Archive for October, 2009

Are we ready for a Pandemic

October 19, 2009

I thought my state had the right idea in preparation for the seasonal flu and the H1N1 flu that has begun to hit our schools and will inevitably be hitting our hospitals and nursing homes. The NYSDOH (New York State Department of Health) had mandated an emergency regulation, which mandated annual flu vaccinations for all healthcare personnel by Nov 30. This is no different to the already in place regulation of requiring mandatory vaccinations of healthcare workers for measles, mumps, rubella and TB testing. As an educator, I also must regulate the company representatives and vendors coming into our organization, that they also must have all the necessary immunizations prior coming to our surgery department. This is not only to protect our patients, who are already at a compromised state, but also to protect them from contact of our patients. We as educators and leadership began to immunize our healthcare workers to proactively prepare for what was to come. As of last week, we had immunized well over 75% of our workers. We know our hospitals have shortcomings in that we ask our workers to stay at home if they contract symptoms or they must stay home with their children, but on the other side of the coin, we reprimanded them if they are sick longer than three days, as they do not have a note from their doctors, as they cannot go to the doctors offices for fear of spreading the disease. As in everything we see each day, we began to hear grumblings from some of our own nurses. "No one is going to make me get a vaccine". They were going to go to our state capitol to argue and try to block the mandatory flu shots-as the subsequent lawsuit stated it was to "protect the rights of nearly 60,000 medical workers" in New York State. As of today, there is a temporary restrain order blocking this mandate. What is the question here? Do the nurses not want to be vaccinated? Do they not want to be "mandated to be vaccinated"™ I think the state made a gutsy move attempting to be proactive in the wake of a possible pandemic. I went into healthcare many years ago to help people, to care for the sick and dying. I participated in a smallpox inoculation workshop, when the threats of bioterrorism and chemical warfare hit home. What is wrong with these nurses- are they more concerned with going to their unions than they are about their patients? During the legal turmoil that will probably take weeks. I read in the paper just yesterday, that the flu virus has claimed eleven deaths of children and teens during the last week-eighty-six in all. Its effects are now seen in forty-one states. Who is going to care for the very sick people that are going to be coming into our organizations? Did you not learn anything from the HIV virus?

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Alcohol use

October 19, 2009

Alcohol is the most commonly used and abused psychoactive agent in the United States. Alcohol does have some therapeutic applications, however it is mostly used for nonmedical use. If it is consumed in moderation, alcohol can prolong life. It actually can decrease the risk of dementia and cardiovascular disorders. I also find that it can increase the joy of living if used in a moderate amount. Many people would disagree with me on this issue. The problems of alcohol come in to play when it is consumed in excess. This is easily done. Abraham Lincoln said "None seemed to think the injury arose from use of a bad thing, but from the abuse of a very good thing. "I agree with our 16th president and find it interesting that we continue to have the same issues with alcohol that our ancestors of many years ago did with alcohol. Working in the emergency room proved to me that at times on night shift, I would have more "drunken" patients than sick ones.

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Drug abuse and addiction

October 19, 2009

Employees who abuse drugs or alcohol are 10 times more likely to miss work, nearly 4 times as likely to be involved in on-the-job accidents and 5 times more likely to file a workers’ compensation claim. They are also responsible for 40% of all industrial fatalities, 33% less productivity and generate healthcare costs that are three times as high as other co-workers. (American Council for Drug Education) "Drug abuse can be defined as using a drug in a fashion inconsistent with medical or social norms." Lehne 2009. When I think of drug abuse, I do not think of cancer patients taking medication for their pain however, if the drug is used inconsistent with their physicians orders, this too can be defined as drug abuse. I personally believe that cancer patients should be allowed to self-medicate to their own comfort level. To me, drug abuse is the recreational use of drugs such as heroin or marijuana. Addiction to drugs from repeated use is caused by molecular changes in the brain. Each time it is taken, it can causes changes in the brain that promote further drug use. I believe that we need to figure out a way to better educate people on the principles of addiction regarding drug abuse and perhaps there would be less drug abuse in the world.

