Archive for April, 2006

A Forensic Nursing Student’s Recommendations on what information to share when having a surgery.

April 30, 2006

As I instruct students in Online Forensic Nursing Certification, I felt that the following article contributed by one of them could be useful in terms of helping people understand what information is important for the staff to have when having surgery performed.

I work in a small community hospital. I am an operating room nurse. The topic of “Clients Having Surgery” is especially important to me. When clients see their doctors and get scheduled for a surgical procedure there are processes that they go through: preoperative, intraoperative, and post operative. Although these processes are streamlined for each patient it is important to get as much information either from the client or their significant other as is possible.

As a intraoperative nurse it is very important that the preoperative nurse get all of the pertinent information on the client. The information that is important to me as an operating room nurse and to anyone else involved in the procedure are; allergies, medications, previous surgeries, any complications with previous surgeries or anesthesia, past medical history, psychological history, and social history.

1) Allergies:

This is important to know because as a nurse in the operating room it is my responsibility to see that no harm comes to the client while in surgery. If I know that the client has a severe reaction to shell fish I am going to make sure that the operative prep, which is usually a betadine solution, is not done with betadine. If the client has allergic reaction to any antibiotics I am going to make sure that the anesthesia provider or the scrub nurse does not administer the antibiotics to the client. The allergy of the most importance is latex. This is a product that is still used in the operating room setting.

2) Medications:

It is important to know what the client takes for medications. I need to know this so that the client is not given other medications during the surgical procedure that might interfere or interact with the client intraoperative or post operatively.

3) Previous surgeries:

The previous surgeries are important because it will make a difference in how the patient is positioned for the surgery. An example of this is if there is a client that has had unilateral or bilateral hips or knee replacements; the positioning for this client is going to be much different than for the client who has not had total joint replacements. This surgery requires the client to be in the knee/chest position. This position requires the client to have their knees or hips at a greater than 90° angle. The client with a total knee replacement loses flexion in the knees and is not capable of bending their knees to that degree. The consequence of this could cause damage to the knee. I would also need to know about other hardware in the client because it will make a difference where the electrocautary pad will be placed for the cautary device. When the electrocautary is used the electrical current from the device will go to the path of least resistants, and if the current goes to a metal implant it will burn the patient from the inside out. Past medical history is very important.

4) Any complications with previous surgeries or anesthesia:

If a client has had any problems with previous surgeries such as they are a tough intubation or the have nausea and vomiting from anesthesia. As an operating room nurse It is also my responsibility to assist the anesthesia provider when the client is be intubated and extubated. If the client has experience nausea and vomiting after surgery I want to make sure that the client has been given antiametic medications before waking up. I do not want to have this client aspirating on vomit.

5) Past medical history:

Past medical history is important because I want to know if the client has any diseases that can infect the operating room staff. If a client has any contagious disease I would need to know that to inform the operating room staff to take all necessary precautions to protect themselves.

6)Psychological and Social history:

Of these two the psychological history is the most important. I need to know what state of mind the client may be in when they come to the operating room. I need to know if the client is for example mentally retarded. If I have a mentally retarded client I am certainly going to respond to this client differently than I would to a client who might have dementia. How clients are dealt with intraoperativly can have a profound affect on them post operatively. My philosophy when dealing with clients in the operating room is I treat them the way I would want to be treated or how I would want my family to be treated in that situation.

The most important aspect of operating room nursing is to “do no harm”.

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Detection of Elder Abuse

April 28, 2006

Every person deserves to be treated with respect and with caring.
Every person deserves to be safe from harm by those who live with them, care for them or come in day-to-day contact with them.(APA)

Elder abuse is the infliction of physical, emotional or psychological harm to an older adult. Elder abuse can also take the form of financial exploitation or neglect by the victim’s caregiver.

In America alone, it is estimated that 2.1 million elderly adults suffer from some form of neglect or abuse each year. Interesting, most incidents of abuse or neglect occurs in the home; to those living on their own, with spouses, children, siblings or other relatives; rather than to individuals living in institutions.

Among those that are more vulnerable to abuse or neglect are disabled, frail, mentally impaired or depressed persons.

Elder abuse is a complex problem and often difficult to detect. Increasing awareness through public education is a key initiative in protecting our older adults. Health care professionals, home care providers, family members and others who provide services should understand that the appearance of unexplained symptoms requires further investigation.

The American Psychological Association has complied a list of symptoms that may signal elder abuse.

