Forensic Nursing Chronicles

Palliative care is defined as all of the services given a person that eases the transition from life to death. Palliative care includes but is not limited to, pain management and management of physical symptoms, but it is much more than physical. Palliative care also includes caring and sympathy for emotional suffering, loss and bereavement.

The World Health Organization (WHO) defines palliative care as the “active total care of patients whose disease is not responsive to curative treatment.” Palliative regards dying as a normal process. It does not hasten or postpone death. It provides relief from pain and other symptoms of distress. Palliative care integrates the psychological and spiritual aspects of patient care. It offers help to patients to live as actively as possible until death. Palliative care also serves as a support system for the family, to help them cope with their own bereavement during the patient’s illness.

It has been said that too many people live and die in pain. 40% of the elderly cancer patients in nursing homes are in pain. 50% of those in hospitals who are seriously ill have a significant amount of pain during the last days of their lives. Only 20% of Americans die in hospice, which is a program designed for all elements of palliative care. Minorities and women are less likely to receive optimal pain management than others. The elderly are also disproportionately under treated for pain.

Today diseases like cancer, AIDS, end-stage renal disease, end-stage COPD and many others that are described as incurable can benefit largely from palliative care. Very few people are equipped to talk about death and dying and the hopes and fears associated with death. Many of our seriously ill patients suffer spiritually and psychologically and end up dealing with their grief, fears and loss of control alone. To live with chronic pain for years can bring about hopelessness, loneliness and a sense of futility. Palliative care can help solve a lot of these problems if used as intended.

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forensic nurse
palliative care

Toxoplasmosis

I adore my cats and like many others I spoil them and get a lot of positive feelings from my relationship with them, however there are many other things that I can get from them as well.

Zoonosis is the term given when disease is communicable from animals to humans under natural conditions. One of the most common zoonoses that we can contract from cats or specifically cat feces is Toxoplasmosis. Toxoplasmosis is an infection caused by a microscopic parasite called Toxoplasma gondii. It is estimated that 60 million people in the United States carry this parasite, which can cause severe illness, particularly in infants infected in utero birth or in persons with a weakened immune system.

When I was pregnant, our veterinarian suggested that my husband clean the cats’ litter box and recommended that the box be changed daily. Today we know that these simple directions are certainly important, but that toxoplasmosis can be problematic in more that just pregnant women and it is not limited to the litter box. In fact, toxoplasmosis gondii can be acquired from many sources such as soil, unwashed fruits and vegetables, raw meat and untreated water. Cat owners or cat handlers are not at significantly higher risk of being infected than the rest of the population.

The cycle of toxoplasmosis is well understood. Cats are the only primary host, and they are the only mammals in which the parasite is passed through the feces. Cats become infected by eating rodents, birds, other small animals, or from anything that becomes contaminated with infected cat feces. Kittens can also acquire it in utero or from their mothers’ milk. This infection persists only for a few weeks before the cat itself becomes immune to the disease. Toxoplasmosis lives in the intestines and the immature form of the parasite is shed through the feces for about 2 weeks after the cat has been infected. The parasite becomes infective 1 to 2 days after it is passed in the feces. The parasite can live in the environment for many months and contaminate soil, water, fruits and vegetables, sandboxes, grass where sheep or goats graze, litter boxes and any place where an infected cat may have defecated. Cockroaches and flies may also serve as transport hosts for T. gondii, carrying cat’s fecal material on their bodies. When one understands the cycle of T. gondii, it is easy to see why its’ transmission is so common.

Health care professionals will need to be vigilant in their education of prenatal women as these are an important target group. A woman, who becomes infected with the parasite for the first time during or just before pregnancy, can pass the infection to her unborn child even if the mother does not have any symptoms. Infants who are infected in utero ( congenital toxoplasmosis ) may range from having no symptoms at birth, but within a few months may develop fever, swollen glands, jaundice, rash, bruising, anemia or enlarged liver or spleen. These may lead to more serious conditions such as blindness or mental retardation, deafness, lung disease, seizures, feeding difficulties, and limp muscle tone. Infection during pregnancy can also cause miscarriage. Education should focus on “The best way to protect your unborn child is by protecting yourself”.

