Archive for April, 2008

Medical Neglect

April 30, 2008

The reading I would like to comment on is Compliance and Noncompliance. This is an issue for many different reasons in any healthcare setting. In the setting that I work (the pediatric outpatient clinic serving mainly low socioeconomic families) noncompliance usually goes hand and hand with medical neglect. A large percentage of our population is of African American decent. I do know that there are some culture beliefs on medical care. The idea of preventive care, for example with well child visits is not seen as a necessity. Taking the time to educate on why preventive care is necessary and can help avoid medical problems is the only way to decrease the noncompliance rate. However a large part of my job is to also monitor appropriate follow up for medical concerns. The compliance rate goes down when people feel that their child is better from their illness. Asthma is chronic diseases where I see parents bring their child to the ER in an asthma exacerbation only to not show for their pulmonary follow up because the child was not wheezing anymore. It is our responsibility to take these opportunities and teach why it is so important to follow up with pulmonary care. The education to the parent that you may not hear anymore wheezing does not mean that the child is not still having problems. Proactive patient education can help with compliance and noncompliance rates.

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Postpartum Depression, comment

April 29, 2008

I agree that a postpartum psychiatric evaluation is an important part of the postpartum patient assessment. Nurses should be looking for signs in the patient of potential problems of postpartum depression as opposed to postpartum blues. As a nurse that works on L & D and postpartum, I watch for things such as: 1) inability of mother to bond with infant or not wanting to hold infant after delivery, 2) Name calling of infant, 3) Just not showing interest in feeding or holding infant. I have witnessed all of these events in my department. Mothers who have a history of postpartum depression with prior deliveries should definitely be referred for a psychiatric evaluation and perhaps follow up visits after discharge, if necessary. Although postpartum depression is a real problem for some women, it is not excuse for child abuse or murder. It can be treated. As health care providers, we need to step in and refer these women by doing a thorough assessment and involve psychiatrics and/or social services in their care.

Original Post:
February 7, 2007
In response to the article “Postpartum Depression” from 9-16-06, I feel that after delivering the baby, a new mother must have a psych assessment done before going home with her baby and maybe they should have a home health nurse or some sort of social worker check in with the new mother at 1-2 weeks postpartum. I feel that these mothers such as Andrea Yates, sometimes claim postpartum depression as a cover up for something they definitely know they did wrong. I do agree that some mothers may have some depression after giving birth because of the hormone levels changing, but I do not believe they don’t know what they are doing at the time, such as murdering their children or drowning them. They sure know enough to be able to tell the police “I was crazy at the time and depressed.” So then they go for the “not guilty by reason of insanity” plea. I believe most of it is to get attention. Most of them also have no remorse.

Original Post:
September 16, 2006
What is postpartum depression? According to American Association for Marriage and Family Therapy (2002), “Postpartum depression is a biological illness caused by changes in brain chemistry that can occur following childbirth. During pregnancy, hormonal levels increase considerably, particularly progesterone and estrogen, and fall rapidly within hours to days after childbirth. Also, the amount of endorphins, the feel-good hormones that are produced by the placenta during pregnancy, drop significantly after delivery. Even the thyroid gland can be affected by the enormous hormonal changes that are associated with pregnancy and childbirth, leaving women more at risk for depression.” Additionally, AAMFT (2002) states, that “for 10 to 15% of those women, the period following childbirth becomes a nightmare as they experience sleeplessness, confusion, memory loss, and anxiety during the already stressful adjustment to motherhood.”
Source:
American Association for Family and Marriage

What comes to mind is the Andrea Yates case in which she murdered her children. A very notable forensic case that has been in the headline in the past but has recently come to light again as the Andrea Yates murder trial begins. In which she has claimed postpartum depression as the major reason she murdered her children. World Wide Web CNN- July 12, 2006, “Yates, 42, is being retried because her 2002 conviction was overturned by an appeals court that ruled erroneous testimony might have influenced the jury. She has again pleaded innocent by reason of insanity. Her attorneys say she suffered from severe postpartum psychosis and did not know that killing the children was wrong.” (www.cnn.com) this is a fascinating case, in the aspect that Yates had been in and out of psychiatric facilities for mental illness and depression prior to the murder of her children, so why did the psychiatrist not see this coming?

