Archive for February, 2009

Testing

February 18, 2009

Testing.

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Informed consent, comment

February 18, 2009
I read in the blog some discussion of informed consent. As a consumer
of medical services I rarely get much out of the informed consent
documents, and will admit that I rarely read them in much detail.
Granted, if we were talking about more than just a general doctor’s
visit I would take a little more notice.
I have also participated on several research studies and have written a
number of IRB applications, including drafts of the informed consent
documents that are given to participants. While I have tried to make
these the most accessible to the participant as I can, the university I
worked for required certain headings and certain, stock legal language.
The purpose of the documents from the IRB’s side didn’t seem to be
“make the participant aware” and the purpose from the principal
investigator’s perspective was “get it through IRB” (and typically
after the research activity had already begun).
I won’t even go into the issues around working with a non-English
speaking population, where while translation is required actually
putting time and resources into achieving a translation that actually
communicates meaning is definitely not the priority. Rather, the
priority is having a document where the written word is in the language
desired regardless of the meaning communicated.
As a massage therapist, I am working directly with clients to provide a
service. There are legal concerns to be addressed, definitely, with the
informed consent. There are also scope of practice issues to be
clarified. Finally, and most interesting to me, are the issues around
getting the client to understand what the purpose of the service is and
how s/he may contribute. I found the one poster’s comments about a
“teach-back” approach intriguing, and will look more into this. While
not brain surgery, a client has the right to understand what they are
about to participate in and having them tell me “in their own words”
what it is–the legal issues, the scope of practice issues, and their
contributions to the outcome–sounds like a great strategy.

Original Post:
February 6, 2009
Informed Consent: Is it really understood?
I find the articles regarding informed consent exceedingly interesting.
It was a subject that was recently brought to my attention regarding
Radiography Techs and consent for IV contrast. For years, RT’s were
able to witness consent, then all of a sudden they could not. Being the
only RN in a busy Imaging Department, this became a huge burden. I did
some research recently and found articles from ARRT that describes the
RT Scope of Practice. Their scope of practice specifically states that
they are to “verify” that consent was obtained. Now comes another
wrench. There is no definition of “verify” and in our department, it
had become a bone of contention among the Radiologists that the
ordering provider was responsible for “Informed Consent”, to include
risks, benefits, options, etc. Now comes the fun part: Some
practitioners don’t even order the proper tests. Try convincing a
steadfast NP that by ordering a CT Thorax WITH CONTRAST, they were
actually prescribing the contrast. She did not appear to get what I was
trying to explain to her. (She must have finally, because she began to
order tests without contrast, which is a questionable practice because
it may not always be the best exam for a patient and they have a delay
in care or another CT with contrast) I even went so far as to go to the
ANA website and download the RN Scope of Practice, which explains
consent is again “verified”, not witnessed like we do. Both the NYS DOH
and DOE do not specifically state whether an RN or an RT respectively
can or cannot witness consent forms. It has come down to many crucial
conversations between patient and staff and the knowledge of the
patient regarding testing. If this wasn’t my job, I would find it
rather humorous and ironic, all these issues that arise that are truly
not addressed in the RT or RN Scope of Practice.

Original Post:
February 2, 2009
Informed Consent: Is It Really Understood?, comment
I
work in a Liver Failure Clinic and have end stage liver failure
patients. I perform paracentesis procedures to remove fluid from some
of these patients peritoneum. The patients are in pain need fluid taken
of their peritoneum NOW so they can breathe.
The patient has to be able to make decisions to sign the consent.
We inform the patient they may need blood if a vessel was punctured. We tell them they may get an infection and even die.
We have the patient sign on a pad that transmits the signature to a computer. A witness and I sign it also.
 All of this is before the procedure is done.
Never
has a patient not wanted the procedure even when death, bleeding, pain
and infection were mentioned in the informed consent.

I agree
that it is important to have an informed consent. It takes time and
sometimes the patient’s signature is almost unrecognizable.
There is
pressure on the patient and staff to get this signature. I agree that
sometimes the patient does not really know what is going to happen
because they are in need of the procedure now. We explain the entire
procedure to them before the procedure but just how much is really
understood is questionable.

