2022 Illinois Renewal Bundle

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The following course content

This 2022 Illinois Renewal Bundle meets renewal requirements for Illinois LPNs and RNs. Upon completion of this course, you will receive a certificate of completion for 20 CE contact hours.  

This course is accredited and approved by American Nurses Credentialing Center (ANCC) (Provider Number: P0614) and includes multiple interesting topics in one easy course. 

 Course Outline

1. Illinois Implicit Bias Training 
2. Illinois Sexual Harassment Prevention 
3. End of Life Care for Geriatric Patients
4. Nursing Interventions for Sepsis: Fluid Management 
5. Alzheimer’s Nursing Care
6. Nursing Care for Pediatric Patients by Stage of Development
7. Opioid Abuse
8. Vaping Induced Lung Injuries
9. LGBTQ Cultural Competence
10. Following a DNR: An Ethical Dilemma in Nursing
11. Effective Communication in Nursing
12. Nursing Documentation 101

Illinois Implicit Bias Training

Introduction

Health equity is a rising area of focus in the healthcare field, as renewed attention is being given to ongoing data covering discrepancies and gaps in the accessibility, expanse, and quality of healthcare delivered across racial, gender, cultural, and other groups. Yes, there are some differences in healthcare outcomes purely based on biological differences between people of different genders or races, but more evidence points to the vast majority of healthcare gaps stemming from individual and systemic biases.  

Policy change and restructuring are happening at institutional levels across the country, but this will only get us so far. In order for real change to occur and the gaps in healthcare to close, there must also be awareness and change on an individual level. Implicit, or subconscious, bias has the potential to change the way healthcare professionals deliver care in subtle but meaningful ways and must be addressed to modernize healthcare and reach true equity. 

This implicit bias training meets the “Implicit Bias Training for Healthcare Workers” requirement needed for Illinois nursing license renewal.  

What is Implicit Bias?

So what is implicit bias and how is it affecting the way healthcare is delivered? Simply put, implicit bias is a subconscious attitude or opinion about a person or group of people that has the potential to influence the actions and decisions taken when providing care. This differs from explicit bias, which is a conscious and controllable attitude (using racial slurs, making sexist comments, etc.). Implicit bias is something that everyone has to some capacity, whether we are fully aware of it or not and it can influence our understanding of and actions towards others. The way we are raised, our unique life experiences, and individual efforts to understand our own biases all affect the opinions and attitudes we have towards other people or groups (6). 

Of course, this can be both a positive or a negative thing. For example, if a patient’s loved one tells you that they are a nurse, you may immediately feel more connected to them and go above and beyond the expected care as a “professional courtesy.” This does not mean that you dislike your other patients or their loved ones, it just means that you feel more at ease in the presence of another healthcare professional and this shapes your thoughts and behaviors in a positive manner.  

However, this is a rare case. Oftentimes, implicit biases have a negative connotation and can lead to care that is not as empathetic, holistic, or high quality as it should be. Common examples of implicit bias in healthcare include:  

• Thinking elderly patients have lower cognitive or physical abilities 
• Thinking women exaggerate their pain or have too many complaints 
• Assuming patients who state they are sexually active are heterosexual  
• Thinking Black patients delay seeking preventative or acute care because they are passive about their health 
• Assuming a chatty college student is asking for ADHD evaluation because she is lazy and wants medication to make things easier 

On a larger, more institutional and societal level, the effects of bias create barriers such as: 

• Underrepresentation of minority races as providers: in 2018, 56.2% of physicians were white, while only 5% were Black and 5.8% Hispanic (2). 
• Crowded living conditions and food deserts for minority patients due to outdated zoning laws created during times of segregation (15). 
• Difficulty obtaining health insurance for minority or LGBTQ clients, decreasing access to healthcare (3). 
• Lack of support and acceptance for LGBTQ populations in the home, workplace, or school as well as a lack of community resources can lead to negative social and mental health outcomes. 
• Due to variations in the way disabilities are assessed, the reported prevalence of disabilities ranges from 12% to 30% of the general population (13). 

Implications

Once you have an understanding of what implicit bias in healthcare is, you may be wondering what it looks like on a larger scale and what it means in terms of healthcare discrepancies. In order to address ways that those in healthcare can identify, address, and overcome implicit biases later in this implicit bias training, we must first cover its implications and outcomes. Listed below are just a few examples of outcomes stemming from subconscious biases in healthcare:

• Medical training and textbooks are mostly commonly centered around white patients, even though many rashes and conditions may look very different in patients with darker skin or different hair textures. This can lead to missed or delayed diagnoses and treatment for patients of color (8).  
• A 2018 survey of LGBTQ youth revealed that 80% reported that their provider assumed they were straight or did not ask otherwise (11).  
• In 2014, a post-physician appointment survey showcased that over half of gay men (56%) respondents reported that they had never been recommended for HIV screening, despite their increased risk for contraction (9).  
• A 2010 study found that women were more verbose in their encounters with physicians and felt unable to fit all of their complaints into the designated appointment time, leading to a less accurate understanding of their symptoms by their doctor (4). For centuries, any symptoms or behaviors that women displayed (largely related to mental health) that male doctors could not diagnose fell under the umbrella of “hysteria,” a condition that was not removed from the DSM-III until 1980 (18).  
• When treating elderly patients, providers may dismiss a treatable condition as part of aging, skip preventative screenings due to old age, or over-treat natural parts of aging as though they are a disease. Providers may be less patient, responsive, and empathetic to a patient’s concerns because they believe them to be cognitively impaired (16).  

Although these are only a few examples, there are obvious and substantial consequences of these biases; which is why it is vital that we address them in this implicit bias training course.  

Below, are just a few more examples of what the long-term effects of what implicit biases in healthcare can lead to if both institutional and personal behaviors are not addressed:  

• A 2020 study found that Black individuals over the age of 56 experience decline in memory, executive function, and global cognition at a rate much faster than white individuals. Data in this study attributes this difference to the cumulative effects of chronic high blood pressure more likely to be experienced and under-treated for Black Americans (14). 
• Lack of health insurance keeps many minority patients from seeking care at all. 25% of Hispanic people, 14% of Black people 8.5% of white people are uninsured in the U.S. This leads to a lack of preventative care and screenings, a lack of management of chronic conditions, delayed or no treatment for acute conditions, and a later diagnosis with poorer outcomes of life threatening conditions (3). 
• A 2010 study reported men and women over age 65 were equally likely to have visits with a primary care provider, but women were less likely to receive preventative care such as flu vaccines (75.4%) and cholesterol screening (87.3%) compared to men (77.3% and 88.8%, respectively) (4).  
• About 12.9% of school aged boys are diagnosed and treated for ADHD, compared to 5.6% of girls, though the actual rate of girls with the disorder is believed to be much higher (5).  
• Teenagers and young adults who are part of the LGBTQ community are 4.5 times more likely to attempt suicide than straight, cis-gender peers (10).  

Exploring Areas of Bias

Culture

Cultural competence is an essential topic to cover as healthcare professional. There are many training and informational programs that cover how various religions, ethnicities, or beliefs can be integrated into medical practices. Students and staff members are often reminded that the highest quality of care must also meet the cultural needs a client may have no matter if these beliefs or needs differ from the provider’s.  An awareness of the potential variances in care, such as dietary needs, desire for prayer or clergy members, rituals around birth or death, beliefs surrounding and even refusal for certain types of treatments, are all certainly very important for the culturally sensitive healthcare professional to have (and the distinctions far too many for the scope of this course); however, there is also a fine line between being aware of cultural similarities and stereotyping. Since this course is an implicit bias training, it is essential that this topic is covered. 

Clinicians should ensure that they understand that people hold different identities, beliefs, and practices across racial, ethnic, and religious groups. Remember that just because someone looks a certain way, or identifies with a certain group, does not mean all people within that group are the same. Holding assumptions about clients of a particular race or religion, without getting to know the individual needs of a client, is a form of implicit bias and may cause a client to become uncomfortable or offended.  

Simply asking clients if they have any cultural, dietary, or spiritual needs throughout the course of their care is often the best way to learn their needs without making assumptions or stereotyping. Overall, it should be thought of as extending care beyond cultural competence and working on partnership and advocacy for a client’s unique needs.  

Where Change is Needed

In order for change to occur, there is a broad spectrum of transitions in individual thought and policy that must occur. This implicit bias training will cover both individual and institutional level focuses. 

On the individual level, efforts must focus on:  

• Identifying and exploring one’s own implicit biases. Everyone has them, and we all need to reflect upon them. This goes beyond basic cultural competence and includes a deeper understanding of how one’s own experiences or environment may differ from someone else, and how these experiences might have developed specific feelings.  
• Reflecting on how one’s biases affect actions. Once one has recognized their internal opinions, they can examine ways that those opinions might have been affecting their actions, behaviors, or attitudes toward others.  
• Educating oneself and re-framing biases. In order to change patterns of thinking and subsequent behaviors that may negatively impact others, one can work on broadening their views on various topics. This can be done through reading about the experiences of others, watching informational videos or documentaries, or listening to the experiences of others and gaining an understanding of how their lives might be different than another. 
  
• Not only understanding, but celebrating differences. Once one learns to see others for their differences, it becomes easier to consider how they can achieve the best care plan and outcomes for well-being. It creates a better, and more promising approach to providing equitable care. This includes understanding differences in experiences, perceptions, cultures, languages, and realities for people different from the provider, recognizing when disparities are occurring, and advocating for change and equity.  

When enough people have recognized and addressed their own implicit biases, advocacy can extend beyond individual care of clients and reach the institutional level where change is more easily seen (though no more important than the small individual changes). One of the most effective ways to make institutional-level changes is through representation of minority groups in positions of power and decision-making.  

Simply keeping structures as they are and dictating change without any evolution from leadership is not likely to be effective in the long term. Including minority professionals in positions of leadership or on decision making panels has the most potential to make true and meaningful change for hospitals and healthcare facilities. Examples of institutional-level changes include:  

Medical school admission committees could adopt a more inclusive approach during the admission process. For example, paying more attention to the background and perspectives of their applicants and the circumstances/scenarios in which they came from as opposed to their involvement in extracurricular activities (or lack of) and former education. Incentivizing minority students to choose careers in healthcare as well as investing in their retention and success should become a priority in the admissions process (8). 

Properly training and integrating professionals like midwives and doulas into routine antenatal care and investing in practices like group visits and home births will give power back to minority women while still giving them safe choices during pregnancy (1). 

Universal health insurance, basic housing regulations, access to grocery stores, and many other sociopolitical changes could also work towards closing the gaps in accessibility to quality healthcare and may vary by geographic location. (3).  

Community programs should be available to create safe spaces for connection and acceptance. Laws and school policies can focus on how to prevent and react to bullying and violence against LGBTQ individuals (11). 

Cultural competence training in medical professions needs to include LGBTQ issues and data collection regarding this population needs to increase and be recognized as a medical necessity (11). 

Medical professionals must be trained in the history of inequality among women, particularly in regards to mental health, and proper, modern diagnostics must be used. The differences in communication styles of men and women should be taught as well (18).  

Medical facilities should emphasize respect of a client’s views on controversial topics such as pregnancy/birth, death, and acceptance or declining of treatments even if it conflicts with a staff members’ own beliefs (12).  

Healthcare facilities can adopt practices that are standardized regardless of age and include anti-ageism and geriatric focused training, including training about elder abuse (16). 

Obviously each geographic area will have differing demographics depending on the populations they serve. What works at one facility may not work at another. Hearing from the community is beneficial for keeping things individualized and allows facilities to gain perspective from the local groups they serve.  

Town hall-style meetings, keeping hospital board members and employees local rather than outsourcing from travel companies (when possible), and encouraging community involvement from staff members are all great ways to keep a community-centered facility transparent and welcoming for clients who may be having a different experience than their neighbor.  

There are many things that will need to be done in order for equitable, bias-free healthcare to become a norm nationwide. However, taking the time to learn from this implicit bias training, apply it to current practices, and continue to learn about others and their respective beliefs and cultures is just the beginning. 

Illinois Sexual Harassment Training for Nurses

Introduction

Sexual harassment is a serious issue within the healthcare workplace. In one study, more than 70% of female staff nurses reported having been harassed by male coworkers or male patients (1). In another study, 35% of student nurses reported having experienced sexual harassment in the previous year. 

The most likely perpetrators for both student nurses and registered nurses were patients. However, physicians and male staff were most likely to be perpetrators of sexual harassment toward registered nurses (2). It is important to remember that sexual harassment is not limited to female registered nurses; male nurses are also at risk of experiencing sexual harassment in the workplace. 

The impacts of sexual harassment affect nurses in many negative ways. There are obvious psychological consequences, but there is also evidence to suggest that work performance can also be affected (3). Many states, including Illinois, have recognized the significant impact of this issue and have taken measures to empower nurses to prevent and/or address sexual harassment. 

Why are Nurses Vulnerable to Sexual Harassment?

Not everyone has undergone training, such as with the valuable preparation you are getting through this Illinois Sexual Harassment training. Even so, nurses are vulnerable to sexual harassment by the very nature of their position. The role of nursing transgresses societal norms regarding physical contact and involves intimate care of patients both physically and emotionally. This role is often exploited by perpetrators – they may take advantage of a nurse’s position and caring demeanor as a means to harass them (3).

Staff-on-staff harassment is also commonly reported by nurses (1). Nurses are pre-disposed to this type of harassment due to their subservient position to many staff members (physicians, administration) and the subsequent power imbalance that results.

What is Sexual Harassment?

Sexual harassment is commonly thought to be unwelcome contact. However, sexual harassment takes many forms. It can be defined as unwelcome sexual behaviors or actions which may be verbal, physical, mental or visual (4).

Listed below are some common examples of potential sexual harassment:

• Actual or attempted rape or sexual assault.
• Pressure for sexual favors.
• Deliberate touching, leaning over, or cornering.
• Sexual looks or gestures.
• Letters, telephone calls, personal e-mails, texts, or other materials of a sexual nature.
• Pressure for dates.
• Sexual teasing, jokes, remarks, or questions.
• Referring to an adults as “girl,” “hunk,” “doll.” “babe,” “honey,” or other similar terms.
• Whistling at someone.
• Turning work discussions to sexual topics.
• Asking about sexual fantasies, preferences, or history.
• Sexual comments, innuendos, or sexual stories.
• Sexual comments about a person’s clothing, anatomy, or looks.
• Kissing sounds, howling and smacking lips.
• Telling lies or spreading rumors about a person’s sex life.
• Neck and/or shoulder massage.
• Touching an employee’s clothing, hair, or body (6).

Here is how sexual harassment is defined in the Illinois Ethics act, which governs state officials and employees:

“…Any unwelcome sexual advances, requests for sexual favors, or any conduct of sexual nature when:

1. Submission to such conduct is made either explicitly or implicitly a term of condition of an individuals’ employment.
2. Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual or
3. Such conduct has the purpose of effect of substantially interfering with an individuals’ work performance or creating an intimidating, hostile or offensive working environment.

For the purposes of this definition, the phrase “working environment” is not limited to a physical location an employee is assigned to perform his or her duties and does not require an employment relationship (5).”

As you can see, the definition of sexual harassment, according to this Illinois sexual harassment training, is broad and can encompass many situations. Though the Illinois Ethics Act primarily relates to employee-employer sexual harassment, there are many other scenarios, such as sexual harassment by patients

Key Points for Sexual Harassment

Sexual conduct vs. sexual harassment – Sexual behavior turns into sexual harassment when the recipient receives the behavior in an unwelcome manner. The term “unwelcome” refers to unsolicited or uninvited behavior and undesirable or offensive behavior.

Females and males can both be victims – Any unwelcome sexual behavior may be considered sexual harassment, regardless of the gender of the perpetrator and recipient. Male-on-male, female-on-female, female-on-male, and male-on-female types of harassment may occur.

