GI Nurses & Associates Week
is March 20-24, 2017!
We wish those of you in this specialty a wonderful week, and we thank you for compassion and dedication. Please enjoy the content below, specially selected to help you in your practice.
For those of us in other specialties, GI disorders can be challenging. Please explore, and share, the content in this collection with your colleagues!
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Have a great week!
As nurses working at the bedside, most of us are familiar with the common lab test, lactate. We know that when cells become hypoxic, lactate levels increase. While working in the intensive care unit, checking a lactate level was routine. Unfortunately, an elevated lactate level is typically a bad sign for the patient, often related to increased organ dysfunction and mortality. In recent years, the blood lactate level has gained wide acceptance as an important marker in the diagnosis of sepsis and septic shock and is useful in evaluating response to fluid resuscitation. An elevated lactate is not only a marker for sepsis and septic shock – it may signal other important clinical conditions as well. So, what is lactate and what exactly does it tell us?
Lactate is an organic molecule produced by most tissues in the human body, with the highest production found in muscle.1
Here’s a quick and basic review of how lactate is produced. The body normally produces energy by way of aerobic metabolism, which requires oxygen to break down carbohydrates, amino acids, and fats. Via glycolysis, glucose is converted into pyruvate, which enters the Krebs cycle to produce oxygen and adenosine triphosphate (ATP) or energy. If oxygen isn’t available to body cells, anaerobic metabolism kicks in to produce energy. In this pathway, pyruvate is metabolized by the enzyme lactate dehydrogenase (LDH) into lactate.2
Lactate leaves the cells, enters the bloodstream, and transports to the liver, where it is oxidized back to pyruvate and then converted to glucose via the Cori cycle.1,2
Lactate is cleared from the blood, primarily by the liver and, to a lesser extent, by the kidneys and skeletal muscles.2
A normal blood lactate level is 0.5-1 mmol/L. Hyperlactatemia is defined as a persistent, mild to moderately elevated (2-4 mmol/L) lactate level without metabolic acidosis.2
This can occur with adequate tissue perfusion and tissue oxygenation. A level > 4 mmol/L defines lactic acidosis3
, a level high enough to tip the acid-base balance, which may result in a serum pH < 7.35 in association with metabolic acidosis. Lactate can be measured from both venous and arterial blood. Serum samples should be processed within 15 minutes to avoid falsely elevated results. If processing cannot occur within this time frame, the sample should be kept on ice.
Hyperlactatemia and lactic acidosis may occur with an increase in lactate production, a decrease in lactate clearance, or a combination of both.3
An increase in lactate production is typically caused by impaired tissue oxygenation, either from decreased oxygen delivery or a disorder in oxygen use, both of which lead to increased anaerobic metabolism.3
Most causes of lactic acidosis are due to significant, systemic tissue hypoperfusion, referred to as type A lactic acidosis. Alternately, in Type B lactic acidosis, the etiology may be related to toxic-induced impairment of cellular metabolism, local hypoperfusion (i.e. regional ischemia) or in many instances, the mechanism is unknown. Below are some common causes of lactic acidosis:
- Sepsis and septic shock: dysfunction in the microcirculation (where oxygen is exchanged) leads to lactate production, while decreased oxygen delivery contributes to a decrease in lactate clearance.3
- Cardiogenic, obstructive and hemorrhagic shock: may cause decreased oxygen delivery and hypoperfusion.
- Cardiac arrest: ischemia and inflammation following cardiac arrest may cause an increase in lactate.
- Severe lung disease, respiratory failure or pulmonary edema: excessive work of breathing causes anaerobic muscle activity.
- Trauma: hypoperfusion due to blood loss is common in trauma patients and may lead to elevated lactate levels.
- Seizures: depending on the type, seizures can produce a significant increase in lactate, but the effect is short-term; once the seizure has resolved, lactate levels typically return to baseline.
- Excessive muscle activity: lactate increases with strenuous exercise due to anaerobic metabolism and may be seen in rhabdomyolysis.
- Regional ischemia: mesenteric ischemia, bacterial peritonitis, acute pancreatitis, extremity compartment syndrome, gangrene and other types of soft tissue infections may elevate lactate.