Today, with the many publicized murder trials of women who have murdered their children supposedly due to postpartum depression as the potential root cause, have encourage healthcare providers, nurses, and even new mom’s to look for the possible signs of this mental health condition. As a nurse, it is part of our nursing assessment skills in looking for potential signs that might indicate a new mom might need further assessment to rule out postpartum depression.

A great example was the other day a new mom of 4 months called the physicians office asking if there was a blood test to test if one might have postpartum depression. The woman claimed that she has noticed recently that she was having a few “sad days” and did not think she needed psychoanalysis but just wanted a blood test to check her hormone levels. When consulting with her physician, he stated that there is no specific blood test to find out if someone’s hormone levels are abnormal that would indicate postpartum depression and the only way to determine if the patient was truly having postpartum depression was an in-person evaluation, which a series of questions and lab work might be obtained. When the patient was advised of the physicians response to her questions, she agreed to a next day appointment but not before the nurse assessed if she was in any danger of hurting herself or anyone else.

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Medical Errors

April 24, 2008

I like one author have worked with many male nurses. I agree that all male nurses are not nurturing, but neither are all female nurses. In some instances I would prefer a male nurse to a female one. They usually are computer literate, able to problem solve computer issues, and willing to help when needed. (Their lifting strength is an asset to have). I see more women in nursing “just for the paycheck”. When either a male or female nurse doesn’t have a caring attitude toward their patients or job, that is where mistakes happen.
Perhaps as more individuals start looking into natural medicine and organic food and natural foods, people will be able to build up their immune system, and therefore be able to fight off some of the disease processes they are coming in the hospital for.

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Nursing Assessment Liability, comment

April 23, 2008

Although a good nursing assessment is an important part of patient care, I don’t believe that there is a definite preventative factor in whether or not a person can or will die from an assessment that something is missed. Assessments can be “hit or miss”. I believe that documentation is extremely important when doing an assessment. One moment, things could be completely normal, and the next, the patient’s life could be in jeopardy. For example, a fatal MI. One patient could have a perfectly normal heart rate and rhythm and then go into a v-tach or v-fib. On the other hand, if the patient is very ill, a careful and thorough assessment should be performed by the RN several times per shift to monitor deterioration in condition. I believe it comes down to documentation of assessment to really be accurate on a patient’s true condition at the time of the assessment.

Original Post:
November 3, 2006
More and more liability is being place on nursing assessments when cases are brought to court and unfortunately, more and more often the nurse is being blamed for the medical mishap.

It is incredible to think the surgical scrub nurses would be liable in the court of law when a physician removed the wrong limb. Today, it is the responsibility of all health care entities to take an active role in assessment of patients prior to any procedure. Did I say health care entities or did I mean to say nurses. As nurses, it is vital that we take our assessment skills seriously and use then at every opportunity in no matter where we work whether in a surgical suite or primary care office.

This brings up the topic of nurses knowing what to assess when caring for their patients. For example when a nurse is caring for the Emphysema patient and the physician orders O2 at 10L via nasal cannula. Using your nursing assessment skills, one might question the appropriateness of such a high flow via the nasal cannula. On the other hand, the patient who has CHF and is receiving 80 mg. of lasix every 6 hours IV for diuresis but potassium replacement has not been ordered nor are post lasix labs ordered and through your nursing assessment, the patient is complaining of feeling strange. Will your nursing assessment skills bring these issues to the attention of the physician and prevent a potential fall, which could end up causing the patient to fracture their hip thus causing a thrombosis, which could potentially cause death in any patient.