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Child Abuse in Cultural Diversity Context, comment

October 15, 2009

Our hospital is located in one of the country’s largest immigration and refugee processing centers. To date, our language assistant coordinator has estimated over 30 different languages or dialects are currently being used throughout our local community. We had to change our Interpreter Policy a few years back following an incident that involved a child. A woman came into the ER with her thirteen year old daughter. She had severe abdominal pain, n/v, pelvic tenderness and was bleeding heavily. She did not speak or understand English. A call was placed to our language assistant coordinator, but it would be some time before assistance would arrive. Suspecting the woman was miscarrying, the doctors and nurses questioned the child -who did speak English as a secondary language. They asked pertinent medical questions in regards to their physical assessment findings. A few days later, our coordinator was contacted by a staff member from the local refugee center explaining that when the child went home that night she was severely beaten by her father. By discussing her mother’s personal medical history, the child had shamed the family. Her culture did not allow for children – certainly not females- to discuss topics that could be termed as sexual, regardless of the circumstances. The policy has since been updated and we can only gather information from a minor sixteen years old or older. We are to use children under 18 only in emergent situations. We need to be cognitive of the fact that even though we have rights and laws in our country – that once that front door closes at night, the laws and customs of the native country’s often prevail.

Original Post
June 4, 2009
Title: Child abuse in Cultural Diversity Context
While studying the chapter on cultural diversity, it made more sense to elaborate on some aspects of cultural diversity which still has a fine line between child abuse and cultural practice. One significant area is the right of African culture where parents make use of spanking as a means of corrective action or discipline. In Nigeria for instance, spanking takes the form of stroking with sticks, ruler or any linear object. Blending this tradition into the American context is another issue altogether. Law enforcement in America sees this type of traditional practice as child abuse and often send social services and child protective cases after parents. Many African families are in dilemma as to how to raise their children when it comes to drawing the line between discipline and child abuse. On observation so far, many families are forced to send their children back to Africa where the society upholds the saying "spare the rod and spoil the child". In recent social gatherings, African families are still debating over this controversy. They believe that the end result is better off if the parents spank the children rather than have the children sent to juvenile camps when their actions get criminal or turns into felonies. They often cite examples from the Bible as the foundation of wisdom and authority when it comes to raising responsible children in today’s society.

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Pediatric medication errors in the PACU (Post Anesthesia Care Unit), comment

October 14, 2009

Medication errors are the fear of many seasoned nurses such as myself. Just today at my work, a nurse gave a TB skin test to a patient instead of a flu vaccine. How could she have done that if she followed the 5 rights that we were all taught in nursing school? I don’t know but I did come across the information discussing the 13 major categories of medication errors that really made me think long and hard! 1. Wrong patient – this is a very important first step to identify the patient correctly. 2. Wrong drug – A busy nurse must very carefully review the drug that they are giving and verify the correctness of the drug on hand. 3. Wrong route- The nurse must assure that the patient is being given the medication in the route specified by the physician’s orders. 4. Wrong time – The nurse must make sure that the medication is being administered at the correct time according to the physician’s orders. 5. Wrong dose – The dosage needs to verified so that the order is administered exactly as prescribed. a. Overdose – The patient is administered more medication than prescribed. b. Underdose – The nurse gives less than the dose ordered to the patient. c. Extra dose – The patient is given a dose other than the prescribed doses for the day. 6. Omitted dose- The patient is not given a dose of the medication that is prescribed for them. 7. Wrong dosage form- The patient is given the dose of medication in a form other than prescribed by their physician. 8. Wrong diluent – The medication was mixed with an incorrect fluid in preparation for administration to the patient. 9. Wrong strength/concentration – The dose was incorrect according to the physician’s orders. 10. Wrong infusion rate – The medication was given at the wrong rate of speed. 11. Wrong technique – An example of this is to crush a pill that should not have been crushed. 12. Deteriorated drug error -Administrating an out-dated medication to the patient. 13. Wrong duration of treatment – Starting or stopping the medication at a time not indicated in the physician’s orders. "According to the 1999 IOM report, among fatal medication errors, the most common types are giving an overdose (36.4%), giving the wrong drug (16.2%), and using the wrong route (9.5%)." Lehne 2009. I believe that as nurses we need to continue to remember the 5 rights and be very aware of the focus it takes to give the correct medications to our patients.