- Burns and smoke inhalation: smoke inhalation victims are at risk of elevated lactate due to potential inhalation of cyanide and/or carbon monoxide.
- Diabetic ketoacidosis (DKA): due to a change in metabolism; elevated lactate in DKA is not necessarily associated with worse outcomes.
- Thiamine deficiency: low thiamine levels result in anaerobic metabolism and increased lactate production; risk factors for thiamine deficiency include poor nutrition, chronic liver disease, alcoholism, hyperemesis gravidarum, anorexia nervosa, and gastric bypass surgery.
- Malignancy: tumors may cause production of glycolytic enzymes, impaired liver clearance and malnutrition leading to thiamine deficiency.
- Liver dysfunction: the liver is the primary organ responsible for lactate clearance; injury or failure results in decreased lactate clearance.
- Genetic: inborn disorders of metabolism, particularly in the pediatric population, may cause elevated lactate levels.
- Drugs and Toxins that may cause increased lactate:
- Metformin (biguanide)
- (Nucleoside reverse transcriptase inhibitors (NRTI)
- Beta-2 agonists
- Alcohols (ethanol, propylene glycol and methanol)
- Carbon monoxide
Treatment of elevated lactate levels should be determined by the underlying cause. If hypoperfusion or hypoxemia is the culprit, focus on improving perfusion to the affected tissues. In shock, treatments include fluid administration, vasopressors, or inotropes. In regional ischemia, surgery may be needed to restore circulation or remove damaged tissue.1
If drugs, seizures, malignancy, or thiamine deficiency is the cause, stop, reverse, and treat the offending agent.1
Multiple conditions can contribute to lactic acidosis, therefore it is critical to carefully evaluate the patient’s complete medical history, conduct a thorough physical assessment, and assess other laboratory or diagnostic tests before beginning treatment.
Myrna B. Schnur, RN, MSN
1. Anderson, L.W., Mackenhauer, J., Roberts, J.C., Berg, K.M., Cocchi, M.N., and Donnino M.W. (2013, October). Etiology and therapeutic approach to elevated lactate. Mayo Clinic Proceedings, 88(10), 1127- 1140.
More Reading & Resources
Laboratory signs of sepsis [Infographic]
The Subtle Signs of Sepsis [Infographic]
Making Sense of the Updated Sepsis Definitions
Focus On: Sepsis
Posted: 3/17/2017 7:59:23 AM
Lisa Bonsall, MSN, RN, CRNP
| with 0 comments
It’s Patient Safety Awareness Week, and I am reminded of an experience I had as a nursing student. My first medication error
has stuck with me all these years. Why? Because like all health care professionals, as nurses, our priority is to do no harm. While not all issues related to patient safety are due to human error, we do feel a personal responsibility to ensure our patients’ safety. In today’s fast-paced health care world, that is not an easy task. While technological advances have provided a lot of support, we know that we can’t rely solely on technology – attention and collaboration, as well as speaking out about our experiences, are key.
In February of 2017, Nursing's Evolving Role in Patient Safety
was published in American Journal of Nursing.
This content analysis documents the history of patient safety related to nursing care, as illustrated by articles published in the journal. What an interesting study demonstrating the importance of our role in keeping patients safe through the years. The analysis dates back to the first issue of AJN
in October of 1900! Go ahead and give this a read – you’ll see just how much has changed and, equally important, how much has stayed the same.
Posted: 3/14/2017 10:57:17 PM
Lisa Bonsall, MSN, RN, CRNP
| with 0 comments
Categories: Patient Safety
Patients with sepsis can present in a variety of ways making sepsis very difficult to diagnose. Clinicians are now encouraged to use tools, such as the Sequential (Sepsis-Related) Organ Failure Assessment Score (SOFA), to assist in screening for septic patients. In addition to the parameters outlined in the SOFA score (hypoxemia, blood pressure, platelets, bilirubin, creatinine, urine output, and Glascow Coma Scale), several other laboratory values may help identify patients at high risk for organ failure and sepsis.
Use this infographic as reference guide for lab results that you may see in septic patients.
