Happy Nurse Practitioner Week!

NP-week.pngMany of you know I still practice on the weekends as a nurse practitioner for Penn Medicine Chester County Hospital and I’m adjunct faculty for Drexel University in Philadelphia. I am currently teaching a course on using evidence in practice and this week is focused on using change theory to implement evidence. Change – one of the hardest things for us to do. We become stuck in doing things the way they have always been done. All you have to do is look at your current practice setting and see others who resist change. Courage and perseverance are the necessary ingredients to implement change. How many of us really have the so-called “right stuff” to make changes in our own practice settings? 

As I look back on our nurse practitioner profession, I am amazed at the courage and perseverance it took for Drs. Loretta Ford and Henry Silver to step out of the so-called “healthcare norm” and decide there needed to be a better way to provide care. A nurse and a physician worked together to change practice. They did not do this for recognition. Rather, they did it to improve access to quality care for those who were in need. They implemented change in a healthcare system by using courage and perseverance.

Why did you become a nurse? Why have many of you gone on to be advanced practice nurses? Were you afraid of making a change? When I think about why I became a nurse practitioner, it was because I saw an opportunity to connect the art and science of nursing and medicine in my own practice to improve patient care. I am sure many of you have a similar story.

This is Nurse Practitioner Week and I want to thank each of my NP colleagues for the work you do each day. You emulate what Drs. Ford and Silver did over 50 years ago; you meet each day with courage and perseverance to implement change and improve patient outcomes one patient at a time.
 
Sincerely,
 
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Chief Nurse, Wolters Kluwer, Health Learning, Research & Practice
Adjunct Faculty, Drexel University
Nurse Practitioner, Penn Medicine Chester County Hospital
Posted: 11/13/2017 2:05:21 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Inspiration


The Opioid Epidemic: Are Women Most Vulnerable?

The opioid epidemic is a serious public health problem that impacts us professionally, as well as many of us personally. Asking about drug use is something we were taught while in nursing school. Assessing and managing pain has always been a big part of our training too. Now, as the United States is in the midst of an opioid epidemic, our assessment and communication skills must reach a new level. Those of us who are advanced practice nurses who are also prescribers, have even more to consider when it comes to pain management.

women-and-opioids.pngAs a women’s health nurse practitioner, new research on age and gender trends related to the opioid epidemic caught my eye. Findings revealed excessive opioid prescribing with persistent use among women. This new report, conducted by the QuintilesIMS Institute, states that “middle-aged women are prescribed more opioids than any other group – twice as many as middle-aged men – making them particularly vulnerable to opioid use.” The research report, The United States for Non-Dependence: An Analysis of the Impact of Opioid Overprescribing in America, shows individuals undergoing surgery are at particular risk, due to the prescribing of opioids to manage postsurgical pain.

Here are some interesting facts from the report that you should know:
  • Patients receive an average of 85 pills following surgery.
  • Overprescribing leads to 3.3 billion pills left unused-leaving them available for misuse.  
  • In 2016, three million surgical patients became persistent opioid users.
  • The majority of opioid addictions start with prescription medications.
  • Surgery is an unintentional gateway to the opioid crisis.
  • 40% more women than men become persistent opioid users after surgery.
  • Women ages 40-59 are prescribed more opioids than any other age group and have the highest death rates from misuse.
Another report from the Office on Women’s Health demonstrates that between 1999 and 2015, the rate of deaths from prescription opioid overdoses increased 471 percent among women, compared with an increase of 218 percent among men; and heroin deaths among women increased at more than twice the rate than among men. Also, the differences in how prescription opioid and heroin use impacts women and men are often not well understood. There are potentially many factors that affect a woman’s path to opioid misuse and dependancy, including biological and social influences, past experiences, geography, and demographic characteristics. However, many knowledge gaps remain on how these relate to the opioid misuse.

According to the The Centers for Disease Control and Prevention (CDC), women are more likely than men to experience chronic pain, and use prescription opioid pain medications for longer periods and in higher doses. Women tend to use substances differently than men, sometimes using a smaller amount of drugs for a shorter period of time before they become dependent. In March of 2016, the CDC issued the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016, which summarized the research literature on the benefits and risks associated with prescribing opioids and provides an evidence-based guide for prescribers and patients to share decision-making responsibility about opioid use, and alternative treatment options for chronic pain management.   

