Sepsis: What nurses need to know

sepsis-(2).pngSepsis is a life-threatening, medical emergency affecting approximately one million persons annually in the United States (NIH, 2017). Patients hospitalized with sepsis are eight times more likely to die during hospitalization (Hall et al., 2011). As nurses, we are in a position to directly impact sepsis-related morbidity and mortality. Early identification and treatment are the cornerstone of sepsis management. We are on the frontline in the care of the hospitalized patient. Being cognizant of the subtle clinical changes indicative of impending clinical decline is critical for timely interventions and avoidance of poor clinical outcomes. 

In 2016, “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” was published (Singer et al., 2016). As nurses, there are several key points from this publication that we should be familiar with. First, the terminology related to sepsis has changed, but the basis of the definition of sepsis has not. Sepsis is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection;” the term severe sepsis has been eliminated; and septic shock is defined as a “subset of sepsis in which underlying circulatory, cellular and metabolic abnormalities are profound enough to substantially increase mortality” (Singer et al., 2016). Clinically, those in septic shock have been given the standard fluid resuscitation (30 mL/kg) with refractory hypotension/hypo-perfusion requiring vasoactive medications to maintain a mean arterial pressure (MAP) > 65 mmHg. Furthermore, Systemic Inflammatory Response Syndrome (SIRS) is no longer part of “sepsis” terminology. Previously, sepsis was considered SIRS with an infectious etiology.

As with many medical conditions that we see on a regular basis, there are continual advances in the understanding of disease, both from a medical and scientific perspective. With these advances come changes to best practice recommendations. It is essential that nurses stay well-informed on these changes. Below is a summary of recommendations based on the most recent literature on sepsis with a focus on what is most pertinent to our practice as nurses.

Tips for nurses taking care of patients with sepsis

Recommendation: Administer 30 mL/kg crystalloids within three hours of confirmed or suspected sepsis or sepsis related hypo-perfusion.
  • Tip: Crystalloids refer to IV fluids with a balanced electrolyte composition, such as normal saline or lactated ringers solution (as opposed to colloids, such as albumin or hetastarch).
  • Tip: This initial fluid bolus is often referred to as a fluid challenge.
  • Tip: In those patients diagnosed with sepsis, the nurse plays a critical role in monitoring appropriate administration of fluids as the patient transitions between levels of care (i.e. ED to floor, floor to ICU).
Recommendation: Measure lactate level; if elevated (>2 mmol/L), ensure that a repeat level is obtained within 6 hours.
  • Tip: Lactate (or lactic acid) is a byproduct of glycolysis in anaerobic metabolism.
  • Tip: In the septic patient, think of elevated lactate as a sign of tissue hypo-perfusion.
Recommendation: Obtain two or more sets of blood cultures prior to the administration of antibiotics; at least one set should be peripheral, the other from a vascular access device, if present.
  • Tip: Bacteremia is common in patients with sepsis; collecting cultures prior to administration of antibiotics gives us the best chance of identifying the correct organism before antibiotics have a chance to affect the growth of pathogens.
  • Tip: A “set” of blood cultures is collected in 2 separate bottles, one anaerobic culture bottle and one aerobic culture bottle.
Recommendation: Administer broad spectrum antibiotics (covering gram-positive and gram-negative organisms) within one hour of diagnosis or in those with high clinical suspicion for sepsis or septic shock.
  • Tip: Controlling the source of infection, either with antibiotics or intervention for those infections amenable (wound drainage, debridement, removal of potentially infected device, cholecystectomy), is the foundation of treating patients with sepsis or septic shock.
  • Tip: Failure to control source of infection could lead to persisting or worsening sepsis or septic shock and inability to stabilize your patient.
  • Tip: If a patient is not getting better, think “Do we have adequate source control?”
Recommendation: Administer vasoactive medications if a patient remains hypotensive or if lactate remains elevated following the initial fluid challenge. Vasoactive medications should be titrated to a mean arterial pressure (MAP) of > 65 mmHg.
  • Tip: Norepinephrine (Levophed) is typically the first vasopressor that is initiated. This is typically started at 2-5 mcg/min and titrated to a MAP > 65 mmHg.
  • Tip: The second vasoactive medication added is typically vasopressin at 0.03 U/min. This medication does NOT get titrated and can be added in attempt to decrease the dose of norepinephrine.
Recommendation: In taking care of a patient with sepsis, it is imperative to re-assess hemodynamics, volume status and tissue perfusion regularly.
  • Tip: Frequently re-assess blood pressure, heart rate, respiratory rate, temperature, urine output, and oxygen saturation.
  • Tip: Dynamic measurements such as passive leg raising (PLR) are recommended to assess for fluid responsiveness. PLR mimics endogenous volume expansion (equivalent to an approximate 300 mL fluid bolus) and can be thought of as a preload challenge. It is used to predict if a patient will respond to additional fluid bolus. ​Follow these steps to perform PLR (Mikkelsen et al., 2016):
    • Position the patient in the semi-recumbent position with the head and torso elevated at 45 degrees.
    • Obtain a baseline measurement.
    • Lower the patient's upper body and head to the horizontal position and raise and hold the legs at 45 degrees for one minute.
    • Obtain subsequent measurement.
    • The expected response to this maneuver in those that are fluid responsive is a 10% or greater increase in cardiac output (CO). Although not considered a validated measure, we often use blood pressure as a surrogate marker of CO in evaluating response to the PLR.
Recommendation: In patients in the ED or admitted to the general hospital floor with infection, use the quick sequential organ failure assessment (qSOFA) to identify patients at risk for clinical decline and sepsis-related organ dysfunction (Singer et al., 2016). The presence of any two of the qSOFA criteria should prompt further evaluation. 
  • Tip: qSOFA
    • Respiratory rate > 22 breaths/min
    • Altered mental status
    • Systolic blood pressure of 100 mmHg or less
    • If your patient has 2 of these criteria, be concerned for sepsis.
  • Tip: It is important to know your patient’s baseline when possible. Be aware of other variables that could potentially affect qSOFA score (dementia, baseline low systolic blood pressure [SBP]). Alternately, if your patient’s SBP is typically in the 200s and now it’s 140 with no other explanation, this should prompt further evaluation.
  • Tip: The qSOFA was derived from the sequential organ failure assessment (SOFA), a tool that numerically quantifies the number and severity of organs failed (Hall et al., 2009). The SOFA score allows us to predict prognosis and severity of illness in those patients with sepsis.
Remember, sepsis is a medical emergency and should be treated as one. Early identification and management of sepsis improves patient outcomes.

