NIC) Labels. International Journal of Nursing Terminologies and Classifications. Retrieved February 4, 2008 from http://findarticles.com/p/articles/mi_qa4065/is_200310/ai_n9312174/pg_7

Dembner, A. (2005, July 25). A Prayer for health. The Boston Globe, Retrieved March 15, 2007.

Grant, Don. (2004 Jan/Feb). Spiritual interventions: How, when, and why nurses use them. Holistic Nursing Practice, 18 (1), 36 – 42. Retrieved January 3, 2007 from Expanded Academic ASAP database.

Lovanio, K., & Wallace, M. (2007 Jan/Feb). Promoting spiritual knowledge and attitudes: a student nurse education project. Holistic Nursing Practice, 21(1), 42-48. Retrieved January 3, 2007 from Expanded Academic ASAP database

Power, Jeanette. (2006 March). Spiritual assessment: developing an assessment tool. Nursing Older People, 18 (2), 16-21. Retrieved January 3, 2007 from Expanded Academic ASAP database.

Ray, Rebecca. (2004 February). The faith connection. Retrieved February 4, 2007 from http://www.nurseweek.com/news/features/04-02/faith_3.asp

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Carl C Ineffective Management of Chronic and Acute Pain

Ineffective management of chronic and acute pain by nursing and other medical staff because of inadequate treatment, education and cultural misconceptions, is a continuing barrier to achieving client wellness. This situation is not a recent development and can be mitigated through the implementation of several strategies of which the nursing cohort is the prime driver.
These strategies include educating nurses to perform adequate and regular pain assessments. These assessments require that the nurse listen to what the client is saying about their pain levels and experience. In addition, the nurse needs to develop awareness in others of cultural and social constructs that create misconceptions surrounding pain and pain treatment therapies. Lastly, the nurse must have the ability to formulate effective strategies to break down these misconceptions of all the involved parties and ultimately, help the client.

Pain is described as;“ A sensation in which person experiences discomfort, distress or suffering due to the provocation of sensory nerves.” (Thomas, 1973) Taber’s then goes on to describe ninety seven different types of pain, demonstrating that pain is a highly complicated subject matter ranging from the metaphorical to sequlae of a specific medical condition. Regardless of the neurological response generated, pain impacts wellness. Acute pain is generally short in duration but severe, such as the pain generated from a surgical procedure or accident. It is expected to abate or at worst convert to chronic pain. Chronic pain is long term and constant, such as the pain of arthritis or cancer. Pain can impact an individual’s ability to lead a participatory life or a patient’s ability to recover from an illness. Pain can impact mental health, acuity and, pain can result in a lifetime of searching for relief (Fine & MacLow, 2006). In her article Managing Chronic Pain (2002), Michelle Meadows relates the story of a woman’s 30 year search for relief from pain resulting from injuries received in a skiing accident. Her search involved multiple surgeries, some of dubious value, therapies, depression and numerous healthcare workers who offered little help or hope.

One strategy for improving outcomes is educating nurses. A qualitative study conducted in a series of Colorado Long Term Care (LTC) facilities found that 25-33% of the residents experience moderate to severe pain on a daily basis (Clark, Fink, Pennington & Jones 2006). Data from this study indicates that this issue is related to inadequacies of the care staff involving training, basic philosophies and communication among the staff and clients, all correctable factors (Clark, Fink, Pennington & Jones 2006). Education of the nursing and support staff caring for these individuals is critical to improving this situation. Regular and complete assessments for pain must be completed on all clients under care. There are numerous tools available to make these assessments complete and in a common format that all care providers coming in contact with these clients can understand and use to the client’s benefit. The most common tool in use is the very effective 0-10 scale. This tool needs to be augmented with observations made by the managing nurse and include input from support staff who may very well have more contact with the client. Proper communication of the client’s reaction to the multitude of stimuli encountered is as important as the formal assessments and needs to be part of the treatment plan.

