Preparing for the Worst: Active Shooter Training

In the fall of 2017, after returning from Nursing Management Congress2017 and the National Conference for Nurse Practitioners, both of which took place in Las Vegas immediately following the mass shooting at the Route 91 Harvest Festival, I received an invitation from my state nurses association to an active shooter training. I felt compelled to attend this training and vowed to write about what I learned here on this blog. I attended the training session and took extensive notes of the valuable lessons I learned. Well, time passed, and that to-do item got pushed down on my list, which both embarrasses me and teaches me a valuable lesson.

Time goes by. While we don’t forget tragedies, over time we do get caught up in the everyday chaos of our lives and think “I’ll get to that later.” On February 14th, the 18th school shooting occurred in the United States since the beginning of 2018. That’s 18 school shootings in 45 days. Unacceptable. We can’t put this on the back burner any longer.

There are many famous quotes about not being able to change others (or the world) without making changes to oneself. So, I challenge you to think about what you can do to address issues related to gun control, mental health, and protecting students, staff, and teachers. What I can do right now is share what I learned from the Pennsylvania State Police back in December of 2017 and share a list of resources to help us all be prepared for an active shooter incident.

active-shooter.jpgPennsylvania State Nurses Association Active Shooter Training: December 4, 2017
Here are some key takeaways from this presentation:
  • Many victims say, “I didn’t know what to do,” or “I was just waiting my turn to be shot.” The important lesson here is to tell people in an active shooter situation to do something. Time is a valuable commodity, and by doing something, one takes some time away from the shooter.
  • 63% of active shooter incidents are in commerce or an education environment, but no place is off limits.
  • Active shooter incidents typically evolve quickly and end (historically) within 10 to 15 minutes; 36% end before the police arrive.
  • Be prepared:
    • Mental preparation – Chaos and panic will occur. As best as you are able, trust your instincts, breathe, and remain calm.
    • Sounding the fire alarm is NOT recommended. The potential negative consequences outweigh the benefit.
      • People are complacent with fire alarms.
      • People won’t think “active shooter.”
    • Role of police – Police officers are there to neutralize the threat, not treat injured.
  • Three options (you may have to do all three):
    • Run – If you have an opportunity to escape, do so.
    • Hide – Don’t let anyone in.
    • Fight – Fight for your life with whatever you have. There is power in numbers and the shooter is typically not looking for a fight.
It is incumbent upon you to be mindful of these things and know how to react if you are involved in an active shooter situation. Think, if you were to be involved in an active shooter situation tomorrow, would you be able to answer the following:
  • Are you prepared?
  • How would you react?
  • Are others prepared?
  • Do you know what to expect?
  • What is your ability to protect?
The final thoughts of the presentation? “Be prepared and plan to survive.”

Important Resources
National Association of School Nurses: Violence in Schools
Active Shooter Resources from the FBI
U.S. Department of Homeland Security Active Shooter Preparedness
National Institute of Mental Health

More Reading
Plunging Forward in the Aftermath of the Las Vegas Tragedy
Is there a Cure for Gun Violence?
Active shooter on campus! [CE]
Active Shooters: What Emergency Nurses Need to Know


Posted: 2/17/2018 7:48:48 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

Palliative Care and Hospice Care: What’s the Difference?

As caregivers, educators, and advocates, we must understand the differences between palliative care and hospice care so that we can ensure that patients and families are getting appropriate care and services at the appropriate times.

Both palliative care and hospice care require an interdisciplinary approach, with a focus on relieving pain and managing physical and psychological symptoms, while improving quality of life. What differs is that palliative care should begin at the time of diagnosis, when possible, and can be offered at the same time as curative treatments. Hospice care is appropriate for those with a prognosis of six months or less and excludes concurrent curative treatment.

Listen in as Dr. Anne Woods and Lisa Bonsall go more in-depth on the differences and similarities between the two, and why it’s so important for nurses to be part of related conversations with patients, families, and the interdisciplinary team. 


Posted: 2/6/2018 12:02:21 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

Why Handwashing Makes Us Healthier – and Happier too!

handwashing.jpgAs nurses, we all know the importance of handwashing. We understand that germs can spread disease, and that hand hygiene can help defend against it. But still, 78 percent of all healthcare professionals tested in a recent study presented at a conference of the Association for Professionals in Infection Control and Epidemiology (APIC) didn’t wash up to the standards of the World Health Organization’s guidelines for reducing the risk of spreading infection to patients. So, why so many slackers?

Perhaps sinks or hand sanitizer dispensers aren’t always in the most convenient locations in hospitals. And if they are conveniently located, there might not always be soap or sanitizing gel in those dispensers. Or maybe it’s just that we’re rushing from one emergency or critical situation to the next, and taking time to stop and wash our hands consistently doesn’t get prioritized. Or simply because, given those same circumstances, we merely forget.

It seems so obvious, yet the importance of handwashing wasn’t always known. In 1847, a physician working in a Viennese maternity hospital with two separate clinics, one run by physicians and one run by midwives, discovered that babies delivered by physicians had nearly triple the infant mortality as babies delivered by midwives. The reason was that the doctors coming into the hospital to deliver babies had just finished up duties in the autopsy ward, thereby infecting mother and child with numerous germs acquired from their deceased patients. Once doctors were instructed to wash their hands with an antiseptic solution before delivering babies, the mortality rate plummeted.

Getting Nurses to Wash Their Hands
Solutions to promote more frequent handwashing can run the gamut for many hospitals. Implementing one of several newfangled, automated hand hygiene monitoring devices such as video-monitored direct observation systems, electronic dispenser counters, and automated hand hygiene monitoring networks can work for some. And while there is empirical proof that these types of monitoring systems work, with the budgetary constraints many hospitals face, adoption can be cost-prohibitive and therefore not an option.