Nurses have the capacity to make a difference both clinically and system-wide. Actively participate in hospital-wide performance improvement programs and share your experiences and expertise. You can have a global impact on how we manage sepsis and septic shock in the future.
Hall, M.J., Williams, S.N, DeFrances, C.J, & Golosinkiy, A. (2011). Inpatient Care for Septicemia or Sepsis: A Challenge for Patients and Hospital. NCHS Data Brief No. 62, June 2011. Centers for Disease Control and Prevention (CDC). Accessed August 22, 2017.
Jones, A. E., Trzeciak, S., & Kline, J. A. (2009). The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Critical Care Medicine37(5), 1649–1654. Accessed September 6, 2017.
National Institutes of Health (NIH): National Institute of General Medical Sciences. Sepsis Fact Sheet. Updated January 2017. Accessed August 22, 2017.
Mikkelsen, M.E., Gajeski, D.F., & Johnson, N.J. (2016). Novel tools for hemodynamic monitoring in critically ill patients with shock. UpToDate. Last updated December 20, 2016. Accessed September 6, 2017.
Singer M, Deutschman CS, Seymour CW, et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).

Posted: 9/13/2017 10:07:02 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions

Top 10 Things Advanced Practice Nurses Need to Know about the Updated Guidelines for Management of Sepsis and Septic Shock

TOP-TEN-THINGS-APNS-NEED-TO-KNOW-ABOUT-NEW-SEPSIS-GUIDELINES_300.pngThe Surviving Sepsis Campaign (SSC) is the leading organization responsible for educating healthcare professionals on the most current scientific evidence on the timely and appropriate treatment of sepsis. This ultimately allows us to positively impact sepsis-related morbidity and mortality.

Over the past year and a half there have been several major updates to best practices in the field of sepsis. In 2016, Singer, et al., published “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” which provided updated definitions and clinical criteria for Sepsis and Septic Shock with the elimination of the terms severe sepsis and SIRS. The new terminology defines sepsis as life threatening organ dysfunction caused by a dysregulated host response to infection and septic shock as a subset of sepsis in which underlying circular and cellular/metabolic abnormalities are profound enough to substantially increased mortality (Singer et al. 2016). Clinically, the septic shock subset are those patients with refractory hypotension despite adequate fluid resuscitation requiring vasoactive medications to maintain a mean arterial pressure (MAP) > 65 mmHg.

In March 2017, the Surviving Sepsis Campaign (SSC) published updated guidelines on the management of Sepsis and Septic Shock. This document, titled “Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016” provides updated recommendations to the version published in 2012 and includes 93 statements on early management of sepsis and septic shock. A major difference evident in the new guidelines is a movement from protocolized management to a more individualized, “patient-centered” approach guided by dynamic variables and ongoing evaluation of clinical response to treatment (DeBaker & Dorman, 2017).

As the scientific and medical community’s understanding of sepsis and the pathobiology driving this life-threatening condition grows, it is essential that the APN stays abreast of changes to management based on the most up-to-date information.