Sexual harassment can affect witnesses – Anyone who is affected by the sexually offensive conduct may be a victim. This may include a person witnessing or overhearing sexually harassing behavior (6).

It can occur outside the working environment – The “working environment” is not limited to the physical location of work. A “working environment” may be extended to any location where work occurs, such as remote locations, off-site locations, and temporary working locations (6).

It doesn’t only occur in person – Sexual harassment can occur on and off the clock. It can occur physically and electronically. Unwelcome sexual conduct through email, phone calls, texts, social media postings and other mediums may constitute sexual harassment.

Two Types of Sexual Harassment

Quid pro Quo

Quid pro quo means “A favor for a favor.” In this sense, it refers to an authority figure (manager or supervisor) requesting a sexual favor in exchange for preferential treatment. This could be in the form of a promotion, raise, preferred assignment or any other job benefit which they may affect (6).

Hostile Work Environment

Another method by which an individual may coerce sexual favors is through the threat or actuality of a hostile work environment. This refers to creating or threatening to create an intimidating, hostile, or offensive work environment in order to influence sexual favors or behavior.

What Should Nurses Do If They Experience Sexual Harassment?

If you feel you have been the victim of unwelcome sexual behavior (sexual harassment) there are avenues available to you for support and to report the behavior.

While it may not be an easy thing to do (or even possible), try to make it known that the sexual behavior is unwelcome and unwanted. It is your right to inform the person of your stance and to demand the behavior cease. Though this can be difficult and uncomfortable, it is often the most effective method (7).

You should be explicit in explaining the behaviors which are unwelcome so that the perpetrator can fully understand his/her actions. If you are uncomfortable confronting the perpetrator, consider confiding in a close friend or supervisor who can accompany you or advise you on next steps.

Next, document the scenario. Write down all details you can recall including any witnesses. This can be helpful in the future.

Reporting the issue is the next step.

How or whether you report the sexual harassment is a personal choice and you are not limited. Remember that according to Illinois law you are entitled to a workplace free of sexual harassment. There are several options for reporting sexual harassment, and there are several nuances with jurisdiction and handling of complaints.

1. Within Your Organization

You may contact your supervisor or human resources representative to report an incident. This is often a more comfortable route for nurses as they may be familiar with these individuals. Your organization should have policies and procedures for handling sexual harassment reports which may include escalation to other organizations, such as IDHR and law enforcement as necessary. This is often the fastest method for reporting. Remember that reporting to your supervisor, ethics officer, or human resources official does not preclude you from reporting to other agencies as appropriate. If you wish to remain anonymous, check with your organization to see if they have a policy that gives you that option.

2. Illinois Department of Human Rights

The IDHR is responsible for administering the Illinois Human Right Act. The IDHR views and sexual harassment as a civil rights violation. The IDHR will investigate complaints and determine if “substantial evidence” for harassment exists, which may provide relief for the complainant and punishment for the accused. Nurses can report to the IDHR by going to www.illinois.gov/dhr/FilingaCharge/Pages/Intake.aspx and filing the requisite information, or by calling 1-800-662-3942 (8). Note: complaints must be made within 300 days of the incident.

The State of Illinois has an agreement with the Chicago Lighthouse Call Center, which operates a 24/7 helpline for victims of sexual harassment and discrimination. By calling, nurses can learn their options for reporting incidents, can file an anonymous report, and can be referred to appropriate agencies. Any information given during the call is confidential.

3. Law Enforcement

Criminal incidents of sexual harassment may be reported to law enforcement as appropriate. Often times your supervisor or human resource officer can assist in determining if this is necessary. If you ever feel that your physical safety is threatened, do not hesitate to contact law enforcement.

4. Office of Executive Inspector General (State Government Employees)

State employees or anyone under the jurisdiction of the OEIG may file a report directly with the OEIG. To initiate a report, it is best to contact your ethics officer for guidance.

5. U.S. Equal Employment Opportunity Commission

Sexual harassment is a violation of section 703 VII. The EOCC is charged with administering this statute and provides another option of relief for those who have experienced sexual harassment. The statute for reporting an offense to the EOCC is 180 days. Of note, the EOCC may hold employers responsible for taking all steps to create an environment free of sexual harassment and can offer an additional avenue for support (9).

Illinois Sexual Harassment Training for Nurses – Whistleblower Protections

Retaliation for reporting sexual harassment is illegal under both federal and state statutes. The Illinois Human Rights Act explicitly prohibits retaliation for reporting sexual harassment. Retaliation is defined as “conduct intended to deter or dissuade a person from making a complaint or filing a report of sexual harassment, or participating in an investigation conducted by the Illinois Department of Human Right or other similar agency” (Illinois Department of Human Right, reference #10). Additionally, the U.S. Equal Employment Opportunity Commission prohibits retaliation aimed at employees who assert their rights to be free of harassment (11).

Conclusion

Sexual harassment can take place in many venues and formats. It is broadly defined as any unwanted or unwelcome sexual behaviors. Sexual harassment is experienced frequently by nursing professionals due to the nature of their positions. You have a right per the state of Illinois and Federal law to be free of sexual harassment in the workplace.

If you experience sexual harassment, you should tell the harasser to stop and report the incident in one of the various methods listed above. Do not forget to document the incident and any reporting thoroughly.

You have a right to report sexual harassment without retaliation, per both Illinois law and Federal laws. This Illinois sexual harassment training has adequately prepared you to do so in the event a situation arises.

End of Life Care for Geriatric Patients

In this course we will discuss some of the major considerations all nurses should be aware of when providing end-of-life care. This course is specific to geriatric patients but can be applied to patients of any age in any setting, as many of the principles remain the same.

What is End of Life Care?

End of life nursing care encompasses a wide range of aspects of care, to include symptom management, appropriate pain management, ensuring patient and family education and support during the death and dying process, providing culturally sensitive care, and ensuring the decision-making process remains ethical (6). Nurses are an integral part of the end of life process and should be sure to be an active advocate for their patients and families. 

End of Life Care vs. Palliative Care

End of life care and palliative care are two terms that are used interchangeably, but are two very different things. Palliative care refers to pain and symptom management during “any time in the trajectory of serious illness or injury and does not replace curative interventions” (8). This means that anyone experiencing a serious illness or injury can receive palliative care to manage symptoms, and doesn’t necessarily mean that they are beginning the dying process. Palliative care can be delivered as either a separate service or the primary care team, and can be given in a variety of settings to include intensive care, inpatient wards, outpatient clinics, and long term care or rehabilitation facilities. In contrast, end of life care (also known as hospice care) refers to patient care before and during the dying process. It may be initiated before, during or after curative treatment and is meant to focus on a patient’s comfort rather than a cure (8). End of life care can be provided in the comfort of the patient’s home, in a long term care facility, or in a hospital. 

End of Life Care Considerations 

End of life care should be given to anyone who is “near the end of life and have stopped treatment to cure or control their disease” (13). It can also be considered for those who are undergoing a curative treatment. 

Talking frankly about end of life care planning is important, and should be done often in collaboration with patients and their families. Nurses should be active in this planning phase, ensuring that the patient and all involved family members understand the death and dying process, all available treatment options that have been presented by the health care team, and all the different methods available to control pain and symptoms. Talking about end of life options early is imperative – by broaching the subject before pain and symptom management become an issue, the nurse can ensure that the patient is an active participant in creating their care plan and final wishes.

Types of End of Life Care

End of life care planning can include a few different things: 

Hospice Care

As was mentioned above, hospice care focuses on pain and symptom management during a chronic illness that will ultimately cause the patient to die. Also known as “comfort care,” hospice can be initiated in several instances: 

• During a curative treatment 
• If a patient wishes not to continue with curative treatment 
• The curative treatment has failed 
• The patient wishes not to pursue curative treatment 
• After withdrawal of lifesaving interventions (ventilatory support, vasopressors, etc.) 

Do Not Resuscitate (DNR)/Do Not Intubate (DNI)

A patient has the right to refuse resuscitation or intubation and mechanical ventilation in the event that they would need it, if they are of sound mind and are able to make their own medical decisions. A Do Not Resuscitate (DNR) order is written by a medical doctor and instructs the health care team not to initiate cardiopulmonary resuscitation (CPR) if the patient experiences a cardiac or respiratory arrest. The order is written only after discussion with the patient. If the patient is not able to make medical decisions, a doctor may discuss options with a designated healthcare proxy. A DNR order does not cover any other lifesaving interventions. A Do Not Intubate (DNI) order is also written by a doctor and states that a patient does not wish to have an artificial airway placed should they experience respiratory arrest. It is possible for a patient to be a DNI but still wish to have CPR in the case of cardiac arrest (9). 

Once a DNR/DNI order is in place, if it is at the patient’s request, the family cannot override it. If a patient has requested a DNR/DNI order but then changes their mind, they have the right to revoke it at any time. A DNR/DNI order must be respected, it is a legal, binding document. As such, verbal DNR/DNI requests from family members cannot be honored – the original signed order must be present for care providers to cease resuscitation attempts. 

Advance Directive

An advance healthcare directive, also known as a living will, is a legal document that specifies what a person’s desires are regarding treatments and lifesaving interventions in the event that they become unconscious or are dying (9). A living will can include instructions on: 

• The use of ventilators or other artificial respiratory support 
• Initiation of CPR in the event of cardiac arrest 
• The use of vasoactive medications 
• Dialysis 
• Organ or tissue donation 

The advance directive may also name a health care proxy can make decisions for the patient if they become incapacitated. 

In order to facilitate advance directive planning, nurses may wish to use a document called “5 Wishes.” 5 Wishes is a legal advance directive document that is written in lay language, and helps patients to choose their end of life care and document it appropriately. This document is widely available in hospitals and other care facilities.

The Role of the Nurse in End of Life Planning 

According to the position statement on end of life care from the American Nurses’ Association, nurses “are often ideally positioned to contribute to conversations about end of life care and decisions, including maintaining a focus on patients’ preferences, and to establish mechanisms to respect the patient’s autonomy” (7). Similarly, a statement entitled “The Right to Self Determination” from the Code of Ethics for Nurses with Interpretive Statements also emphasizes the nurse’s role in end of life planning and care: 

“The importance of carefully considered decisions regarding resuscitation status, withholding and with-drawing life-sustaining therapies, forgoing nutrition and hydration, palliative care, and advance directives is widely recognized. Nurses assist patients as necessary with these decisions. Nurses should promote advance care planning conversations and must be knowledgeable about the benefits and limits of various advance directive documents. The nurse should provide interventions to relieve pain and other symptoms in the dying process consistent with palliative care standards and may not act with the sole intent of ending a patient’s life” (7). 

What these statements say is that nurses have ethical roles and responsibilities that are fundamental to nursing practice. Nurses should ensure that both patients and family members understand the options and treatments that have been presented to them, and should ensure that the patient’s autonomy is being respected throughout all aspects of their care. Nurses are first and foremost patient advocates, and this is especially crucial during the end of life stage. Nurse advocacy during this time can encompass anything from symptom and pain management, culturally sensitive care provision, and ethical decision making (6). 

Talking to Patients and Families 

Talking to a patient and their family about end of life care can be a huge challenge for nurses. In addition to managing patients’ and families’ emotions, nurses must manage their own emotions and approach the subject with professionalism as well as empathy. 

Often, during the end of life planning phase, patients will go through the five stages of grief, as outlined in the book “On Death and Dying” by Elizabeth Kubler-Ross. The five stages of grief include (6): 

• Denial: Usually a temporary defense, patients may say that they’re fine, or that this is some mistake. 
• Anger: Once the patient is no longer in denial, anger is often the next stage. It may be difficult to care for the patient during this stage, as they may misplace their angry feelings on their caregivers. 
• Bargaining: At this stage, the patient seeks ways to postpone death – often in the form of promising to reform a lifestyle in exchange for more life. 
• Depression: This stage may involve the refusal of treatments or visitors, and the disconnection from people, love, and affection. 
• Acceptance: The final stage, which is not reached by all patients. In this stage, the patient has come to terms with their mortality and has accepted that death will happen. 

It is important for the nurse to understand these five stages, as most patients will be experiencing one or more of the stages during the end of life process. 

Here are some helpful techniques for nurses to use when talking to patients about hospice or end of life planning, according to the American Academy of Family Physicians (10): 

Make sure you have time. 

While this may seem impossible while on a shift when you have other patients, it’s imperative that a nurse allow enough time to have this difficult conversation. This is not a conversation that can be rushed – rushing through the conversation may make a nurse miss important details that the patient has shared. 

Turn off your phone. 

Minimizing distractions during these difficult conversations will ensure that the nurse can get ample information from this patient and family interaction. 

Listen to the patient.  

Above all, listen to what the patient is saying. Begin the conversation by asking what the patient and their doctor have already discussed. Be sure that the plan of care has been reviewed with the doctor prior to this conversation, then have the patient repeat their plan of care as they understand it. If there are major differences in the plan of care and what the patient says, this may warrant further conversation with the health care team to clarify and identify knowledge gaps. 

Learn what the patient’s goals are.  

Active listening is crucial during the conversation phase of end of life care planning. Once the nurse has determined that the patient understands the options that have been presented, it is vital to ask them what their goals are for palliative and comfort care. Understanding a patient’s goals can help identify what resources will be best suited for their individual needs. 

Conversations surrounding end of life care should happen as soon as possible. Do not wait until the patient is no longer able to participate in the discussion. Encourage the presence of family members, but be sure to respect the patient’s wishes regarding who is involved in the planning process. Other members of the healthcare team that should be included in the planning process include social workers, patient navigators (if applicable in that setting), and any primary and specialist physicians involved in the patient’s care.  

Caring for an End of Life Patient

Transitioning to End of Life Care

There may come a point during a patient’s hospital stay where it becomes evident that curative or life-supporting measures are no longer effective, thus necessitating the transition from curative treatment to comfort/end of life care. Of course, it is preferable that comfort care be initiated during the curative treatment – this makes the transition to end of life care somewhat easier, since the conversation and planning were ideally initiated before treatment began, and with the collaboration of the healthcare team, family and patient. 

Social Considerations

When preparing a patient and family for the end of life process, a nurse should be sure to consider several social perspectives of both the family and the patient: 

Patient and family education: This is crucial to ensuring that the end of life process goes smoothly for both the patient and any involved family members. It is imperative to assess the patient’s level of understanding of their diagnosis and all treatment plans. If a knowledge gap is identified, consider calling a meeting of the healthcare team to review the plan of care. The nurse should be present at as many planning meetings and patient conversations as possible. This way, the information is getting passed firsthand and nothing is lost in translation. 

Physical location: What are the patient’s wishes for where they want to be when they die? If the patient wishes to leave the hospital, every effort should be made to accommodate their wishes, should their clinical status allow it. At this point, social workers should be involved to coordinate home hospice care or transfer to an appropriate hospice facility. 

Advance directives: If the patient has an advance directive in place, what are their wishes? If the patient can participate in discussions surrounding end of life care, their autonomy should be respected. If the patient wishes to create an advance directive, the nurse should be sure to confirm the patient’s and family’s understanding of available options. 

Clinical Considerations

Medically ineffective interventions: This can also be called “futility of care.”  According to the American Medical Association’s Code of Medical Ethics (11), these interventions may be requested by family members but are deemed inappropriate by the physician. According to the AMA, the following steps should be taken by the physician when dealing with a futility of care situation: 

1. “Discuss with the patient the individual’s goals for care, including desired quality of life, and seek to clarify misunderstandings. Include the patient’s surrogate in the conversation if possible, even when the patient retains decision-making capacity. 

2. Reassure the patient (and/or surrogate) that medically appropriate interventions, including appropriate symptom management, will be provided unless the patient declines particular interventions (or the surrogate does so on behalf of a patient who lacks capacity). 