Another strategy involves specific cultural issues surrounding how a client may deal with or express pain. Strategies that resolve these issues need to be understood and incorporated into daily care. A known example of this is individuals from some Asian cultures will readily accept pain relief if they are asked several times. They simply feel it is impolite to accept the offering immediately and expect that it will be offered a second time. In this instance, offering pain relief to this client one time and walking away under the assumption they are able to tolerate their pain is an error in care. An adjunct to this is having this specific knowledge and not communicating it to other care staff. In some ways this is no different than ignoring the client’s pain altogether. Key information such as this needs to be available to all the care givers requiring clear and adequate communication are part of the routine of daily care.

A third strategy involves the clarification of misconceptions surrounding pain in general and treatments for pain. In addition to factors elucidated in the LTC study regarding how social constructs impact how pain is treated another issue involves direct treatments for pain. Often times the most effective therapies for pain is the use of opioid drugs or narcotics. While their proper use is known and accepted in much of the medical community, societal controls over these substances places blocks to their proper and effective application. Physicians and practitioners wanting to prescribe these materials are faced with regulations governing their use that are so onerous these professionals physicians often use less effective therapies (Berry & Dahl 2007). Patients and family members often question the use of these therapies based on a fear of addiction and place a self imposed stigma on their use, a situation largely derived from their own ignorance (Mercadante 2007).

The technology and techniques to effectively manage pain already exist. Through the implementation of strategies that include educating nursed in proper assessments, secondly improve social and cultural awareness and lastly that address misconceptions that hinder treatment these techniques can be better utilized. In many instances the barriers to their implementation are created by the very professionals meant to administer these therapies (Berry & Dahl 2007). As primary caregivers the ranks of professional nurses are in an ideal position to make these changes across the entire spectrum of healthcare.

Intervention One

Educate professional care giving staff to adequately assess and treat pain

Disadvantage 1

Currently there are multiple tools in use to measure or attempt to quantify pain. This includes the visual analogue scale (VAS), the numeric rating scale (NRS), the verbal rating scale (VRS), the category ratio (CR-10 scale) and McGill pain questionnaire (Ergun et al, 2005). What is to be taught and how is it to be taught. Are the existing tools up to the task of providing a universal description of pain and quantifying it. Are the existing tools up to the task interpreting across the breadth of cultural and educational diversity that health care professionals are required to address. At this point in time the answers for these questions is not a definitive yes, there are still tools in development that may be more effective. So the question is what is to be taught.

Ergun, U et al, Trial of a New Pain Assessment Tool in Patients With Low Education: The Full Cup Test. International Journal of Clinical Practice 63(3) 2005, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Disadvantage 2

Pain and its assessment is by nature subjective, what is tolerable to one person is not to another. Pain is also a symptom of a condition that may or may not be identified. In this case therapies for pain relief mask the existence of underlying pathology which may go untreated. With these instances in mind, is it even reasonable to assume that effective assessments for pain and the implementation of effective therapies can be adequately taught. A simple 0-10 scale is may not be adequate to the task at hand. (Vallerand et al, 2007).

Hazard Vallerand et al, Knowledge of and Barriers to Pain Management in Caregivers of Cancer Patients Receiving Homecare. Cancer Nursing, 2007, 30(1):31-37, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Intervention 2

Removal of barriers to effective pain control

Disadvantage 1

Many of the most effective therapies for pain relief involve the use of opiates, the ability to use these medications more freely would improve pain control. The vast majority of the governments in the world place heavy regulation on the use and distribution of these dangerous chemicals for good reason. Reducing the control mechanisms already in place over these materials would reduce the responsibilities associated with their prescription and dispensing(Mercadante 2007). Given the potential for abuse and danger here facilitating their use is unwise.

Mercadante, S. (2007). Why are our patients still suffering pain? National Clinical Practice Oncology 4(3) pp 138-139. Retrieved April 19, 2007 from Medscape Today Search. <>

Disadvantage 2

Fear of addiction is a very legitimate fear and a distinct possibility where the regular use of strong pain medications is involved. A patient’s or their family’s concern over this matter is well placed. In many instances the populations of not only inner city but urban hospitals display drug seeking behaviors (McCaffery et al, 2007). Are these individuals in pain or are they seeking an alternate source to better serve their additions. Is it the job of the medical community and the population of those responsibly insured to support these actions. Can a medical system that is not capable of providing services to the population as a whole afford to support addictive behavior (Levine et al, 2007).