Original Post:
July 10, 2008
Informed Consent: Is It Really Understood?
It
is good to see the topic of informed consent included in the text book
Health Promotion Throughout the Lifespan. As a nurse, who practiced for
twenty plus years in the acute care field, this topic is of vital
interest to me. It was not often enough that I felt patients fully
understood what they were agreeing to. Now, with mounting concerns
about patient safety and lawsuits arising out of botched
communications, the area of informed consent is drawing national
attention. Informed consent is one aspect of patient autonomy. Informed
consent occurs when with “substantial understanding” and without
substantial control by others an individual authorizes a professional
to do something. As a witness to the typical “informed consent”
process, in the acute care setting, it is no wonder that breeches in
patient autonomy are realized and being awarded financial remuneration
following legal action. In my opinion, critical flaws in the current
system include; the patient condition at the time information is being
provided, lack of complete information including treatment
alternatives, lack of patient education prior to procedures including
the recovery phase, lack of time to process information, cumbersome
written consent documents, language and other communication barriers.
The Centers for Medicare and Medicaid Services have now called upon
hospitals to design patient-friendly informed-consent processes. Theses
processes are now required to include treatment alternatives and the
consequences of declining recommended therapies. The Joint Commission,
which accredits hospitals, is advocating the use of easy-to-read forms
and the use of “teach-back” methods, which involve asking patients to
repeat back what they have been told about the proposed treatment,
risks and benefits. The Department of Veterans Affairs (VA) hospital
system is conducting several new studies in the area of informed
consent utilizing the “teach-back” method to determine patient
understanding. It is the beginning of what I believe to be a long
overdue focus in healthcare delivery. Hopefully, the inf
ormation gained
will be utilized in a standardized approach to increase patients
understanding of proposed treatments with the outcome of preserving
patient autonomy.

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Benadryl, comment

February 12, 2009
Benadryl is a medication that most people
would consider safe because it’s given over the counter on a regular
basis. All the comments made about this medication and the tragic
occurrences resulting from overdose is a very serious issue that needs
to be looked at. This is the first i’ve heard of adolescents smoking
benedryl to get high, because it is a cheap and easily accessible drug.
It becomes very scary when you hear of these things happening on a
regular basis. But really what is the answer? Parents need to be
educated, as well as elementary and highschool students about the
possible effects of experimenting with even over the counter
medication. I think more time needs to be spent with elementary and
highschool students, so that they are well aware of the possible
outcomes of consuming foreign substances, as well as ones they are
familiar with.

Original Post:
February 9, 2009
Benadryl, comment
Reading articles like the Benadryl article
scare me. Society appears to be very flippant about the use of
medications for other that what they are intended. Articles abound from
ISMP. One that comes to mind recently had to do with a Fentanyl patch.
The grandmother was watching a young girl who was complaining of pain.
Grandma had some “leftover” Fentanyl patches and placed one on the
granddaughter, subsequently leading to respiratory arrest and death.
Now I see commercials by lawyers, soliciting through the TV for people
who have had problems with Fentanyl patches and the potential for
overdose. Education about the proper use of and misuse of all drugs
should be paramount. If medication errors are one of the leading causes
of death IN the hospital, what are the numbers that are associated with
death OUT of the hospital. Action needs to be taken, not in the form of
litigation, but through vigorous education, with understanding by the
learner, so that these horrible incidents can be prevented.

Original Post:
December 29, 2008
Benadryl, comment

It is a tragedy when a child is injured or killed secondary to a
pharmaceutical drug. Children are given prescription and OTC
medications too often. There are many herbal and homeopathic remedies
available to treat everyday complaints. This tragedy not only impacted
the mother of the child, but the siblings as well. In the instance
presented here, perhaps the natural herb valerian would have been a
safer choice over benadryl.

