New ways to manage pain

For those of us caring for patients, pain management is always an issue. I rarely see patients in my practice who aren't experiencing some sort of pain issue. Unfortunately, many times what I use to manage pain doesn't work for every patient.

I was glad to see in the latest issue of Nursing2010, an article addressing some of the new advances in pain management. Yvonne D"Arcy, MS, RN, CRNP, CNS does a great job discussing some of the recently developed drug delivery systems and applications for pain control. Her article, "An update on new pain medications," in the Controlling Pain column in the Nursing2010 November issue reviews topical NSAIDS, double-action oral medications that have both opioid and non-opioid activity in one drug, and a new extended release medication, Embeda, which is a combination of an extended release morphine and has a core of naltrexone, an opioid reversal agent that is activated if the drug is crushed, chewed, or dissolved. Quite a nice little abuse deterrent built right into the drug. The article also discusses a new capsaicin patch used to treat intractable pain from postherpetic neuralgia.

Without a doubt, this article will give you some new ideas to help manage your patients' pain. 

Posted by Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC

Posted: 11/5/2010 5:41:57 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

ABC is now CAB

Wow - big changes announced today by the American Heart Association! Based on recent studies demonstrating the priority of adequate circulation in saving cardiac arrest victims, chest compressions are now the first step in cardiopulmonary resuscitation (CPR). The rate of chest compressions should be 100 per minute, with a depth of at least 2 inches in adults and children and 1.5 inches in infants.

Exceptions to the new guidelines include newborns and those with primary respiratory arrest. In these victims, the steps should remain airway management, followed by rescue breathing, and then chest compressions.

Here are some helpful links with more about these changes:

Also, here are links to the abstracts from the supporting studies:

Posted: 10/18/2010 6:54:17 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

Misconceptions about pressure ulcers

The 25th Annual Clinical Symposium on Advances in Skin & Wound Care was held from September 30, to October 2, 2010 in Orlando Florida. This gathering of top wound care clinicians and presents clinical skill-building sessions for beginners in wound care as well as advanced sessions for expert clinicians and researchers. Some presentations addressed issues including inadequate education of general practitioners and misconceptions that have detrimental effects on patients and possible costly consequences including reduced reimbursement and malpractice claims. Reflect on your own practice setting to examine if these problems or misconceptions exist regarding pressure ulcers.
  • Pressure ulcers cannot be staged in the reverse.
  • Not all pressure ulcers form from the outside and become deeper. Pressure ulcers can be caused by deep tissue injury and form from the inside out.
  • Pressure ulcers are not considered “never events” by the Center for Medicare and Medicaid Services because not all pressure ulcers are avoidable.
  • Pressure ulcer staging cannot be used for other types of wounds
Take action to improve awareness by discussing these issues in journal clubs, inviting the wound care specialist in your organization to provide education, and implementing appropriate clinical practice guidelines. For more information on this subject and educational materials, go to the National Pressure Ulcer Advisory Panel website at

Posted by Karen Innocent, MS, RN, CRNP, ANP-BC, CMSRN
Posted: 10/15/2010 7:58:44 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

Where should "acute care" issues be treated?

A research article was published in the September issue of Health Affairs, that looked at how patients are using healthcare services for acute care. The study reviewed 354 million visits to healthcare institutions or healthcare providers for acute care  between 2001 and 2004. Twenty eight percent of the visits were handled by hospital emergency rooms, 22% were handled by general/family practitioners, 20% were seen by non-primary care specialists, 10% by general internists, and 7% by hospital outpatient departments.  The uninsured received more than half of their acute care in emergency departments and much of this occured on the weekends or weekday after hours. Two of the most frequent conditions seen were stomach pain and chest pain.

By definition, shouldn't "acute care" issues be seen in acute care? If you or your relative was having chest pain, would you send them to the primary care provider's office? I would hope not; you would call 911 and send them to the nearest emergency department for evaluation for an acute myocardial infarction.  If you or your relative were having severe abdominal pain, would you send them to the family practice office? No, of course not; you would send them to the nearest ED to be evaluated and have an ultrasound or CT scan done if appropriate.