Below is a summary of the recent SSC guidelines (Rhodes, et al., 2017) with a focus on material most pertinent to our practice as APNs.
  1. Initial Resuscitation
    1. Fluids
      1. Begin fluid resuscitation with crystalloid fluids immediately for sepsis-induced hypo-perfusion. Ideally, aim for at least 30 mL/kg completed within the first 3 hours from time of diagnosis.
        • Crystalloids are the fluid of choice for initial fluid resuscitation.
        • Recommendations against hydroxyethyl starches or bicarbonate therapy as an agent to improve hemodynamics or reduce vasopressor requirement.
      2. Following initial resuscitation, hemodynamic assessment should be used to guide further fluid administration using invasive and non-invasive measures.
        • Include clinical exam and evaluation of available physiologic variables including heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output.
      3. Evaluate fluid responsiveness by the following means:
        • Dynamic variables:
          • Passive leg raise
          • Pulse or stroke volume variations induced by mechanical ventilation
        • Lactate clearance
      4. Discontinue fluid administration if response is no longer beneficial.
      5. Target a mean arterial pressure (MAP) of 65 mmHg in those with septic shock.
    2. Vasoactive Medications
      1. Initial vasoactive medication of choice should be norepinephrine.
      2. Consider the addition of vasopressin (at 0.03 units/min) or epinephrine to reach target MAP or to decrease the dose of norepinephrine.
      3. Consider arterial catheter placement for the monitoring of blood pressure in those requiring the use of vasoactive medications.
    3. In the absence of response or if clinical assessment does not lead to clear diagnosis, consider evaluation for other types of shock (DeBaker & Dorman, 2017).
  2. Diagnosis/Source Control – obtain both as soon as possible with early antibiotic therapy.
    1. Goal to identify or exclude anatomic source requiring emergent intervention as soon as possible; this includes removal of intravascular access if possible source of infection.
    2. Obtain at least two sets of blood cultures prior to initiation of antibiotics in all patients with suspected sepsis or septic shock if it will not delay initiation of treatment.  
  3. Antibiotic therapy
    1. Initiate one or more empiric broad-spectrum antibiotics as early as possible and within 1 hour (maximum) of recognition of sepsis or septic shock to cover all suspected pathogens.
    2. Evaluate daily for potential de-escalation/narrowing of antibiotics based on pathogen identification and clinical improvement.  
    3. Limit combination therapy (double coverage) to patients with septic shock.
    4. Do not continue antibiotics for severe inflammatory states (i.e. systemic inflammatory response syndrome [SIRS]) with no infectious etiology.
    5. Duration of antibiotic treatment should be 7-10 days.
      • Extend for slow clinical response, undrainable foci, staph aureus, or neutropenia.
      • Shorten course for quick clinical response, adequate source-controlled, GU/UTI or simple pyelonephritis.
    6. Consider procalcitonin measurement to support de-escalation of antibiotics in patients with sepsis and to support discontinuation of antibiotics in those who ultimately have limited clinical evidence of bacterial infection.
      • Although there is low quality of evidence and a weak recommendation by the SSC, many institutions have adopted use of this biomarker in the management of sepsis.
  4. Blood products
    1. Limit red blood cell transfusions to those patients with hemoglobin concentration < 7 g/dL. Consider higher threshold in select clinical populations (i.e. acute hemorrhage/ongoing active bleeding, acute coronary syndrome with ischemia, symptomatic anemia).  
  5. Mechanical ventilation
    1. In all mechanically ventilated patients with sepsis:
      1. Utilize lower tidal volume strategy using predicted body weight.
      2. HOB 30-45 degrees.
      3. Spontaneous breathing trials in those ready for weaning.
      4. Minimize sedation and set targets for titration end points.
    2. In patients with sepsis-induced acute respiratory distress syndrome (ARDS):
      1. Target tidal volume = 6 mL/kg
      2. Upper limit goal for plateau pressures of 30 cm H20
      3. Higher PEEP strategy
      4. Recruitment maneuvers for those with sepsis-induced severe-ARDS and refractory hypoxemia  
      5. Consider prone positioning if paO2/FiO2 ratio < 150.
      6. Conservative fluid strategy
  6. Glucose Control
    1. Begin an insulin administration protocol for patients with sepsis and two consecutive blood glucose readings > 180 mg/dL.
    2. Target glucose ≤ 180 mg/dL, rather than upper limit ≤ 110 mg/dL
  7. Nutrition
    1. Begin early enteral nutrition rather than parenteral nutrition or combination in critically ill patients with sepsis or septic shock (Rhodes et al. 2017).
    2. If early enteral feeds are not possible, begin IV dextrose and advance enteral feeds as tolerated rather than initiating parenteral nutrition during the first seven days of critical illness. This may include trophic or hypocaloric feedings and advance as tolerated.
    3. Gastric residual volumes should only be considered when there is enteral feeding intolerance or high risk of aspiration, rather than routinely.
  8. Stress Ulcer prophylaxis
    1. Begin in those patients with sepsis and septic shock AND risk factors for gastrointestinal bleeding; may use either proton pump inhibitor or histamine-2 blocker.
  9. VTE prophylaxis
    1. Initiate pharmacologic prophylaxis unless contraindicated. Rhodes et al. (2017) recommends LMWH rather than UFH in absence of contraindications to LMWH, in combination with mechanical prophylaxis in absence of contraindications.
  10. Communication
    1. Discuss goals of care and prognosis with patients and family as early as feasible, incorporating end-of-life planning and palliative care principles, when appropriate.
De Backer, D. and Dorman, T. (2017). Surviving Sepsis Guidelines. A Continuous Move Towards Better Care of Patients With Sepsis. The Journal of the American Medical Association, 317(8).
Rhodes, M.B., Evans, L.E., Alhazzani, W, et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3).
Singer M, Deutschman CS, Seymour CW, et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).