Original Post:
December 1, 2008
Benadryl, comment
I
agree that Benadryl, an antihistamine often used for its sedation
effect in adults, can cause paradoxical central nervous stimulation in
children with effects ranging from excitation to seizures and death.
Many young parents have used Benadryl to give their children to calm
them down when they travel. I was working the emergency room one night
when a mother with 3 small children came running into the emergency
room with her youngest who was 12 months old. She said they were
traveling to Iowa and she stopped at a road side park to change the
baby’s diaper. She started screaming her baby was cold and not
breathing. She tried to do CPR and drive at the same time. She did not
have a cell phone and no other cars were at the park. We assessed the
baby and did a tox screen which also showed nothing. I asked the mother
if she ever gave her kids any over the counter medicine for colds or
coughs. She said sometimes. The 6 year old sister said, “mommy gave us
some pink medicine”. The mother then told us she gave them Benadryl
liquid. We tried to revive the baby, but after 45 minutes of CPR she
died. The death was ruled accidental and no charges were made. But I am
sure the mother was emotionally blaming herself for what she did and
will have to live with that the rest of her life. I think there needs
to be an education program for parents that over-the-counter
medications can be lethal at any age.

Original Post:
November 21, 2008
Benadryl, comment
How
do we combat the abuse of drugs that are unable to be detected through
any toxicology tests? The fact remains that people, especially young
teenagers, will try almost anything to attempt to get high. It becomes
almost impossible for law enforcement to prevent such actions and
therefore lies solely on the parents. It is definitely time to be
involved in the lives of your kids and know what they are doing.

Original
Post: November 12, 2008 Benadryl, comment I have a response for the
blog entry from November 10, 2008 entitled Benadryl. In the emergency
department I work in we had an adolescent arrive in a psychotic state.
He was hallucinating, was manic, combative and then would calm down and
become very docile. He was slightly tachycardic and at times tachapneic
and his blood pressure wavered between normo to slightly hypertensive.
He didn’t have a diagnosed mental disorder. Our toxicology screens all
came back negative and so we were getting ready to transfer him to an
inpatient mental hospital when one of his relatives came in with
Benadryl wrappers and opened capsules of Benadryl found in his waste
basket in his room (they think he may have smoked it on a cigarette or
joint). The kid overdosed on Benadryl. Not because he wanted to die,
because he wanted to get high. Benadryl doesn’t show up in a tox screen
and all his other labs were pretty normal. He ended up going to our ICU
for a day and was discharged.

Original Post November 10, 2008
Benadryl, an antihistamine often used for its sedation effect in
adults, can cause paradoxical central nervous stimulation in children
with effects ranging from excitation to seizures and death. Teenagers
have discovered Benadryl, an over-the-counter medication, which is
easily obtainable and affordable. The effects of Benadryl produce a
“High.” Benadryl in this population is also taken with alcohol and high
energy drinks. Parents also give their infants Benadryl to produce
sleep and the outcome has been fatal intoxication. I have been made
aware of Benadryl and its deadly side effects when a 10-year-old child
was told by his mom to take a Benadryl tablet for his allergies. The
child unfortunately took an overdose and was placed in the hospital for
2 days to withdraw from medication.

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Narcotic Abuse

February 11, 2009
At this time I own/operate a drug testing business and we currently have a program through the court system to prevent juveniles from serving “adult” sentences if there are drugs involved. I live in eastern KY and I’m sure if you watch the news you have seen we are the RX drug capital of the US. Anyway, these kids are stealing their parents narcotics and snorting them or selling them. The parents are doctor hopping and have not 2-3 bottles but 40-50 bottles of different narcotics. It sickens me to think about the life these kids are getting into. Sometimes I wonder if it wouldn’t just be better to let them serve some “real” time and see what “innocent” snorting will get you. As a nurse, this is a rampant problem even among professionals. I am shocked at the number of nurses, doctors and nursing students that we have positive drug tests on that are taking large volumes of narcotics with legal RX while treating patients. It makes me want to drug test all physicians or nurses before they touch me!!

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Deep Vein Thrombosis

February 11, 2009
In regards to forensic science, a DVT can have an affect on the cause of death. If a thrombi is not discovered and treated in time it will continue to flow through the artery and finally make its way to the heart which may results in a possible death. If a coroner is trying to decide the cause of death, if they come across the thrombi, they will most likely have found the cause of death for the individual.

