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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