While there is no universal solution, many hospitals have taken steps to further encourage handwashing by investing in alcohol-based hand rub solutions (significantly more efficient in reducing hand contamination than antiseptic soaps), both by installing wall-mounted dispensers and by providing individual containers for each healthcare worker. Changing posted messages around the hospital from, “Wash Your Hands to Protect Yourself” to “Wash Your Hands to Protect Your Patients" can be helpful, along with peer pressure and personal incentives like drawings for free monthly manicures (yes, we all know the toll that constant handwashing can have on our skin and nails).
New incentives
It’s apparent that handwashing keeps us healthier, but what isn’t noticeable is the additional, subtle psychological effect handwashing has on us all as well. The Dalai Lama tells us, “as human beings we all want to be happy and free from misery… and we have learned that the key to happiness is inner peace.” So, what if you could achieve inner peace and happiness through the simplest of daily activities – like handwashing?

A study from the University of Cologne in Germany examined how the act of washing one’s hands can positively affect us after a bad experience or stressful event while also making us feel more optimistic after recent failure. Earlier research from the University of Michigan also found that handwashing can be physically and emotionally cleansing, suggesting that this simple act can make us feel more comfortable about decisions we’ve made or actions we’ve taken.

Personally, when I finish a workout at the gym, the first thing I do is wash my hands. Somehow, this simple ritual of washing my hands afterwards provides a sense of finality and accomplishment. The workout ritual, however, is far more complex (at least for me).

The act of seeking cleanliness has two distinct meanings to us humans. The first is the obvious physical hygiene benefits. The second is more psychological in nature. Psychological studies have shown that the simple act of washing one’s hands can help you feel more optimistic, less doubtful, and even a bit morally superior – as “clean” people have been found to be more judgmental towards other people’s bad behavior. Think Lady Macbeth.

So, maybe now as we endeavor to wash our hands for the hundredth time today, recalling the Nightingale Pledge and our duty to protect our patients’ safety, we can also reflect on our own goals for self-improvement, including eating healthier, trying to exercise more, and being kinder to others and to our planet, knowing that this simple act of handwashing might be a more logical path to happiness and inner peace. Or, at least we can tell ourselves that. 
Brun-Buisson, C., Girou, E., Legrand, P., Loyeau, S., Oppein, F., (2002, August 17). Efficacy of
handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. Retrieved from NCBI, US National Library of Medicine National Institutes of Health
Johnson, N., Niles, M. (2016, June 2). Hawthorne Effect in Hand Hygiene Compliance Rates. American
Journal of Infection Control, Volume 44(Issue 6), S28-S29. Retrieved from AJIS
Kaspar, K. (2012, April 10). Washing One’s Hands After Failure Enhances Optimism but Hampers Future
Performance. Social Psychological and Personality Science, Volume 4(Issue 1), 69-73.
Retrieved from
Psyblog (n.d.). 6 Purely Psychological Effects of Washing Your Hands. Retrieved from
Deborah Baldwin
Wolters Kluwer Health


Posted: 12/3/2017 10:52:56 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

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.
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 :

Office on Women's Health. (2016, December). White Paper: Opioid Use, Misuse, and Overdose in Women. Retrieved from Women'

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:
Lynne Centrella Rudderow, MSN, RN, CRNP, WHNP-BC, CCE



Posted: 11/6/2017 8:30:56 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

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

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

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

Transmission-based isolation precautions for common pathogens

As a follow-up to our previous post on isolation guidelines, here is a list of transmission-based precautions recommended for common pathogens. 

Megan Doble, MSN, RN, CRNP
Centers for Disease Control (CDC), 2016. Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. Available at:

Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee, (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Available at:

Add this infographic to your website by copying and pasting the following embed code:



Posted: 4/9/2017 5:43:04 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions Patient Safety

Brushing up on isolation guidelines

As the influenza season begins to subside, we can take a step back and reflect on best practices. Isolation guidelines in the health care setting continue to come up year after year as an area that brings some confusion to the clinical realm. According to the CDC, on average, 200,000 persons are hospitalized with influenza-related illnesses on an annual basis. It is imperative, therefore, that we take proper precautions to prevent the spread in the health care setting. 

Influenza is transmitted from person to person through large particle respiratory droplets which can travel up to 6 feet. Transmission may also occur via contact of infectious particles to mucosal surfaces, such as when someone coughs or sneezes in close contact or on a surface.  Thus, patients with confirmed or suspected influenza must, in addition to standard precautions, adhere to droplet precautions. According to the CDC, patients with confirmed or suspected influenza should adhere to droplet precautions for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms in the health care setting. Some health care facilities may have a specific policy requiring a longer duration of adherence to droplet precautions.

Most health care facilities have an infection control nurse or department to contact if there are any questions regarding the level of transmission-based precautions. Furthermore, the CDC offers a comprehensive reference with explicit details on preventing the spread of influenza in the health care setting.

As a review, the CDC guidelines for isolation precautions are presented in the infographics below.
(Please click infographics to view larger sizes.)
Isolation-Precautions-300x750.png  Transmission-Based-Precautions-300x750.png

Megan Doble, MSN, RN, CRNP
Centers for Disease Control (CDC), 2016. Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. Available at:

Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee, (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Available at:


More Reading & Resources
Transmission-based isolation precautions for common pathogens
Evaluating Isolation Behaviors by Nurses Using Mobile Computer Workstations at the Bedside
Clinical Challenges in Isolation Care



Posted: 4/6/2017 9:34:16 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Patient Safety

Patient Safety: A personal memory and professional history

cone-164333_640.jpgIt’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 by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

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