As a women’s health nurse practitioner, this has significant impact to my practice, and my licensing. Some states now require opioid education in order to renew prescriptive authority. Combatting this problem requires a multi-factorial approach. We all need to be more aware and vigilant with prescribing, confirming orders, patient education, and post-surgical follow up.
References:
Dowell, D., Haegerich, T., & Chou, R. (2016, March 18). CDC Guideline for Prescribing Opioids for Chronic Pain — United States,  2016. Retrieved from Centers for Disease Control and Prevention : https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Office on Women's Health. (2016, December). White Paper: Opioid Use, Misuse, and Overdose in Women. Retrieved from Women'sHealth.gov: https://www.womenshealth.gov/files/documents/white-paper-opioid-508.pdf

Pacira Pharmaceuticals, Inc. . (2017, September 26). Plan Against Pain . Retrieved from The United States for Non-Dependence: An Analysis of the Impact of Opioid Overprescribing in America: http://www.planagainstpain.com/resources/usnd/
Lynne Centrella Rudderow, MSN, RN, CRNP, WHNP-BC, CCE
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Posted: 11/6/2017 8:30:56 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety


Inspired Nurses Calendar 2017: Beautiful Colors

Lippincott NursingCenter.com is partnering with Lippincott Solutions to bring you an inspired nurse’s story every month. Here is October’s nurse story, “Beautiful Colors.” 

Beautiful Colors
Leeann Vidt, R.N. supervisor
Oakmont Center for Nursing
 
beautiful-colors_october-2017.jpgAs all life must come to an end, some families find it difficult to face emotionally. I observe them looking scared to talk with or touch a dying loved one, so I will often enter the room, sit on the bed, and take the patient’s hand in mine, then I will ask them if they think the fall leaves are beautiful with all those wonderful colors. They always answer, yes, and look at me puzzled. I then tell them that those leaves are actually dying and that something so beautiful should not be feared. I tell them the greatest gift to give their loved one is loving memories. I ask starter questions, such as what their favorite vacation or holiday spent together was. As they answer with smiles across their lips, I quietly exit the room and close the door. Nothing warms my heart like hearing the laughter behind that door. And then after the patient passes, I am thanked for making the passage from this life a better memory for them. I tell them that their loved one left within a circle of love, just as they had lived.

This is why I love nursing. To be able to help someone change such a scary situation into a sweet memory, makes those difficult, stressed shifts well worth my nursing cap.

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 http://lippincottsolutions.com/inspirednurses.  Be sure to check our blog every month for a new inspired nurse’s story.
 
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Posted: 10/29/2017 7:53:23 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Inspiration


National Conference for Nurse Practitioners (NCNP): Fall 2017

anne-woods-lisa-bonsall-at-ncnp-(1).JPGEarlier this month, we had a great showing of advanced practice nurses for our fall National Conference for Nurse Practitioners (NCNP). It was one week after Nursing Management Congress2017 and one week after the deadly mass shooting in Las Vegas. Being in town for both conferences was an experience – as we shifted gears for a different group of nursing professionals and also remained a presence in a city that was dealing with tragedy and starting to heal.

As a frequent attendee at NCNP, I often attend a wide variety of topics and speakers. With my background in critical care and women’s health, I am interested in both the acute care and primary care sessions. I had the opportunity this time to meet and learn from new experts and I found myself picking up on a certain theme, which I didn’t realize when I originally registered and picked my sessions! I think you’ll pick up on this as you read through some of these clinical and professional pearls that I picked up at the conference…

“Isn’t it time that nursing is referred to as one of the STEM [science, technology, engineering, and mathematics] professions?”
Keynote Address: Finding Your NP Voice
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP
 
“A high HDL cholesterol is only as good as a low LDL.”
Dyslipidemia: Going Beyond the Current Treatment Options
Joyce L. Ross, MSN, CRNP, CLS, FNLA, FPCNA
 
“One in four heroin users started with prescription opioids.”
New Trends in Street Drugs and Legal Highs Part 1
Andrea Efre, DNP, ARNP, ANP-BC
 
“The opioid OD triad: unresponsive/coma, respiratory depression/failure, and CNS depression (mioisis).”
New Trends in Street Drugs and Legal Highs Part 2
Andrea Efre, DNP, ARNP, ANP-BC
 