Original Post
September 17, 2009
Title: Pediatric medication errors in the PACU (Post Anesthesia Care Unit), commentThank you for this post… it is a great reminder of the importance of the "5 Rights" of medication administration. Med errors happen more times than we would all like to admit. I have worked in the Neonatal ICU for many years and I will admit I just had a wake-up call. It was an extremely busy day in the unit and I was caring for a set of premature twins with almost identical birth weights, therefore same calculation weights used for dosages. I had a laundry list of meds to give to these patients. After I administered a med and I was tearing the patient label off I realized… the med I just gave was for twin "A" and not "B". It was the Right Medication, the Right Dosage (thankfully being twins of the same size… which does not happen all the time), the Right Route, the Right Time and Right Rationale but not the Right Patient……. the label said "XXXXX, baby-A" and not "XXXXX, baby-B". This was a major wake-up call that thankfully did not cause any harm since both of the patients were to get that exact medication at that exact time but regardless this was a reported Med Error! It really reminded me that no matter how busy you may be….. Take your time when administering medications to your patients… the other tasks can wait!! It can happen to any of us¦ BE CAREFUL!!

Original Post
July 30, 2009
Title: Pediatric medication errors in the PACU (Post Anesthesia Care Unit)

When we, as nurses perform assessments on our patients, in this case, a pediatric patient that will be going for any surgery, we often forget the word beneficence (principal of doing well for our patients) or take it for granted.  We go though the assessment form with the patient and most often the parent assisting, sometimes taking aspects of it as routine or perform a ‘run of the mill assessment’. 

The patient, now has his or her surgery and moves through to the PACU.  We always believe that we will always act in the best interest of our patient, the principal of ‘doing good’.  We always plan on never doing harm to our patients- to do no harm-provide the principal of nonmaleficence. 

‘Medication errors involving pediatric patients in the PACU, may occur as frequently as one in 20 medication orders and more likely to cause harm when compared to medication errors overall.’(AORN 2007, vol 85 page 731)  There have been many instances of late with pediatric medication errors, but the one that is foremost in everyone’s mind is the much published case of the newborn twins of actor Dennis Quaid. A medication(heparin) was administered and the dosage was incorrect.   We as nurses have long been educated and re-educated on the ‘5 rights’ of medication administration.  If we would just take the time to check and re-check the medications, there perhaps would be a decreased number of errors.  Pediatric medication dosages are based on the child’s age, weight and condition. A higher percentage of errors were found of pediatric patients where calculations involving decimals, dosage forms and math related as we have to calculate the proper dosage. Hospitals, pharmacists and nurses are continually trialing and attempting to establish standardized policies, procedures and educating our nurses in the proper handling of our pediatric populations, so errors don’t occur.  Do I think we have the problem solved…no.  But we are well aware of this problem and we have begun the journey to rectify the problems.   I certainly do not want any of our pediatric patients to become statistics and our nurses go through the immense pain and suffering if a negative outcome happens. There are many regulatory bodies that could  get involved.  Not to mention, the family and their worries and concerns for their child, and yes, the lawsuit that may prevail. We must all be very cognizant of not only our pediatric patients, but all our patients.  

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Screening for abuse, comment

October 12, 2009

As I read through the various postings, many readers have voiced the same concern – the need for doctors and in particular nurses, to be further educated in the screening and assessing of suspected victims of abuse. I agree with the theory that the medical profession has an obligation to reach out to this patient population -whether they are willing or not to admit they are in an abusive relationship. I have a lot of mixed emotions on this topic – I think what is needed is a bit more than assessing our patients. I think it has to start with us, the nurses – taking a look at ourselves and our own relationships. In the past week I had to take my daughter to a wake and two funerals. One of her best friends had to bury both her parents, separately. The mother died a violent death – the victim of domestic violence, the father then took his own life. The mother was not only a truly loving and special person, she was a smart, educated professional. A nurse. I think as nurses, doctors – "healers" – we sometimes overlook the very things that we are trained to look for. Most of us enter this profession to "help" others, to make a difference, to not allow our patients to give up, but rather to be strong and overcome. I think it is in most of our nature to root for the underdog, take on the stray – we can help and change those who can’t help themselves. This young woman saw the signs, began to live in fear for the safety of not only herself, but for her children as well. She tried to help her husband deal with his emotions and his behaviors. She tried to help and be supportive. Tragically, the very day she took legal steps to protect her family, was the day she died. I think as healthcare professionals we not only hold an obligation to help those we provide care for, but we must also recognize the obligation to help ourselves. To reach out to our peers and our co-workers. I think that sometimes we are just blinded by the need to make things better.