Physical Abuse:

  1. Bruises or grip marks around the arms or neck.
  2. Rope marks or welts on the wrists / ankles.
  3. Repeated unexplained injuries.
  4. Dismissive attitude or statements about injuries.
  5. Refusal to go to the same emergency room for injuries.

Emotional/Psychological Abuse

  1. Uncommunicative and unresponsive.
  2. Unreasonably fearful or suspicious.
  3. Lack of interest in social contacts.
  4. Chronic physical or psychiatric health problems.
  5. Evasiveness.

Sexual Abuse

  1. Unexplained vaginal or anal bleeding.
  2. Torn or bloody underwear.
  3. Bruised breasts.
  4. Venereal diseases or vaginal infections.

Financial Abuse or Exploitation

  1. Life circumstances don’t match with the size of the estate.
  2. Large withdrawals from bank accounts, switching accounts, unusual ATM activity.
  3. Signatures on checks don’t match elder’s signature.

Neglect

  1. Sunken eyes or loss of weight.
  2. Extreme thirst.
  3. Bed sores

If you suspect elder abuse don’t be afraid to become involved, you could be saving a life. However it is important to ensure that you do not put the person in more danger confronting the suspect abuser. Every community has reporting agencies that are designated to investigate allegations or can provide help to individuals that may have the potential for abusing.

Source:
(Abuse and Neglect: In search of Solutions – American Psychological Association)

Prescription Drug Abuse: It is Really a Problem?

April 28, 2006

The development of a new pharmaceutical drug brings the hope and promise that lives will be made better, and that for some an end to their suffering is possible. The prevalence of prescription drug abuse is on a steady rise.

The most common medications abused are opioids, CNS depressants, and stimulants. It is estimated by the Substance Abuse and Mental Health Services Administration that as many 20 million have used some type of prescription medication for non-medical purposes at some time in their lives.

Medication abuse is defined as the use of a prescription or OTC medication in any way that deviates from the instructions given by the doctor, or printed on the label, or using another person’s prescribed medication.

Is the answer to stop the production and prescribing of these addictive substances?

These medications do have an important place in the treatment of many conditions, and they are recognized as potentially addictive which is why they are scheduled drugs that require a prescription and physician monitoring.

Many of those abusing prescription medications go from doctor to doctor to get their prescriptions filled. The responsibility of identifying someone with a potential problem needs to include nurses and pharmacists.

Thus it is crucial that nurses and pharmacists work closely with physicians and communicate any concerns or suspicions of abuse. All medical professionals need to know what the signs and symptoms are of someone who is abusing medications.

Perhaps more parameters need to be in place regarding who can prescribe these medications that we now know are being abused. Some sort of check and balance system that can red flag those who are doctor shopping.

Until then the best thing that physicians can do is educate themselves about abuse of these drugs, and prescribe them when all other avenues of treatment have been exhausted

The Role of Forensic Nurses in the Assessment of Psychotic Disorders

April 26, 2006

Psychotic disorders include things like loss of reality, hallucinations and delusions, and deteriorating ability to function socially. Because of the variety in characteristics and symptoms of psychotic disorders, the treatment of them is highly individualized and usually involves a combination of different therapies (both drug and non-drug).

The ultimate goal of treatment as outlined by Clayton and Stock in Basic Pharmacology for Nurses is to “restore behavioral, cognitive, and psychosocial processes and skills to as close to baseline levels as possible so that the patient is reintegrated into the community.” The treatment appears to be difficult and complex due the individuality of each persona’s psychosis as well as their reactions to treatment (drug and non-drug).

There are several classes of drugs that are used in the treatment of psychotic disorders: antipsychotic agents, benzodiazepines, beta-adrenergic blocking agents, anti-parkinsonian agents, and anticholinergic agents can all play a role in treating psychosis.

Most antipsychotic agents adjust the seratonin or dopamine uptake or release in the body. There is more to psychotic disorders than dopamine and seratonin levels, however, and there is not enough known about the specific way these drugs are relieving psychotic symptoms. This can account for some of the variety in therapeutic responses to the antipsychotic drugs.

Once specific drug selected for a patient, simply getting that patient to take the drug can sometimes be a huge trial. This is due to many of the patients being out of touch with reality and not believing that they need any sort of treatment. Many patients will pretend to swallow the medication, and spit them out later. This is an interesting detail to consider as a nurse administering these medications. It becomes imperative to ensure that the patient has indeed swallowed the pills, and not just ““cheeked them”” as Clayton and Stock point out.