I agree that our emergency departments are over taxed with patients coming in for complaints that could easily be treated in a primary care office or clinic. But, chest pain, severe stomach pain, fractures, and severe lacerations, just to name a few, need the attention of the experts who have the experience and the resources to treat those things that are clearly "acute care" issues.

Posted by Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Posted: 9/9/2010 5:06:51 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

Another flu season is just around the corner

Although the H1N1 influenza pandemic has been officially declared over (you can read the statement from the World Health Organization here), it is not too soon to start thinking about the upcoming 2010-2011 flu season. Actually, during a recent visit to our local pharmacy, I noticed the sign “Flu shots available here.” Hmmm… there is a difference between thinking and doing - is it really time to vaccinate now?

Here’s what I found:

  • The 2010-2011 flu vaccine will protect against 3 flu viruses: an H3N2 virus, an influenza B virus and the H1N1 virus.
  • Routine influenza vaccination is recommended for everyone ages 6 months and older.
  • As in the past, all children aged 6 months to 8 years who receive a seasonal influenza vaccine for the first time should receive 2 doses.
  • For the 2010-2011 season, children 6 months to 8 years who did not receive at least 1 dose of an influenza A (H1N1) 2009 monovalent vaccine should receive 2 doses of a 2010-2011 seasonal influenza vaccine.
  • And lastly, yes…the Centers for Disease Control and Prevention is encouraging health care providers to begin vaccinating patients as soon as the vaccine arrives (shipments have already begun.)

You may remember from an earlier post that I never got my flu shot or H1N1 vaccine during the 2009-2010 season. The reason was simply one of convenience, or actually, inconvenience. The vaccines weren’t available when I had a visit with my physician and then there wasn't enought staff to administer the vaccines when they did become available.

I’m planning on getting vaccinated this year. How about you?


Red Book Online Influenza Resource Page from the American Academy of Pediatrics

Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010

Posted: 8/30/2010 6:23:51 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

My patient is a little too sweet...

According to a recent article published in the American Journal of Nursing, "Diabetes under control; improving hospital care for patients with diabetes", "the American Diabetes Association estimates that people with diabetes account for 22% of hospital inpatient days, and in 2007 their in-hospital care accounted for an estimated half of the $174 billion spent in the United States on diabetes care."  These statistics are staggering; however, when you consider the number of people diagnosed with diabetes, they are not surprising.  Every day we manage patients with hyperglycemia, some are diabetics and some are not. The article in AJN points out that hyperglycemia in the acute care setting can be indicative of  a diagnosis of diabetes, undiagnosed diabetes or prediabetes, or transient stress hyperglycemia, which can result from the stress of illness.  As we all know, a fingerstick glucose reading is a snap-shot in time of the blood glucose.  In no way is it indicative of the glycemic control of the patient. 

Hemoglobin A1C gives clinicians a more accurate picture of the patient's blood glucose control over the past 60 to 90 days. In people without diabetes, the A1C is around 5%.  The American Diabetes Association recommends that diabetics have an A1C of 7% or less as a goal for good glycemic control.  So why is the A1C an important lab value in acute care?  Research has shown that patients who maintain glycemic control have better outcomes than those who don't. Knowing the A1C will help you manage the patient's blood glucose more effectively and efficiently and can aid in discharge planning.  Research has shown you can't maintain glycemic control in diabetics by just using short acting insulin to cover meals.  The patient must have an oral agent or a long acting insulin in addition to the short acting insulin.

Does your institution have a policy to to identify elevated blood glucose in all hospitalized patients, not just the ones who have the diagnosis of diabetes?  Is your standard of care to control hyperglycemia in all patients?  If you want more information on how to implement this standard at your hospital, read the June issue of AJN, "Diabetes under control, improivng hospital care for patients with diabetes".

Posted by Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC

Posted: 6/16/2010 6:18:56 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

H1N1 ~ Details from the past year

A headline from last week about determining the end of the 2009 H1N1 influenza pandemic caught my eye. Was it really officially over?