3. Negotiate a mutually agreed-on plan of care consistent with the patient’s goals and with sound clinical judgment. 

4. Seek assistance from an ethics committee or other appropriate institutional resource if the patient (or surrogate) continues to request care that the physician judges not to be medically appropriate, respecting the patient’s right to appeal when review does not support the request. 

5. Seek to transfer care to another physician or another institution willing to provide the desired care in the rare event that disagreement cannot be resolved through available mechanisms, in keeping with ethics guidance. If transfer is not possible, the physician is under no ethical obligation to offer the intervention.” 

The above steps are not limited to physicians. While nurses cannot make ultimate treatment decisions for the patient, they can ensure that the patient and family understand what the physician has explained. Furthermore, the nurse can act as an advocate for the patient. This kind of advocacy ensures that the patient’s wishes are being respected and that the care they are receiving is ethical. 

How to Prepare a Family for End of Life Care

Physical signs of end of life: When the dying process starts, it is important that the family members present understand what is happening. The following are common signs of the end of life: 

• Increased sleeping 
• Loss of appetite 
• Labored breathing 
• Decreased urine output 
• Confusion 
• Hallucinations 
• Decreased heart rate 
• Irregular breathing patterns (Cheyne Stokes respirations) 

When you’re not a medical professional who has experienced the dying process with a patient, it can be jarring – especially when it’s your family member. Put yourself in the family members’ shoes and explain what is happening. Knowledge can be comforting for most but may not be in every case. Talk to the family members and assess how much they know and how much they would like to know. Be empathetic but do not dance around the subject. Use terms such as “die” instead of “pass away.” Using alternative terms for death and dying may leave it open to interpretation, and in some cases may give family members or patients false hope.  

Family Support 

Along with assessing the patient’s needs, the nurse should also frequently assess the needs of the family. Providing emotional support to the family member of a dying person is incredibly important, both during the dying process and afterwards (12). Be sure to involve social work if you identify any potential need for continued support for the family, i.e. support groups.

Conclusion

Nurses are an integral part of the end of life process, both in the planning and active phases. Among the biggest responsibilities for the nurse during this difficult time is the assessment of understanding of the treatment plan and goals, as well as ensuring that the patient’s autonomy and dignity are respected at all times. The healthcare team should work together as a whole to ensure that the dying process is as comfortable as possible for the patient and their family.

Nursing Interventions for Sepsis: Fluid Management

Introduction – The Importance of Fluid Resuscitation in Nursing Interventions for Sepsis

There are many nursing interventions for sepsis; one of the most important, fluid resuscitation, helps to restore tissue perfusion. However, there is a great deal of variation in the type of fluid, rate of administration, and the total volume of fluid administered that goes into fluid resuscitation protocol in managing a patient with sepsis. 

IV fluids should be prescribed like any other drug we give our patients. A critical evaluation related to the indication and contraindication for different fluid types should be done on each patient (1).  

Circulatory insufficiency and shock result from inadequate perfusion relative to the tissue demands (2). Of all the nursing interventions for sepsis, early fluid resuscitation is one of the most essential in determining the outcome of patients with circulatory insufficiency and shock.  

What can cause circulatory insufficiency?
  – Pump failure
– Insufficient vascular tone (the vasodilation we see in sepsis)
– Hypovolemia (2) 

Patients with distributive shock (the primary shock seen in sepsis) may experience circulatory insufficiency due to the profound vasodilatation that is associated with the inflammatory reaction to an infection (3).  

How Sepsis Affects the Different Organ Systems 

Cardiovascular

As shock progresses and the mean arterial pressure (MAP) trends downward, the cerebrocortical functions are the first to be impaired, which often manifests as a change in the level of consciousness or altered mental status (2). 

Gastrointestinal & Renal

As perfusion decreases from vasodilation or from decreased cardiac function, tissue beds become globally hypoxic. The GI tract and the kidneys are known to be intolerant of hypotension, and precipitous decrease in MAP, which can lead to impaired mucosal function, bowel integrity, or in extreme cases frank ischemic necrosis (2). 

Overall Metabolism

Secondary to developing tissue hypoxia and as a result of anaerobic metabolism in the absence of adequate tissue oxygenation, patients may develop a high lactic acid level as a response to the progressive tissue hypoxia. Serum lactate of 4 or greater is associated with increased severity of illness and poorer outcomes even if hypotension is not present (3). 

With this knowledge, providers should be prepared to fluid resuscitate patients who are hypotensive or have a lactate ≥4 mmol/L to expand their circulating blood volume and restore tissue perfusion pressure (3). Fluid resuscitation should be considered as one of the primary nursing interventions for sepsis in these patients.

The Great Debate: Crystalloid vs. Colloid

Crystalloids 

• Low-cost salt solutions that are known to be the go-to, easy to grab, and, often, first choice fluids (4). 
• Isotonic crystalloids are the most commonly administered IV fluid internationally. 
• Crystalloid solutions were first prepared in response to the cholera pandemic in 1832.  
• Only about 20-30% of administered crystalloid fluid will stay in the intravascular space. (5). 

Examples: Sodium chloride (Normal saline), Lactated Ringers, or Plasmalyte 

Colloids 

• They are suspensions of molecules in a carrier fluid with high enough molecular weight to prevent crossing healthy capillary membranes; thus, a larger percentage of the administered fluid will remain intravascular (5).  
• Colloids are more expensive fluids and are either man-made (starches, dextrans or gelatins) or naturally occurring.  

Examples: Albumin or fresh frozen plasma (4). 

The physiologic rationale behind favoring colloid over crystalloid is the thought that colloids may expand intravascular volume more effectively by remaining in the intravascular space and maintaining colloid oncotic pressure (5). 

Choice of Crystalloid Fluid for Resuscitation: Is Normal Saline Really “Normal”? 

The use of saline versus a balanced crystalloid solution has been a topic of ongoing debate. Due to the high mortality, the burden to society, and increasing awareness surrounding sepsis, there has been extensive research done to identify the optimal fluid treatment protocols. Ultimately, provider preference, hospital protocol, and regional availability dictate much of choice due to a lack of evidence-based guidelines on specific fluid choice. 

Fluid composition can have unintended physiological effects, such as altering the pH balance through the metabolism of lactate and acetate, leading to a decrease in bicarbonate, and eventually metabolic acidosis, and the potential for acute kidney injury (6). 

Normal Saline vs. Lactated Ringers 

The Saline Against Lactated Ringers or Plasma-Lyte in the Emergency Department (SALT-ED) study is a pragmatic, cluster, multiple-crossover trial at a single center evaluating the clinical outcomes of patients treated with 0.9% NS versus balanced crystalloids in the setting of resuscitation in the emergency department (7). The trial included 13,347 patients who received a median of 1 liter of fluid (7). Saline increased the risk of death or renal failure when compared to LR/Plasmalyte (5.6% vs 4.7%, p= 0.02). The subgroup of patients with renal injury at the time of admission was more susceptible to adverse kidney events from saline administration (37.6% vs 28%, p= <0.001) (7). This trial confirmed that, when used in nursing interventions for sepsis, saline increases the risk of renal failure when compared to balanced solutions.  

These results were then duplicated at Vanderbilt and included critically ill patients. The SMART trial, a pragmatic, cluster-randomized, multiple – crossover trial, was conducted in five intensive care units at an academic center and included 15,802 adult patients (5). Patients were randomized to receive either 0.9% NS or LR/Plasmalyte. Among the 7,942 patients in the balance crystalloid group, 1,139 (14.3%) had an adverse kidney event, compared to 1,211 of the 7,860 (15.4%) patients in the NS group (p = 0.04) (5). In-hospital mortality at 30 days was higher in the NS group when compared to the balanced crystalloid group, as well (11.1% vs 10.3%, respectively, p = 0.06) (5). The mortality difference in the two groups suggests that NS may not only be causing renal failure but may also be causing harm to patients via additional mechanisms, including increased inflammation. (8). 

Normal saline as a resuscitation fluid should not be administered in high amounts as it carries the risk of inducing a hypernatremic hyperchloremic metabolic acidosis (8). Some patients are already extremely acidotic and giving them fluid that will exacerbate their academia is poor practice. The truth is that “normal” saline is not physiologically normal. It is a hypertonic, acidotic fluid that can cause more harm than good, especially in patients who need large volume resuscitation. The development of electrolyte disturbances secondary to fluid administration also depends on the electrolyte status of the patient before resuscitation is initiated. 

All of this is not to say that saline is all bad and should never be used, but to point out that just because “it’s what we’ve always used,” “it’s easy to grab,” or “the patient is hyperkalemic!” are not justifiable reasons to use high volumes of NS in the resuscitation of your patients.

How Much Fluid do Septic Patients Need? 

The concept of prompt IV fluid administration was first accepted after the 2001 study of early goal-directed therapy (EGDT). The results of this landmark study propelled early and protocolized fluid management to the forefront of sepsis management. Because of this study and future studies that replicated the results, the Surviving Sepsis Campaign (SSC) began promoting EGDT fluid resuscitation as a cornerstone of sepsis and septic shock management (5). 

EGDT Study Protocol:  

In the study, patients either received standard therapy, which involved arterial and central venous catheterization and a protocol targeting a CVP 8-12 mmHg, mean arterial pressure (MAP) at least 65 mmHg, and urine output of at least 0.5 ml/kg/hr, or the EDGT group (5). The EDGT group included the aforementioned components but also included a catheter to measure central venous oxygen saturation (SvO2), six hours of treatment in the emergency department before admission, and administration of 500 mL of crystalloid fluid every 30 minutes to achieve CVP goals, vasopressors, and vasodilators to maintain MAP goals, and blood transfusions or dobutamine to achieve ScvO2 ≥ 70% (5). Overall, in-hospital mortality was found to be 16% less with EDGT when compared to standard therapy (46.5% vs 30.5%; p= 0.009) (5). 

The SSC 3-hour and 1- hour bundle both recommend the initial administration of 30 mL/kg of crystalloid fluid for hypotension or lactate ≥ 4 mmol/L as a fluid challenge with a target CVP goal ≥ 8 mmHg, ScvO2 of ≥ 70%, and normalization of lactate (9).  

A patient may need repeat fluid challenges in the initial phases of sepsis/septic shock. This bolus dose is meant to rapidly expand the patient’s blood volume to allow providers to assess the patient’s response to fluid resuscitation. 

A key concept for dosing fluid therapy in the critically ill population is to actively address ongoing losses (drains, stomas, fistulas, or hyperthermia, open wounds, or various causes of polyuria) paired with the frequent reassessment of the need for further hemodynamic support (10). While fluid administration is a critical aspect of resuscitation, excessive fluid accumulation has been associated with worse clinical outcomes- particularly the development of acute kidney injury (AKI), pulmonary edema, pleural effusions, and in some cases, an increase in ventilator days (10). 

The idea of interrelated phases of fluid management, coined “ebb and flow,” differentiated according to the patient’s clinical status, with evolving goals for fluid need, is highly individualized, but an important concept in the management of the septic patient. This helps to avoid adverse events related to poor fluid management (10).

Phases of Fluid Resuscitation 

Initial Phase 

In the initial phase of fluid resuscitation, the objective is the restoration of effective circulating blood volume, organ perfusion, and tissue oxygenation. Fluid accumulation and a positive fluid balance are to be expected here (10).  

Second Phase 

In the second phase, the goal is a maintenance of intravascular volume homeostasis (10). The goal is to prevent excessive fluid accumulation and to avoid unnecessary fluid loading. By the second phase, the patient should show evidence of adequate tissue perfusion. 

Third Phase 

In the third and final stage, the objective centers around fluid removal and the concept of “de-resuscitation” as dictated by the state of physiologic stabilization, organ injury recovery, and convalescence (10). During this phase, unnecessary fluid accumulation may add to secondary organ injury and adverse events. 

Below is a photo depicting the potential consequences of fluid overload on end-organ function as adapted by Malbrain et al (1).

It is important to be aware of theses potential consequences when using fluid resuscitation as on of your nursing interventions for sepsis. Fluid resuscitation needs to be done properly to ensure the safety of the patient.

Macrocirculation End Points of Sepsis Resuscitation 

As mentioned previously, resuscitation goals for the septic patient are to return the patient to a physiologic state that promotes adequate organ perfusion and matching metabolic supply and demand. 

Ideally, resuscitation end points should assess the adequacy of tissue oxygen delivery (DO2), oxygen consumption (VO2), and should be quantifiable and reproducible. Since there fails to be a single resuscitation endpoint despite years of research, providers must be able to rely on multiple endpoints to determine the patient’s overall response to therapy (11). The SSC focuses their resuscitation guidelines on the original EGDT protocol with an emphasis on macro and microcirculatory endpoints (11): 

Central Venous Pressure 

A previously well-established starting point in determining a patient’s need and subsequent responsiveness to fluids is to utilize a static measurement, such as the central venous pressure (CVP) or pulmonary artery occlusion pressure (PAOP) (11). As most providers know, using CVP as an initial resuscitation target and estimate of preload adequacy is fundamentally flawed. Factors such as total blood volume, cardiac output/venous return, pulmonary hypertension, cardiac tamponade, arrhythmias, and human error are all factors that have the potential to impact the central venous pressure (11).

The correct interpretation of a CVP value is as follows: a low CVP value of ≤6 almost always indicates hypovolemia. However, a high value does not exclude hypovolemia, nor does it guarantee hypervolemia. It is important to consider this when using CVP as a measurement to ensure that your nursing interventions for sepsis are the most beneficial and effective.

Lactate 

Moving from a “macro” point of view to a “micro” point of view, providers use several clinical and laboratory values to assess the microcirculation. Most commonly, lactate, central venous oxygenation, and capillary refill time. 

Lactic acid is one of the most widely accepted biomarkers used to diagnose sepsis-related organ dysfunction. The working theory behind increased lactate in septic shock is that as global tissue hypoxia occurs, oxygenation fails to meet tissue oxygen demand, therefore increasing anaerobic metabolism…and lactic acid level (11). Just like when you show up for that 1st day of spring 5K after spending the last 4 months on your couch watching Netflix documentaries… need... more... oxygen!!! 

Unfortunately, this basic explanation fails to consider other contributions to elevated lactate. It continues to be widely accepted and used as a marker of microperfusion, but providers should be aware that there are still limitations. 

Elevated lactate can be attributed to 4 broad categories: 

1. Decreased tissue oxygen delivery – you could see elevated lactate in individuals who have had a tonic-clonic seizure, severe asthma attack, severe anemia, carbon monoxide poisoning, or chose to do one of those Spartan Races in July. 
2. Underlying disease – you could have increased lactate in patients who have fulminant liver failure, lymphoma/leukemia, small cell lung cancer, pheochromocytoma, or thiamine deficiency (sepsis would also fall under this category) (11). 
3. Drugs & toxins – Drugs and toxins that can often be responsible for an increased lactate include Biguanides, Linezolid, Cyanide poisoning, NRTIs, and beta 2 agonists (11). 
4. Inborn errors of metabolism – The rarer inborn metabolism errors are the patients who have enzyme deficiencies such as pyruvate dehydrogenase, pyruvate carboxylase, Fructose-1-6-diphosphatase, and phosphoenolpyruvate carboxykinase (11).
   
   

   SvO2/ScvO2 

   Moving past lactate measurement to more technical measurements tissue oxygenation, both mixed venous oxygen saturation (SvO2) and ScvO2 have been considered as important targets because they can be used to estimate a global balance of cellular oxygen demand vs delivery (11).  

   A ScvO2 <70% is indicative of inadequate oxygen delivery to tissues, increased oxygen extraction, or a combination of the two. It is important to note that a true ScvO2 must be obtained via a central venous catheter with the tip appropriately placed at the junction of the superior vena cava and the right atrium (11). 

   Assuming it is measured at the correct location, a ScvO2 of 70%-89% is suggestive of a well-balanced VO2/DO2. A ScvO2 ≥90% suggests poor oxygenation utilization at the cellular level, tissue dysoxia, or microcellular shunting (11). Currently, the routine uses of SvO2 and ScvO2 are not supported in the literature, but the role may become more apparent as sepsis end-goal resuscitation research continues to increase in prevalence. 