Overall, there are a great many things to consider as a nurse involved in the assessment process of someone with psychosis. Observations and monitoring are critical in assessing for adverse drug effects. Patient history is important in determining the effectiveness of the treatment method and drug for therapy.

Canada’s Public Health Ignores Lyme Disease Crisis

April 26, 2006

Lyme disease is caused by a bacteria carried and spread by ticks. One tick bite allows the bacteria to enter the body, entrenching themselves within tissues and then migrate throughout the body. The Lyme bacteria has the ability to evade the body’s immune system and causes innumerable symptoms making it very difficult for many physicians to diagnose.

Due to the multi-system symptoms, Lyme disease is often misdiagnosed as lupus, multiple sclerosis, rheumatoid arthritis, fibromyalgia, irritable bowel syndrome, Crohn’s disease or chronic fatigue. Due to its’ affect on the nervous system, Lyme disease in children can result in learning disabilities, poor attention span, memory and word finding difficulty, often interfering with the child’s academic ability.

Lyme disease is the most prevalent bug-borne illness. It is estimated that there are now 3 million cases in the United States with the Centre for Disease control reporting approximately 20,000 new cases yearly – but this is thought to be underestimated 10 fold. Most of these cases have been identified in states bordering Canada, however Canada reports only a few hundred cases a year and does not recognize several of its’ provinces as even having the disease.

With the approach of spring in the northern hemisphere, people will be out more enjoying the warm weather and health care personnel should be increasing alert to the possibility of Lyme disease in our population. Health promotion and disease prevention being our first priority. It is important for people to understand that you need not be in the “woods” to be exposed to ticks.

Ticks are transported to lawns, gardens, low bushes, wild grasses, weeds, and especially along pathways by mice, birds or deer. Pets can also transport the ticks into our homes. Wear pants tucked into socks, light coloured clothing and long sleeves, preferably using DEET repellent. It is important to perform “tick checks” regularly over the entire body, especially warm moist areas.

Secondly, Lyme disease treatment is most effective with early diagnosis. It is therefore important for Canadian front line nurses to collect concise and accurate information from their clients. Since many of the early symptoms are flu-like, such as fever, headache, fatigue, nausea, muscle ache, jaw pain, red eyes, and stiff neck, it is easy to see how clinical diagnosis is difficult.

he Canadian Lyme Disease Foundation has prepared a checklist of 75 symptoms of Lyme disease and clients are asked to indicate which symptoms they are or have experienced. It is suggested that 20 YES responses represent a serious potential and Lyme disease should be included in the diagnostic workup. This would be an excellent tool to assist nurses with their data collection. The checklist can be found at: http://www.canlyme.com/patsymptoms.html

Thirdly, it is important to collect any tick specimens that are removed from clients and submit them for accurate identification along with the region in which it was obtained. According to the Canadian Lyme Disease Foundation, Canadian medicine, due to the lack of recognition of the clinical diagnosis, combined with lack of surveillance and research, places Canada low on the scale in dealing with this crisis.

Reporting is therefore a vital step to ensure that Lyme disease is not ignored by Public Health and this will hopefully reflect in better diagnostics, public education programs, and improved training for medical personnel in recognition and treatment.

Child Sexual Abuse: Why is it underreported in the Medical Community?

April 26, 2006

Child sexual abuse (CSA) is a problem that exists everywhere. CSA is defined as any sexual activity with a child when consent is not or cannot be given. Every state in the U.S. mandates that professionals report any suspicion of sexual abuse to a child protection agency. This mandate includes physicians and nurses.

Data collected in 2002 stated that out of all reported CSA cases made by professionals, medical personal represented the smallest number of reported cases. Some studies suggest that professionals do not always report suspected CSA. Perhaps inadequate training and knowledge on the subject matter is partly to blame.

The American Academy of Pediatrics strongly recommend that health care providers screen for CSA during routine visits, and that pediatricians make it a part of all well-baby visits.

Physicians and nurses play an important role in recognizing and reporting any suspicion of CSA. Physical signs of abuse are not always present, therefore it important that all healthcare providers develop a trusting relationship with their patients.

Simply asking the child if they have any questions or concerns may prompt them to disclose their situation. In the absence of physical evidence and without patient disclosure here are a few important things that all healthcare providers should do: Stay informed about the psychological and behavioral signs of abuse, increase your level awareness of how prevalent CSA really is, and remember that as a professional it is pertinent that you advocate for any child you suspect may be a victim of CSA.