Original Post
September 28, 2009
Title: Screening for abuse, comment
I think that all nurses and doctors should receive additional training in screening for abuse depending on their specialty area. Patients will present differently depending on whom they are being interviewed by. Many times in the situation of children they are with their abuser when they present and it is difficult to separate the two. The abuser does not want you to have words alone with their child. I worked many years as a school nurse and suspected many cases of abuse that were reported to the appropriate authorities only to find that the child was disbelieved and then years later found to be telling the truth. Adults are very savvy at making a child look like a liar but seldom do these children have the capabilities to make up the horrendous story I heard. Unfortunately the investigators seem to want to believe the abuser. These children were also ones with poor grades (not sleeping at night due to the abuse), behavioral issues (they just wanted someone to listen) and many times documented storytellers (the only way to get attention) so it was very easy for the abuser to discredit them. If we are all trained to look for something other than physical marks we may start to diminish abuse against our children. Part of the assessment should not include where the parents reside in society. Several times the investigators simply found out what the parents did for a living and that in itself ended the investigation.

Original Post:
September 8, 2009
Title: Screening for abuse
Thank you for this important message. It is absolutely imperative that ALL providers know the signs and symptoms of physical, emotional and sexual abuse. Furthermore, it is absolutely necessary that ALL providers screen every patient at EVERY patient encounter for abuse. Providers should incorporate screening for abuse into their health assessment. It is very easy to do. Providers can accomplish this important task by 1. Printing the screening question on the pre-assessment paperwork, 2. Asking the patient during the assessment, "Do you feel safe at home?" 3. Knowing the s/sx and incorporating screening into every pt encounter. So very important.

Original Post
September 2, 2009
Title: Abuse
Child and elder abuse continue to be very under reported making it imperative that doctors and nurses have education on signs of abuse. Nursing home abuse is also very under reported since nursing home pts. are lacking in visitors and seen as demented. Nurses also need to know who to contact should abuse be suspected.

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Brad Renfro and the ending to his life

October 9, 2009

Brad Renfro was born on July 25, 1982 in Knoxville Tennessee and passed away in his apartment in Los Angeles January 15, 2008. He started his career at a young age in 1994’s The Client. As a mere child, I was obsessed with this rising celebrity. I was heartbroken when I heard the news of his death. He had a lot of potential, but unfortunately he battled drug addiction. He passed away from accidental heroin overdose.

Pharmacodynamics as explained by Lehne (2007), is the study of the biochemical and physiologic effects of drugs and the molecular mechanisms by which those effects are produced. Pharmacodynamics is the study of what drugs do to the body and how they do it (Pg. 46). Brad Renfro never would have looked into this term and stopped to think how the illegal drugs could be harmful enough in taking his life. I think it is ironic how as young children we enter into DARE programs and they are taught to us in school, yet we soon forget all that was learned about substance abuse. Children may experience peer pressure throughout their years in school and what was once taught gets overlooked as they start experimenting with illegal substances and then become addicted. Brad Renfro played in a school production sponsored by DARE, a program in which young people learn about the danger of drugs. It is too sardonic that he went down the path that led to drug addiction.

Brad Renfro was never on prescription drugs as Heath Ledger and Anna Nicole Smith were from my previous postings, so there were no side effects from illegal drugs and prescription drugs. Two occurrences in which I found engaging was that Brad Renfro auditioned for a role in 2000’s The Patriot, which went to Heath Ledger and Heath Ledger passed away exactly a week after Brad Renfro. What are the odds of that?

Brad Renfro mingled with cocaine, marijuana, and heroin through his young years. No one knows if he ever mixed anything with another substance in causing a drug interaction. He was arrested a few times in his life for possession of illegal narcotics. Another habit of his was abusing alcohol in which he drove under the influence and was arrested as well. He was working on his sobriety, but the night before his death he drank with some friends. There are other reports of not knowing whether the drugs or the combination of both the drugs and alcohol killed him. For all intents and purposes he was looked upon as a talented person who was discovered at age ten for a successful life in the movie business. It is such a shame that his life came to an end so suddenly.

It was reported that his death had no foul play intentions. Since he abused different drugs, toxicity comes into the picture. According to Lehne (2007), the formal definition of toxicity is an adverse drug reaction caused by excessive dosing (Pg. 65). A toxicology test was to determine what drugs played a role in his death (The Los Angeles Times).