Another good example would be the potential for medication errors committed by either nurses or physicians. Many forensic medical cases are related to some sort of health care entity error. Having good assessment skills along with good nursing knowledge has prevented many deaths while caring for patients. But then again having good nursing assessment skills can reassure a nurse that she/he has done the very best in caring for the patient.

This reminds me of a situation that happened back in the mid-nineties when I floated to a dialysis in-patient unit. I was assigned to care for four patients. All of the patients on this unit were on cardiac monitors. One of my patients was a young woman in her early fifties. She had just been diagnosed with renal failure and had received her first dialysis treatment via IV cannula that day. This patient was also an employee at this very hospital. Early in the evening, the patient complained of anxiety and it was noted that she had valium ordered for anxiety, so after a thorough assessment of the situation the patient was given the valium. Later that evening around 10 pm, the patient complained that she was still feeling anxious and was not able to sleep. According to the physician order, the valium could be repeated if needed. After again a thorough nursing assessment and consultation with the charge nurse, the second valium was given to the patient. As the early morning was approaching and the lab technicians were doing their morning lab draws and the nurses were at the nursing station closing their patients charts, one of the cardiac monitors went off indicating abnormal heart rhythm- it was my patient. We called the code blue and ran to the patient’s room with the crash cart. The lab technician stated that the patient was talking normal with no complaints to her and all of a sudden, she stopped talking and fell back into the bed. Within a couple of minutes the room was swarming with it seem everyone trying to resuscitate this patient. After an hour of resuscitation attempts, the ER physician called the code. We were all in shock and no one could figure out what happened. Personally, I quickly reviewed all my assessments of this patient trying to look for anything I might have missed. It wasn’t until a month later I found out that via an autopsy that the patient had had a massive heard attack and there that no way anyone could have know this was going to happen on that very morning. Oh, yes the valium had no relevance in this patient’s death.

Again, good nursing assessment skills are vital in the care of our patients. Someday, this could mean that your precious nursing license may be on the line as well. Doing the best nursing assessment at all times is vital in the life of every patient we have been entrusted to care for and should be utilized at every opportunity in the attempt of providing the best care possible for the good of all.

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Assessment, Interview, and Documentation with Forensics, comment

April 22, 2008

As a nurse, I agree that physical as well as emotional assessment is vital in completing a thorough assessment. I believe just looking at the patient when entering the room is a big part of assessing them along with actually doing a physical assessment. Time should be taken to do a thorough assessment just by speaking to the patient because it gives you more information and insight. It can also lead to more answers with abnormal findings with a physical assessment, such as increased heart rate due to stress, for example. Subjective information should be documented as the patient describes the events. This protects the nurse legally. I have learned in my career that this is essential in performing thorough and accurate assessments.

Original Post:
September 26, 2007
Forensic nursing was traditionally associated with death and homicide. Today forensic nursing can be defined as the application of nursing as it overlaps with the legal system. Nurses have been taught how to perform a health assessment with history and physical examination. This includes subjective and objective findings. Good assessment skills by the nurse are important to detect both physical and emotional abuse. This is accomplished with the first interaction the nurse has with the patient.
Accurate documentation is imperative. Record direct quotes as often as possible. Avoid using medical terminology, correcting the patient’s grammar or paraphrasing the patient’s descriptions.
A unique concept of forensic assessment is alternate interviewing techniques. One such method is the “forensic genogram”. This is expanded from the traditional genogram, and includes information about the transmission of family patterns, including violence. Understanding family influences assists in understanding events that may have led to the abusive behavior.

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General Assessment and Forensic Nursing

April 17, 2008

Forensic nursing was recognized as a specialty by ANA in 1995. I believe nurses have long worked with forensic patients in other areas such as emergency room, operating room and general areas where admission assessments are done. Primary care nurses are in an ideal position to identify victims of abuse and violence and hopefully refer to agency for help to prevent future abuse or injury. At present I work in an area with surgery patients, it is part of our assessment to screen all patients for abuse, neglect and asking the patient if they are being threatened. If a patient is positive for above, we refer to an agency, involve the legal system and social services.
This is so important to include identification of trauma or abuse from living patients to hopefully save a life. Nurses share a responsibility in caring for the holistic approach of patients hopefully saving a life, whereas forensic nursing is a patient advocate for the deceased or the victim.