Detecting, Reporting and Preventing Child Abuse

April 11, 2006

We hear news of child abuse in many forms: physical abuse, sexual abuse, neglect, street children, child fatalities, child prostitution, emotional abuse and child labor, etc. For the safety of all children, we have to improve the screening and prompt detection of abuse. Early childhood screening and treatment programs are especially needed.

Abuse should be suspected when the injury, clinical history or findings on diagnostic imaging studies suggest the possibility. Not only with SBS (Shaken Baby Syndrome), but with other forms of abuse as well it is sometimes difficult to diagnose from the first signs.

Abusive injuries often go unrecognized because there can be nonspecific signs or symptoms. That is why we need to train all nurses, teaches, and have parenting education as well. Some states are already requiring teacher training on child abuse.

I agree that all states require teachers to report abuse; this can aid in the early detection and help to limit child abuse. “All states require teachers to report suspicions of child abuse, but a growing number require teachers to be trained to detect child abuse and neglect as a prerequisite for receiving or renewing a teaching license.” “More states require teachers to be trained to detect child abuse”, (July,2004) Carol Chmelynski .

According “Tips and Facts”, Kempe, http://www.kempecenter.org/parents/tipsAndFacts.html
Signs of possible abuse:

  • The explanation the child gives for the injury is not believable or credible
  • Repetitive injuries without adequate explanation
  • The child changes the story of how the injury occurred
  • Significant and sudden mood change – perhaps more withdrawn, poor concentration or more aggression
  • Lack of interest in usual activities
  • Decrease in school performance

But the final determination of abuse/neglect will be made by a professional.

I learned that abusive behavior is often part of a family cycle, “many health and developmental problems in early childhood can lead to behavioral, educational, and psycho-emotional problems in later adolescence and adulthood, which could lead to the recurrence of abusive behavior.” A Primer in Preventing Child Abuse Study Number: 15 Cohn Donnelly, A. (1997), (An Approach to Preventing Child Abuse. Chicago, IL: Prevent Child Abuse America)

I feel that we have to foster early detection, treatment, and prevention programs to do our part to have no child abuse in the community. I believe that it is most important to have no incidents of child abuse.

Prevent Child Abuse America is committed to preventing child abuse before it occurs. Many agencies are committed to increasing public awareness of all forms of violence against children, developing activities to prevent such violence, and promoting the rights of children. Education plays a big role in abuse prevention.

It is important that community-based programs to prevent child abuse exist, that prevention and information training also exist, and that the community learns to recognize the signs of child abuse and know to whom they should report their findings.

Strange Sleep Behavior Blamed on Sleeping Pills

April 11, 2006

A number of recent news stories on the side effects of Ambien. I read an article in our metro newspaper, and listened to a women speak on a national news program, about a variety of strange behaviors that were experienced during sleep.

There were even a large percentage of people arrested in the state of Wisconsin for DUI, who it was later detected had no BAL but were instead under the influence of Ambien.

Another one of the frequently reported behaviors is “sleep-eating”. Sleep researchers at Mayo Clinic in Rochester, MN first reported such cases in 2002.

Recently a physician who specializes in sleep disorders at the Minnesota Regional Sleep Disorders Center in Minneapolis, MN said he and his colleagues have documented 32 cases of sleep-eating in patients taking Ambien.

Sanofi-Aventis, the maker of Ambien say it’s safe when taken as directed. The warning label does caution it might cause sleepwalking and hallucinations.

According to the National Institute of Health, about a third of all adults say they have insomnia at least sometimes. Last year, there were an estimated 26.5 million prescriptions for Ambien sold in the US, making it the leading sleep medication on the market.

Researchers say that Ambien somehow increases the amount of time in the stage of sleep that promotes sleepwalking in people who have no history of it. It seems to me that if assessing a patient with a sleep disorder such as insomnia, it would be wise to caution them about the findings in persons taking Ambien, and also to provide them with some guidance if it is decided to be the drug of choice.

Some of the suggestions I would make would be to:
1.)try non-drug remedies to solve their insomnia before trying a sleeping pill,
2.)take the lowest dose necessary to fall asleep if it is decided a sleeping pill is necessary,
3.) to try putting chimes or some other type of noise maker on their bedroom door (to wake them if up sleepwalking).

“Critical Incident” Stress in the Workplace

April 4, 2006

Many health care professionals at one time or another have experienced a “critical incident’ that has caused them strong emotional or physical reaction. The critical incidents vary from threats / assault, suicide, accidents, deaths or injury. These experiences may impair their ability to work safely and effectively in their care of patients for weeks or even months after the incident has occurred.