   Capillary Refill Time 

   While technology and invasive tests offer pertinent information, these interventions should be performed in conjunction with frequent clinical examinations to assess the response. 

   Capillary refill time is a basic examination skill that new literature is examining as a valuable tool to assess regional and global tissue perfusion during septic shock resuscitation. 

   Capillary refill time is defined as the duration of the time needed for the patient’s fingertip to regain color after direct pressure is applied to cause blanching. In a healthy patient, the refill time should be <3.5 seconds (11). It is important to note that skin temperature, room temperature, age, and use of vasoactive medications can impact capillary refill time and should be taken into consideration. Assuming the patient’s extremities are normothermic, a refill time of >5 seconds suggests the presence of abnormal microcirculatory flow (11). 

   Serial assessment with normalization within 6 hours is associated with successful resuscitation when compared against traditional resuscitation targets. You must always measure and evaluate to ensure that your nursing interventions in sepsis are successful.

Estimating Fluid Responsiveness with SVV and Bedside Echocardiography  

Dynamic indices such as stroke volume variation (SVV), pulse pressure variation, and inferior vena cava variability all have been found to have a better predictive value, sensitivity, and specificity than the static indices (11). In patients who are spontaneously breathing or have arrhythmias, direct measurement tests such as the expiratory occlusion test and passive leg raise may be preferred (11). 

As SVV of >12 has an 88% sensitivity and 89% specificity for predicting fluid responsiveness in a patient without cardiac arrhythmias and requiring mechanical ventilation. Some monitoring equipment may calculate SVV with a standard arterial line only; other times, a special arterial line may need to be inserted to measure SVV (15). 

Sepsis-induced cardiac dysfunction is well described and often presents as a reduction in left ventricular stroke volume and impaired myocardial performance. Noninvasive ways to measure the cardiac output and cardiac indexes include devices such as the FloTrac or Vigileo systems or basic bedside echocardiography, have become more common. The use of invasive pulmonary artery catheters are associated with more risk than patient benefit, and their use has significantly decreased. The information gained from bedside echocardiography includes a rough estimate of cardiac output, LV and RV function, chamber fluid status, IVC size and variability, and global cardiac function. This information can be invaluable when utilized in real-time, especially to measure the responsiveness of treatments. 

Fluid Challenge Without the Fluid

What could be better than determining the effect of a fluid bolus without actually infusing any fluid? Though these techniques are imperfect, they can provide insight into the “fluid responsiveness” of a patient. 

Passive Leg Raise

The passive leg raise test is another noninvasive means to assess fluid need by mimicking a fluid bolus. It involves moving a patient from the semi-recumbent position to a position where the legs are lifted at 45 degrees, and the trunk remains horizontal (2). This induces a transfer of 250-350 mL of venous blood from the inferior limbs and the splanchnic compartment towards the thoracic and cardiac cavities, mimics the increase in cardiac preload induced by fluid infusion. The threshold to define fluid responsiveness with a passive leg raise test is a 10% increase in stroke volume or cardiac output (1). Cardiac output changes can be detected 1-2 minutes after the maneuver is performed using either SVV via a noninvasive technology (Flo-Trac) or by utilizing bedside echocardiography to visualize cardiac function changes (12). A positive response may also be noted if blood pressure increases with a decrease in heart rate, though this is less sensitive and specific. Like capillary refill, the passive leg raise can be done regardless of arrhythmia or mechanical ventilation mode (12). 

End-Expiration Occlusion Test

The end-expiration occlusion test is another fluid responsive test, but specifically for the subset of patients who require mechanical ventilation. The test consists of stopping mechanical ventilation at end-expiration for 15 seconds and measuring the changes in cardiac output. By pausing mechanical ventilation, there is an increase in cardiac output by stopping the cyclic impediment of venous return that occurs at each ventilator-triggered breath. An increase in the cardiac output above the threshold of 5% indicates fluid responsiveness. 

Putting it Together – Performing Nursing Interventions in Sepsis 

The best approach is to use multiple techniques to measure the efficacy of fluid resuscitation. Relying on any single parameter is not ideal practice and may lead to under or over-resuscitation. The best way to use this data is to perform interventions that increase perfusion (usually a fluid bolus in sepsis) and re-measure the endpoint. A trend toward better perfusion (lower lactic acid level, faster capillary refill, etc.) indicates a positive response. A negative response can be due to either: 1.) inadequate volume of fluid resuscitation OR 2.) a patient that is no longer fluid responsive. It can be difficult to discern the difference and the passive leg raise or occlusion test may be helpful here. There is no fixed rule, but it is generally thought to be better to over-resuscitate than under-resuscitate. 

By systematically using this approach, the aim is to properly resuscitate the patient while avoiding the pitfalls of both over and under-resuscitation. Endpoints should be measured after each intervention. 

For example if you measure a lactic acid level of 8 and note delayed capillary refill on the exam, you may determine that fluids will augment cardiac output and increase tissue perfusion. Thus you choose to administer 1L bolus. Once the bolus is complete, you should re-check the lactic acid level and capillary refill. It may not normalize, but there should be an improvement. 

Summary – Nursing Interventions for Sepsis

In summary, fluid resuscitation in sepsis is a controversial topic. Nurses should utilize a variety of endpoints to measure fluid status and perfusion status. Newest evidence is suggesting that LR may have a physiologic benefit over NS, and albumin may have a role in the resuscitation of septic patients. 

Alzheimer’s Nursing Care

Introduction 

Alzheimer‘s disease is a destructive, progressive, and irreversible brain disorder that slowly destroys memory and thinking. Alzheimer‘s is the most common cause of dementia in older adults (1). For most people who have Alzheimer‘s disease, symptoms first appear in their mid 60‘s (1). Studies suggest more than 5.5 million Americans, most 65 or older, may have dementia caused by Alzheimer‘s (1). It is currently listed as the sixth leading cause of death in the United States. It is important to understand the signs and symptoms of Alzheimer’s dementia and how to manage the care of a patient, family member, or friend suffering from the disease. 

Dementia is the loss of cognitive functioning-thinking, remembering, and reasoning- and behavioral abilities to such extent that it interferes with activities of daily living (1). The severity of dementia ranges from mild to severe. In its mildest stage, it begins with forgetfulness, with its most severe stage consists of complete dependence on others for general activities of daily living (1).  

History of Alzheimer’s 

Alzheimer’s disease is named after Dr. Alois Alzheimer. In the early 1900’s, Dr. Alzheimer noticed changes in the brain tissue of a patient who had died of an unknown mental illness. The patient’s symptoms included memory loss, language problems, and unpredictable behavior. After her death, her brain was examined, and was noted to have abnormal clumps known as amyloid plaques and tangled bundled fibers, known as neurofibrillary or tau tangles (1). These plaques and tangles within the brain are considered some of the main features of Alzheimer’s disease. Another feature includes connections of neurons in the brain. Neurons are responsible for the transmissions of messages between different parts of the brain and from the brain to other parts of the body (1).  

Scientists are continuing to study the complex brain changes involved with the disease of Alzheimer’s. It seems that the changes in the brain could begin ten years or more before cognitive problems start to surface. During this stage of the disease, the people affected seem to be symptom-free; however, toxin changes occur within the brain (1). Initial damage in the brain occurs within the hippocampus and entorhinal cortex, which are the parts of the brain that are necessary in memory formation. As the disease progresses, additional aspects of the brain become affected, and overall brain tissue shrinks significantly (1).  

Signs, Symptoms & Diagnosis of Alzheimer’s Disease

Memory problems are typically among the first signs of cognitive impairment related to Alzheimer’s disease. Some people with memory problems have a condition called Mild Cognitive Impairment (MCI) (4). In this condition, people have more memory problems than usual for their age; however, their symptoms do not interfere with their daily lives. Older people with MCI are at increased risk of developing Alzheimer’s disease. The first symptoms of Alzheimer’s may vary from person to person. Many people display a decline in non-memory related aspects of cognition such as word-finding, visual issues, impaired judgment, or reasoning (4).  

Providers use several methods and tools to determine the diagnosis of Alzheimer’s Dementia. To diagnose, they may conduct tests of memory, problem-solving, attention, counting, and language. They may perform brain scans, including CVT. MRI or PET to rule out other causes for symptoms. Various tests may be repeated to give doctors information about how memory and cognitive functions change over time. They can help diagnose other causes of memory problems such as stroke, tumor, Parkinson’s disease, and vascular dementia. Alzheimer’s disease can be diagnosed only after death by linking clinical measures with an examination of brain tissue in an autopsy (4). 

Stages of Disease  

Mild Alzheimer‘s  

As the disease progresses, people experience significant memory loss along with other cognitive problems. Most people are diagnosed in this stage (1). 

• Wandering/getting lost  
• Trouble handling money or paying bills  
• Repeating questions  
• Taking longer to complete basic daily tasks 
• Personality/behavioral changes (1) 

Moderate Alzheimer‘s  

In this stage, damage occurs in the area of the brain that controls language, reasoning, sensor processing, and conscious thought (1).  

• Memory and confusion worsen  
• Problems recognizing family and friends  
• Unable to learn new things  
• Trouble with multi-step tasks such as getting dressed  
• Trouble coping with situations 
• Hallucinations/delusions/paranoia (1) 

Severe Alzheimer‘s 

In this stage, plaques and tangles spread throughout the brain and brain tissue shrinks by a significant amount.

• Cannot communicate  
• Completely dependent on others for care  
• Bedridden– most often as the body shuts down  

Prevention

As a person ages, many worry about developing Alzheimer‘s disease and dementia. Especially if they have had a family member who suffered from the disease, they may worry about genetic risk. Although there have been many studies on the prevention of the disease, and many are still ongoing, nothing has been proven to prevent or delay dementia caused by Alzheimer‘s disease (2).  

A review led by experts from the National Academies of Sciences, Engineering, and Medicine, found encouraging yet inconclusive evidence for three types of interventions related to ways to prevent or delay Alzheimer‘s Dementia or age-related cognitive decline (2):  

• Increased physical activity  
• Blood pressure control  
• Cognitive training  

Treatment of Disease

Alzheimer‘s disease is complex and is continuously being studied. Current treatment approaches focus on helping people maintain their mental function, manage behavioral symptoms, and low the symptoms of the disease. The FDA has approved several prescription drugs to treat those diagnosed with Alzheimer‘s (3). Treating symptoms of Alzheimer‘s can provide patients diagnosed with comfort, dignity, and independence for a greater amount of time, simultaneously assisting their caregivers. The approved medications are most beneficial in the early or middle stages of the disease (3). 

Cholinesterase inhibitors are prescribed for mild to moderate Alzheimer‘s disease; they may help to reduce symptoms. Medications include Rzadyne®, Exelon ®, and Aricept ® (3).  Scientists do not fully understand how cholinesterase inhibitors work to treat the disease; however, research indicates that they prevent acetylcholine breakdown. Acetylcholine is a brain chemical believed to help memory and thinking (3). 

For those suffering from moderate to severe Alzheimer‘s disease, a medication known as Namenda®, which is an N-methyl D-asparate (NMDA) antagonist, is prescribed. This drug helps to decrease symptoms, allowing some people to maintain certain essential daily functions slightly longer than they would without medication (3). For example, this medication could help a person in the later stage of the disease maintain their ability to use the bathroom independently for several more months, benefiting the patient and the caregiver (3).  This drug works by regulating glutamate, which is an important chemical in the brain. When it is produced in large amounts, glutamate may lead to brain cell death. Because NMDA antagonists work differently from cholinesterase inhibitors, these rugs can be prescribed in combination (3).  

Medications to be Used with Caution

Some medications such as sleep aids, anxiety medications, anticonvulsants, and antipsychotics should only be taken by a patient diagnosed with Alzheimer‘s after the prescriber has explained the risk and side-effects of the medications (3).  

Sleep aids: They are used to help people get to sleep and stay asleep. People with Alzheimer‘s should not take these drugs regularly because they could make the person more confused and at a higher risk for falls.  

Anti-anxiety: These are used to treat agitation and can cause sleepiness, dizziness, falls, and confusion (3).  

Antipsychotics: they are used to treat paranoia, hallucinations, agitation, and aggression. Side effects can include the risk of death in older people with dementia. They would only be given when the provider agrees the symptoms are severe enough to justify the risk (3).   

Care-giving: A Major Component in Alzheimer’s Nursing Care

Coping with Agitation and Aggression  

People with Alzheimer‘s disease may become agitated or aggressive as the disease progresses. Agitation causes restlessness and causes someone to be unable to settle down. It may also cause pacing, sleeplessness, or aggression (5). As a caregiver, it is important to remember that agitation and aggression are usually happening for reasons such as pain, depression, stress, lack of sleep, constipation, soiled underwear, a sudden change in routine, loneliness, and the interaction of medications (5). Look for the signs of aggression and agitation. It is helpful to be able to prevent the problems before they happen.  

Coping with agitation and aggression (5):  

• Reassure the person. Speak calmly. Listen to concerns and frustrations.  
• Allow the person to keep as much control as possible  
• Build in quiet times along with activities 
• Keep a routine 
• Try gently touching, soothing music, reading, or walks 
• Reduce noise and clutter  
• Distract with snacks, objects, or activities

Common Medical Problems

In addition to the symptoms of Alzheimer‘s disease, a person with Alzheimer‘s may have other medical problems over time. These problems can cause confusion and behavior changes. The person may be unable to communicate with you as to what is wrong. As a caregiver, it is important to watch for various signs of illness and know when to seek medical attention for the person being cared for.  

Fever: Fever could be a sign of potential infection, dehydration, heatstroke, or constipation (4).  

Flu and Pneumonia: These are easily transmissible. Patients 65 years or older should get the flu and Pneumonia shot each year. Flu and Pneumonia may cause fever, chills, aches, vomiting, coughing, or trouble breathing (4).  

Falls: As the disease progresses, the person may have trouble with balance and ambulation. They may also have changes in depth perception. To reduce the chance of falls, clean up clutter, remove throw rugs use armchairs, and use good lighting inside (4). 

Dehydration: It is important to remember to ensure the person gets enough fluid. Signs of dehydration include dry mouth, dizziness, hallucinations, and rapid heart rate (4).  

Wandering

Many people with Alzheimer‘s disease wander away from their homes or caregiver. As the caregiver, it is important to know how to limit wandering and prevent the person from becoming lost (5).  

Steps to Follow Before a Person Wanders (5) 

• Make sure the person carries a form of ID or wears a medical bracelet  
• Consider enrolling the person in the Medic Alert® + Alzheimer‘s Association Safe Return Program® 
• Alert neighbors and local police that the person tends to wander and ask them to alert you immediately if they are seen alone  
• Place labels on garments to aid in identification 

Tips to Prevent Wandering (5) 

• Keep doors locked. Consider a key or deadbolt 
• Use loosely fitting doorknob covers or safety devices  
• Place STOP, DO NOT ENTER, or CLOSED signs on doors  
• Divert the attention of the person away from using the door  
• Install a door chime that will alert when the door is opened  
• Keep shoes, keys, suitcases, coats, and hats out of sight  
• Do not leave a person who has a history of wandering unattended  

Conclusion

Alzheimer‘s is a sad, debilitating, progressive disease that robs patients of their life and dignity. As research continues on the causes, treatment, and prevention of the disease, it is important for healthcare workers and caregivers to know the signs and symptoms of a patient with Alzheimer‘s disease and potential coping mechanisms and management strategies of the disease. More information on the disease is available through several various resources, including:  

Family Caregiver Alliance  

800-445-8106 

NIA Alzheimer‘s and related Dementias Education and Referral Center  

800-438-4380 

Pediatric Patients with Special Healthcare Needs 

As a former special education school health consultant for children in grades kindergarten through 12th grade, this author became proficient at reading students’ needs or discerning when she could not determine their needs and had to rely on other cues. This pediatric population encompasses many complex health issues that may be chronic and lifelong. Beneath all the tubes, devices, special needs equipment, there is a child who is like many children without special needs. They are longing to be seen, to be heard, and to be accepted as they are. 