McCaffery et al, On the Meaning of "Drug Seeking" Pain Management Nursing 8(3) 2007, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Levine et al, Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform. The Hasting Center Report, 2007;37(5):14-19. Retrieved February 2, 2008 from Medscape Nursing Search. <>

Bibliography

Berry, P.; Dahl, J., Advanced Practice Nurse Controlled Substances Prescriptive Authority: A Review of the Regulations and Implications for Effective Pain Management at End-of-Life. Medscape Nurses. Released October 30, 2007. Retreived November 6, 2007 from Medscape Nursing Search.

Clark, L, Fink, R, Pennington, K & Jones, K, (2006) Nurses' reflections on pain management in a nursing home setting. Pain Management Nursing 7(2) pp 71-77, Retrieved April 13, 2007 from Medscape Today Database.

Ergun, U et al, Trial of a New Pain Assessment Tool in Patients With Low Education: The Full Cup Test. International Journal of Clinical Practice 63(3) 2005, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Fine, P. & MacLow, C., (2006). Principles of effective pain management at the end of life. Medscape CME/CE Activity. Released October 5, 2006. Retrieved April 19, 2007 from Medscape Today Search. <>

Hazard Vallerand et al, Knowledge of and Barriers to Pain Management in Caregivers of Cancer Patients Receiving Homecare. Cancer Nursing, 2007, 30(1):31-37, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Levine et al, Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform. The Hasting Center Report, 2007;37(5):14-19. Retrieved February 2, 2008 from Medscape Nursing Search. <>

McCaffery et al, On the Meaning of "Drug Seeking" Pain Management Nursing 8(3) 2007, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Meadows, M. (2004, March-April ). Managing chronic pain. FDA Consumer Magazine. Retrieved April 13, 2007. <>

Mercadante, S. (2007). Why are our patients still suffering pain? National Clinical Practice Oncology 4(3) pp 138-139. Retrieved April 19, 2007 from Medscape Today Search. <>

Thomas, C. L. (Ed.). (1973). Taber’s cyclopedic medical dictionary (12th ed.) p-4. Philadelphia, PA: Davis.

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Childhood Obesity by Molly London

Childhood obesity has increased at an alarming rate over the last 20 years. Today, nearly one in five children is battling this condition and if patterns predict the future, almost all of America’s children will be living with diabetes, heart disease, and dying younger due to obesity within the next 20 years.

Childhood obesity has increased at an alarming rate over the last 20 years. Today, nearly one in five children is battling this condition and if patterns predict the future, almost all of America’s children will be living with diabetes, heart disease, and dying younger due to obesity within the next 20 years. The educated nurse can influence the caregiver’s strategies in promoting healthy lifestyle behaviors for obese children through proper education of prevention, lifestyle changes, and offering treatment options for obesity.

Childhood obesity alone is not the only issue facing children today, although being overly large may inhibit the child from living life to the fullest. However, the co-morbidities relating to childhood obesity are the real killers. Hypertension, type 2 diabetes, respiratory ailments, sleep apnea, and depression are just some of the common problems linked directly to obesity in children (Henry 2005). Others are increased likelihood of having elevated cholesterol, raised systolic blood pressure, experience of early menarche which links with future instances of breast cancer, and increased risk for cardiovascular disease (Ruxton 2004). All of these issues are associated with childhood obesity, and this is a fact that many people do not realize. Steps must be taken to prevent obesity and to promote wellness in children of all ages in order to save America’s children.

First, nurses can influence prevention through sharing information on misunderstood topics. Many people do not know which food choices will keep their children healthy, and these healthy choices should begin at infancy. Numerous women choose not to breastfeed their infants and according to a study done by Mayer-Davis, et al. (2006), breastfeeding can decrease the incidence of overweight/obese children by 13-22%. It is the concern for the children that many mothers say is the reason they do not want to breastfeed, as the mothers are either obese or battling diabetes and don’t want to transfer their health problems into their infant through diet. However, the study conducted proved that regardless of the mother’s weight and diabetic status, the infant equally benefited from the mother’s breast milk (Mayer-Davis 2006). Another piece of information that many people do not realize is the long-term health problems related to childhood obesity. In a separate study done by the American Obesity Association (AOA), over 30% of parents were concerned of their children’s weight, yet only 5.6% of those parents chose “being overweight or obese” as their child’s greatest long-term health risk (Childhood Obesity). These parents need to be told that their children are at risk for poor organ functioning due to large amounts of fat inhibiting normal function, that the excess weight will place unnecessary strains on growing joints and limbs, and that the adipose tissue will have major effects on the metabolic and endocrine systems (Ruxton 2004). Discussing the long-term effects of childhood obesity can play a crucial part in prevention because, as the AOA’s study confirms, people are not aware of the permanent effects this disease can have on a child. Prevention and education are key to battling childhood obesity, but once the knowledge is there, the lifestyle changes must be implemented.