Myrna B. Schnur, RN, MSN
Neviere, R. (2017, February 28). Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis. Retrieved from UpToDate: https://www.uptodate.com/contents/sepsis-syndromes-in-adults-epidemiology-definitions-clinical-presentation-diagnosis-and-prognosis
Add this infographic to your website by copying and pasting the following embed code:
March is Multiple Sclerosis (MS) Awareness Month and a great opportunity to spread the word about multiple sclerosis, a chronic, unpredictable autoimmune disease of the central nervous system (CNS), as well as to introduce you to a new patient resource site, LiveWiseMS.org
According to the National MS Society, there are over 400,000 people in the U.S. and 2.3 million people worldwide living with multiple sclerosis. Chances are that you see patients with MS in your practice and probably know people personally who are affected by this disease.
MS causes a varying array of symptoms, including balance issues, muscle spasms, cognitive problems, pelvic floor disorders, depression, disability, and much, much more. No two cases of MS are exactly the same, and there is currently no cure.
Advances in research and treatment have been on the rise in the past few decades for MS. There is hope on the horizon for potential new therapies and treatment options that seek to repair, as well as prevent, damage to the CNS. Current disease-modifying therapies (DMTs) only work to hold off any worsening of the disease; they do not treat or repair any damage already done. More DMT options are being approved all the time, and current therapies have had some success for keeping MS at bay for as long as possible, and hopefully, in turn improving quality of life for patients. Fortunately, MS is not the disease it used to be, but there is still a lot of work that needs to be done.
I am one of those 400,00 people in the U.S. living with multiple sclerosis, and I live my life daily trying to raise awareness, educate, and most importantly, support others living with this disease. Recently, my personal and professional lives met in what, I believe, to be a serendipitous moment, and I am fortunate to be part of an exciting new MS patient and caregiver resource site, LiveWiseMS.org
LiveWiseMS.org emerged out of a partnership between Wolters Kluwer and the International Organization of MS Nurses (IOMSN)
, supported by an unrestricted educational grant from EMD Serono, Inc., a subsidiary of Merck KGaA. Working with nurses for over 15 years, I couldn’t be more excited to work with the nurses at the IOMSN and to be a part of this new site about a topic near and dear to my heart.
seeks to educate patients and care partners on an even higher level than typical patient education materials and to further empower them to live the best possible life with multiple sclerosis. This unique site features condensed patient summaries of articles and information from trusted medical journals and textbooks. Patients can read these summaries, and if so desired to further educate themselves, they can continue on to read the original article. While focused on the MS patient, this site also serves as a great resource for those nurses and health care practitioners who may see patients with MS, but may not necessarily specialize in that particular area.
As I said, I couldn’t be more excited to be a part of LiveWiseMS.org. I share my story in the LiveWiseMS.org Blog section
and interact with others through the Community section
and social media pages such as Facebook
. My hope is to continue to support and empower the special population of #MSWarriors out there who seek to take back control over this disease that can make one feel so powerless.
I encourage you to visit LiveWiseMS.org
today and to recommend it to your patients, as well as colleagues and friends. Knowledge is power so spread awareness about MS and gain valuable information through LiveWiseMS.org.
Posted: 3/3/2017 6:30:43 AM
| with 0 comments
Today is the first day of National Nutrition Month
! We have several journals dedicated to the topic of nutrition, plus a vast amount of related content from this blog and our other nursing journals. We are happy to share these selections with you here – enjoy!
Nutrition related to specific disorders
Nutritional concerns in pregnancy
If nutrition is a topic you are passionate about, please Consider Writing an Article for Nutrition Today
. Thank you!
As we get deeper into 2017, let’s remember that we are all leaders, no matter where we work, the patient populations that we care for, or our role in nursing. As nurses, we lead every day – some of us at the bedside or in the clinic, some of us in the classroom, some of us in patients’ homes, some of us in the boardroom – there are too many places to list! For 2017, I’d like to focus on you – as a leader in nursing – no matter where you are. Hopefully, you already realize that you are a leader every day, but if you do need a little convincing, through the course of this year we’ll make it clear to you.
So how are you a leader? Ask yourself the following questions…
1. Are you an expert?
Think of the things that your colleagues come to you for repeatedly. Maybe it’s a question about a certain diagnosis or patient population. Perhaps you’re the go-to person for placing I.V.s when there is a patient who is a difficult stick.