Some suggestions for nurses when interacting with this population are (17): 

• To leave any labels at the door and interact with this population as individuals with distinct needs similar to the pediatric population at large. 
• Even though a child may have a cognitive diagnosis he/she still shares dreams, hopes, and feelings. These children desire to be seen as individuals who relish conversations with people and interactions. Talk in a normal tone and give them eye contact. 
• A child’s loud verbalization does not necessarily mean pain. Get to know these individuals on a personal level. Oftentimes this verbalization could be laughter. Trust in your own senses to determine the difference. 
• Respect these children’s bodies regardless of ability. Explain to this child what you are doing before doing it. 
• Even though a child with special needs might not interact or talk; provide care, respect, and compassion as you would any other patient. 
• Provide comfort as you would any patient, even though these children express themselves differently. They need love, kindness, and patience. 
• Show advocacy for each child you care for regardless of ability, diagnosis, or IQ. Involve special needs children in the conversation; even though they do not participate verbally, they understand what is happening. 
• Use the checklist developed for non-communicating children to assess the pain level of these special needs children (see non-communicating children’s pain checklist at http://www.community-networks.ca/wp-content/uploads/2015/07/PainChklst_BreauNCCPC-R2004.pdf) (6). 
• Treat each child with the special care and a patient approach that they so deserve and require. 
• Communication is vital with the child and his/her family members. 
• Nurses must not place judgments on patients but keep an open mind and an open heart to guide patients towards their best healthcare outcome. 
• Nurses have expressed concern with having adequate time to care for the special needs pediatric patient in a holistic manner (18). Nurses desire to engage in a thorough way with these patients and their families but time constraints limit over-involvement and sometimes lead to frustration and guilt on the nurses’ part. They describe it as an art to balance the time factor with the multiple needs of these patients, and the other patients on the nurses’ caseload. 

Summary 

The pediatric population requires nurses who embrace the cohesive bond between parents and child. The nurse must work well with both to enhance the best care possible for the family. Advocacy takes on many forms as a pediatric nurse; the parent, the child, and the family unit must all be promoted and supported. 

Nurses make the difference, and their care is multiplied through each patient and each hospitalization. Pediatric nurses through dedication and mutual problem solving with families show responsiveness to children’s experiences, age, and development to meet the child in his/her world. 

Opioid Abuse

What are Opiates? 

Opiates are powerful substances which are commonly used to alleviate both acute and chronic pain. The history of opiate use / abuse goes back many thousands of years. The first recorded reference is from 3,400 B.C. when opium was cultivated in southwest Asia. There were even wars fought over the previous flow in the mid 1800s (1). The most famous historical event related to opium were the advent of “opium dens.” These were underground “dens” where opium was bought, sold, and used (1). Much like today, the addictive properties of opium overcame many individuals and caused great harm to the world and communities. Indeed, the opiate epidemic of the 2000’s is not the first in modern history, though it is much different and more severe than previous epidemics. 

Today opiates are used for both acute and chronic pain. The ability to quickly, reliably, and (when used appropriately) safely reduce pain is what makes the drug class so valuable. Many common drugs are opiate derivatives or synthetics including morphine, codeine, oxycodone, heroin, hydromorphone, and fentanyl. 

In the United States Opiates are considered controlled substances and most of them are classified as schedule II (with heroin classified as schedule I) (2). Opiates will always have a place in medicine and treatment of pain and are incredibly useful, however, the current opiate epidemic in America makes clear the potential consequences of opiate abuse. 

Preventing Abuse, Misuse, and Harm 

Every day 130 Americans die of opiate overdose (3). Additionally, there are 4.3 million Americans each month who engage in the non-medical (non-prescribed or illicit) use of opiates (5).  However, it is key to remember that opiate-related deaths are not the only negative consequences. There are many overdoses which do not end in death, and on the other end of the spectrum many negative affects do not cause death. Addiction can cause loss of job, damage to relationships, psychologic distress, homelessness, and many more negative side-effects. 

So how do healthcare professionals help reduce the impact of opiate addiction and misuse? The approach must be multi-modal, aimed at primary, secondary, and tertiary prevention.  

• Primary prevention includes appropriate opiate prescribing, risk stratification with patients, and preventing opiate addiction. 
• Secondary prevention is aimed at mitigating the effects of opiate addiction. This includes rehabilitation and cessation of opiates in addicted individuals, ideally in favor of non-opiate treatment options. 
• Tertiary prevention is the reduction in harm from opiate addiction and overdose. This includes resuscitation of overdose patients and helping patients recover from the effects of opiate addiction.
  

Appropriate Prescribing 

The Centers for Disease Control and Prevention (CDC) offers excellent guidance on how to appropriate prescribe opiates, though it will continue to require a great deal of knowledge and effort from individual prescribers and managers of chronic pain. For the purposes of this article, we will focus on the CDC recommendations. Below we will discuss the 12 key points of opiate management, per the CDC. 

Opioids Are Not First-Line Therapy 

“Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.” (5) 

Author’s Input 

Many patients experience pain. Indeed, it is one of the most common complaints in primary care offices. When dealing with chronic pain, we should consider ALL non-opiate therapies for patients prior to prescribing opiates. This can include physical therapy, meditation, exercise / movement, treatment of underlying depression and/or psychiatric issues, meditation, modification of aggravating factors, and many more interventions. In some cases, none of these alone or combination will be enough to provide satisfactory relief, but we must utilize non-opiate and non-pharmacological solutions as much as possible to reduce opioid abuse, and dose (if opiates are necessary). 

Establish Goals for Pain and Function 

“Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety” (5).

Author’s Input 

Many patients erroneously believe that cessation of pain is the goal of therapy. This is not based in fact nor is it reasonable, as many patients (even with opiate therapy) will not have complete remission of pain. The goal of the clinician should be to work with the patient to provide the minimal risk intervention that will provide acceptable pain control. 

Discuss Risks and Benefits 

“Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy” (5). 

Author’s Input 

A prescription for an opiate should never be written to a patient without a through discussion of the risks and benefits. The clinician must first be convinced that the risk to benefit favors prescribing an opiate. Then, they must discuss their rationale with the patient. An individual assessment regarding the risks should be provided to each and every patient. 

Prescribe Immediate-Release Opioids First 

“When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/ long-acting (ER/LA) opioids” (5). 

Author’s Input 

Extended-release opioids have been associated with higher rates of overdose and higher potential for Opioid abuse. Immediate-release opioids should be utilized first, whenever possible. 

Clinicians Should Prescribe the Lowest Effective Dosage 

“Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.”  

Author’s Input 

The clinician must keep in mind that the “minimum required dose” may change over time. As a patient implements more non-pharmacologic interventions the required dose may decrease. Conversely, there can be some degree of tachyphylaxis with opiates and the required dose may also increase. Dose titration requires careful clinician judgement. 

Prescribe Short Durations for Acute Pain 

“Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed” (5). 

Author’s Input 

It is well established that chronic opioid therapy is not the most effective therapy for pain management. Clinicians should consider adjuncts for ongoing or chronic pain patients. 

Evaluate Benefits and Harms Frequently 

“Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids” (5). 

Author’s Input 

It is important that clinicians consider changing circumstances. A patient’s health status or life circumstances may change such that opiate therapy benefits no longer outweigh the harm, or vice-versa. 

Use Strategies to Mitigate Risk 

“Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day)” (5). 

Author’s Input 

Naloxone therapy should be considered for all patients who are at high risk of Opioid overdose. 

Review Prescription Drug Monitoring Program Data 

“Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months” (5). 

Author’s Input 

Each state has robust data regarding prescription medication; utilizing this data can help reduce opioid misappropriation and concurrent prescriptions (doctor shopping). 

Use Urine Drug Testing 

“When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs,” (5). 

Author’s Input 

The author recommends that clinicians take great care in this area. Indeed, drug testing can help identify those who are already abusing other substances, but it can also harm the trusting relationship developed between a patient and clinician. The patient should be re-assured that the testing is performed for their own good and out of concern for their own health, rather than punitively or because the clinician “mistrusts” them, as these may be the default thoughts of many patients. 

Avoid Concurrent Opioid and Benzodiazepine Prescribing 

“Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently ‘whenever possible’ “(5). 

Author’s Input 

The highest risk of overdose of opioid abuse is commonly seen when opiates and benzodiazepine (or any combination of sedating medications) are prescribed concurrently, especially in conjunction with alcohol. For this reason, clinicians should strongly consider avoiding such risks and only prescribing this combination when absolutely necessary. 

Offer Treatment for Opioid Abuse Disorder (OAD) 

“Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid abuse disorder” (5). 

Author’s Input 

In acute cares settings, clinicians often view OAD as a secondary illness and it is frequently left unaddressed. However, there are now effective treatments for OAD. Given the significant morbidity, mortality, and associated quality of life issues, patients with OAD should be offered treatment, even if it not the primary reason for treatment.

Risk Factors for Opiate Harm or Misuse 

The risk to benefit has been discussed many times previously and is often referenced by the CDC. The benefits of opiate therapy are typically obvious (reduced pain, increased quality of life, etc.), but the risks are less often discussed. So how do nurses know who is at higher risk of the negative effects of opiates? 

According to the CDC, the major risk factors are: 

• Illegal drug use; prescription drug use for non-medical reasons. 
• History of substance use disorder or overdose. 
• Mental health conditions (e.g., depression, anxiety). 
• Sleep-disordered breathing.
• Concurrent benzodiazepine use (6). 

Mortality from opiates is highest in those who are middle-aged, have psychiatric conditions, and/or have previously abused substances (7). It is important that clinicians utilize this information when consider risk and benefits associated with opiate therapy.

Signs of Abuse, Diversion, and Addiction

Clinicians should remain vigilant for signs of opiate use disorder, as it can occur in any patient (even those not prescribed opiates). Opiate use disorder is characterized in the DSM-5 as a desire to utilize opiates despite social and professional consequences (12). It includes dependence and addiction, with addiction being on the severe end of the spectrum (12). Opiate use disorder can be diagnosed when at least two of the following are observed in a 12-month period: 

1. Opioids are often taken in larger amounts or over a longer period than was intended. 
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use. 
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects. 
4. Craving, or a strong desire or urge to use opioids. 
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home. 
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. 
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use. 
8. Recurrent opioid use in situations in which it is physically hazardous. 
9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 
10. Exhibits tolerance (discussed in the next section). 
11. Exhibits withdrawal (discussed in the next section) (centers for disease control, reference 13). 

Urine drug screening can be useful in patients with suspected opiate abuse disorder as it may identify concurrently abused substances. If a patient is found to have opiate abuse disorder the “risk” side of the “risk-to-benefit” equation is now shifted, and the continued use should be carefully weighed against the potential for negative effects, including addiction. Addiction is defined as continued use despite adverse events or consequences (12). 

For those prescribed opiates, clinicians should have candid conversations about the risks of continued use for those with OAD. The CDC offers some creative examples of how to discuss the condition with patients, which nurses may find helpful in their interactions (these are only examples, and the wording depends on the patient’s specific scenario and needs): 

“Trouble controlling the use of opioid medication makes it unsafe, and long-term risk over time is substantial.” 

“The medicine has become a problem in itself. You have developed a known complication of therapy that we should not ignore.” 

“Continuing the current medication is not a reasonable option due to the risks, but there are options for treating what we call opioid use disorder, also known as OUD.” 

“It seems as if you are running out of your medication more quickly than anticipated.” 

“Sometimes people become too comfortable with the medications and start to take them for reasons other than pain.” 

“You meet the criteria for opioid use disorder, also known as OUD. It’s helpful to put a name on it because it opens up a variety of approaches to help with your specific circumstance.” (All derived from source 13). 

So, once we identify a patient with OAD, what do we do? At this point, as above, a candid conversation with the patient must occur. A treatment plan should be formulated, which would include a careful consideration for discontinuing for the opiate (if possible). This provides an excellent transition into our next section, opiate alternatives. 

Opiate Alternatives 

Opiate alternatives can be broadly classified as pharmacologic and non-pharmacologic. We will first discuss pharmacologic alternatives. 

Pharmacologic: 

Acetaminophen

Commonly known as Tylenol ™ is over the counter and has a very favorable safety profile when used correctly. Acetaminophen is considered first-line therapy in any pain management regimen (9). 

NSAIDs (Nonsteroidal anti-inflammatory drugs)

NSAIDs can be immensely powerful in pain management, as many pain conditions are related to inflammation. However, patient tolerance can be an issue with chronic NSAID exposure. Indeed, many clinicians shy away from NSAIDS due to the perceived risk profile (9). 

Tricyclic Antidepressants

TCAs provide significant pain relief to many patients, as they have the unique ability to change the perceptions of pain (5). However, tricyclics have many side-effects of their own and thus have been phased out in lieu of newer antidepressants. This in the pain realm they should be considered for certain patients, particularly those with concurrent untreated depression. 

SSRI Antidepressants

SSRIs are typically tolerated better than tricyclics (9) but again are not recommend for first-line analgesia. They are typically reserved for those with concurrent psychiatric illness which may benefit from the overall effect of the drug, and on a case-by-case basis for selected patients. 

Muscle Relaxants

Medications such as gabapentin can be extremely useful especially in pain originating from musculoskeletal causes. However, the mechanism of action is poorly understood (9) and side effects can be troublesome. In one study approximately 25% of patients taking muscle relaxants for chronic pain discontinued the agents due to adverse effects. 

Topicals

Many topical agents now exist, including NSAIDS (9). Topicals are typically considered analgesic-sparing rather than standalone treatment (9). The American College of Rheumatology has excellent and detailed guidance on how to utilize topicals, which deserves a course of its own. 

Corticosteroids

Corticosteroids have very potent anti-inflammatory effects (9) and have a proven role in pain management. Short-term therapy is typically favored over long-term therapy due to the potential issues of long-term systemic therapy (osteoporosis, immunosuppression, risk of serious or fatal infections, weight gain, muscle weakness, diabetes, Cushing’s syndrome, hypertension, glaucoma, and cataracts). Though some serious adverse events can occur with short-term therapy (psychosis, anxiety, avascular necrosis, etc.) (9). corticosteroids can be beneficial for patients with acute pain. Perhaps the best use of these agents is in targeted (injectable) delivery. 

Non-Pharmacologic: 

These therapies will be discussed less in-depth, as they typically require referrals for treatment. However, it is important that nurses are aware of the of the existence of these therapies and can make appropriate referrals and recommendations. Physical therapy consults are invaluable as they often utilize many of the tools below and are more knowledge about non-pharmacologic therapies in general. 

• psychological interventions (including distraction, stress management, hypnosis, and other cognitive-behavioral interventions) 
• acupuncture and acupressure 
• transcutaneous electrical nerve stimulation 
• physical therapies (including massage, heat/cold, physiotherapy, osteopathy, and chiropractic) (10) 

Conclusion

Nurses should view the non-pharmacologic therapies as “tools” available to help patients dealing with acute and chronic pain. Though opiate therapy is a valuable tool as well, its potential negative effects are often under-considered, and the rate of opiate prescription currently is excessive (10). 

When evaluating patients with pain, nurses should work with patients and providers to ensure that the patient is on an optimal pain regimen, which ideally should include both pharmacologic and non-pharmacologic therapies. Seeking referral and consultation from relevant professionals can also be powerful in pain management (physical therapists, chiropractors, psychiatrists, etc.). 