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Chronic Inflammation

February 11, 2009
In terms of forensic pathology, keeping on eye on chronic inflammation can help during an autopsy that is done on a deceased person. If cause of death is to be determined it could possible be traced back to a chronic inflammation due to prolonged exposure to potentially toxic agents. An example of this would be exposure to silica which when inhaled can result in inflammatory lung disease called silicosis. This information would be very important for a coroner to know because it would be able to find the cause of death due to prolonged exposure to such toxins. If people were exposed to these toxins in factories, workshops, etc… then a cause of death would be able to be established and the family would be able to fight back due to the long exposure to this chemical if need be. I would have never thought that prolonged exposure to certain chemicals could produce a chronic inflammation and this is very important information for me to know because I am going to work in the medical field and this is something that can be useful in a history of a patient if there is some kind of infection going on.

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Medication Identification

February 9, 2009
In this day and time patients have to be their own advocate. Many take whatever the doctor prescribes and doesn’t even ask questions. When they are admitted to the hospital they possibly have no idea of what they are taking or why they are taking it. I guess working in the medical field my eyes have opened up and I realize that doctors are not perfect. They are overworked with a high patient load. Sometimes patients walk into the office and are surprised that the doctor does not remember them or what medications they are on. I think this is probably the normal. I have seen doctors order the wrong medications, order medications the patient is allergic to, forget to order medications, etc. We don’t want to alarm our patients but we must make sure that they see the advantage of being their own advocate. There is nothing wrong with asking questions. If the doctor seems too busy or annoyed, find another doctor. It is also vital to use the nurse as a resource. The public relies on doctors and pharmacists to keep up with their medication list. For some reason if they get a prescription filled at a different pharmacy, they think magically their regular pharmacist will know and add it to their list. Or if they see a different doctor, they think that doctor would have called and made sure they have the correct information on hand. As nurses I also think we have a responsibility to be strong advocates for our patients. We need to look after them, ensure their medications are correct, and most importantly, educate the patients on the importance of looking out for theirselves.

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Benadryl, comment

February 9, 2009
Reading articles like the Benadryl article scare me. Society appears to be very flippant about the use of medications for other that what they are intended. Articles abound from ISMP. One that comes to mind recently had to do with a Fentanyl patch. The grandmother was watching a young girl who was complaining of pain. Grandma had some “leftover” Fentanyl patches and placed one on the granddaughter, subsequently leading to respiratory arrest and death. Now I see commercials by lawyers, soliciting through the TV for people who have had problems with Fentanyl patches and the potential for overdose. Education about the proper use of and misuse of all drugs should be paramount. If medication errors are one of the leading causes of death IN the hospital, what are the numbers that are associated with death OUT of the hospital. Action needs to be taken, not in the form of litigation, but through vigorous education, with understanding by the learner, so that these horrible incidents can be prevented.

Original Post:
December 29, 2008
Benadryl, comment

It is a tragedy when a child is injured or killed secondary to a pharmaceutical drug. Children are given prescription and OTC medications too often. There are many herbal and homeopathic remedies available to treat everyday complaints. This tragedy not only impacted the mother of the child, but the siblings as well. In the instance presented here, perhaps the natural herb valerian would have been a safer choice over benadryl.

Original Post:
December 1, 2008
Benadryl, comment
I agree that Benadryl, an antihistamine often used for its sedation effect in adults, can cause paradoxical central nervous stimulation in children with effects ranging from excitation to seizures and death. Many young parents have used Benadryl to give their children to calm them down when they travel. I was working the emergency room one night when a mother with 3 small children came running into the emergency room with her youngest who was 12 months old. She said they were traveling to Iowa and she stopped at a road side park to change the baby’s diaper. She started screaming her baby was cold and not breathing. She tried to do CPR and drive at the same time. She did not have a cell phone and no other cars were at the park. We assessed the baby and did a tox screen which also showed nothing. I asked the mother if she ever gave her kids any over the counter medicine for colds or coughs. She said sometimes. The 6 year old sister said, “mommy gave us some pink medicine”. The mother then told us she gave them Benadryl liquid. We tried to revive the baby, but after 45 minutes of CPR she died. The death was ruled accidental and no charges were made. But I am sure the mother was emotionally blaming herself for what she did and will have to live with that the rest of her life. I think there needs to be an education program for parents that over-the-counter medications can be lethal at any age.