Posted: 9/8/2017 12:04:17 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions

Collaboration, communication, cooperation

Nurse Wubbels…If you haven’t heard, seen, or read this story, here is a link to The Washington Post article, which includes the video. Briefly, nurse Alex Wubbels was arrested after refusing to allow a detective to obtain a blood sample from an unconscious patient. And here are the details:
  • The detective didn’t have a warrant and the patient was not under arrest.
  • Consent could not be obtained because the patient was unconscious.
  • Nurse Wubbels followed hospital policy – and the law – by refusing the blood draw.
  • Nurse Wubbels acted professionally and responsibly, by confirming policy with her supervisor.
  • Nurse Wubbels was threatened, assaulted, and arrested.
My initial reactions were anger and shock, and these feelings still come to the surface when I read the story and watch the video. After more time has passed and I’ve given it more thought, three words come to mind: collaboration, communication, and cooperation. Here’s why…

My experiences with law enforcement at the bedside have always been positive. If there was a patient in our unit who was under arrest, the officers and nurses depended on each other to share information with each other that was necessary and within the law. Oftentimes, if a patient was restrained or combative, the officers were a calming presence for all the hospital staff; we felt safe. I think (hope) that the officers knew, we were providing care to a patient and would uphold the highest level of care, no matter who that patient was.

I don’t know anything about training of law enforcement, but I know how much emphasis is placed on communication during a nurse’s education! We focus on verbal and nonverbal cues, learn strategies to get the information we need, and practice our communication skills from those very first semesters of nursing school. It’s an important part of our job and I must give a shoutout to nurse Wubbels for maintaining professionalism despite being bullied.

team.pngI think of cooperation, not in the sense of doing what one is told, but to take this unfortunate incident and work together to learn from it. As nurses, we are obligated to our patients. Who are police officers obligated to? Is it the public? Is it the law? Nurse Wubbels put the patient first, while risking her own well-being and safety. The detective in this case did not demonstrate duty to the public, nor the law. It is that cooperation that is missing here – respectfully working together to meet the goals of our chosen professions and to serve the people who depend on us.

We’ve all got a job to do – and to do it well, we must work together.
*At the time of this writing, two members of law enforcement are on administrative leave, and an investigation is underway.


Posted: 9/5/2017 2:16:20 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

Sepsis: Learning from the past to improve patient outcomes

As many of you know, I am a practicing acute care/critical care nurse practitioner in a hospital in the Philadelphia area. Recently I was called to a rapid response on a medical floor. The patient was an elderly gentleman who was admitted for a urinary tract infection the day prior and now had a temperature of 103° F, a systolic blood pressure of 80/50 mm Hg (normally 130/72), a respiratory rate of 26/min and has gone from being awake, alert and oriented to being lethargic. This scene plays out every day in our healthcare system; so how did the nurse know to call for the rapid response team to come evaluate the patient? She used the qSOFA (Quick Sequential Organ Failure Assessment) tool which identifies patients who are at risk for a poor outcome. Based on the nurse’s quick, critical thinking, the patient was evaluated and the diagnosis was changed to septic shock secondary to a urinary tract infection and he was transferred to the critical care unit for management and he survived. The nurse was the hero in this situation because she recognized this patient was in septic shock.  

Sepsis, learning from the past
Sepsis is thought to occur in 750,000 people in the U.S. each year and it’s one of the leading causes of mortality and critical illness worldwide (Angus, 2013; Dieter-Lessnau, 2015). Sepsis is not a new diagnosis but, the guidelines on how to best recognize and manage it have been refined over the years as we learn more about this devastating diagnosis. In 2016, the definition of sepsis was changed to better reflect new knowledge on the pathophysiology of sepsis. For years, we have used the Systematic Inflammatory Response Syndrome (SIRS) criteria to identify patients with sepsis; however, new research has determined that the SIRS criteria was unhelpful because a SIRS response occurs with many other conditions and does not indicate dysregulation as once thought (Singer, et al., 2016; Rhodes, et al., 2017).

A new sepsis definition
As a result, a new definition of sepsis was established and was described in The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) in 2016 (Singer, et al., 2016). In 2017, The Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock were published (Rhodes, et al., 2017).  Sepsis is now defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer, et al., 2016; Rhodes, et al., 2017).  Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality (Singer, et al., 2016; Rhodes, et al., 2017). The term ‘severe sepsis’ has been eliminated from the definitions.