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Assessment for Child Abuse

April 16, 2008

Listening as well as observation is a skill that must be perfected to perform a good, thorough assessment. One patient I had felt her stress was due to her work environment however she also related that she was a newly diagnosed diabetic and probably the most important information in the interview was the revelation of a sisters death; a sister she thought of as her best friend. This event seemed to alter her ability to cope. When doing any assessment, paying attention to every word, emotional display, body movement and physical finding can lead to clues regarding the patients mental and physical health, but will also assist in the recognition of the smallest details in a forensics exam. When a child or young adolescent presents with vague physical symptoms or new behavioral problems, do we do an oral exam to see if the child as been abused or assaulted; being forced to perform oral sex. While working with the Inuit in AK, oral exams became part of the routine health-screening exam as a clue to diet and nutrition. Many children had multiple caries secondary to the enormous sugar consumption. Was this neglect or cultural mores? We look for severe nail biting as signs of stress in children as well as adults despite patients’ denials, cigarette stains with those who smoke occasionally, poor skin turgor or dry mucous membranes with the patient who tells us they drink lots of fluids. Good assessment skills should help us identify multiple conditions and/or problems by reading between the lines with all our clinician tools.

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Nurse To Patient Ratios, comment

April 10, 2008

It is true that the nurse to patient ratio is not fare to nurses or patients. But how about the fact that nurses are called off when the census goes down and there is not enough patient per nurse? The same nurse has to take off when census is down and use her/his PDO, which was earned over a period with hard work.

My question is why not let the same nurse work with less pt that day or that night and give the nurse a chance to catch her breath for those busy time that she even did not have time to take a lunch break or go to the bathroom in 8 or 12 hrs shifts? Why don’t make them educate the nursing assistants that they are there to help and make them CNA (certified nursing assistance)? Why the same nurse who had 8 to 10 patient can not work on the days the census is down? Why should the ratio be 2:1 in ICU which was the case in two local hospitals I have worked, but in step-down the ratio is 1 nurse to 5 pts. In step down unit if the censes goes down and ratio become 2 to 3 patient a nurse will be cancel and are called extra nurses. In my humble opinion as an experienced nurse, it is not important how much less patients you have it is the acuity that is important. Nurses are dealing with the person’s life. Patients and nurses are humans they not object. Hospitals and care organizations are 24/7 they are not a department store that open and closes in certain hours, they can not tell the patient sorry we are going to close in ½ hr you should not have chest pain now, you have to wait, nursing is a matter of life and death and they should be treated as partners in this endeavor.

This practice causes nurses to move around for more equitable pay, and leaving their own place where the patients need them, which has given rise to nursing shortage, but with more traveling and agency nursing for temporary assignments. Another drawback to this is that local nurses who take care of patients with the same standard are unhappy because they are working under the same condition with the same patient ratio and getting paid less. There seems to be no justification to make nurses satisfied as far as these issues are not solved. May be some of the hospitals should reduce the
manager to nurse ratio and not waist nursing staff to management so much. Let nurses do nursing job and take care of patients not spend long hours in meetings and unnecessary paper work. Of course patients deserve best and safe care no matter where they are with justified and fair patient to nurse
ratio.

