2022 Mississippi Renewal Bundle

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➀ Read and Learn

The following course content

In this course, we will cover the variety of nursing topics listed in the course outline below. This course is appropriate for both RNs and LPNs. Upon completion of this single module, you will receive a certificate for 30 contact hours.

 Course Outline

1. The State of the Nursing Profession
2. Nursing Documentation 101
3. Flu Treatment, Symptoms, and Red Flags
4. Measles
5. Childhood Asthma Treatment and Prevention
6. Nursing Interventions for Sepsis: Fluid Management
7. One Hour Sepsis Bundle
8. Chest Tubes Nursing Care
9. Effective Communication in Nursing
10. Alzheimer’s Nursing Care
11. References

The State of the Nursing Profession

Introduction: Issues Faced By Modern Day Nurses

Nurses have been treating patients for as long as illness has been afflicting humans. The history of nursing is a long and at times, difficult story that most of us can sympathize deeply with. What other profession has both relieved the burden of disease while also carrying a portion of the burden themselves? Every nurse knows that bond forged between a patient and nurse is sacred and highly unique. The nurse allows the patient to cast his or her pain, suffering, and worries upon them. They do so willingly and return to them comfort, peace, and care.

Nurses also hold a unique position within healthcare. What other profession does so much and has such an impact on patient care? Bedside nurses deliver the vast majority of treatments, perform the majority of assessment and in today’s profession they are becoming increasingly responsible for treatment decisions. Bedside nurses are no longer handmaidens and water fetchers. Today’s bedside nurse is a highly competent, trained professional with an expansive knowledge base. It is not uncommon to see experienced nurses training residents, fellows, and at times, attending physicians. The line between nursing and medicine is becoming blurred as nurses continue to advance and grow into their profession. On a given day you may see Nurse Practitioners and Nurse Anesthetists performing highly complex procedures such as endotracheal intubation, central line placement, chest tube placement, and even diagnostic cardiac catheterization in some facilities!

However, this growth has not come without its own growing pains. In this lesson we will discuss some challenges and issues that are unique to modern day nurses and potential solutions.

Nursing Burnout

From ambulatory facilities to ICUs, everyone is working longer hours. As budgets become thin, nursing workloads become more and more stretched. The acuity of patients is higher than ever thanks to advanced medical care. It seems our profession has not kept pace with the demands of today’s patients, or rather it has not acclimated to provide an environment which fosters high level care from nurses. Indeed, many studies (1) have linked increasing levels of nursing burnout to decreased patient safety. Another study (2) found that higher levels of burnout correlated with worse patient satisfaction.

Most nurses would not be surprised by this. It is safe to say that most nurses have experienced some degree of burnout. One study (3) found that up to 35% of nurses experience signs of burnout in their roles. So what are the risk factors and protective factors for nursing burnout?

Risk Factors

• Inpatient (hospital) work setting
• Increasing or unreasonable workloads, which impair or impede nurses’ abilities to perform their jobs correctly
• Increasing patient : nurse ratios
• Negative physician-nurse relationships
• Unsupported management

Protective Factors

• Supportive management and environments
• Positive physician-nurse relationships
• Being involved in decisions affecting nursing and patient care
• Being able to discuss new ideas openly

*Based on data from studies (1-4)

This list is by no means all-inclusive and as you can see many of the factors listed are unfortunately not uncommon. We have demonstrated that burnout is bad for patients, and it is obviously detrimental to nurses. Furthermore, we can assert that it is a threat to the entire profession. One in six nurses (5) frequently considers leaving the profession. This is no surprise to those practicing in areas at high risk for burnout. It seems that nurses leave the profession or advance their degree in order to avoid the stress of bedside nursing.

So how do we combat this issue? The first step is acknowledgement. Though the term has created quite a buzz in the healthcare world, there is little action being taken to prevent burnout. It is difficult to blame anyone given the amount of pressure healthcare systems are under as they adapt to ever-changing regulations and legislation with increasingly meager budgets. However, the author believes that without proper resource allocation the burnout epidemic will continue to grow, which will affect patients and nurses alike.

The answer is not simple. Interventions must be multi-faceted and be aimed at several levels.