“When calculating the anion gap, for every one gram decrease in albumin from normal, add 2.5 to anion gap.”
Understanding Sepsis
Sophia Chu Rodgers, FNP, ACNP, FAANP, FCCM, FAANP
 
“Repeated doses of ibuprofen and acetaminophen can prolong the duration of a viral illness.”
Antimicrobial Update: A Focus on Respiratory Infections
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP
 
“Adverse drug reactions are responsible for an increase of two days for hospital length of stay.”
Pharmacogenomics and Chronic Pain: Putting Science Back Into the Treatment of Pain
Brett Badgley Snodgrass, MSN, FNP-BC
 
“Herbal and dietary supplements are at least the fourth most common cause of drug-induced hepatic disease necessitation liver transplant.”
5 Things I Wish I Knew Last Year
Louis Kuritzky, MD
 
“Prescribing cascade refers to when a new problem arises that is associated with the side effect of a medication and additional medications are added to treat it.”
Polypharmacy: What the Nurse Practitioner Should Know
Audrey M. Stevenson, PhD, MPH, MSN, FNP-BC
 
The theme I’m referring to above is drug information. These pearls are just a handful from the sessions I attended. There were also sessions on pharmacologic management of dementia, biologics, hormone replacement, direct oral anticoagulants, sleep medications, medical marijuana, opioid prescribing, non-opioid analgesics, and pharmacologic management of obesity. Wow!
 
I also attended back-to-back sessions on street drugs and spent some time with the Drug Enforcement Agency in the Exhibit Hall. The current opioid epidemic in the United States is not just a big city problem; it’s happening no matter where you are, among all ages, and it’s a big concern. Think about the prescribing you do on a daily basis. Drug approvals, indications, and warnings are constantly changing, and we must keep our knowledge up-to-date. Now, think about the number of drug overdoses you see, or patients and families that you know are dealing with addiction. These numbers are rising and, as nurse practitioners, we have a responsibility to appropriately assess and manage pain, and prescribe responsibly.

 
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Posted: 10/27/2017 11:00:34 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Continuing Education


Lippincott NursingCenter.com Announces a Donation Campaign to the American Red Cross

In a time following numerous natural disasters and the deadliest mass shooting in modern U.S. history, healthcare professionals are reminded how vitally important emergency preparedness protocols are in times of crisis. However, the rippling side effects continue after the initial impact of traumatic incidents. Crises of this size and scale can trigger post-traumatic stress disorder (PTSD) among anyone who experiences or witnesses the traumatic event. In the wake of these recent events, Lippincott NursingCenter.com is offering a PTSD continuing education (CE) collection for $1.00 until 12/31/2017. All proceeds from this collection will be donated to the American Red Cross.

Recognizing PTSD Symptoms
Nurses are in the position to make an impact in times of crisis beyond providing acute patient care. In the aftermath, recognizing the signs of post-traumatic stress disorder (PTSD) is critically important. Managing PTSD in patients and, at times, amongst peers requires nurses to stay in-the-know on what classifies as PTSD and how they can deliver care. The National Institutes for Mental Health identifies four diagnostic criteria for PTSD (National Institute of Mental Health, 2016):

  1. At least one re-experiencing symptom (flashbacks, bad dreams, frightening thoughts)
  2. At least one avoidance symptom (staying away from places that are reminders of the trauma, avoiding related thoughts and feelings)
  3. At least two arousal and reactivity symptoms (startling easily, feeling tense, sleeping difficulty, angry outbursts)
  4. At least two cognition and mood symptoms (trouble remembering key features of the trauma, negative thoughts about self or the world, guilt or blame, loss of interest in enjoyable activities)

Continuing Education
It is imperative for nurses to perpetually learn and prepare for crises of this nature in an effort to provide optimal patient care and patient outcomes. Lippincott NursingCenter.com offers an array of free journal articles and resources that can be found here to help nurses be prepared to exercise their training in an unpremeditated situation and successfully recognize and manage PTSD in patients and peers.