Original Post:
September 19, 2007
There are 2 distinct sides to one of the most controversial dilemmas facing nurses today. First, the patients deserve to have better care from their nurses who don’t already have 9 other patients to take care of. If a nurse is responsible for 8-10 patients on a typical med-surg floor how can they be expected to provide the best possible care, or even just the standard of care? The more you spread a nurse out the less attention one single patient is going to receive. This puts them at greater risk for nosocomial infections, medication errors, incorrect or omitted assessments, the list could goes on. Even if a super nurse is able to accomplish this inhuman standard in their occupation what harm will be done to the nurse? A nurse, the backbone of the medical industry, does not deserve to be worked like a dog, to put these kinds of physical and mental demands that ultimately will harm their ability to take care of themselves and their patients. A standard in setting how many patients a nurse can be assigned to is a top priority for are already overworked nurse workforce.
Of course, you have valid arguments provided by hospital administrators and government agencies, but they are not strong enough arguments to persuade this nurse to think any different. The costs are too high, there aren’t enough nurses to staff this way. This is the mentality the non-nurses elect to have. If there are not enough nurses to staff a set ratio then it just supports the fact that nurses should be respected and not overworked to the point where they have to quit nursing. When aspiring nurses see how very little the hospital administrators actually care for their then the smart ones will choose another field and only add to the nursing shortage. The costs are high now because of law suits and problems that arise from not having a healthy ratio standard in place. By reducing errors caused now by not staffing patients well should reduce the unexpected costs that hospitals have to eat on a regular basis.
Really when it comes right down to it the golden rule should be considered by all. Would you want to be just another vulnerable patient that is one of 10 total care patients that the same nurse has to juggle?

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Male Nurses

April 9, 2008

Having worked in the nursing profession for 16 years, I have had the opportunity to work with male nurses. I confess that my initial reaction to this concept was anything but welcoming. Human nature tends to dictate that men are non-emotional beings. They are the hunters and the defenders of their domain. The strong silent species; using the right side of there brain; reacting to the here and now. How could such a being be a nurse? I look back on this now and acknowledge that this is a chauvinistic view point. I’ve come to realize that these are the same characteristics that have helped me to be the nurse that I am today. I’ve acted in a non-emotional way to crisis. I’ve hunted down doctors to meet my patients’ needs. I’ve defended my patients’ rites to receive or refuse treatment. I’ve stood strong in the wake of multitasking. I’ve been silent when listening to my patients concerns. I’ve even reacted professionally to a doctors comment of “here we go again” and “what the heck do you want now?” So, there in-lies the synergistic relationship between male characteristics and the nursing profession. They fit in just right!

Original Post:
August 28, 2007
It is estimated that by the year 2010, we will need one million new nurses. Where will these come from? One answer may lie with changing the traditional role of nursing. Nursing has always been primarily female. With more opportunities open to females now, no as many women choose nursing. This is adding to the nursing shortage and the nursing faculty shortage. As long as there is a shortage, more nurses will burn out and make more medication errors. With the field becoming more appealing to men, maybe they are our answer. The pay is certainly good as well as the opportunities and diversity. The only way to decrease med errors is for the nurses not to be overworked. The only way to accomplish this is to find more nurses. Male nurses may be the answer.

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The Importance of Teaching Children the Signs of Sexual Abuse

April 8, 2008

I believe it is everyone’s responsibility to teach or inform children of sexual abuse or encourage the child to report any signs that someone is attempting to potentially setting up the child. Typically most sexual abuse is done by someone that the family knows and is working on gaining the trust of the child. It is the parents or caregivers responsibility to inform the child and question the child, had anyone ever tried to touch your privates? Tried to get you to sit in their laps? Showed you their private parts?
It is so important that the child understand that he has done nothing wrong and he will not get hurt if he tells you. A child always wants to please his parents and will be hesitate to tell if he believes it is his fault. Sexual abuse of children is heard in the news daily; we have to do something to stop this. Teachers, daycare workers, church, family must start explaining to children it is okay to tell someone if any sexual abuse happens to them. Sometimes it is too late before the pediatrician can identify the signs of abuse objectively if the child does not go to doctor or there could already be an emotional impact if the child is older.
As a nurse, we must take time to gain the cooperation and understanding of the child, and relate to the age and development of the child. I believe that is the key to having a child open up if abuse is present.

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