Early recognition is key
We know that early recognition of a patient with sepsis and septic shock is the first step in sepsis management. What tools are available to nurses to identify a patient who is likely to have a poor outcome due to organ dysfunction potentially related to sepsis? New definitions and guidelines have identified two tools that can be used by healthcare professionals to help identify a patient at risk for poor outcomes.

The qSOFA tool is a resource to be used outside of a critical care unit, such as in the emergency department or a medical/surgical unit, or primary care/urgent care, to identify these types of patients.

The qSOFA tool looks at 3 variables:
  • Respiratory rate greater than or equal to 22/min
  • Altered mentation
  • Systolic blood pressure less than or equal to 100 mm Hg (Singer, et al., 2016; Rhodes, et al., 2017).
The SOFA tool is used with critical care patients to identify a higher risk of patient mortality. Any change in 2 points or greater is equal to a higher risk of mortality. The variables evaluated in the SOFA tool are:
  • Respirations
  • Coagulation
  • Liver function
  • Cardiovascular system
  • Central nervous system
  • Renal system
Post-Sepsis Syndrome Reality
Patients who live through an experience of sepsis often have post-sepsis syndrome and exhibit long-term physical, psychological, and cognitive disabilities which result in health and social implications (Iwashyna, 2010). It is imperative that nurses recognize this syndrome and educate their patients and their families and other members of the support network, about this condition.

Sepsis-Alliance-SAM-Support-Badges-(2).pngNurses, you are an integral part of the interdisciplinary team
Without a doubt, nurses are key in sepsis early recognition, management and education because you are with the patient 24 hours a day. Having access to the latest evidence-based clinical practice guidelines and using them for clinical decision support is crucial to improving patient outcomes. Sepsis Alliance has an assortment of valuable resources for healthcare professionals and patients on sepsis. Wolters Kluwer is proud to partner with Sepsis Alliance to improve knowledge on this devastating, but preventable, condition.  
Angus, D. C. (2013). Severe sepsis and septic shock. New England Journal of Medicine, 840-851.
Dieter-Lessnau, K. (2015, Oct. 8). Distributive shock. Retrieved July 20, 2016 from Medscape:
Iwashyna, T., et al. (2010). Long-term cognitive impairment and functional disability among survivors of sepsis. JAMA,304(16):1787-1794.
Rhodes, M.B., Evans, L.E., Alhazzani, W., et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3).
Singer M., Deutschman, C.S., Seymour C.W., et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).




Posted: 8/31/2017 5:39:49 AM by Lisa Bonsall, MSN, RN, CRNP | with 5 comments

Categories: Diseases & Conditions

Using the art and science of nursing to fight the opioid crisis

emergency.jpgEvery day we see it in the news and in our emergency departments, a person overdosing on prescription or street drugs. Every day, 90 Americans die due to an opioid overdose and in 2015, 33,000 lives were lost (Rudd, et al., 2016).  Age, gender, socioeconomic class, it doesn’t matter; opioid overdose has become a crisis that causes heartache for not only the overdose victim, but their loved ones too. Some victims are lucky; they receive naloxone and are revived, but too often they just repeat the behavior that landed them in trouble in the first place. So why are we, as one of the most developed nations in the world, in this predicament? What can we do as a country and as nurses to change this precarious course?  

We’ve all seen patients in pain and know it’s real. But, something happened over the past 20 years. Somehow, we thought patients should be pain free no matter what the cause, and we even considered it a 5th vital sign, although it was never meant to be considered that way (Morone & Weiner, 2013).  Let’s think about that for a minute. It’s completely unrealistic that after surgery or an injury, a person won’t experience pain; in fact, pain gives us information that something maybe wrong. We should have been focusing on decreasing pain, not totally alleviating it.  

With the availability of tablet formulations  growing in the 1990’s, the number of opioid prescriptions and the length of time they were prescribed grew. When their prescriptions ran out, many turned to less costly street drugs like heroin; in fact, 80% of patients who use heroin today used prescription opioids first (Muhuri, et al., 2013). Many people can access prescription opioids by using a family member’s or friend’s medication or buying them on the street. Today 21% to 29% of patients prescribed opioids for chronic pain misuse them and 8% to 12% of these people will develop an opioid use disorder (Vowles, et al., 2015; Muhuri, et al., 2013; Cicero, et al., 2014; Carlson et al., 2016). 

The federal government is trying to alleviate this crisis. The Department of Health and Human Services is working to improve access to drug treatment programs, promote the use of overdose-reversing drugs (such as naloxone), and improve public health surveillance. The National Institutes of Health has devoted funding for research on innovative pain management and addiction treatment. 