2. Are you an educator?
Do you teach students? Do you ever precept new or new-to-your-unit nurses? Do you teach colleagues from other disciplines about the unit where you work? What about patient education? (We all do this one!)
3. Are you an advocate?
Do you speak up for your patients and their families? How about for yourself? Your colleagues? The nursing profession?
4. Are you a role model?
Do you take on the charge nurse role? Are you a team player? Are you a nurse that others strive to be like? Do you model healthy behaviors for patients and the public?
5. Are you a voice for our profession?
Are you educated about the global issues affecting nursing and health care? Are you a committee member at your institution? Are you a member of a professional nursing organization? Are you involved in local, state, or national boards?
6. Are you a nurse?
We know we are trusted by the public – in fact, we’ve been voted the most trusted of all professions for the past 15 years in a row
! How often do family members and friends come to you with a health-related question or advice? The title ‘nurse’ signifies leadership to those around us.
If you answered yes to any of the above, then you are a leader!
Stay tuned as we dig deeper into each of these areas throughout the year. We’ll share resources, advice, and personal stories, and some helpful strategies as you continue to develop the nurse leader within.
Have a great year!
Posted: 2/10/2017 4:33:27 AM
Lisa Bonsall, MSN, RN, CRNP
| with 2 comments
February 4th is World Cancer Day
, and the theme for the day between 2016 and 2018 is “We can. I can.” Here, at Lippincott Nursingcenter, we know there are a number of ways nurses can help bring awareness to this day, along with ways nurses can better care for patients affected by cancer.
1. Spread the word:
Follow these hashtags on your social media accounts to join the discussion around World Cancer Day.
2. Stay informed:
Stay up-to-date on the latest research and evidence around cancer.
Subscribe to the peer-reviewed journals, Cancer Nursing
and Oncology Times.
3. Take action:
- Earn continuing education credits with over 160 CE activities related to oncology.
- Access evidence-based cancer content instantly at the point of care with Lippincott Advisor. The individual version of the app used by leading hospitals includes over 1,000 evidence-based content entries on cancer symptoms, drugs, treatments, and more. Download it now for only $29.95.
Get certified in oncology by visiting our Guide to Certification
page and scrolling down to the Oncology Nursing Certification Corporation
Posted: 1/31/2017 8:34:22 AM
| with 0 comments
Categories: Diseases & Conditions
For this special edition of Nurse On the Move
, we are featuring Lori Mayer, DNP, MSN, RN, MSCN, an MS-certified nurse and editorial board member of LiveWiseMS.org
. LiveWiseMS launched in December of 2016, and is a site dedicated to supporting patients with MS, their caregivers, and health care providers.
Our own senior editor, Kim Fryling-Resare
, joined LiveWiseMS to offer her technical skills as their web editor, but also as the voice and face of the site. She was diagnosed with multiple sclerosis
in 2003 and has dedicated part of her life to supporting patients like herself. She recommended that I speak with Mayer, who holds a Doctor of Nursing Practice degree and is the director of Medical Research Services for Central Texas Neurology Consultants/Multiple Sclerosis (MS) Clinic of Central Texas, as well as a chair for the IOMSN Research Committee, and member of the editorial board of the International Journal of MS Care.
Listen to our conversation to learn more about what an MS nurse is, how to create a nursing care plan for an MS patient, and to discover what LiveWiseMS.org is all about.
Listen for the whole interview…
Be sure to check out LiveWiseMS.org
and recommend it to your colleagues or patients.
Posted: 1/25/2017 9:10:59 AM
| with 0 comments
, Nurse On the Move
You know who I’m talking about, right? Don’t we all know a nurse who seems to hit a vein every. single. time? I think every unit has the go-to nurse when there is a “tough stick” in need of I.V. access. Actually, a few nurses come to mind when I think back to my days in the unit. Back then, we just ‘knew’ who the experts were. Maybe it was (or is) you!
Now, infusion nurses are getting the recognition they deserve. Every year on January 25th
, we celebrate I.V. Nurse Day
to recognize our colleagues who provide specialty care to those patients requiring the expertise of an infusion nurse. Infusion nurses have a special knowledge and skillset, and from acute care settings to home care, and among most specialties, having an infusion nurse as part of your team is important.
Happy I.V. Nurse Day!