                                                                More Reading & Resources
                                                              Focus On: Post-Traumatic Stress Disorder

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Posted: 10/20/2017 10:31:07 AM by Lindsey Lynch | with 6 comments

Categories: Diseases & Conditions


Plunging Forward in the Aftermath of the Las Vegas Tragedy

Las Vegas is different this week. And that’s no surprise. This city has been shocked by the largest mass shooting in modern U.S. history. Some of us were here that day; some of us flew in on Monday. All of us are safe. All of us are deeply saddened. All of us want to do something to help.

Nursing Management Congress 2017, our annual conference for nurse leaders, is taking place this week at The Mirage Casino & Resort. Conference staff and attendees came to Las Vegas to continue our tradition. And while it’s been a different mood here this week, we will not let the actions of one person stop us from learning, networking, and supporting one another. We’re nurses. We are here and we are here to help.


What we’ve been doing

Upon arrival here, our conference chairperson, Pamela Hunt, BS, MSN, RN, NE-BC, immediately contacted University Medical Center to see how our large group of nurse leaders could best serve their network. Because of the overwhelming response from local businesses and volunteers, our services have not been required on-site. Like many all over the world, we have been thinking and praying for the victims and their families, and all the first responders and health care providers.
 
 “We are truly saddened and heartbroken at the recent events and tragedy in Las Vegas. While we continue to hold the victims and families in our thoughts and prayers – we are a resilient and dedicated group of nursing professionals who have gathered for a week of learning, education and networking. Our goal is to remain committed to providing strategies for improving the quality and cost-effectiveness of care delivery as nursing best practices. And no one will take that from us.”
-Pamela Hunt, BS, MSN, RN, NE-BC, Nursing Management Congress2017 Chairperson

NMC-Dr-Cheatham.JPGIn a sad coincidence, the topic of the keynote address was Orlando Active Shooter: Lessons Learned.  We all listened closely to this sobering presentation from Michael L. Cheatham, MD, FACS, FCCM, Chief Surgical Quality Officer, Orlando Regional Medical Center. Dr. Cheatham emphasized the importance of preparation and drills, focusing on being ready when, not if, the next mass casualty occurs.

Here are some things other things I learned:
  • There have been 273 mass casualty events this year as a result of gun violence.
  • During a mass casualty event, the Health Insurance Portability and Accountability Act (HIPAA) allows sharing of names and conditions to identify victims.
  • While we know gun violence is a public health crisis, the Dickey Amendment prohibits the use of federal funds to study this issue.
  • Stop the Bleed is an initiative to train the public how to help in a bleeding emergency. 
 In coordination with the Mirage Casino & Resort, a blood drive was organized to be held here at the conference. We are proud of the nurse leaders who are lining up to contribute to this cause! As nurses, we know how important it is to have an adequate supply of blood products for a typical shift. I can only imagine the number of units of blood that have been transfused at UMC over the past several days.
NMC-Blood-Drive.JPG NMC-Heroes-Thank-you.JPG   
 

What you can do

Thousands of people attended the outdoor concert on Sunday, October 1, 2017. There were also many witnesses including hotel guests, entertainers, and employees in the tourism industry  During a cab ride from the airport to Nursing Management Congress, Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN, Executive Director, Continuing Education, listened to her taxi driver share her experience driving many frightened concert-goers away from Mandalay Bay. The driver kept repeating “I was in shock.”.

Unlike many other mass casualty events that had a local impact, the survivors and witnesses who were tourists in Las Vegas will be heading home to their communities around the U.S. They may present to your health system, clinic, or office for health care in the coming months. They may experience post-traumatic stress disorder (PTSD). Will you be able to recognize it?
 
The National Institutes for Mental Health identifies four diagnostic criteria for PTSD (National Institute of Mental Health, 2016):
  1. At least one re-experiencing symptom (flashbacks, bad dreams, frightening thoughts)
  2. At least one avoidance symptom (staying away from places that are reminders of the trauma, avoiding related thoughts and feelings)
  3. At least two arousal and reactivity symptoms (startling easily, feeling tense, sleeping difficulty, angry outbursts)
  4. At least two cognition and mood symptoms (trouble remembering key features of the trauma, negative thoughts about self or the world, guilt or blame, loss of interest in enjoyable activities)
It is critical for all of us to be prepared both for the occurrence of mass casualty events and for the care of patients who are affected as a result. Recognize the importance of preparation and drills. Make sure your institution has a Hospital Incident Command Center. Ask questions. Get involved. Be prepared.
Reference
National Institute of Mental Health. (2016, February). Post-Traumatic Stress Disorder. Retrieved from National Institute of Mental Health: https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
 
Lisa Bonsall, MSN, RN, CRNP
Senior Clinical Editor, Lippincott NursingCenter.com
 
Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Executive Director, Continuing Education
 
 
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Posted: 10/5/2017 8:20:27 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories:


Inspired Nurses Calendar 2017: I’m Just Like You

Lippincott NursingCenter.com is partnering with Lippincott Solutions to bring you an inspired nurse’s story every month. Here is September’s nurse story, “I’m Just Like You.”
 