Nurses are an integral part of the interdisciplinary team fighting the opioid crisis. For those of us who prescribe opioids, before writing the prescription, we must now check the Prescription Drug Monitoring Program Database to investigate the patient’s opioid prescription history. We must advocate for and practice responsible prescribing of opioids; we do not want any organization dictating our prescription practices. We need to encourage patients to seek treatment for opioid addiction and help them find those resources. We need to teach patients how to properly dispose of their used opioid medications.

Nursing is both an art and a science, and using those principles can help guide our pain management practice through:
  • Educating patients that reducing pain, not completely alleviating it, is often the goal.
  • Evaluating and managing the patient’s anxiety through relaxation techniques.
  • Using correct patient positioning.
  • Using ice or heat when appropriate.
  • Using compression and elevation for sprains or strains.
  • Encouraging rest.
  • Using acupuncture, meditation, and other alternative or naturopathic techniques.
When we do administer an opioid medication to a patient, we need to consider: is this the right drug for the right level and right type of pain? Would an alternative drug such as acetaminophen, ibuprofen, gabapentin or something else be more appropriate?

The opioid crisis has brought too much heartache to this country. As nurses, we must recognize we are integral to assessing and managing pain appropriately, be able to identify patients who need addiction therapy and help them gain access to those resources, and we must be a voice for responsible prescribing. Together with the interdisciplinary team, we can help to alleviate the opioid crisis; we owe it to our patients!
Rudd RA, Seth P, David F, Scholl L. (2016). Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;65. doi:10.15585/mmwr.mm655051e1.
Morone NE, Weiner DK. (2013). Pain as the fifth vital sign: exposing the vital need for pain education. Clin Ther. 2013;35(11):1728-1732. doi:10.1016/j.clinthera.2013.10.001.
Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576. doi:10.1097/01.j.pain.0000460357.01998.f1.
Muhuri PK, Gfroerer JC, Davies MC. (2013). Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBHSQ Data Rev. August 2013.
Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. (2014). The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366.
Carlson RG, Nahhas RW, Martins SS, Daniulaityte R. (2016). Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug Alcohol Depend. 2016;160:127-134. doi:10.1016/j.drugalcdep.2015.12.026.
Chief Nurse, Wolters Kluwer



Posted: 8/30/2017 4:52:14 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

Clinical Nurse Specialist Week 2017

Posted: 8/29/2017 10:24:19 AM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Inspiration

Inspired Nurses Calendar 2017: A Better Life

Lippincott is partnering with Lippincott Solutions to bring you an inspired nurse’s story every month. Here is August’s nurse story, “A Better Life.”
A Better Life
Helene Vossos, DNP, PMHNP-BC, ANP
Stewart Marchman ACT Behavioral Services
August-2017.jpgAs nurses, we must recognize how vulnerable mental health patients often feel, which can impact their access to mental health services.
As a mental health nurse, I participated in an "Open Access Model" to "walk in" appointments in an outpatient clinic that improved access to mental health services from 54% up to 94%. Many of our inpatient, outpatient, home health care and homeless patients lack communication skills and resources, and all nurses can help make a difference when coordinating their care. As a case study, we talk about Miguel, who is a 32-year-old immigrant from Puerto Rico, homeless in Florida, has a history of schizophrenia and is a new resident. He came to the states by boat, "for a better life." His history includes three previous self-inflicted stabbings to his abdomen and chest when he was out of medication and when "the voices were loud and commanding."
Historically Miguel was in contact with emergency department nurses, medical-surgical nurses, OR nurses, case manager nurses, mental health nurses and nurse practitioners for the past three years. All of these nurses are "mental health nurses" by proxy, as they all touched his life, saving him and helping him to maintain stability and get the health care services he needs by providing "walk-in" status during open-access for mental health services, and have provided a translator as well as additional assistance in maintaining appropriate medication and continuing outpatient services. Nurses save lives in all ways of collaboration, caring and research translated into clinical practice!
To see all 2016-2017 stories or to share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit  Be sure to check our blog every month for a new inspired nurse’s story.



Posted: 8/28/2017 9:31:48 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Inspiration

Body Mass Index and Body Surface Area: What's the Difference?

Body mass index (BMI) and body surface area (BSA) are two measures used frequently in health care, however, they are not well understood. While they are both indicators of body size, they provide very different information. What exactly do each of these measures tell us and how should they be used?

Body Mass Index (BMI)

BMI is a measure used to determine a person’s degree of overweight. Calculated based on height and weight,1 BMI is easy to measure, reliable, and correlated with percentage of body fat mass. It is a more accurate estimate of total body fat compared with body weight alone.2 BMI can also help gauge a person’s risk for conditions such as heart disease, high blood pressure, type 2 diabetes, gallstones, respiratory problems, and certain cancers. One downside of measuring BMI alone is that it may overestimate body fat in athletes or people with a muscular build. Conversely, it may underestimate body fat in the elderly or in people who have lost muscle.

BMI is calculated by taking the body weight in kilograms (kg) and dividing it by the height in meters (m) squared.

While there are programs and mobile applications that will calculate BMI for you, it’s important to know the formula and how to derive the answer. Let’s practice!

