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.
Monday, March 3, 2008
The Cultural Diversity of Patients and the Importance of Providing Culturally Competent Care
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
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.
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
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.
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
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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