Original Post:
November 21, 2008
Benadryl, comment
How do we combat the abuse of drugs that are unable to be detected through any toxicology tests? The fact remains that people, especially young teenagers, will try almost anything to attempt to get high. It becomes almost impossible for law enforcement to prevent such actions and therefore lies solely on the parents. It is definitely time to be involved in the lives of your kids and know what they are doing.

Original Post: November 12, 2008 Benadryl, comment I have a response for the blog entry from November 10, 2008 entitled Benadryl. In the emergency department I work in we had an adolescent arrive in a psychotic state. He was hallucinating, was manic, combative and then would calm down and become very docile. He was slightly tachycardic and at times tachapneic and his blood pressure wavered between normo to slightly hypertensive. He didn’t have a diagnosed mental disorder. Our toxicology screens all came back negative and so we were getting ready to transfer him to an inpatient mental hospital when one of his relatives came in with Benadryl wrappers and opened capsules of Benadryl found in his waste basket in his room (they think he may have smoked it on a cigarette or joint). The kid overdosed on Benadryl. Not because he wanted to die, because he wanted to get high. Benadryl doesn’t show up in a tox screen and all his other labs were pretty normal. He ended up going to our ICU for a day and was discharged.

Original Post November 10, 2008 Benadryl, an antihistamine often used for its sedation effect in adults, can cause paradoxical central nervous stimulation in children with effects ranging from excitation to seizures and death. Teenagers have discovered Benadryl, an over-the-counter medication, which is easily obtainable and affordable. The effects of Benadryl produce a “High.” Benadryl in this population is also taken with alcohol and high energy drinks. Parents also give their infants Benadryl to produce sleep and the outcome has been fatal intoxication. I have been made aware of Benadryl and its deadly side effects when a 10-year-old child was told by his mom to take a Benadryl tablet for his allergies. The child unfortunately took an overdose and was placed in the hospital for 2 days to withdraw from medication.

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Forensic Nursing in Correctional Facilities, comment

February 9, 2009
I’m sure this is a hot topic among may people. I have to admit as an ER nurse who has seen children who have been physically and sexually abused the thought of having to provide humane care to these animals disgusts me. However, as a nurse we are taught we must heal and teach. I try to treat all patients with dignity no matter what they may have done, but I also believe that with any nursing position you shouldn’t go into it for the money but because it is an area you enjoy. I am not a pysch nurse. I don’t believe in all of the mumbo jumbo, but I do love forensics in trying to determine how a crime was committed and discovering the “who dunnit”. The individuals who work with the criminally insane and the prisioners have to be special people because of the horrible things they see and hear that these prisoners have done. It is a “right” I suppose that all individuals receive adequate healthcare but I have to wonder if were able to subject these criminals to an ounce of the pain that they caused some of their victims would we have less crime?

Original Post:
February 2, 2009
Forensic nursing in Correctional Facilities, comment
I have worked in a Forensic Mental Hospital. I am sure your are speaking about other correctional facilities.
In the Forensic Mental Hospital all of the patients are monitored differently that other patients with very strict rules. Only large strong young men can be the attendants because often the patients are “taken down’ But again this is because they are mentally ill criminals who have a history of hurting even killing people.
One of the forensic mentally ill patients was out in the community. A brutally mean child predator who was given large amts of Depo Provera to chemically castrate him. He could not achieve an erection but state he could not get the idea of hurting young girls out of his mind. He was readmitted to the hospital because he took a razor blade to his penis and testicles.  My job was to change the dressings once a day I had to have two strong young men with me when I was with this patient.  Even though people are locked up maybe the reasons they are criminals are not resolved.