Nurses’ Coping Mechanisms

We teach pilots how to deal with stressful situations as a basic aspect of their training. We have seen the effects of unchecked stress in our war veterans as the nation reels in a PTSD epidemic that is seemingly impossible to control. The nursing profession would be wise to intervene earlier. This can start with teaching nurses appropriate coping mechanisms and preparing them for the stresses they will inevitably face. A BREATHE technique (6) was developed and tested with positive results. Nurses who utilized this program and the techniques reported lower stress levels than controls. The key aspects of this course were:

1. Assessing stress;
2. Identifying stressors;
3. Managing stress;
4. Avoiding negative coping;
5. Recognizing when professional mental healthcare is necessary.

Though these techniques cannot change the work environment or other factors, they can potentially render nurses more resistant to the effects.

Work Environments

As we have discussed, the work environment is a major factor in nursing burnout development. In order to minimize the effects of burnout, it is required that healthcare institutions identify the contributing factors and make burnout reduction a priority. This includes:

• improving nurse:patient ratios;
• improving nurse-physician communication/interactions;
• creating open communication about burnout; and
• other advocacies.

Leadership

Nursing leaders have been traditionally chosen based on experience and performance at other roles, such as bedside nursing. However, this does not directly correlate with management/leadership aptitude. It has been demonstrated that effective leadership and management (2) can reduce the burden of nursing burnout. Choosing and training effective leaders is a must for the profession of nursing.

Burnout Summary 

Burnout is without a doubt one of the great challenges of our generation of nurses. It remains under-studied and under-addressed. By educating and empowering nurses we hope to raise awareness of the issue, which is pivotal to the future of our profession and for quality patient care.

Other useful resources:

• ANHA holistic stress reduction 
• Cleveland Clinic Nursing Burnout Reduction Strategies
• Sign and symptoms of nursing fatigue by USF Health

Social Media

As our world evolves, social media has become a highly personal yet public aspect of all lives, including nurses and patients. Traditional nurse-patient relationship boundaries can be blurred by social media. Most nurses have read or heard stories about nursing professionals losing their jobs or licenses due to issues stemming from social media. So what are best practices for nurses when it comes to social media?

• Avoid posting any negative materials concerning patients, healthcare facilities or the profession in general on social media.
• Avoid posting any material that may violate HIPAA, ethical standards, or any institutional policies.
• Approach social media relationships between yourself and patients with a great deal of caution. Always consult with your state board of nursing, leadership, and institutional guidelines on this matter. An initiation of contact (friend request or message) by a patient does not make the action permissible.
• Avoid taking any pictures at work that reveal patient information or that may breach any institutional policies.
• Never discuss protected information with a patient over social media, even if you intend on disclosing this information via another route (in-person visit, phone call, etc.)

Acts of Violence Against Nurses and Healthcare Personnel

Reports of violence leading to serious harm and even death have increased in the healthcare world. Factors leading to patient agitation / violence include:

1. Staff behavior;
2. Patient behavior;
3. Care settings;
4. Waiting times.

The most common reasons reported for an eruption of violence were:

1. Dissatisfaction with the perceived quality of care;
2. An unacceptable comment by a staff member;
3. Lack of staff professionalism (6).

We know that when violence erupts, both patients and staff members report having felt fear, frustration, loss of control, and pressure (7). The outcome of a violent event is not beneficial to either party. Patients may be subject to civil justice and potentially a reduced quality of care. Nurses who are attacked may suffer severe mental and physical damage; both short- and long-term (7).

It is evident that avoiding healthcare violence is in the best interest of all parties. However, the factors that lead to these situations are multi-faceted and cannot be reduced by a single measure. Let’s explore the factors surrounding violent episodes a bit more closely. Below are the results from a survey of patients who were violent with hospital staff detailing their specific complaint/trigger:

1.  Staff behaviors: dismissive, arrogant, superiority, blunt tone of voice, mismanaged patient expectations, and poor guidance provided by healthcare staff.
2. Patient factors: violent tendencies, feelings of sickness, anxiety, having underlying psychiatric disease, and feeling fearful.
3. Disturbing hospital settings: uncomfortable accommodations (physically), lack of adequate staffing,  lack of transparency.

*Based on data from (7).