Lifestyle changes will be crucial to reverse childhood obesity if prevention measures are not taken or are unsuccessful. The nurse should teach that lifestyle changes include diet appropriate for the growing child as well as increased amounts of physical activity. Many professionals (i.e. pediatricians, pediatric nurse practitioners, and registered dieticians) are hesitant to put a child on a diet because the child is still growing into his/her body; however, it is appropriate to limit the amount of high fat foods and soft drink consumption while encouraging low-fat dairy products, breakfast each day, and an increase in fruit and vegetable intake (Barlow 2002, Ruxton 2004). Creating a healthy eating environment can help teach kids to make healthier choices; such as assisting with meal preparations, eating slowly to enjoy the family’s time together, and avoiding the use of food as a reward (Childhood Obesity). Along with diet, physical activity is vital to the health of a child. Many children are content to sit in front of a television and play video games for hours at a time. Encouraging physical activity as a family or enrolling the child in a structured activity that he/she enjoys are ways to decrease the amount of TV time, and assigning active chores to every family member is both productive and heart-healthy. Limiting the amount of sedentary time a child is allowed, whether it is computer time, video games, or television time is always a good idea as the child can learn creativity and problem solving outside of the technological world.

Finally, if preventative knowledge and lifestyle changes are not enough, medical-surgical interventions can be implemented. Bariatric surgery for pediatric patients, normally adolescents, has been found to be effective in resolving obesity as well as any obesity-related co-morbidities. This surgery is a last-chance option for these children and should be addressed as so by the informing nurse, as there are many criteria that must be met before a pediatric bariatric surgery will be implemented. For instance, the patient must have a BMI of >/= 40 or be more than 100 lbs. overweight, must have high risk comorbidities, must have a life-threatening cardiopulmonary problem and must have potentially other problems that interfere with lifestyle (Henry 2005). The American Academy of Pediatrics and the American Pediatric Surgical Association have both approved of this method, though they do require additional criteria to be met and they reach the conclusion that bariatric surgery is the answer much more slowly than other organizations. One final point the nurse should make very clear to families discussing this option is that Medicare has recently passed a bill stating that adult obesity is a disease and therefore will be covered by insurance as a disease. However, childhood obesity is not yet labeled as a disease; therefore, families will likely bear the entire cost of this surgical procedure (Henry 2005).

Obesity does not merely inhibit a child from living a normal life, but prevents the child from having a healthy and favorable future. With the rate of childhood obesity increasing like it is, all children will likely become affected in one way or another. The educated nurse must intervene to promote healthy lifestyle behaviors for obese children, as well as educate on prevention, changes in lifestyle and offer treatment options for obesity.


A. Intervention 1: The educated nurse can influence the caregiver’s strategies in promoting healthy lifestyle behaviors for obese children through lifestyle changes.
I. Disadvantage 1: Knowledge Deficit
A parent’s lack of knowledge is a difficult barrier to cross when trying to implement lifestyle changes for an obese child. The skewed thoughts of the parents are often what enable the child to continue with unhealthy lifestyles. In a study done by Myers and Vargas, about 80% of parents understood that obesity led to heart disease and had negative long-term effects; however, only 5% of the parents thought that an increase in physical activity could decrease their child’s weight and only 3.5% understood that decreasing their child’s consumption of soda and Kool-Aid could help their child’s weight loss. Others thought their child was slightly overweight when the child was well beyond the recommended weight for his/her age, but were not concerned with any long-term health risks (Myers, Vargas 2000).
II. Disadvantage 2: Low Socioeconomic Status
Lifestyle changes are also difficult to implement in a family of low socioeconomic class. When there is no money for healthy food choices, which are by far the more expensive foods, families will tend to choose quick, cheap food choices that are higher in fat and calories. Lack of financial means is also related to decreased physical activity. The cause is not certain, but one can assume that many organized activities require some sort of fee and those of low socioeconomic class may not have the funding to participate in those organized physical activities. A study found that there was a direct correlation between low socioeconomic status and sedentary lifestyles with poor dietary choices, though the authors noted that additional longitudinal studies should be done to confirm these findings (Lioret et al 2008).