Vaping Induced Lung Injuries

Vaping Trends: The Appeal and the Rise in Popularity 

What started as a product designed for cigarette smokers wanting to wean off the habit while still allowing them to have the physical ritual of smoking, vaping has now become a cultural phenomenon. Minimal odor, sleek packaging, and few, if any, regulations about when and where people can vape created an appeal even to those who had never used nicotine before and the market quickly turned its attention to gaining new customers through the addition of flavors, additives like THC, and devices that look like flash drives. 

The use of electronic cigarettes involves a battery-operated device and a cartridge of nicotine-containing liquid. The liquid is heated into an aerosol which is then inhaled (or vaped). The devices are most popular among adolescents, with 27.5% of high schoolers having used e-cigarettes in the last 30 days in a 2019 survey (1). Adults are using them too, with as many as 2.8% of US adults regularly vaping in 2019, many of whom had never even been cigarette smokers (1). 

One of the main reasons vaping has become so popular so quickly is because of the common misconception that it is a low-risk alternative to cigarette smoking, with many companies claiming fewer toxins and not including complete ingredient lists. While e-cigarettes do contain fewer chemicals than traditional cigarettes, they are by no means a “healthy” alternative and contain their own slew of ingredients, including heavy metals such as nickel and lead, glycerin, carcinogens, and nicotine, which is a highly addictive substance (8). The nicotine level in the cartridges is also extremely high, with a typical “pod,” or cartridge, containing the same amount of nicotine as a package of cigarettes (6). This is enough to make even casual users quickly addicted. The FDA has cracked down on these loopholes in recent years, now requiring warning labels and attempting to regulate the production of flavors, but the popularity of vaping has already exploded and the effort to reverse the trend is an uphill battle. 

Health Risks 

EVALI (e-cigarette or vaping induced lung injury).  

Not surprisingly, the increase in vaping has been followed by a rise in health issues for the users. Most notably among emerging illnesses (and in the media recently) is lung damage referred to as e-cigarette/vaping associated lung injury, or EVALI (2). 

A recent Morbidity and Mortality Weekly Report classifies EVALI as a diagnosis of exclusion as there is currently no specific testing for the illness, but it is one that should be considered early in the presentation of symptoms to not delay treatment (3). Most patients affected presented with cough, chest pain, and dyspnea, with many others having fever, chills, weight loss, vomiting, or diarrhea. At least 30% of patients presented with an oxygen saturation of less than 95%. Tachypnea was not frequently noted, but tachycardia was common. Xray revealed abnormal lung findings in 82% of patients and CT of the lungs was abnormal in 96% (3). This emerging issue is placing significant burden on the healthcare system, as most of these patients require inpatient management with steroids and supplemental oxygen, at least for the first 24-48 hours. 

When this diagnosis resulted in several deaths in mid to late 2019, it was met with panic in the media and general public as healthcare professionals scrambled to find what exactly about vaping was causing the decrease in lung function. Emerging evidence now strongly suggests that the injury to the respiratory tract is caused by Vitamin E acetate, an additive in many e-cigarette pods (3). Fluid collected from symptomatic patients’ lungs was found to contain Vitamin E acetate in most cases and buildup over time is believed to be responsible for this lung injury (3). It is too early to rule out damage from other additives (like the glycerin used for flavoring) and researchers note that while these components are safe for oral consumption and often found in food, the effects of inhalation have not been studied and frequent exposure to the lungs should not be considered safe (4). 

For now, though, Vitamin E acetate is considered the main culprit and is most commonly found in cartridges containing THC, particularly those made informally by people at home rather than those purchased from a manufacturer (3). 

While all vaping should be avoided, for those who do use e-cigarettes it is safest to avoid cartridges containing THC and home-made cartridges. 

Other Health Concerns 

In addition to the potentially lethal complications of EVALI, routine nicotine use of any kind can have serious health implications, and e-cigarettes are no different. Cardiovascular health is affected, with increased heart rate and blood pressure within minutes of nicotine use. Risk of heart attack, stroke, chronic cough, compromised immune system, and impaired oxygenation, all are increased. Nicotine’s effects on a young, developing brain are well documented as well, with attention problems, impulse control issues, and an increased addiction response all posing serious risks to teens who vape regularly (6). Substance use of any kind is closely tied to mental illnesses such as anxiety and depression as well as ongoing struggles with addiction and substance abuse throughout adulthood (6). 

The risk of cancer is also not solely tied to traditional cigarettes, with many substances found in e-cigarettes believed to be carcinogenic. A 2018 study tested urine and saliva samples from vaping teens and found the levels of carcinogens present to be significant and concerning (7). In general, the belief that vaping is a low-risk alternative to cigarettes is grossly erroneous. 

What Can Healthcare Providers Do? 

 Screen for Vaping Use 

One of the best ways to prevent vaping related health issues is to ensure that patients do not start vaping in the first place. Pediatric providers or those working with children and teens 11 years and older are in a particularly advantageous position to start the conversations early and often. Ask questions about what they know about vaping, if they have any friends who vape, and if they themselves have tried vaping. Try to maintain a non-judgmental attitude and allow them to lead the conversation. Provide education to patients and their parents about the dangers and health risks of vaping. Talk about the strengths of the student (academics, sports, arts) and discuss how a nicotine addiction or disciplinary action for vaping at school could negatively impact these enjoyable activities. For any patients who are already vaping, create a plan for cessation (discussed below). Adult patients and established cigarette smokers should also be screened for vaping and health risks discussed (2). 

Early Detection of Vaping Related Lung Injury 

Screening for vaping is not only important at routine wellness visits, but also for acutely ill patients in the outpatient, inpatient, and emergency room settings. Any patient presenting with cough, chest pain, or other respiratory symptoms should be questioned about current or recent vaping habits, including the use of THC pods. Chest x-ray should be strongly considered in the workup for anyone with respiratory symptoms and a history of vaping, particularly those with a pulse oximetry <95%. Flu and pneumonia should be considered in the differential diagnosis, as vaping increases the risk of both illnesses. In patients hospitalized or treated outpatient for a suspected EVALI, close follow up for the first few weeks is recommended (2). 

Cessation 

For patients with or without acute lung injury related illness, vaping cessation should be counseled. For adults, many employers will offer smoking-cessation incentive programs which have been shown to be effective. Encourage your patients to ask their employer if this is offered and if they qualify. There are multiple nicotine products designed to help wean slowly from nicotine with the ultimate goal of cessation such as gum, patches, and lozenges. Either gain familiarity with prescribing these yourself or find a local provider who you can refer your patients to for these products (5). Psychotherapy or counseling can be beneficial for patients trying to break an addiction and there are typically addiction counselors available at mental health facilities. There is a Substance Abuse and Mental Health Services Treatment Locator tool that can be found at FindTreatment.samhsa.gov or patients can call 1-800-662-HELP (4357) to find the nearest resources (1). Finally, if you have patients using vaping as a method of stopping cigarette smoking, you should counsel that this is not a long-term solution and has no current supportive evidence as an effective smoking cessation tool. The risks of vaping far outweigh any perceived benefits and vaping should not be counseled as a method of smoking cessation.

Case Study 

Austin is a 19-year-old male presenting to the ED with 6 days of coughing, fever, lethargy, decreased appetite, and (in the last 2 days) increasing chest pain, particularly with deep inspiration. 

He is a student at the local university with a history of ADHD for which he takes 20mg of Adderall XR daily. No other pertinent medical history and no other medications. He reports drinking socially on the weekends. 

Vital signs are as follows: Temp: 100.9, HR: 147, BP: 134/85, RR: 20, SPO2: 87%. Physical exam reveals pallor, diaphoresis, diminished air exchange in all lung fields with crackles in the bases. Deep inspiration results in coughing fits with no improvement or clearance of crackles and rhonchi. He is most comfortable in the tripod position, but overall is restless. CBC with differential is normal, flu swab is negative. Chest x-ray reveals bilateral infiltrates. 

The nurse notices a Juul device in the clear plastic bag of the patient’s belongings and when asked, he admits to vaping ¾-1 cartridge per day for 2 years. He also states he will use a THC cartridge 2-3 times per week with friends. 

He is diagnosed with EVALI and admitted for treatment with corticosteroids and supplemental oxygen. He is discharged in stable condition after 2 days with scheduled follow up in 1 week. He is counseled on vaping cessation, particularly of THC cartridges, and makes a full recovery over the next 2 months.

Conclusion 

Vaping is a fairly new trend and health risks are still emerging as the number of people using e-cigarettes grows. Staying abreast of trends in vaping and the growing information about symptoms, treatment, and causes of EVALI are important responsibilities of healthcare providers. Early detection of vaping related illnesses is key to best treatment outcomes and screening for vaping should become a routine part of all healthcare exams, both preventive and acute.

LGBTQ Cultural Competence

Introduction

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals represent a rapidly growing segment of the U.S. population [1]. This rapid growth brings with it risk for stigmatization [1]. Implicit physician biases may result in LGBTQ patients receiving a lower standard of care or restricted access to services as compared to the general population [2]. Even when institutions and providers make commitments to equitable care explicit, implicit biases operating outside of conscious awareness may undermine that commitment. There is an urgent need to ensure that health care providers are prepared to identify and address their own implicit biases to ensure they do not contribute to the health care disparities experienced by LGBTQ and other vulnerable populations. Only by addressing their own implicit biases will health care providers be able to provide patient care in accordance with LGBTQ cultural competence. 

LGBTQ individuals face significant disparities in physical and mental health outcomes [3]. Compared to their heterosexual counterparts, LGBTQ patients have higher rates of anal cancer [4], asthma, cardiovascular disease [5,6,7,8], obesity [6], substance abuse [8,9,10], cigarette smoking [11], and suicide [12]. Sexual minority women report fewer lifetime Pap tests [13,14,15], transgender youth have less access to health care [16], and LGBTQ individuals are more likely to delay or avoid necessary medical care [17] compared to heterosexual individuals. These disparities are due, in part, to lower health care utilization by LGBTQ individuals [3, 18,19,20]. Perceived discrimination from health care providers and denial of health care altogether are common experiences among LGBTQ patients and have been identified as contributing factors to health disparities [21,22,23,24]. Disparities in health care access and outcomes experienced by LGBTQ patients are compounded by vulnerabilities linked to racial identity [25,26,27] and geographic location [28]. 

Biases among health care professions students and providers toward LGBTQ patients are common [29, 30] despite commitments to patient care equality. These biases, also known as negative stereotypes, may be either explicit or implicit [31]. These biases contribute to a lack of LGBTQ cultural competence in patient care. A large study of heterosexual, first-year medical students demonstrated that about half of students reported having negative attitudes towards lesbian and gay people (i.e., explicit bias) and over 80% exhibited more negative evaluations of lesbian and gay people compared to heterosexual people that were outside of their conscious awareness (i.e., implicit bias) [29]. Research in social-cognitive psychology on intergroup processes defines explicit biases as attitudes and beliefs that are consciously accessible and controlled; they are typically assessed via self-report measures and are limited by an individual’s awareness of their attitudes, motivation to reveal these attitudes, and ability to accurately report these attitudes [32, 33]. In contrast, the term implicit bias refers to attitudes and beliefs that are unconscious (i.e., outside of conscious awareness) and automatic [34, 35]. Implicit bias can be assessed with the Implicit Association Test (IAT) [36], which measures the strength of association between concepts [37]. 

Health care provider biases are correlated with poorer access to services, quality of care, and health outcomes [31, 38,39,40]. Explicit biases held by health professionals towards racial/ethnic minorities, women, and older adults are known to affect clinical assessments, medical treatment, and quality of care [41]. Importantly, implicit bias measures are more strongly associated with real-world behaviors than explicit bias measures [42] and are linked to intergroup discrimination [43]. Health care provider’s implicit biases towards vulnerable patient groups may persist despite an absence of negative explicit attitudes [44], resulting in preconceived notions about patient adherence, poor doctor-patient communication, and micro-aggressions, all of which can interfere with optimal care. With less time and limited information processing capacity, provider’s decisions are increasingly governed by stereotypes and implicit biases [45]. Medical student and provider biases may contribute to health disparities in vulnerable populations by negatively impacting communication with patients and decisions about patient care [33, 35]. Taken together, these findings suggest that medical students and healthcare providers are likely to underestimate or to be unaware of their implicit biases towards LGBTQ patients, particularly when they are rushed or fatigued, which could impact their behavior and judgments in ways that contribute to health disparities experienced by LGBTQ populations. By learning about and addressing their implicit biases, health care providers can work towards demonstrating LGBTQ cultural competence and providing optimal care (Introduction section courtesy of Morris, M., Cooper, R. L., Ramesh, A., Tabatabai, M., Arcury, T. A., Shinn, M., Im, W., Juarez, P., & Matthews-Juarez, P.- reference 45).

Terminology

Understanding the standard terminology utilized is pivotal to treating and interacting with LGBTQ patients. Below are listed some of the common terms and how they should be referenced.

Ally– A person not identifying as LGBTQ, but whom promotes equality and support of LGBTQ peoples in a variety of ways.

Androgynous– Identifying as neither masculine nor feminine.

Bisexual – A person who is emotionally, romantically, or sexually attracted to more than one sex, gender, or gender identity.

Cisgender – A person whom identifies with their gender which as assigned at birth. For example, a person assigned female gender at birth who identifies as female.

Gay – A person who is emotionally, romantically and/or sexually attracted to those of the same gender.

Gender-fluid – A person who identifies as a fluid or unfixed gender identity.

Lesbian – A woman who is emotionally, sexually, and/or romantically attracted to other women.

LGBTQ – Acronym for “lesbian, gay, bisexual, transgender, and queer.”

Non-binary – Adjective describing person(s) who do not identify exclusively as man nor woman.

Pansexual – A person who has the potential for romantic, emotional, and/or sexual attraction to people of any gender.

Queer – Often used interchangeably with “LGBTQ”, or to express fluid identities or orientations.

Sexual orientation – An inherent or enduring emotional, romantic, or sexual attraction to other people.

Transgender –Umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth. It does not imply any specific sexual orientation and transgender persons may identify as straight, gay, lesbian, bisexual, etc.

*Definitions largely derived from (46).

Best Practices 

Below we will list and discuss the best practices for ensuring a positive, equitable healthcare experience for LGBTQ persons, according to the Joint Commission (this is not a comprehensive list, just highlights). 

Create a welcoming environment that is inclusive of LGBT patients and demonstrates LGBTQ cultural competence. 

• Prominently display the hospital nondiscrimination policy and/or patient bill of rights. 
• Waiting rooms and common areas should be inclusive of LGBTQ patients and families. 
• Unisex or single-stall restrooms should be available. 
• Ensure that visitation policies are fair and do not discriminate (even inadvertently) against LGBTQ patients and families. 
• Foster an environment that supports and nurtures all patients and families. 

Avoid assumptions about sexual orientation and gender identity. 

• Refrain from making assumptions about a person’s sexual orientation and/or gender identity. 
• Be cognizant of bias, stereotypes, and other communication barriers. 
• Recognize that self-identification and behaviors do not always align. 

Facilitate disclosure of sexual orientation and gender identity but be aware that disclosure is an individual process. 

• Honor and respect patient’s decisions to provide or not provide sexual and/or gender information. 
• All forms should contain inclusive, gender-neutral language that allows patients to self-identify. 
• Use neutral and inclusive language when communicating with patients. 
• Listen to and respect patients’ choice of language when they describe their own sexual orientation. 
• Conduct confidential patient satisfaction surveys that include questions regarding sexual orientation and gender identity. 

*Information largely derived from Joint Commission field guide, reference 47.  

For more information on best-practices in the workforce, visit the Joint Commission website by clicking here.

Establishing Relationships with LGBTQ Patients 

When interacting with patients, one should not assume gender or sexuality. Addressing a patient who identifies as a female as a male can cause grave harm to the relationship. Instead, nurses should use open-ended questions. For example, rather than saying “Hi sir, what brings you to the hospital,” a nurse might say, “Welcome, what brings you to the hospital today (48)?” 