September-2017.jpgI’m Just Like You
Angela Townsend, BSN, RN
Home Health
 
When I was 17, I was diagnosed with Type 1 Diabetes. It was at that moment when I decided to become a nurse. I've found that my own personal experience having a chronic illness has not only increased my understanding and passion for teaching others with diabetes, it has allowed me an empathy towards my patients that I never thought possible. I teach my patients about their illnesses and let them know, "hey, I have to do this too." It has made my experience as a nurse in an ever-changing world of medicine, so much more rewarding!
 
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 http://lippincottsolutions.com/inspirednurses.  Be sure to check our blog every month for a new inspired nurse’s story.

 
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Posted: 9/27/2017 8:01:04 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Inspiration


What is sepsis? What the public needs to know

sepsis-is-a-medical-emergency-(2).PNGSepsis is a medical emergency. It is a complication of the body’s response to an infection that can lead to life threatening tissue damage, organ failure and death (CDC, 2017). By increasing awareness of the early signs and symptoms of sepsis and risk factors for developing sepsis, we could improve survival and decrease complications. Like many life-threatening conditions, time is of the essence. Early detection and treatment of sepsis is the cornerstone of managing this medical emergency. According to the most recent data from 2013, sepsis was the most expensive condition treated in US hospitals accounting for $23.7 billion, or 6.2% of aggregate cost for all hospitalizations (Torio & Moore, 2016). To increase awareness and improve outcomes related to sepsis, we summarized key teaching points to communicate with patients and the public about this medical emergency. 


Here are the top 10 things to teach patients and the public about sepsis:

  1. Any type of infection can lead to sepsis. The four most common are lung, urinary tract, GI tract, and skin infections (CDC, 2017). 
  2. Sepsis begins outside the hospital in 80% of those affected (CDC, 2017).
  3. Sepsis affects approximately one million people in the US annually (NIH, 2017); patients hospitalized with sepsis are eight times more likely to die during hospitalization (Hall et al. 2011). 
  4. Sepsis is the result of an abnormal inflammatory response that the body has to an infection. The overwhelming inflammatory reaction is what leads to the symptoms of sepsis and the associated organ failures.
  5. Risk factors for developing sepsis are age (those older than 65 and those under one-year old [CDC, 2017] are highest at risk); weakened immune systems due to medication or disease; and chronic illness, such as diabetes or COPD.
  6. Early signs and symptoms of sepsis include fever, chills, fast heartbeat, confusion, shortness of breath, rapid breathing or severe pain (with no obvious cause).
  7. There are no specific diagnostic tests for sepsis. Diagnosis is based on clinical examination which is why it is critical to seek prompt medical attention if there is any concern for sepsis.  
  8. Taking measures to prevent infection, such as hand washing, vaccinations, and smoking cessation (since chronic lung disease is a risk factor), can help prevent infections that could lead to sepsis.
  9. There are likely genetic components and other biological factors that make some people more susceptible to developing sepsis in response to an infection. Ongoing research continues to help us understand sepsis and the optimal treatment supporting the goal to improve early diagnosis and improve outcomes. 
  10. Seek medical attention if you have an infection and any signs or symptoms of sepsis. Early identification and treatment are critical in improving survival and reducing complications.
Improving public awareness of sepsis can save lives. By educating patients and the public, you can make a difference by encouraging someone to seek treatment for this medical emergency that can potentially be overlooked and mistaken for other less threatening illness. Are there any other important items you routinely educate your patients and families about to improve awareness of sepsis? If so, please share your expertise with us.