While searching for this answer or at least information about declaring the end of a pandemic, I came across a comprehensive summary of pandemic H1N1 in the May 6th issue of The New England Journal of Medicine. I thought I’d share some highlights with you:

Estimates of cases in the U.S. (as of February 2010):
*59 million illnesses
*265,000 hospitalizations
*12,000 deaths

International information:
*Almost all countries have reported cases
*More than 17,700 deaths among laboratory-confirmed cases

Hospitalization rates were highest for those younger than 5 years (especially age 1 year and younger) and lowest for those over 65 years. Certain groups have been overrepresented among those with severe 2009 H1N1 virus infection. These groups include pregnant women (especially in 2nd and 3rd trimester), women less than 2 weeks postpartum, and patients with immunosuppression or neurologic disorders. Also, severe obesity or morbid obesity has been shown to contribute to the risk of severe or fatal disease.

So, is the pandemic over? An expert panel of the World Health Organization will review the status of 2009 H1N1 influenza later this month or in early June.  I’ll keep you posted!

Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza,
Clinical Aspects of Pandemic 2009 Influenza A (H1N1) Virus Infection
N Engl J Med 2010 362: 1708-1719

Posted: 5/16/2010 6:29:21 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

Get up to speed on Kawasaki disease

Several weeks ago, my goddaughter was diagnosed with Kawasaki disease (KD). Luckily, her pediatrician had seen this before (although only in the distant past) and diagnosed her and initiated treatment early in the course of the disease. Both her mother (also an NP) and I had never heard of this rare condition, and yet while spreading the word to family and friends, several people had a Kawasaki story to share.

Whether you have young children of your own, know someone with young children, or care for young children, it is important to be aware of this rare, yet serious disease. My goddaughter had most, if not all, of the classic signs and symptoms:

• persistent, high fever
• red eyes
• red lips
• red tongue with white coating
• red palms of hands and soles of feet
• swollen lymph nodes
• joint swelling and pain
• swollen hands and feet
• skin rash (worse in the groin area).

KD causes inflammation of the blood vessels and the major risk is the possible development of aneurysms in the coronary arteries. Fortunately, she received the standard treatment of IVIG and high-dose aspirin and is doing well.

Want to learn more?
• Kawasaki Disease Foundation
• Short film to raise awareness of KD  (Kawasaki Disease Foundation)
• American Heart Association: Kawasaki Disease

Posted: 4/26/2010 5:40:03 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

The "D"s have it

What type of personality did the last cardiac patient you took care of have?  When I think about my last cardiac patient, a Type "A" personality automatically comes to mind. But, an article in the American Journal of Cardiology may change our perception about who is having a heart attack. The article I am referring to looked at patients who either had a myocardial infarction or died of it. People with a Type "D" personality had triple the risk of having an MI or dying of an MI. What does a Type "D" personality look like you ask? It's someone who is angry or suppresses their anger. 

This makes a lot of sense when you think about it. Someone who is always angry or suppresses their anger, does sound like quite a few of the cardiac patients I've taken care of recently. Do we tell patients to let loose with their anger? Of course not. We need to help educate these patients in anger management techniques and connect them with a counselor who can teach them to handle their emotions in a more constructive way.  

So next time you take care of a patient experiencing a cardiac event, don't be so quick to give them an "A". They may be a "D" after all.

Posted by Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC

Posted: 4/21/2010 7:01:18 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

Putting a face on ostomy complications

Both the American Journal of Nursing and Nursing2010 published articles in their February issues on ostomy management and complications.  I read these articles with great personal interest but I wondered, where were these articles 10 years ago? 

My oldest daughter was diagnosed with ulcerative colitis when she was 7 years old and despite aggressive treatment for her disease; she required a total colectomy, temporary ileostomy, and an ileo-anal anastamosis when she was 12.  As a nurse I thought I was equipped to care for her ileostomy; was I ever wrong.  I had experience taking care of hospitalized patients with ostomies, but I quickly learned caring for someone who is active is a totally different story. The 3 months she had her ileostomy were sheer hell!  She developed a multitude of complications and we went through several different types of appliances before we found the one that fit her and wouldn’t fall off when she moved. The nurses who were helping us were good but, it was clear there wasn’t a real understanding of how to manage active patients, let alone children, and their complications. 

I am thankful that my daughter is well. If you ask her, she will tell you that the date of her surgery was the beginning of her new life.  But she will also tell you, living with an ostomy was the most challenging experience she has ever endured.  Thank goodness we now have access to the information and equipment that can make an active person’s experience living with an ostomy better.     

Posted by Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC

Posted: 2/17/2010 7:09:17 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions

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