So how do nurses and healthcare staff go about reducing violence? The organizational factors (uncomfortable accommodations, lack of staff, etc.) will continue to agitate and provoke patients. Healthcare workers must take a position of de-escalation when tensions rise. This includes managing expectations, maintaining a  respectful and professional nature despite patient behaviors, and maintaining transparency with patients.

Behaviors to be avoided include: harsh mannerisms and tone, condescending comments (7), and healthcare workers should be focusing on de-escalation of conflict and avoid confrontation when patients become upset. Early and judicious use of security staff is also imperative in preventing serious physical harm.

Despite the best intentions of nursing staff, violent events will continue to occur. The role of the patient has changed significantly in recent years and some hypothesize this is partially to blame for the epidemic. The role of the patient has gone from “passive” and “a receiver of care” to an “empowered, knowledgeable participant in care”. However, patients often do not have the requisite knowledge to assume this role, which may lead to feelings of frustration, fear, and misunderstanding. Working collegialitywith patients and attempting to educate them at each juncture of care may help reduce these feelings.

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 being admitted to 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.

Flu Treatment, Symptoms,

and Red Flags

Introduction

Every year, ER waiting rooms, outpatient clinics, and inpatient hospital beds fill up with patients seeking treatment for the miserable symptoms brought on by the influenza virus. This illness does not discriminate and afflicts all ages, from young babies, to the elderly, and everyone in between. Symptoms can range in severity from several days of fever, chills, and cough in bed at home, to weeks of hospitalization, respiratory distress requiring mechanical ventilation, and even complications resulting in death.

Starting in October and often lasting well into spring, flu season tasks healthcare workers everywhere with promoting prevention, quickly and efficiently identifying those infected, and appropriately managing symptoms and any secondary complications that may arise. In the last two years, the overloading of the healthcare system with COVID-19 infections has meant hospitals and clinics are even more pressed to provide appropriate staffing, treatment, and medical resources to people affected by influenza.  

An illness affecting the population on such a large scale requires healthcare professionals to stay up to date on disease trends, diagnosis and treatment protocols, and “red flags” of more serious cases in order to minimize the impact of flu season and keep complications and mortality as low as possible.

This course will review disease trends in recent years, common and more insidious symptoms to help identify flu infections, available testing methods and their accuracy, pharmacologic treatments and the importance of their timing, supportive treatments and symptom management, and the “red flags” of dangerous secondary infections and complications.

Upon completion of the course, the reader should be comfortable participating in prevention, identification, and management of the seasonal influenza virus.

Current Practice, Barriers and Need for Continued Education

Influenza is a serious global issue that has been affecting mankind since the beginning of recorded history. Despite medical advances in recent years, flu remains a major public health concern, with up to 11% of the US population being affected annually (13).

Between 140,000 and 710,000 people are hospitalized nationally each year, with around 52,000 deaths. Those most at risk are young children, those over age 65, and those with other chronic or underlying conditions such as asthma, diabetes, immunosuppression, etc.

Despite high rates of infection and risk of complications, the estimated annual vaccination rate amongst the general population remains at about half, 50.2% for adults (3) and 58.6% for children for the 2020-2021 flu season (4). There is an increased rate of vaccination amongst healthcare workers (78.6%), but as these are the people most likely to come in contact with and spread the virus, even that number could be improved upon (6).

Further complicating the situation, influenza virus has several strains and possesses the ability to change its DNA (referred to as “drift and shift”) as it replicates, making it difficult to produce a highly accurate vaccine for flu treatment (2). Because of this, vaccines cannot be created very far in advance if the most current strain is to be targeted. Vaccine shortages can result if new vaccines are not created at a fast enough rate throughout flu season (6).

There are antiviral medications available for prevention and treatment of flu, however this requires proper identification of those infected or most at risk for infection, and the administration of these medications is typically time-sensitive (5). Health care professionals should be familiar with common symptoms of flu and be comfortable assessing patients, testing for and diagnosing flu.

All of these considerations for flu treatment illustrate the intense need for educated, proactive health care workers to promote vaccines, quickly identify those most at risk or with active infections, and treat effectively in order to keep the impact of flu minimized.

The National Institute of Health has ongoing projects to keep available resources robust (14), but this research is only as strong as the health care professionals who implement it and are on the front lines of patient care. Staying up to date on current practice is paramount for national and global management of this resilient pathogen.

What is Influenza?