In these chapters I mentioned above, they deal with adverse drug reaction and toxicity with medications required to aid in relieving pain, helping with a disease, etc, but it goes to show that illegal substances play a vital role in adverse drug reactions and the toxicity it may cause on the body and eventually leading to death for some. These terms are serious and should be taught to all patients because one day they may have to take more than one medication, which will cause side effects as well adverse drug reactions. It is better to know and be aware than to be left with the unknown and possibly death as a result.

           References

Lehne, Richard A. (2007). Pharmacology For Nursing Care (Sixth Edition).  St. Louis,

MO: SAUNDERS ELSEVIER. (Pgs. 46-65).

The Los Angeles Times, (2008).

http://www.mtv.com/movies/news/articles/1579719/20080115/story.jhtml

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Screening for abuse, comment

October 6, 2009

This post really touches home… as nurses we have an obligation to report anything we may suspect to be abuse. There are many situations in which the patient cannot answer truthfully therefore I always say go with your "gut feeling" or when in doubt- REPORT it!! Wouldn’t you rather the investigation prove the accusation to be false than not be investigated at all? I do agree that more education on abuse screenings should be provided to all of us in the workplace.

Original Post
September 28, 2009
Title: Screening for abuse, comment
I think that all nurses and doctors should receive additional training in screening for abuse depending on their specialty area. Patients will present differently depending on whom they are being interviewed by. Many times in the situation of children they are with their abuser when they present and it is difficult to separate the two. The abuser does not want you to have words alone with their child. I worked many years as a school nurse and suspected many cases of abuse that were reported to the appropriate authorities only to find that the child was disbelieved and then years later found to be telling the truth. Adults are very savvy at making a child look like a liar but seldom do these children have the capabilities to make up the horrendous story I heard. Unfortunately the investigators seem to want to believe the abuser. These children were also ones with poor grades (not sleeping at night due to the abuse), behavioral issues (they just wanted someone to listen) and many times documented storytellers (the only way to get attention) so it was very easy for the abuser to discredit them. If we are all trained to look for something other than physical marks we may start to diminish abuse against our children. Part of the assessment should not include where the parents reside in society. Several times the investigators simply found out what the parents did for a living and that in itself ended the investigation.

Original Post:
September 8, 2009
Title: Screening for abuse
Thank you for this important message. It is absolutely imperative that ALL providers know the signs and symptoms of physical, emotional and sexual abuse. Furthermore, it is absolutely necessary that ALL providers screen every patient at EVERY patient encounter for abuse. Providers should incorporate screening for abuse into their health assessment. It is very easy to do. Providers can accomplish this important task by 1. Printing the screening question on the pre-assessment paperwork, 2. Asking the patient during the assessment, "Do you feel safe at home?" 3. Knowing the s/sx and incorporating screening into every pt encounter. So very important.

Original Post
September 2, 2009
Title: Abuse
Child and elder abuse continue to be very under reported making it imperative that doctors and nurses have education on signs of abuse. Nursing home abuse is also very under reported since nursing home pts. are lacking in visitors and seen as demented. Nurses also need to know who to contact should abuse be suspected.

Legal Services regarding abuse

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Forensic Nursing Online Introduction Course

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Second puzzling autism case reported, comment

October 6, 2009

This is a very interesting topic. From my experience in pediatrics, I am noticing many parents rejecting immunizations these because of the Autism/Immunization controversy. Others are deciding to do a delayed vaccine schedule because of the belief that injecting numerous viruses into a child’s system at one time may cause harm to the brain, which may be a better solution than no vaccines at all. There are several books, articles and Internet sites supporting the delayed vaccine schedule but just be very selective in the source; not all information is accurate.

Original Post
July 1, 2009
Second puzzling autism case reported
Federal health officials at an upcoming conference the controversial cases of a 9-year-old girl who became autistic after receiving numerous vaccinations. In January a 6-year-old girl received a flu vaccine and a week later became ill requiring hospitalization and ultimately died. Study after study has failed to show a link between vaccines and autism but many parents of autistic children claim that childhood vaccinations they received are responsible. In 1986 a National Vaccine injury compensation program was introduced to compensate injured children from vaccines. Many deadly epidemics have been prevented by vaccination. For the parent of a child injured following vaccination, grief and ambivalence would prevail. The questions that continue regarding these very complicated situations cause great concern for parents trying to decide whether to immunize a child.

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