B. Intervention 2: The educated nurse can influence the caregiver’s strategies in promoting healthy lifestyle behaviors for obese children through offering treatment options for obesity.
I. Disadvantage 1: Lack of Insurance Coverage
Medicare has recently declared adult obesity to be a disease, and therefore covers any interventions needed to change the adult’s obesity status. However, childhood obesity is not considered a “disease” and therefore is not covered by most insurances, since many insurances follow Medicare’s lead on deciding coverage. Though bariatric surgery is considered elective for most children and is a last resort in most situations, some children’s lives depend on losing weight rapidly. Diabetes, heart disease, and organ failure due to increased adipose tissue are among the very serious issues that obese children face, and these factors can be life-threatening and often need to be dealt with immediately. Surgery options should be implemented only if activity levels and lifestyle changes do not affect the child’s obesity status, unfortunately this is not a realistic factor if the insurances do not cover the child’s surgery (Henry 2005).
II. Disadvantage 2: Non-Compliance
Though banding is the most common childhood bariatric surgery, many different methods are used to help a person lose weight. Other methods are: removal of part of the stomach and rerouting the intestines, stapling the stomach, and gastric bypass, all which effectively help a person lose weight but are all a bit riskier than the band. Regardless of which method is used, it can only be successful if the obese person also changes their eating habits and exercise habits. The likelihood of a child changing these habits after surgery is very small, often because the parents are enabling the child to continue with their poor lifestyle choices or the child is not interested in physical activity and continues with their sedentary activities. Unless the child is very mature and responsible enough to make life-changing decisions, compliance is likely to be an issue and needs to be addressed with a psychologist as well as with a dietician, life-counselor and/or exercise physiologist prior to and following the child’s bariatric surgery (Marchione 2006).


REFERENCES:
Barlow, S.E., Trowbridge, F.L., Klish, W.J., & Dietz, W.H. (2002). Treatment of child and adolescent obesity: Reports from pediatricians, pediatric nurse practitioners, and registered dieticians. Pediatrics, (110)1, 229-235. Retrieved January 4, 2007 from Expanded Academic ASAP database.

Childhood Obesity (n.d.). Retrieved February 2, 2007, from
http://www.obesity.org/subs/childhood/prevention.shtml.

Henry, Linda L. (2005). Childhood obesity: What can be done to help today’s youth? Pediatric Nursing, (31)1, 13-16. Retrieved January 4, 2007 from Expanded Academic ASAP database.

Lioret, S., Touvier, M., Lafay, L., Volatier, J.L. & Maire, B. (2008). Dietary and physical activity patterns in French children are related to overweight and socioeconomic status. The Journal of Nutrition (138)1, 101-107. Retrieved February 3, 2008 from Expanded Academic ASAP database.

Marchione, Marilynn. (2006). Weight-loss surgery growing: Doctors, patients debate which kind of procedure is best. Columbian. Retrieved February 3, 2008 from Expanded Academic ASAP database.

Mayer-Davis, E.J., Rifas-Shiman, S.L., Zhou, L., Hu, F.B., Colditz, G.A., & Gillman, M.W. (2006). Breast-feeding and risk for childhood obesity: Does maternal diabetes or obesity status matter? Diabetes Care, (29)10, 2231-2238. Retrieved January 4, 2007 from Expanded Academic ASAP database.

Myers, S. & Vargas, Z.. (2000). Parental perceptions of the preschool obese child. Pediatric Nursing, (26)1, 23-30. Retrieved February 3, 2008 from Expanded Academic ASAP database.

Ruxton, Carrie. (2004). Obesity in children. Nursing Standard, (18)20, 47-55. Retrieved January 4, 2007 from Expanded Academic ASAP database.
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