Example 1: What is the BMI for Mr. Jones weighing 210 pounds with a height of 6 feet, 3 inches?
  1. Convert pounds to kilograms: 210 pounds ÷ 2.2 kg/pound = 95.45 kg
  2. Calculate height in meters:
    1. 6 feet, 3 inches = 75 inches
    2. 75 inches x 2.54 cm/inch = 190.5 centimeters (cm)
    3. 190.5 cm ÷ 100 cm/m = 1.905 meters
    4. Square the height (1.905 x 1.905) = 3.63 m2
  3. Calculate BMI by dividing the weight by the height (m)2
    1. 95.45 ÷ 3.63 = 26.3 m2
Example 2: What is the BMI for Mr. Smith weighing 210 pounds and 5 feet, 4 inches tall?
  1. 210 pounds = 95.45 kg
  2. Calculate the height in meters:
    1. 5 feet, 4 inches = 64 inches
    2. 64 inches x 2.54 cm/inch = 162.56 cm
    3. 162.56 cm = 1.625 meters
    4. Square the height (1.625 x 1.625) = 2.64 m2
  3. Calculate BMI:
    1. 95.45 ÷ 2.64 = 36.2 m2
Example 3: What is the BMI for Mrs. Williams weighing 110 pounds and 5 feet, 8 inches tall?
  1. 110 pounds = 50 kg
  2. Calculate height in meters:
    1. 5 feet, 8 inches = 68 inches
    2. 68 inches x 2.54 cm/inch = 172.72 cm
    3. 172.72 cm = 1.727 m
    4. Square the height = 2.98 m2
  3. Calculate BMI:
    1. 50 ÷ 2.98 = 16.8 m2
What do these scores mean? According to the BMI Classification scale adopted by the National Institute of Health (NIH) and the World Health Organization (WHO), Mr. Jones would be considered slightly overweight, Mr. Smith would fall under the category of obese, and Mrs. Williams would be considered underweight.
The BMI scores are classified based on risk for cardiovascular disease and can be applied to people of Caucasian, Hispanic, and African-American race. However, these standards may underestimate the risk of obesity and diabetes in people of Asian and South Asian descent. A lower threshold should be used for these populations.

Measurement of waist circumference in conjunction with BMI can provide additional information on risk that is not accounted for by BMI. The NIH recommends measuring waist circumference in overweight and obese adults to assess abdominal obesity. A waist circumference > 40 inches (102 cm) for men and > 35 inches (88 cm) for women may indicate an increased risk for cardiovascular and metabolic disorders.2

When further assessing the patients above, Mr. Jones was found to have a waist circumference of 37 inches and was deemed to be at a lower risk for obesity. For Mr. Smith, measuring waist circumference is not necessary as most patients with a BMI > 35 kg/m2 are already considered at high cardiometabolic risk.

Body Surface Area (BSA)

BSA measures the total surface area of the body and is used to calculate drug dosages and medical indicators or assessments. The first formula was developed by Du Bois in 1916 and since then, several others have been developed. The Mosteller formula, which is the easiest to calculate and remember, is the most commonly used formula in practice and in clinical trials.2
The Mosteller formula takes the square root of the height (cm) multiplied by the weight (kg) divided by 3600.
Let’s use the same examples above and calculate each patient’s BSA.
Example 1: Mr. Jones
  1. Calculate weight in kilograms: 210 pounds ÷ 2.2 = 95.45 kg
  2. Calculate height in centimeters: 6 feet, 3 inches = 75 inches x 2.54 cm/inch = 190.5 cm
  3. Multiply height by weight and divide by 3600
    1. (190.5 cm x 95.45 kg) ÷ 3600 = 5
  4. Take the square root of 5 = 2.24 m2
Example 2: Mr. Smith
  1. Weight in kg = 95.45 kg
  2. Height in cm: 5 feet, 4 inches = 64 inches x 2.54 cm/inch = 162.56 cm
  3. (162.56 cm x 95.45 kg) ÷ 3600 = 4.3
  4. Take square root of 4.3 = 2.07 m2
Example 3: Mrs. Williams
  1. Weight in kg = 50 kg
  2. Height in cm: 5 feet, 8 inches = 68 inches x 2.54 cm/inch = 172.72 cm
  3. (172.72 cm x 50 kg) ÷ 3600 = 2.39
  4. Take square root of 2.39 = 1.55 m2
The average adult BSA is 1.7 m2 (1.9 m2 for adult males and 1.6 m2 for adult females). This number is used to calculate dosages for cytotoxic anticancer agents. To minimize variation in patient size, dosing for most chemotherapeutic agents use mg of drug per m2 of body surface area.2 Although this methodology has not been rigorously validated, BSA-based dosing has become the standard when prescribing most cytotoxic agents and some therapeutic monoclonal antibodies. In theory, BSA mitigates the variability of patient size and abnormal adipose tissue to help optimize drug efficacy, improve drug clearance and to minimize or prevent toxicity.2
BSA is also used to provide more precise measures of hemodynamic parameters such as cardiac index (CI = cardiac output divided by BSA), stroke volume index (SVI = stroke volume divided by BSA), systemic vascular resistance index (SVRI = systemic vascular resistance divided by BSA) and pulmonary vascular resistance index (PVRI = pulmonary vascular resistance divided by BSA). In addition, BSA is used to adjust creatinine clearance when comparing it with normal values to assess for the presence and severity of kidney disease.2
Let’s look at cardiac index. If Mr. Jones, whose BSA is 2.24 m2, has a cardiac output of 4.3 L/min, his cardiac index would be 1.92 L/min/m2 (4.3 L/min divided by 2.24 m2). If Mrs. Williams, whose BSA is 1.55 m2, has the same cardiac output of 4.3 L/min, her cardiac index would be 2.77 L/min/ m2. While 4.3 L/min falls within the normal range for cardiac output, Mr. Jones’ cardiac index of 1.92 L/min/m2 is below the normal range of 2.5 – 4.0 L/min/m2. Further assessment is required to determine the underlying cause of his low cardiac output and plan treatment modalities. He may require a fluid bolus for dehydration and tachycardia or an inotropic agent for heart failure.
I hope this review of BMI and BSA was helpful. We would love to hear your feedback for ways in which you use BMI and BSA in your daily practice.
  1. US Department of Health & Human Services. National Institutes of Health. Assessing your health and weight risk. Retrieved on 7/18/17 from
  2. UpToDate: Obesity in adults: Prevalence, screening and evaluation. Retrieved on 7/18/17 from
 Myrna B. Schnur, RN, MSN 