References
Centers for Disease Control and Prevention (CDC). Sepsis Questions and Answers. Updated April 13, 2017. https://www.cdc.gov/sepsis/basic/qa.html. Accessed August 21, 2017.  
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). https://www.cdc.gov/nchs/data/databriefs/db62.htm. Accessed August 22, 2017.
Torio, C.M. & Moore, B.J. (2016). National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013. Statistical Brief #204. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. May 2016. https://www.ncbi.nlm.nih.gov/books/NBK368492/#sb204.s2. Accessed August 20, 2017
National Institutes of Health (NIH): National Institute of General Medical Sciences. Sepsis Fact Sheet. Updated January 2017. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Accessed August 22, 2017.

Megan Doble, MSN, RN, CRNP, FNP-BC, AGACNP-BC
 
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Posted: 9/19/2017 10:39:22 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Diseases & Conditions


Take an Ethical Stance!

This blonobc-logo-300.pngg is the second in the series, Nurses on Boards: Building a Healthier America. Wolters Kluwer is a Founding Strategic Partner of the Nurses on Boards Coalition

In this turbulent era in healthcare, we are all called to be cognizant of our input and its potential impact on our society and nursing, specifically in inner cities, rural America, suburban America, U.S. territories, and internationally. Sharing your input on important decisions often requires taking an ethical stance. The decision-making lenses that we use are impacted by our personal and professional core values, experiences, backgrounds, and preparedness. The American Nurses Association Code of Ethics and Nurses on Boards Coalition’s Board Core Competencies may serve as a guide as you take a stance for building a healthier America. 

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10 Key considerations in ethical decision-making for a positive outcome:

  1. Do your homework on the topic.
  2. Be objective; consider all perspectives before drawing your own conclusions.
  3. Maintain curiosity and an eagerness to explore all relevant ideas and approaches.
  4. Seek out the perspective of all stakeholders; listen with an open mind.
  5. Consider the social determinants of health.
  6. Express empathy; consider the implications of the decision on others.
  7. Provide evidence-based rationale to substantiate your position.
  8. Strive for the best possible outcomes for the benefit of all.
  9. Communicate your position with clarity, and be succinct.
  10. Engage in reflective practice.

According to Pam Rudisill, DNP, RN, MSN, NEA-BC, FAAN, Senior Vice President and Chief Nursing Officer at Community Health Systems (CHS) in Tennessee, AONE, Past President, "Nurse leaders are faced with challenges and opportunities every day that impact patient outcomes and quality of life for patients and their families. It is a moral imperative of the profession that our collective thoughts and actions model the highest ethical standards. The same principles chief nurse executives use in everyday practice are applicable to service on a board. The Code of Ethics developed by the American Nurses Association serves as a guide to assure nursing responsibilities are consistent with quality of care and ethical decision making.

Call to Action:
Your role and confidence as a nurse leader in taking an ethical stance is critical as you serve or aspire to serve on a board. We hope our column serves as a reflective tool to strengthen your ethical influence when serving on boards and in other leadership roles.
References 
American Nurses Association (2015). Code of Ethics. http://www.nursingworld.org/codeofethics
International Council of Nursing (2012). The ICN Code of Ethics for Nurses. Geneva, Switzerland. http://www.icn.ch/who-we-are/code-of-ethics-for-nurses
Nurses on Boards Coalition (2017). Board Core Competencies. http://www.nursesonboardscoalition.org
M. Lindell Joseph, PhD, RN, AONE Board of Directors and The University of Iowa College of Nursing
Laurie Benson, BSN, Executive Director, Nurses on Board Coalition                                                                    
For more information or comments contact us: maria-joseph@uiowa.edu and laurie@nursesonboardscoalition.org
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Posted: 9/17/2017 9:28:21 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Leadership


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.
 
References:
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). https://www.cdc.gov/nchs/data/databriefs/db62.htm. 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. http://doi.org/10.1097/CCM.0b013e31819def97. Accessed September 6, 2017.
National Institutes of Health (NIH): National Institute of General Medical Sciences. Sepsis Fact Sheet. Updated January 2017. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. 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. https://www.uptodate.com/contents/novel-tools-for-hemodynamic-monitoring-in-critically-ill-patients-with-shock?source=search_result&search=passive%20leg%20raise&selectedTitle=1~13#H2842418748 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).
 
Megan Doble, MSN, RN, CRNP, FNP-BC, AGACNP-BC
 
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Posted: 9/13/2017 10:07:02 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions


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