Nurses and other health care professionals are often expected to carry on after these incidents by simply relying on their own coping skills. However the use of formal debriefing in the workplace has been found to be a key component of recovery. Debriefing has produced many positive side effects for staff and their employers including:
• increase in team cohesiveness and mutual support.
• reduced sick time
• increased awareness of critical incidents and their impact
• decrease in staff turnover

Many hospitals and health care facilities have incorporated a formal model, the “Critical Incident Stress Management” (CISM) program that includes:
1. Defusing – a chance for to talk immediately after the incident, 45 to 60 minutes to restore order in a chaotic situation.
2. Formal Debriefing – longer, structured meeting including other professionals – chaplains, social or mental health workers.
3. Follow-up – possible long-term therapy to be arranged.

The best remedy for a nurse who has suffered this kind of reaction is often to get back to work as soon as possible; “to accelerate normal recovery in normal people with normal reactions to abnormal events.”

Should these programs not be adequate in reducing the after-effects, individuals and their co-workers should be aware of reaction symptoms that may occur. The following symptoms may be displayed:

Physical: nausea, rapid heart rate, dizziness, thirst, chills & headaches
Cognitive: poor concentration, disorientation, nightmares, memory
disturbances
Emotional: grief, guilt, fear, depression, anger, exaggerated responses
Behavioural: withdrawn, loss of appetite, sleep disturbances,
hyperalertness

Being aware of these symptoms when they occur and responding ethically and professionally will ensure that safe and effective patient care is maintained.

Signs of Prescription Drug Abuse by a Nurse

April 1, 2006

Substance abuse is the number one reason named by state boards of nursing for disciplinary action (Sullivan & Decker, 2001). I started thinking about this topic recently when my mother’s best friend (a registered nurse) relapsed into a Vicodin / morphine addiction after a terrible car accident.

I watched her eyes roll into the back of her head as she slurred out the word “ten” every time the nurse asked her how much pain she was in. Before she received treatment, she was apparently addicted to every pain relieving medication she could get her hands on.

She was told to receive help when her nursing supervisor discovered she was withholding her patients’ pain meds for herself, ultimately keeping her patients in a state of excruciating pain. The unfortunate truth was that she had been addicted to pain relieving medications since nursing school. When she was caught, she had already been a nurse for ten years.

I’ve heard several other stories about nurses becoming addicted to prescription pain medications in which they fall asleep on the job, steal from their patients, hurt themselves…etc. and it should be a growing concern within hospitals to take strict precautions in monitoring drug dispensing and nursing behaviors.

It wasn’t until 1984 that the American Nurses Association (ANA) publicly recognized the problem of narcotic addiction in nursing (Dabney, 1995). Though more widely recognized as a growing problem, it is still hard to identify.

It is noted that the rate for prescription type drug misuse is 6.9% (Trinkoff, Storr, & Wall, 1999), with the average rate of narcotic and alcohol abuse in nursing at 6 to 8% total.

Identifying a nurse who is participating in prescription narcotic abuse can be difficult because denial is the first reaction to an accusation. However, the nurse’s behavior will eventually make things clearer. Usually, there is not just one indicator but several. There may be an increase in absenteeism, tardiness, and use of sick time with vague excuses. The nurse may take long or frequent breaks. Job performance becomes inconsistent as function declines. Charting suffers with errors and omissions. Inadequate reporting and discrepancies with what is charted may be apparent. The nurse does just enough to get by with increased complaints from other nurses, doctors, or patients.

When challenged, the nurse may offer implausible excuses for behavior or become defensive. Behavior changes may include mood fluctuation, sleeping on the job, or isolation. The nurse may have a chaotic home life or feel picked on at work.

They may over react emotionally with snapping out or disproportionate crying. Signs of diversion can be subtle. The nurse may volunteer to administer medications for others or hold the narcotics keys/count. Their patients receive more PRN pain medications but report non-effective pain relief. There may be frequent reports of lost or wasted medications.

Medications should be checked for tampering such as torn packets, missing vial tops, puncture holes, and uneven fluid levels. This nurse may request to work in an area of high pain medication administration. If injecting at work, there may be blood spots on clothes. (Smith, L., Taylor, B., & Hughes, T. (1998).

Effective peer responses to impaired Nursing practice.
Nursing Clinics of North America, 33(1), 105-18.).” It is quite obvious that all of these behaviors put the patient at risk, and the nurse in question should be asked to receive some sort of treatment. Patients go to the hospital to receive relief from pain. I couldn’t even imagine how her patients must have felt when they asked for true pain relief and received a Tylenol instead.


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