Viruses are small pathogens containing genetic material that infect host cells and replicate within that host. They can exist for short periods of time outside of a host as an infectious virion and are spread between hosts through a variety of ways. Influenza is a specific group of RNA viruses that replicate within the epithelial cells of the respiratory tract (15).

There are three main types of flu viruses (A, B, and C). Viruses B and C typically only exist in humans, but A has been found in other mammals such as pigs and horses (15). There are also subtypes of each virus, depending on specific structure of the virus; these are labeled as H1-16 and N1-9 for hemagglutinin and neuraminidase, however, further discussion of these is beyond the scope of this course (15).

As the virus replicates within host cells, there can be subtle changes to the RNA over time, eventually adding up to more noticeable changes and resulting in these different subtypes. These slow changes are referred to as antigenic “drift” and are part of why creating a highly accurate flu vaccine is so difficult (2).

Typically viruses that have drifted some are still susceptible to the current vaccine or there is some acquired immunity within the population. However, there is sometimes a more dramatic structural change referred to as antigenic “shift” that results in a completely new viral subtype and a population with virtually no immunity to this new agent (15). This can result in serious infection of pandemic proportions, such as the 2009 H1N1 outbreak (15).

Influenza viruses are typically spread through droplet transmission, when an infected person spreads microscopic drops of bodily fluids, typically through sneezing or coughing, which then come in contact with another susceptible person (8). These droplets usually only travel across air distances of 6 feet or less, however they can be transferred further via indirect contact such as handshaking or by vectors (surfaces or objects where virions survive temporarily while waiting on contact with the next host) (8).

Once a host touches a contaminated vector and then touches their own mucous membranes (nose, mouth, eyes, etc), they can become infected. Other bodily fluids such as loose stools, vomit, and sputum can contain viral RNA and contribute to disease spread (8).

Prevention: Flu Vaccines

Once pathogenicity is understood, providers are better able to prevent spread of infection. The primary and most effective way to help prevent the spread of flu is through a high rate of vaccination in the general population. Current recommendations are for all individuals 6 months of age and older to receive a vaccine unless otherwise contraindicated (8).

It is especially important that those most at risk (children under age 2, adults older than 65, and those with comorbid conditions) and those working with high risk individuals (healthcare and childcare workers) receive vaccines.

For the optimum protection, the goal for vaccine timing should be by the end of October, keeping in mind that full antibody production takes about two weeks after the vaccine is received. Though early vaccination is ideal, a flu vaccine can be administered at any point during flu season and patients requesting immunization later in the season should still be vaccinated (8).

The first time children between 6 months and 8 years of age receive a flu vaccine, they will need 2 doses, 4 weeks apart (8). After receiving 2 doses, children only need 1 dose for all subsequent flu seasons (8).

There are some individuals who should not receive a flu vaccine, but this group is typically very small. Among those who are absolutely contraindicated are infants under 6 months of age and anyone with a previous life-threatening reaction to a flu vaccine(6).

It was previously thought that anyone with an egg allergy should not receive the vaccine, since the viral components are grown in an egg medium, however most recent recommendations suggest that this does not cause a reaction for most people and should be reviewed on an individual basis with one’s own primary care provider (6).

Anyone with a history of Guillain-Barré Syndrome should also consult their provider and may be advised to omit the vaccine. Patients with a current cough or cold accompanied by fever may be advised to postpone the vaccine until their symptoms have resolved (6).

Each year, the CDC studies two factors of the current flu vaccine: efficacy and effectiveness. Randomized controlled trials are used to study efficacy, or the intended result, of the vaccine in optimal conditions with healthy participants (6). Less formal observational studies are used to study effectiveness, or how well the vaccine is working in the “real world.”

As previously discussed, antigenic drift and shift mean that the annual vaccine is imperfect and does not always prevent illness as well as intended. For a general idea of the typical effectiveness, we can look at data from recent years: the vaccine was shown to be 38%, 29%, and 39% effective in 2017-2018, 2018-2019, and 2019-2020 flu seasons, respectively (12).

Regardless of the lower levels of effectiveness compared to other vaccines, such as MMR, vaccination against flu can still prevent substantial numbers of illness and death when considering the population of the United States.