Posted: 8/23/2017 5:57:12 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

ANCC Premier Prize

Lippincott Professional Development (LPD) is the 2017 winner of American Nurses Credentialing Center’s (ANCC) Premier Program Award. We are very honored to receive this award which is given to very few organizations that compete each year. The Premier Prize is a public acknowledgement of continuing education (CE) providers that foster leadership, collaboration, and organizational change to overcome barriers to learning, and to improve nursing professional development and/or patient outcomes. The ANCC award also recognizes the innovation used to tackle the challenges of providing lifelong learning to professional nurses inside and outside our organization.   

LPD is committed to developing CE that meets the specific and unique learning needs of nurses who work in a variety of settings, specialties, and who perform a variety of roles. LPD collaborates with professional nursing organizations on research, strategic planning, and identification of learning needs of their members to develop relevant CE activities.  LPD strives to include innovative delivery mechanisms in its CE activities.  Because of the need to engage nurses with different learning styles, we have developed learning activities that include innovative and interactive strategies. 

I’m pleased to share photos of our team receiving the ANCC Premier Award on July 18th, 2017. 

ANCC-photo-1-(1).jpg          ANCC-photo-2.jpg  

Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Executive Director, Continuing Education
Lippincott Professional Development
Wolters Kluwer

Posted: 8/14/2017 7:23:12 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Continuing Education

Inspired Nurses Calendar 2017: Meant to be a Nurse

Lippincott is partnering with Lippincott Solutions to bring you an inspired nurse’s story every month. Here is July's nurse story, “Meant to be a Nurse.” 
Meant to be a Nurse
Adriana Pirez, BSN, RN
Saint Luke's Cornwall Hospital, Medical/Surgical Unit
July-2017.pngAll my life I've wanted to be a nurse. The inspiration was in my family, as my aunt Mercedes was the nurse coordinator for a private hospital in my native country of Uruguay. She married a doctor and one of their sons became a doctor too.

On Sunday's when we would gather at grandma's house, as a little girl, I remember hearing conversations about new drugs in the market to fight illnesses, and many stories my cousin would tell about his experiences as a new doctor doing an internship in a local hospital ED. I was mesmerized by their stories, their intelligence and mostly for their love and dedication to their professions. It took me a long time as a woman, a mother, and a wife, in my forties to realize that that dream of being a vocational nurse could be possible here in the U.S. So, after working for years in different hospitals as a unit secretary and a registrar for the Emergency Department, I enrolled in a nursing program at my local community college.

Finally, after so many struggles, lack of support and discrimination from some professors for me speaking with an accent and being different, I maintained a positive attitude, and transferred to a new nursing program in a prestigious Christian College in Rockland County, NY. In 2013, I graduated with honors. It wasn’t always easy, but I would do it all over again – nine years, three colleges and a huge debt in student loans.
Today, I work in my local hospital, the one where the nurses in that ED inspired me even more. I love the smiles on my patients when they see me coming on my second day of my shifts. Their smiles and their trust in my care is the greatest support I can get, knowing that nursing is in my heart and in my Christian soul, and that I was truly meant to be a nurse.

To see all 2016-2017 stories or to share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit  Be sure to check our blog every month for a new inspired nurse’s story.


Posted: 7/29/2017 6:01:23 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Inspiration

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