The second group of individuals that are at significant risk are individuals with weakened immune systems, such as those undergoing chemotherapy, organ transplant recipients or those infected with human immunodeficiency virus (HIV), the virus that causes AIDS. During the 1990’s there was a decline in the number of toxoplasmosis cases to about 350 reported annually in the United States, however with an increase in the number of HIV infected individuals, the number of cases is now steadily increasing. These individuals, especially children, may develop toxoplasmic encephalitis exhibiting severe symptoms including headache, confusion, difficulty with speech, vision, movement, possible psychosis and fever as well as seizures, poor coordination, nausea and vomiting. Infection in these individuals can be fatal.

Information about these two groups is well documented and typically a physician closely follows them and monitoring of health status is therefore ongoing.

In terms of public health significance toxoplasmosis education should not be limited to pregnant women or immune suppressed individuals because individuals with healthy immune systems are also at risk. It is estimated that about one half of the world’s human population has been exposed to toxoplasma at some time in their lives. Many of these people received their infection from consuming undercooked meat or from products that were contaminated with cat feces (sheep or goats grazing on contaminated grasses). It is sometimes passed through infected dairy products. These individuals may become infected and not be aware of it because they may not have any or only mild symptoms. However they may present with flu-like symptoms, listlessness, fever, swollen glands and muscles aches / pain, lasting up to several weeks, however some individuals have no symptoms. Once a person has become infected with toxoplasmosis, the infection remains in the body for life, usually in a latent form that won’t cause the person any side effects or harm, but the infection can be reactivated if the immune system becomes compromised. I think this fact alone is relevant as health care professionals begin dealing with an increased aging population.

Flu-like symptoms such as swollen glands, fever, and muscle aches are often the presenting complaints of many individuals in clinics. The fact that these symptoms may be recurring or that the individual does not respond / improve with an initial treatment regime makes this group particularly interesting and also requiring more investigation. It is paramount that individuals with persistent undiagnosed symptoms for periods of several months receive further assessments so the health care professionals has a clear understanding of their clients’ lifestyle, occupation and culture. If we look at the Safety Tips that are part of the education program, we may be able to use these as part of our assessment tool to develop a clearer understanding of the clients’ personal habits. Should the results of the assessment warrant further investigation in this realm, a blood titer may be necessary to establish a diagnosis, since diagnosis cannot be based on clinical signs alone. A definite diagnosis is based on clinical signs in the presence of a high or rising antibody titer level, which can be done through a blood test.

Safety Tips:
1. Cook meat completely until no pink is seen and juices are clear.
2. Freezing meat for several days prior to cooking will greatly reduce the chances of infection.
3. Wash all cutting boards and utensils thoroughly with hot soapy water after each use.
4. Wash hands with soap and water after any exposure to soil, sand, raw meat or unwashed fruits or vegetables.
5. Wash and / or peel all fruits and vegetables before eating them.
6. Wear gloves when gardening or handling sand from a sandbox. Wash hands well afterwards.
7. Avoid drinking untreated water, particularly when traveling in less developed countries.

Assessments:

1. Do you have cats or have you been in a home or yard where cats roam?
2. Have you eaten any raw or rare meat?
3. Have you eaten or drank unpasteurized
milk-products?
4. Are lamb, sheep or goats part of your diet?
5. Have you handled raw meat? Did you thoroughly wash all utensils afterwards?
6. Do you do work with soil or sand? Do you wear gloves? Do wash with soap and water after exposure to the above?
7. Do you wash all fruits and vegetables prior to eating?
8. Have you traveled out of the country recently?
9. Have to drunken water that may not have been treated?
10.
Do you thoroughly wash with hot water and soap on a regular basis during the day and after completing various tasks?

A few simple questions, but directly related to the possible exposure of individuals may prove usefully in guiding the health care professional toward a diagnosis and improved health care of the client.