There are a few side effects to be aware of and to include in patient education with administration of flu vaccines. The most commonly reported side effect is local soreness around the injection site. This occurs in about 65% of patients vaccinated, does not typically interfere with activity, and resolves within a week (6).

More systemic symptoms such as fever, headache, and malaise are sometimes reported, but interestingly these symptoms are reported at similar rates in patients who received a placebo vaccine (6). Rarely, an allergic reaction can occur, ranging from urticaria to anaphylaxis.

Children under age 2 are at a slightly increased risk of febrile seizures, particularly if a flu vaccine is given in combination with Prevnar and DTaP vaccines, therefore timing of routine vaccines in conjunction with a seasonal flu vaccine should be discussed with parents of young children (6).

Though the actual correlation is unclear, there is also a suggested link between flu vaccines and the extremely rare condition of Guillain-Barre Syndrome (GBS). This often life-threatening paralytic condition occurs in about 1-2 people per 100,000 each year, regardless of flu vaccine status.

Ongoing research indicates it is unlikely flu vaccines directly cause GBS and that other triggers such as recent viral illness are more likely to be the culprit, but the CDC estimates there may be a 2 per 1 million chance of experiencing this complication after receiving a flu vaccine (6).

Standard Precautions

In addition to vaccines as the front line of disease prevention, there are multiple ways to help slow or prevent the spread of disease once flu season starts.

Hand hygiene and cough etiquette are amongst the most effective measures to prevent spread of illness (1). These steps are easy and can be followed by anyone, whether they are ill or not.

Avoid touching your mouth and nose. When coughing or sneezing, use a tissue to cover your nose and mouth and then dispose of the tissue and wash your hands. Handwashing should be done with soap and water or alcohol based hand sanitizer (9). In addition to standard precautions during flu treatment, anyone with respiratory symptoms and/or fever is encouraged to wear a surgical mask, a recommendation that was in place prior to more widespread masking with COVID-19 pandemic

Hospitals and clinics can help stop the spread of infection by separating well patients from those with respiratory symptoms (1). People who are ill should not attend work or school and should limit their contact with well people as much as possible while symptoms are present (9).

Infected individuals are considered contagious 1-2 days before showing symptoms and up to a week after illness begins; they should be fever free for 24 hours before returning to work/school (9).

Recognition and Treatment of Flu: Symptoms

Despite prevention efforts, hundreds of thousands of people nationwide will contract the influenza virus each season.

When prevention efforts fail, the next important step is early identification. It is important for all healthcare workers to be familiar with the symptoms of flu and be able to quickly and accurately identify those with a probable diagnosis of flu.

Typical influenza infections start suddenly, with a combination of fever, headache, sore throat, fatigue, nasal congestion or runny nose, body aches, and chills.

Fever and acute symptoms can last more than 7 days, with fatigue and weakness lingering for weeks. While fever is typical of influenza infection, not all who are infected present with a fever (15).

Testing for Influenza

It should be noted that patients with suspected flu can be treated purely based on clinical presentation and regional flu trends at that time; rapid flu tests do not have the highest sensitivity and therefore should not be the determining factor in regard to the necessity of treatment. However, there are several methods of testing for flu that can help confirm a suspected diagnosis of flu.

There are two main types of testing for flu: ​molecular assays ​and antigen detection tests​. Molecular assays work by identifying viral nucleic acids or RNA in a respiratory specimen (7). They are highly sensitive and specific, meaning they can detect the virus at even very low levels and the risk of false positive is very low.

There are rapid molecular assays that can result in as little as 15 minutes, identifying flu A or B, and there are also Reverse Transcription-Polymerase Chain Reaction (RT-PCR) and nucleic acid amplification tests available which take closer to 45 minutes to an hour for results and can identify specific subtypes of flu for a more in-depth diagnosis (7). Antigen detection tests are typically used in outpatient settings due to their cost-effectiveness and rapid results (10-15 minutes). These rapid tests are up to anywhere from 50-70% sensitive and have specificity >90% (7).

While more accessible to the clinic setting, antigen detection tests are less accurate and a negative result does not exclude a diagnosis of flu. In cases where flu is highly suspected and a rapid test result is negative, the result can be confirmed with a molecular assay or treatment can be started based on clinical presentation and a presumed false negative test result (7). Other illnesses such as COVID-19 may need to be ruled out or a simultaneous infection confirmed as well.