If a nurse uses the incorrect pronoun, the best practice is to apologize and ask the patient what pronoun and name they prefer. For example, a nurse may say, “I apologize for assuming your gender. How would you like to be addressed? (48). 

In conversation, the nurse should use the name and/or pronoun the patient prefers without drawing special attention to the subject (48). For example, if a male patient prefers to be identified as his partner’s wife, you should follow suit. 

The core of relationship-building with LGBTQ patients is no different than any other patient, fundamentally. If nurses have a basic understanding of best practices and a healthy dose of respect and compassion for LGBTQ patients, a positive relationship is likely to develop.

Health Disparities of LGBTQ Patients 

LGBT Americans are at higher risk of substance use, sexually transmitted diseases, cancer, cardiovascular disease, obesity, bullying, isolation, anxiety, depression, and suicide when compared to the general population (49). LGBT youth are frequently bullied at schools (49). In fact, early victimization and subsequent emotional distress accounted for 50% of the disparities between LGBT youth (49). In other words, LGBT Americans are discriminated against and disadvantaged from a very young age. 

When home life also reflects a lack of LGBTQ cultural competence, more problems arise. A major cause of LGBT distress is family rejection. Disclosure of gender identity or sexuality can cause very significant interpersonal conflicts among family and friends of LGBT persons (49). This explains some hesitancy and should help nurses understand the importance of respecting privacy, while giving options to patients about disclosing sexuality and gender. 

Providing an Inclusive and Accepting Care Environment 

LGBTQ patients often experience difficulty in finding healthcare environments in which they feel accepted and understood (48). Past negative experiences, lack of knowledge among healthcare providers, and limited access to healthcare in general may become major barriers for LGBTQ persons when seeking care (48). 

The core tenant of providing an inclusive environment is understanding the needs of LGBTQ patients and working diligently to create an environment which does not disadvantage or discourage them from seeking care. 

Policies and procedures at institutions should be designed to reflect a non-discriminatory environment. For example, many hospital policies dictate that only legal family spouses or partners can visit in specific circumstances. Policies such as this are inherently discriminatory toward LGBTQ patients, as they may not have legal spousal status due to social, legal, or personal reasons.

Exercises on LGBTQ Cultural Competence 

To help solidify your learning, please complete the following exercises at your own pace. The answers/guidance for each are provided below. 

Scenario 1 

A patient enters your emergency department, and you assume the patient identifies as a female. You introduce yourself and say, “Ma’am, how can we help you? What brings you in today?” 

The patient appears dismayed but answers the question. The nurse is confused and does not understand why the patient appears distressed. What is the best course of action? 

Answer: The nurse should apologize to the patient and ask the patient how they would like to be addressed. Then, the nurse should update the patient’s records to reflect such, to reduce further confusion.  

If the nurse does not address the issue, the patient may feel uncomfortable and develop a negative association with healthcare, which can lead to disparities in the future. 

Scenario 2 

A patient in your ICU has had a deterioration while his husband was in the room. After a family meeting, a member of the healthcare team makes a derogatory remark about the patient’s sexuality. What is the next best action for the nurse? 

Answer: Pre-conceived phobias and stigmatizations can cause significant distress to LGBTQ patients, even if not stated directly to them. These types of remarks are abusive and should not be tolerated. The nurse should confront the co-worker (if safe) and consider reporting the comments to the Human Resources department.  

Scenario 3 

A LGBTQ patient is being admitted and prefers not to disclose their sexuality. However, the nurse is unable to proceed with the admission process without this information. What could be done to rectify this system-level issue? 

Answer: The nurse should work with administration to ensure that all charting and paperwork allows individuals to self-report sexuality and/or gender if they want. However, healthcare systems should not force patients to “come out” unless it is absolutely medically necessary.

Conclusion 

LGBTQ cultural competence must be ingrained in our healthcare systems in order to foster excellent relationships between members of the LGBTQ community and medical staff. Hospitals and healthcare systems have a great deal of work to do in becoming LGBTQ-friendly. The efforts must continue until LGBTQ patients and families do not feel disadvantaged, anxious, or frustrated when interacting with healthcare systems. As the patient’s ultimate advocate, nurses are at the front-line and should advocate for patients both individually and from a policy perspective. Nurses should work with and spearhead efforts to ensure that healthcare policies reflect best-practice and do not discriminate against LGBTQ patients in any way.

Following a DNR: An Ethical Dilemma in Nursing

Introduction

End-of-life issues are often full of emotion and difficult to deal with for all involved. Do-not-resuscitate (DNR) orders can present many moral and ethical dilemmas in nursing. It takes the entire healthcare team, including the patient and their family, to ensure that all final wishes for the patient are followed. In order to understand this ethical dilemma in nursing, we must first define what ethical dilemmas are and what a DNR order is. 

What is an Ethical Dilemma in Nursing?

Ethics are a system of moral principles or rules of conduct recognized by a particular group; however, the American Nurses Association (ANA) has developed its own code of ethics (1). The ANA Code of Ethics with Interpretive Statements includes nine provisions that direct a nurse’s moral and ethical practice, it reads:  

Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.  

Provision 2:  The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.  

Provision 3:  The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.  

Provision 4:  The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.  

Provision 5:  The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.  

Provision 6:  The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.  

Provision 7:  The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.  

Provision 8:  The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.  

Provision 9:  The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy (2). 

An ethical dilemma in nursing arises when decisions are made that go against the ANA Code of Ethics with Interpretive Statements.  

It is important to note that the nurse’s main duty is to be an advocate for their patient, meaning that all actions should be in the patient’s best interest. Adhering to this principle will ensure a clear moral path where ethical dilemmas in nursing can be avoided.   

DNR

A DNR is an order written by a physician that is usually given to those who are critically or terminally ill. The order states that in the event of cardiopulmonary arrest, should the patient’s heart stop or should they stop breathing, cardiopulmonary resuscitation (CPR) will not be administered. The decision for a DNR order is always discussed with the patient if they are conscious and have the capacity to make informed decisions. Should the patient be incapacitated, their power of attorney (POA), health care agent, or family member may be allowed to make the decision for a DNR. If a patient is known to be gravely ill, they may already have an existing DNR order, or an advanced directive/living will. Once this document is produced for the institution, the order will go into effect. If a DNR order has been put in place by the patient and physician, the family should not have the power to lift the order once the patient deteriorates and can no longer make decisions (3). 

There was a time in the history of healthcare when there were different tiers of a DNR order. For example, there used to be a medication only/chemical code where medication could continue to be administered, but no compressions or artificial respirations could be performed by the healthcare team; in the end, this proved to be a wasted effort as the medication would be circulated and provide no effect. Many institutions have gotten away from the tires of DNR; what I mean by this is, either there is a DNR order in place for a patient, or there is not.

Ethical Dilemma in Nursing: DNR

If a DNR order is put in place by the physician in conjunction with the patient, how could there possibly be any ethical dilemmas in nursing? There should be no problems associated with a DNR order; however, ethical dilemmas arise when the team (patient, physician, healthcare workers, and family) are not all on the same page regarding the DNR. One of the main problems is that different healthcare workers have different interpretations of what a DNR means. It must be understood that a DNR means “do not resuscitate,” and does not mean “do not treat.” To better explore the ethical dilemmas in nursing associated with a DNR order, we will look at scenarios that I have come across over my 25 years of nursing: 

Scenario 1 

A patient is sent from a telemetry unit to radiology for a CT scan. The patient has severe cardiomyopathy and requests a DNR upon admission. The order is noted on the patient’s chart. When they are sent to radiology for the scan, the floor nurse neglects to place the code status on the patient hand-off form. During the scan, the patient becomes unresponsive, and a code blue is called; CPR is initiated, and the patient is intubated.   

During the resuscitation, it is discovered that the patient has a DNR order. The physician running the code continues with CPR, rationalizing that he could ‘not just stop’ the life-saving measures that they had already begun. The patient is revived and transferred to the ICU. Later, during the admission, the family withdraws life support, and the patient expires.  

In this first scenario, we can see that a communication error led to the DNR order not being followed. Once discovered, the physician in charge refused to comply with the order.  Ultimately, the patient passed after a few days on life support.   

This ethical dilemma came to play once the code team realized that the patient had a DNR. The code could have been stopped at this point, and the lead physician could have spoken with the patient’s family to explain what had occurred. Many facilities do have policies in place where if a patient goes for a procedure/surgery, the DNR order may be on hold during the time that they are in the procedure; this does not generally include diagnostic scans.   

Scenario 2

A G-tube is ordered for a terminally ill cancer patient. The patient is unable to eat and needs a G-tube for nutrition and medication administration. When the gastroenterologist comes in to do the consult, he discovers that the patient has a DNR order. He refuses to place the G-tube due to the DNR order and claims that the G-tube is a ‘life-saving’ measure. The patient is sent back up to their room without having the G-tube placed. After two days, a second consult is placed, and a different doctor approves and places the G-tube. 

The ethical dilemma in this scenario is that the provider refuses to provide treatment based on a poor understanding of what a DNR really means. Again, DNR does not mean “do not treat.”  There are many procedures that can and should be performed regardless of a patient’s code status. Though a G-tube can prolong someone’s life, it also serves as a means to keep them comfortable through both nutrition and the administration of needed medications, including analgesics. A G-tube insertion can ultimately assist the patient to die with dignity by allowing them to receive alimentation and medicines. It is not solely the provider’s responsibility to decide what measures are heroic and which are not. The entire multidisciplinary healthcare team should be involved in the care of the patient, especially when questions could arise as to if a certain procedure is ethical.   

This scenario led to a peer review of the provider’s actions.   

Scenario 3

A patient, along with his healthcare team and family, has decided to enact a DNR order. He has been gravely ill for a long time and wants “nature to take its course.” After the DNR order was placed, one of his daughters arrives from out of town; she does agree with the DNR order and wants it to be revoked. The patient refuses, and the DNR is left in place. The next day, the patient becomes unresponsive while the daughter is in the room. She insists that the nurse begin CPR and threatens legal action if the code blue is not started immediately. The nurse becomes intimidated by the daughter, as she does not fully understand the DNR order, and commences the code blue. 

The patient is revived and is transferred to the ICU. He voices his anger to the healthcare team that his wishes were not followed; CPR was not to have been administered. Three days later, he becomes unresponsive and expires; however, this time CPR was not administered, and the DNR was followed. 

Once again, the ethical issue occurred due to misunderstandings and a lack of knowledge from both the patient’s family and the healthcare team. The patient’s daughter sought to go against her father’s explicit wishes to cancel the DNR. When he would not, as soon as he became unresponsive, she demanded that the staff perform CPR. The nurse should have refused, as this daughter was not the legal decision-maker, and the patient’s expressed wishes were known prior to him falling unresponsive; instead, the nurse breached the DNR and performed life-saving measures. 

Conclusion

A DNR order is put in place when a patient does not want life-saving measures to be performed. The healthcare team and family are involved in the decision-making process, but the decision ultimately belongs to the patient. A patient with a DNR order still needs to be treated for their medical problems and, like any other patient, needs to be treated with dignity and respect. It is important that the healthcare team understands what the DNR encompasses and who can make decisions for the patient should they deteriorate. The nurse must always do what is best for the patient and follow the ANA Code of Ethics with Interpretive Statements. 

Effective Communication in Nursing

Introduction

Communication in nursing is key, and the ability to communicate effectively can be our lifeline. We depend on ourselves and others to be fluent and effective in the art of communication in order to perform our role as nurses successfully. When any link in our communication chain fails, we immediately see poor outcomes, wastage of resources, reductions in patient and staff satisfaction as well as a decline in the quality of patient care (1).

Types of Communication

In order to master effective communication in nursing, it is important to understand the various types of communication, their definitions, and the impact they can make.  

Non-Verbal 

This form of communication relies solely on the utilization of body language, including body and facial mannerisms, and completely lacks spoken words or sounds (2). We perform and identify non-verbal communication in nursing daily without giving it a second thought. We may see a newborn sucking on their hands, providing us a non-verbal cue that they are hungry. When assessing a patient holding their abdomen, we would look to initially target that area because they have communicated (non-verbally) that this is where they are experiencing discomfort. Smiling when the next shift nurse is walking in the door communicates to them that you are happy to see them, and that it’s about time for you to go home!  

Since we perform non-verbal communication so often, it can become an incredibly powerful tool or an extremely negative one. This form of communication in nursing can be used positively to show our patients and co-workers that we have compassion, and we are engaged. Negative forms can make patients uncomfortable with sharing their medical history and result in a lower quality of patient care. Additionally, it can lead to dysfunctional teamwork among staff. 

Verbal 

Verbal communication occurs when we use words or sounds to discuss concepts with others (2). This form of communication in nursing has the conception to be a very easy notion, but it can create unfavorable consequences when used ineffectively. In order to produce clear verbal messages, we should always speak concisely and with confidence. As health care professionals, we have our own language, and understanding when to incorporate our medical jargon into conversations versus when to not is crucial in providing care. When communicating among co-workers, our medical knowledge can display professionalism and it is evident that they can follow along. However, when speaking with patients and their families, this may not always be the case and we must be able to effectively gauge our audience and ensure that they have a clear understanding of what we are teaching or explaining; this is an extremely valuable tool.  

Written 

This form of communication can be either a formal or informal transcription of words that are intended to serve as a direct communication form (2). Written communication in nursing is used daily and incorporates one of our most important duties, documentation. Throughout our nursing practice, we have learned the importance and necessity of our documentation; it can be useful for legal protection or provide critical data to other health care professionals. Written communication can also be accessed through the policies and procedures we employ to perform various tasks. Having sound, written communication, and interpretation skills is vital to the overall success of our nursing career.  

Receiving Communication

The most common communication perception is usually directed to producing communication through non-verbal, verbal, or written forms. While the production of communication is important, the reception of it potentially holds even greater value. In nursing, ensuring our communication is received correctly affects every clinical, orientation, or job experience we have encountered thus far. Think about it…  

• Taking notes in class or during a shift. 
• When a preceptor or instructor educates you on a brand-new skill or piece of equipment. 
• Teaching your patient, family, or student about a new diagnosis.  
• Watching your patient breathe for rate, depth, and effort. 

We must provide and receive communication in nursing through verbal, non-verbal, or written forms successfully. If communication fails, we will experience extremely negative effects throughout our entire nursing system. 

Hearing & Listening 

Hearing describes the process or act of perceiving sounds or spoken words (2). We hear sounds upon auscultation, varying frequencies of alarms, and patient concerns when they are voiced. Hearing all these sounds are heavily dependent on how they are used. To achieve successful implementation of these sounds, we must also listen to these sounds and words. To listen, we must hear and then interpret these sounds carefully (2). We interpret these sounds and words by asking additional questions, performing additional assessments, or paraphrasing the information presented.  

Communication Transmission Threads

Communication in nursing occurs multiple times a day between a wide range of communication threads. The type of communication through non-verbal, verbal, and written communication produced and received, must be effectively performed. Success and implementation are heavily dependent on the communication between the nurse and the communication thread.  

Nurse-Nurse 

Communication among nurses is continuous throughout a shift while working within a team environment. Whether it is us passing our documentation on to another nurse for review or vice versa, there is consistent communicative flow of all variants (non-verbal, verbal, and written) between the team in order to provide care for patients. 

Nurse-Ancillary Staff 

Your team members will vary depending on your nursing career setting, but some items will remain consistently important despite wherever you are. We must provide clear verbal communication when delegating or reporting critical information from the nurse to ancillary staff participating in patient, client, or resident care.  

Charge Nurse-Team 

When stepping into a charge nurse role, there will always be unexpected tasks, staff conflicts, or emergent situations. In this position, you will be taking all the communication skills you have acquired and putting them into practice at an all-time high. As the charge nurse, you will be viewed as a leader, meaning that you are a role model for your fellow team members. Now, in addition to producing and receiving communication effectively, you will now be identifying poor communication and assisting with its correction.  