I think the topic of this article is important for all healthcare workers who care for patients, as well as family and friends of the patients. The recent technology and advancements in medicine are exciting and bring about a sense of hope in conquering some very debilitating diseases. Although this new era in medication is exciting, it is also scary to think of the most serious side-effects associated with these new medications. Often times I think patients feel so helpless that they rely on the expertise and opinions of healthcare professionals to make the best judgment regarding new medications. Patients hope and trust that these new medications are safe and effective. It is difficult for someone outside the drug industry to understand how much effort is put into testing a new drug. Despite all the testing, the final phase of patient administration can bring about unintended side-effects. Because of these issues, healthcare workers must do their best to watch for side-effects and report anything out of the ordinary when a patient is taking a newly marketed medication. I agree with the author of this article that it is of great importance for the health practitioner to monitor for side-effects and report all incidents. I believe it is also the role of the nurse to help the physician look for side-effects and monitor closely for any changes. Often times the physician is very busy and can only see the patient during brief rounds throughout the day. The nurse often comes in contact with the patient more frequently, and therefore should also aid in the monitoring process. Just as the author of this article mentioned, practitioners should be sure to ask patients about any and all heart conditions including palpations, shortness of breath, etc. There is also a good opportunity for the admissions nurse to key in on any of the above heart issues as well. The admissions nurse asks key questions of the patient and their family, being sure to cover all pertinent areas. This would be another chance for the patient to verbalize any concerns, changes, or history pertaining to their heart condition. Although this article focused on the newly marketed meds for ADHD, these precautions are crucial for all newly marketed meds as well.

I have been a nurse for 25 years and during that time the amount of medication that has become available is beyond the expectations that a nurse could be familiar enough wiht all of the potential side effects and synergistic complications. Therefore, it has become critical that the Pharmacists be involved directly in the day to day education of both the patients and the nursing staff. The Pharmacists in our facility are on the floor everyday communicating with Physicians and Staff. This has served to be a key factor in providing safe and effective medication for the patients. We have meetings once a week and go over the plan of care for all patients and the Pharmacists are present at this meeting and more than once have been able to pick up on symptoms that are being discussed and identify them as possible medication related issues.
This model has worked benficially for our hospital and I believe has saved lives.

Child sexual abuse I agree is definitely under reported. I feel if there was mandated universal screening of all children entering the health system there would be a higher level of detection and therefore reporting. As an emergency nurse I find it difficult to always assess for child sexual abuse (CSA). If the child is not presenting with any obvious signs of CSA there is a limit opportunity to question the child without parental presence. Most children who are being abused will not speak in front of the adult they are presenting with due to fear. Due to this it makes it very difficult. At the emergency department in which I work we do ask a universal screening question to all patients during the triage process regarding their feelings of safety and security in the environment in which they live. It has helped us to identify abuse victims who may have slipped through the cracks before.

I agree strongly with the author of this article that pesticides are poison. After all, pesticides are used to kill bugs on crops, bugs around the home, business, school, etc. It seems to me that despite the fact that these bugs and insects are much smaller than the average human, we should still proceed with caution when it comes to exposing ourselves and our pets or wildlife to the chemicals. Educating the general public on topics such as this seems to be the first step in getting the word out about possible health risks and side-effects.
I believe a key population effected by exposure to pesticides is pregnant mothers and their unborn babies. This should be an area of concern for nurses because educating patients on the risks of exposure is key in preventing possible birth defects. Patients need reliable information regarding pesticides so that they can make an educated decision regarding the health and wellness of their family. For example, many states in the United States have either the Black Widow Spider or the Brown Recluse Spider. Both of these spiders have a bite that can cause serious side-effects and even death in small children or the immunocompromised. Many families with small children may wish to exterminate the insects around their homes to keep their families from being bitten. However, many people do not understand the potential hazards in using pesticides in and around the home. Proper patient education from nurses or health care providers could help families to make educated decisions regarding the health and well-being of their families.