In fact, where high risk populations are concerned, such as asthma, heart disease, immune disorders, and other comorbid conditions, prompt treatment when flu is suspected may be recommended regardless of testing results (7).

Viral cultures are also available for the most in-depth results. While not practical for the clinical setting due to long result windows (3-10 days), viral cultures offer extremely detailed and useful information about the genetic details of current flu strains, which is helpful when developing the next year’s vaccine (7).

Treatment

Once flu has been identified clinically and laboratory confirmation is obtained (if desired), treatment of flu should be started as quickly as possible in order to maximize benefits of treatment and minimize potential complications of untreated illness.

Three antiviral medications known as neuraminidase inhibitors are available by prescription in the US (oseltamivir, zanimivir, and peramivir). These medications work by blocking neuraminidase, an enzyme that allows newly replicated influenza viruses to be released from host cells (5). Another antiviral, baloxavir, works by stopping replication of the virus within the host cells (5).

Treatment should ideally be started within 48 hours of symptom onset; however, there may still be benefits for severely ill patients or those who are very young, elderly, suffering from comorbid conditions, or already hospitalized, and treatment initiation after 48 hours may be considered (5). Treatment should also never be delayed while awaiting laboratory results (5).

Treatment may be initiated based on clinical symptoms alone, if symptoms are highly suggestive of influenza during an endemic period. The decision to treat is based on many factors, including risk of complications and time since symptom onset.

The most common side effects of these medications include nausea, vomiting, headache, dizziness, and sometimes a skin reaction. Typically, these medications are well tolerated and prompt initiation of treatment should be encouraged (5).

In addition to antivirals, supportive care is a mainstay of treatment. Rest, hydration, cool mist humidifiers, antipyretics, and throat lozenges have all been shown to provide comfort and help with symptoms. Multiple studies have shown honey to be an effective cough suppressant and 1 tbsp. in warm tea or water can work well to provide some relief.

Patients should be monitored for signs of dehydration, including dry mucous membranes and reduced urine output. Ill patients should also isolate themselves as best as possible to prevent further spreading the illness (12).

“Red Flags” – Potential Complications and What Not to Miss

The majority of flu cases make a full recovery after 1-2 weeks of illness, however there are some more serious complications that can develop, including life-threatening symptoms and even death (11). Flu can sometimes trigger systemic inflammation, leading to myocarditis, encephalitis, rhabdomyolysis, or multi-organ failure.

These conditions can be difficult to diagnose if suspicion is not high. Flu infections attack the usual defenses of the respiratory tract and predispose the body to secondary bacterial infections like pneumonia.

The body’s initial inflammatory response is beneficial to help the body fight off a flu infection, but increasing inflammation or prolonged inflammation puts too much stress on the body and this extreme response can result in autoimmune disorders or sepsis (13). Those with asthma, heart disease, or other chronic conditions are at an increased risk of complications, as are young children and the elderly (11).

Post-influenza pneumonia is a well-described phenomenon and the most common causative pathogen is Methicillin-Resistant Staphylococcus Aureus (MRSA). This secondary infection should be considered in patients with respiratory symptoms and/or sepsis after a recent resolution of flu followed by returning or new/acute symptoms. It is important to consider MRSA as a causative agent when prescribing antibiotics to patients with post-influenza pneumonia (15).

“Red Flags” or warning signs that the body is working too hard to deal with the flu virus, or is not compensating well, include: fast respiratory rate or difficulty breathing, cyanosis, tachycardia, hypotension, chest pain, dizziness, confusion, decreased urine output (>8 hours), severe muscle pain, or seizures. In children, fever >104 (or any fever in children <12 weeks of age) and retracting are concerning signs.

Any other signs/symptoms that are concerning or seem to be worsening warrant further workup and possible hospitalization to prevent further decline (11).

Case Study 1

This case study involves a real patient’s experience with seasonal flu. Names, genders, ages, and some details have been changed to protect patient information.