I also applied at the State Prison. While I was waiting for my interview I saw young men hand cuffed through a bench. (i.e. one side of the hand cuff was on the patient and the other through the bench holding the prisoner on the bench)
I decided not to apply because the environment was scary. I agree with the article of Forensic nursing in Correctional facilities but feel it is a dream or fantasy to think that nursing can be like this.
These men and women are in a locked house without normal privileges; sometimes they are fighting for their life.  It is good to treat them normally but there is always the underlying ‘roar’ that they may be trying to get something more than they need. After all a large amount of criminals have sociopathic personalities
 
I work in a poor family clinic in a large city. I often have people who have gotten out of prison come to my clinic because they usually do not have money for health care.
It seems that more often then not, these patients continue their pre prison activities.  They come to us with infected needle lesions. They cry that they just cannot stop. They plead and cry for narcotics, show attitude, and sometimes are mean.
I agree we should treat them with dignity but so should show us respect also.  
I try to remember that most of them are in prison because they do not have people skills and have learned how to ‘play’ people to get what they need. How can a small clinic ‘provide nursing care that is free of bias and judgment’s when the patient (a previous criminal) has showed anger and attitude in the clinic. When I have to spend more than 15 minutes with this patient because he/she needs more help and expects it.
My company had to put a break proof piece of glass between the receptionist and the patient because one of these patients threatened the intake person. Now all the patients have to speak on a phone to the intake person.
It seems that even in a correctional facility they have rules and monitors to decrease the roots of violence. Now when the criminals are let out some of them continue the attitude and continue to cause problems.
Where does it end?

Original Post:
December 30, 2008
Forensic nursing in Correctional Facilities
This chapter started with a wonderful summary of some of the issues that forensic nurses had to contend with in correctional facilities. These nurses are not concerned about the crime that was committed because that has nothing to do with how the patient is to be treated. The same holds true for a psychiatric patient. The ED seems to be the only area where the entire story of the person is portrayed; for better or for worse. The text succinctly summarized the tasks of the correctional nurse: a. Consult and advocate on human rights issues b. Perform medicolegal examinations (not where employed) c. Teach and perform detailed, unbiased documentation d. Provide nursing care that is free of bias and judgment e. Advocate for healthcare and healthcare education f. Inspire health-care for offenders g. Assist nursing and other professionals in creating protocols with the highest ethical standards h. Assist in providing an impartial and secure environment for offenders and staff i. Develop and implement initiatives that decrease the roots of violence. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby

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Narcotic Abuse

February 6, 2009
An increase in potential narcotics diversions were occurring within our Emergency Department after an influx of Agency nurses. What was happening; pain meds were being administered without corresponding orders and single dose vials were being used as multidose vials. We discovered that orders were not being written when crucial conversations took place between practitioner and nurse. Nurses were adminstering meds based on verbal orders, not thinking to follow-up with the physician or even hand the chart to the physician so they could write the order “real time”. I had worked in the ER for many years prior to my current position and there was always a sense of trust between nurse and physician. You helped each other out by doing for the other or even prompting when necessary. I find it rather interesting that there seems to be a new culture within the department that seperates physician and nurse; a form of alientation that fosters distrust. You hear things like: “That’s not my job” by nurses when discussing giving meds without orders, or “I didn’t know he did not write the order” or “I can’t give these meds even though I had a verbal order?” The other issue of using single dose vials as multi-dose vials come from not wanting to waste resources and work-arounds. I can understand the issues presented here. It happens when the physician orders 1mg of Morphine that comes in a 2mg vial. The nurse withdraws the 1mg, administers it, then saves the other 1mg for later, knowing it will be used at some point in time. Unfortunatly, all these actions may and do cause suspicion. Narcotics diversion was becoming such an issue that we ended up contacting an agent from the NYS Health Department, Bureau of Narcotics Enforcement. Imagine my surprise when this gentleman showed up for his in-service sporting a utility belt complete with handcuffs and a lovely government-issue 9mm handgun. Needless to say, his in-service caught the attention of many staff members, not just our ER staff. His presentation was very inciteful, replete with numbers about jail time and fines. Some of the “simple” penalties exceeded $5,000, loss of license, etc. Our numbers regarding narcotics diversion did diminish after his visit, but time will tell if the department goes full circle right back were it started.

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