Nurse-Patient 

The nurse-to-patient communication thread is one of the ultimate and most important exchanges in the nursing profession. Patients need us, so we must be able to keep consistent and effective communication flow with them because any assessment, report, and administration of medication is contingent upon it. 

Nurse-Family 

The thread between the nurse and the patient’s family can be the foundation for your nurse-to-patient communication and its effectiveness. The family could be the responsible party or guardian for your patient and could potentially serve as your sole historian for patient information if the patient is unable to communicate at the time of data collection. Ensuring that the family is aware of and understands discharge instructions can further help them to recognize any potential signs or symptoms that could result in calling a physician or visiting the emergency room in the future. 

Barriers and Improvements to Communication

Barriers of communication in nursing happen frequently and are sometimes out of our control. These barriers include:  

Language barriers 

Utilizing available resources for language barriers through interpreter staff members or interpretation devices can ensure effective communication pathways between two individuals. 

Cultural differences 

Identification of cultural differences during admission and cultural awareness will allow for effective communication management throughout each culture you are presented with. 

Patient acuity, staffing levels, time constraints 

Patient acuity, staffing levels, and time constraints can be improved by utilizing staff huddles and working together with administration in order to overcome conflicts.  

Emergent situations 

Emergent situations that arise during your shift can be relieved through adequate knowledge of the policies and procedures and by performing debriefs after the situation resolves. Debriefings hold valuable insight into reflections of the emergent situations we face as nurses, especially on communication performance. 

In each thread and form of communication in nursing, we must remember the following items to receive information. While producing communication, we must always be clear, concise, and accurate with the correct corresponding tone when expressed to others. When we are receiving the information, we must ensure we are understanding, investigating, and acting according to the communication presented to us. Utilizing various communication platforms, including emails, boards, and group messaging apps, can help to assist in ensuring education is received. 

Benefits of Effective Communication in Nursing

When we achieve effective and therapeutic communication between both our team and patients, it will create opportunities for enhancements throughout our practice. Fostering a unity of teamwork with co-workers will increase satisfaction and reduce burnout rates. Reduced health care costs through reduced re-admissions or emergency room visits will be established by successful patient education and understanding. Our quality of patient care will be heavily influenced by the nursing communication threads created through their care. 

Nursing Documentation 101

Introduction

“I just love charting,” said no nurse, ever. If you ask most people why they want a career in healthcare, their response is that they wanted to help people. They did not want to spend hours in front of a computer clicking boxes. This time-consuming task of documenting in the medical record, or charting, is dull, repetitive, and sometimes disconcerting. It takes time away from being able to provide care for the patient. Yet documentation in the medical record is truly a vital part of patient care. 

Nursing documentation fills a significant portion of the medical record. Nurses need make sure what they are adding is accurate and complies with the guidelines set by their facility and the state board. This principle is the same, even though there are differences to be aware of now that the electronic medical record has become the standard. 

The Who, What, When, Where, Why, and How

Who: 

There are approximately 2.9 million working RNs in the United States, with about 1.6 million working in hospitals (1). Nurses on a med-surg unit typically spend about one-third of their total working hours documenting (2). Considering a nurse on a med-surg floor spends about 2.5 hours per shift charting, that roughly translates into 7 billion hours spent charting each year. And that is only for the nurses! 

Every discipline of the healthcare team contributes to the patient’s medical record. These different clinicians may not have the opportunity to report off to one another, and they must refer to the medical record to gather the information they need in order to care for the patient. Even kitchen staff responsible for preparing meals for patients must be able to see the dietary order for the patient. The following are a few examples of the clinicians who contribute to or review the patient’s medical record: 

• Medical Team: physicians, nurse practitioners, physician assistants, surgeons, specialists, residents 
• Nurses and LPNs 
• Medical Assistants, CNAs, patient care assistants or technicians 
• Specialty technicians: radiology, anesthesia 
• Therapists: physical, speech, occupational, respiratory 
• Pharmacists 
• Dieticians 
• Case managers or social workers 
• Coding and billing specialists 
• Researchers 

What:

The primary purpose of the medical record is to communicate data about the patient and care provided between different members of the healthcare team. The bulk of the medical record is a collection of assessment data obtained from the patient. Details concerning assessments and results from lab tests or radiology comprise a large portion of the data. Assessment data is usually collected on a flow sheet system. Progress notes are written by the medical team or therapists and help to guide the intended plan of care for the patient. This is considered narrative charting. The medical record also includes orders for prescribed medications and treatments from the medical team. The following are typical components found in a patient’s medical record.

• Patient demographics: name, age, gender, contact information, language, and insurance information
• Past medical history: surgeries, chronic conditions, family history, allergies, and home prescriptions
• History and Physical (H&P): this can contain information about admitting diagnosis or chief complaint and narrative of the story leading to admission
• Flowsheet of assessment data: vital signs, head-to-toe assessment, intake and output record
• Laboratory test results
• Diagnostic test results: from radiology or procedures
• Clinical notes: progress notes from the medical team, procedure notes, notes from consulting clinicians, education provided, and discharge planning
• Treatment orders
• Medication Administration Record (MAR)

When:

The medical record should document every interaction the patient had with a member of the healthcare team. An encounter is created upon admission and everything occurring during a particular admission becomes part of the medical record. Phone calls made to patients and/or families may also become a part of the medical record. 

Where:

Medical records are stored in various ways depending on their format and the facility. Paper records from small outpatient offices may be kept onsite. Records are now largely kept electronically. This is referred to as the electronic medical record (EMR) or electronic health record (EHR) and consists of Protected Health Information (PHI). They will be stored on a secure server, typically only accessible by authorized personnel. 

Why:

The medical record is essential to nursing documentation for several reasons. The primary reason for the medical record is that it allows members of the healthcare team the ability to review and analyze data in order to deliver appropriate care. It allows clinicians to keep track of all the care that has already been completed for the patient. It also provides the patient with a record of the treatment they received for as part of their lifetime medical history. The medical record is used for coding and creating a bill for the services the patient received. Medical records may also be used for reviewing processes and research purposes. Ultimately, it is also a legal document and may be used in a court of law as applicable.

How: 

Medical records are in the final stages of evolution from a paper chart to an electronic medical record system (EMR). By 2017, 96% of acute care hospitals and over 80% of physician offices possessed certified health IT (3). This migration of medical records from paper to electronic format was made possible with advances in technology in the last 30 years. The EMR allows members of the healthcare team to access the medical record instantaneously and improves continuity of care. Utilization of the EMR ultimately reduces costs in healthcare (4) and increases efficiency. 

While EMR does have some drawbacks, the benefits that it provides are substantial enough that the government has encouraged its adaptation. The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009. This program provided tens of billions of dollars in financial incentives for healthcare facilities to adopt an EMR system (5,6). 

Privacy and Security

Since 1996, HIPAA, The Healthcare Information Portability and Accountability Act, has been the governing legislation that provides for the privacy protection of medical records. Compliance with HIPAA mandates that anyone who interacts with patients receives training that will ensure that they will maintain privacy for the patient. Part of the HIPAA legislation also allows the patient to request their medical records. 

The patient also has the right to request to amend their medical record. Patient permission must be given prior to a third party’s access to their medical record (7). HIPAA legislation was introduced at the advent of EMR technology. A provision of HIPAA provided a framework to ensure privacy of electronic health records (8). However, breaches in security by hackers or cyberterrorists remains a potential threat. 

Benefits of EMR: 

• Immediate data accessibility and communication of patient status
  1. Clinicians can view records remotely, analyze the findings, and place orders immediately for faster patient treatment.
  2. Multiple clinicians can view the chart at one time.
  3. Records can be viewed easily from previous admissions and/or outpatients visits easily.
  4. Records can be instantly shared between facilities (in instances of shared systems).
• Reduction in errors
  1. Errors due to misinterpretation of handwriting in nursing documentation are eliminated.
  2. Allows for increased safety checks. The EMR can be set to flag missing components of information, tasks that were not yet completed or are overdue, recognize duplicates, and present warnings if documentation has not yet been validated or “signed.”
  3. Scanning medications is possible with EMR systems to reduce the risk of medication administration errors.
• Assists with appropriate billing by capturing charges of services provided to the patient.
• The EMR can provide reminders for necessity of certain preventative health screenings or vaccines.
• Automatic “signature” of data is completed simply by the user logging in with a unique ID and password. All entries are date and time stamped. If a correction is made, the original data can be accessed.
• Accessing patient EMR is tracked and can be audited to protect patient privacy from unnecessary viewing.

Downsides of EMR: 

• It is expensive to convert records system to an electronic system:

  1. The initial cost of the EMR software is very expensive
  2. More work hours must be paid for staff training and coverage of patients during initial implementation of the program
  3. Maintaining appropriate encryption and cybersecurity technology against viruses and hacking are also a costly component

  Computer systems can be temporarily inaccessible, for example when updates and reboots are required. Paper charting is still necessary in the interim.

  Template charting has limitations (9). Templates for nursing documentation may not exist for a specific problem and does not accurately reflect the patient’s condition. Atypical patients may have multiple problems or extensive interventions that must be documented in detail.

  Templates may also encourage cloned or copied documentation. It creates unnecessary redundancy and at times inaccurate information in the EHR. Some EHR systems are designed to facilitate cloning with such popular features as:

  • “Make me the author” to assume the content of another person’s entry
  • “Demo recall” of “Duplicate Results” to copy forward vital signs or assessment data
  • “Smart phrases” pulls in specific identical data elements

  Automated insertion of previous or outdated information through EHR tools, when not modified to be patient-specific and pertinent to the visit, may raise significant quality of care and compliance concerns.

The Legal Requirements

If it wasn’t documented, it wasn’t done. Every healthcare practitioner has had this mantra ingrained in them from the very beginning of their career. Nurses are trained to document defensively, that is, if they are taught at all.

In a 2014 study, only 20% of new graduate nurses had received electronic medical record training as a part of their nursing school curriculum (6). It is not uncommon for clinicians to have the tendency to view the medical record as a defense tool against potential legal problems, rather than its more significant role as a communication tool for patient care.

Regardless, accurate and complete documentation is essential. Your career, and more importantly, patient care, depends on it.

When Documentation Becomes Your Defense

In the dreaded event of a legal problem, medical records will be scrutinized to every detail. It is usually the primary source of evidence for the case. A malpractice lawsuit requires four elements to be proven (10):

• That a medical professional assumed a duty to provide care for the patient.
• The clinician failed to provide appropriate care within their scope of practice for the patient.
• The failure in appropriate care caused an injury to the patient.
• The injury resulted in damage to the patient.

Potential legal problems that may arise include the following (11):

• Administrative liability – Professional licensure discipline and/or discharge (firing) from position.
• Civil Liability – Malpractice lawsuit, failure to provide necessary care.
• Criminal liability – Misdemeanor or felony charges for cases of gross negligence.

The Cost

Fortunately, medical malpractice claims have begun to drop since 2001. In 2004, the medical practitioners involved who were known as the defendants won the case 83% of the time. The legal fees can still amount to $18,000 if the case is dropped, to as much as $93,000 even when the case is won (12,13).

In 2018, there were 8,718 malpractice cases that resulted in payments to injured patients (14). Of those events, 310 reports of malpractice suits that resulted in payments related to nursing care.

However, 180 of those, about 60% of those had payments to the injured patient that were over $50,000 (14). However, there were nearly 15,000 adverse action reports filed against nurses, which was more than the number combined filed against physicians, NPs, and PAs combined.

The majority of medical malpractice cases primarily target the physician and the facility. However, anyone who made an entry into the patient’s medical record may be required to participate in legal proceedings.

Most common malpractice claims against nurses include failure to (15):

• Follow standards of care

1. Follow safety protocols
2. Perform procedures according to guidelines
3. Use equipment properly

Use or operate equipment within the manufacture’s details

• Failure to correctly document
  1. Communication with the provider
  2. The care you completed
• Follow assess and monitor
  1. Report a change in status of the physician
  2. Assess a patient with change in status
• Communicate pertinent data
  1. Provide appropriate discharge education and information
  2. Communicate properly and completely between shifts

What is Required for Nursing Documentation

Necessary medical record nursing documentation can vary significantly depending on the care area. For example, the documentation a circulating nurse in the operating room completes will be very different from what is documented on an emergency room patient. While the basic principles of documentation stay constant, the nurse needs to be familiar with the documentation requirements for that area based on requirements of the state board of nursing, the facility, and the unit.

There are standard requirements for medical record documentation that are applicable in all patient care settings, and in both paper and EMR systems. These standards include the following (16):

• Accurate: Clinicians must be careful to proofread documentation to make sure it is free from errors. A small typo can have serious repercussions, as it is more likely to be misinterpreted by others.
• Relevant, concise, organized and complete: It is important to keep the information concise and relevant so that other care providers can quickly find the pertinent information that they need. Assessment data should be entered in a systematic way. Complete documentation ensures all of the unit policies for documentation are addressed.
• Free of bias: Clinicians should only include information that is pertinent to the care of the patient and remain free from personal bias. Direct quotations within the proper context should be utilized with proper context.
• Factual: Clinicians should not exaggerate or minimize findings. Charting is to be completed after completing a task, not before. Do not speculate data. Observations need to include exact times and measurements. Avoid approximations. Make sure to chart on the correct patient.
• Timely: What occurred during the shift should be documented during the shift. Documentation should be done as soon as possible after completing tasks. If something needs to be added in after the shift was completed, it should be denoted as a late entry with a reason as to why. Your facility likely has strict requirements regarding late entries.
• Legible/decipherable and clearly written: Paper documentation must be clearly legible. Writing must clearly convey meaning.
• Standardized: Clinicians must use appropriate medical terminology and approved acronyms and abbreviations.
• Labeled and Auditable: Paper documentation must be signed with credentials and must include date and time of the entry. When charting in the EMR, all entries and corrections are recorded and time stamped. Password sharing or having another clinician assist in documenting under incorrect username is fraudulent.

Examples of Effective and Ineffective Charting

The following will show some examples of these principles in action. These are based on the scenario of a patient admitted in the Emergency Department for chest pain. 

Common Documentation Errors

• Falsification of a record. This can happen when charting an action isn’t completed in a timely manner, or from charting information before that action was completed.
• Fraudulent charting is the act of knowingly making a false record. Criminal charges of forgery can result if the misrepresentation is done for personal gain. An example of this would be a nurse documenting at administration of a controlled substance but instead was diverting the medication.
• Inappropriate use of cloning features. Information “copied and pasted” from a different patient’s record or that is completed by another provider. Data copied from previous shift assessments that isn’t updated to reflect current status is also a false record (9).
• Fail to document communication. Notification of the medical team of a change in patient status or critical lab values should always be included. Clarification or confirmation of orders should also be documented (17). Include notification of other providers who assisted with patient are. This includes failure to document transfer of care to another nurse.
• Failing to document a reason why something isn’t done. If a patient doesn’t receive a prescribed medication, the reason why the medication isn’t given needs to be described. If you communicate with the provider, this should also be included.

Conclusion

Including all of the necessary information into each patient’s medical record can be a daunting task. The nurse must make sure that they have included all of the relevant and accurate information that is required by their facility guidelines. It must usually be done in a loud environment and is frequently interrupted by actually having to provide care to the patients.

It is not only a tedious chore, but it also tends to cause a lot of apprehension. There is usually a worry of “did I chart enough?” or “did I chart everything I needed to?” This is due to the defensive practices and attitudes healthcare workers have adapted to protect against malpractice lawsuits. In this way, charting is similar to paying taxes. No one likes it, but it still has to be done.

Perhaps a way to develop a healthy perspective toward charting is to change the focus to its original purpose: to communicate care about the patient. The purpose of charting is to relay to the other healthcare team members what is going on with the patient. With this objective in mind, the nurse will inevitably cover all the necessary details and it may also be a bit more satisfying to know that even though they are in front of the computer, they are performing and completing important information for the patient.

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