Jennifer is a 35 year old female who presents to an urgent care clinic in mid February with 2 days of rhinorrhea, cough, sore throat, body aches, and tactile fever. She has not received a flu vaccine this season. Recent medical history significant for COVID-19 infection six weeks ago. Following triage, her vitals are recorded as: ​HR: 110, RR: 22, Temporal temp: 101.3, SPO2: 97%, BP: 110/76. ​

She is visibly uncomfortable but sitting up on the exam table and able to cooperate and carry on a conversation. She is breathing a little shallowly and has a frequent, coarse sounding cough, but is overall not in any respiratory distress. She is congested and has clear rhinorrhea, eyes are watery, she has some posterior pharynx erythema, no cervical lymphadenopathy, and some faint rhonchi to her lungs that she is able to clear when coughing.

Rapid strep, flu, and COVID-19 swabs are collected and the results are negative. She is given a prescription for 5 days of 75mg BID TamifluⓇ (oseltamivir) which she fills and begins taking that afternoon. A viral culture is collected from her via nasopharyngeal swab for confirmation of suspected influenza.

Within 3-4 more days, Jennifer is fever free and beginning to feel better despite some persistent fatigue. She works from home until her fever has resolved and cough is improving. She makes a full recovery without sequelae. Three days later her viral culture indicates she has type B influenza, despite her negative rapid influenza test. This is a typical case of influenza and the Tamiflu may have hastened her recovery and possibly prevented severe illness. It also illustrates that rapid influenza testing has a low sensitivity and per CDC guidelines treatment may be based on clinical signs and symptoms.

Case Study 2

This case study involves a real patient’s experience with seasonal flu. Names, genders, ages, and some details have been changed to protect patient information.

Braxton is a 9 year old male who presents to his PCP’s office with sudden onset of high fever (tmax 103), headache, and cough that started that morning. It is December and he has not received a flu vaccine. His vitals are stable.

Exam reveals clear rhinorrhea, erythematous and enlarged tonsils, and frequent barky cough. Rapid strep and COVID-19 tests are negative, but a rapid flu test is positive for Influenza A. He is given a prescription for TamifluⓇ (oseltamivir), however his parents have some reservations about the medication due to an article they read on social media and decide not to give him the medicine.

They manage his symptoms with analgesics, Gatorade, and rest. About 11 days later, he follows up in the office with complaints of persistent fatigue and new complaints of dizziness and abdominal pain. Parents report a syncopal episode at home that morning, prompting today’s visit.

His cough is still present, but better than it was, and he has been afebrile for about 5 days now. He looks very pale, and complains of some dizziness as he gets up onto the exam table; his behavior is sluggish. He has some abdominal bloating and tenderness with mild spleen enlargement. Furthermore, he has lost 4 pounds since his previous visit. Vitals are somewhat concerning: ​HR: 145, RR: 27, Temporal temp: 98.8, SPO2: 98%, BP: 90/54. ​

This patient seems poorly hydrated, and his overall appearance is concerning, so you order some stat labs. Multiple abnormal lab values return, the most critical of which is a hemoglobin of 3.4. He is admitted to the local children’s hospital PICU and treated for hemolytic anemia secondary to viral infection as well as multisystem organ failure.

After multiple blood transfusions and aggressive steroid therapy, he is discharged after over two weeks of hospitalization, with no permanent organ damage.

This case illustrates one of the rae (but potential) complications of the viral influenza infection. It is possible that early antiviral treatment may have avoided this complication and/or minimized it.

Summary

While influenza is an annual problem and can often seem routine or overshadowed by COVID-19, it is still of utmost importance that healthcare professionals stay vigilant in their knowledge of flu treatment and treat each case on an individual basis.

As the front lines for promotion of flu prevention, early identification and treatment of flu, and maintaining alertness for potential complications, health care workers can have the biggest impact on the severity of the current flu season.

Staying up to date on current practice can help reduce overall numbers of infection, rate of complications, and mortality.

Measles

The History of Measles

Medicine has come a very long way in curing diseases that once wiped out entire populations. Before the vaccine, measles was a serious health concern. Each year, millions of people became infected with measles, and in the United States alone, an average of 495 people died of related complications.

Even beyond the mortality rate, 48,000 people experienced hospitalizations, and 1,000 of those developed a significant and lifelong disability every year. One of the most dreaded complications of measles involves the spread to the central nervous system, causing subsequent inflammation and risk for brain injury from acute encephalitis (4).

Measles is an acute, viral respiratory illness that is one of the most contagious of all infectious diseases. In fact, 9 out of 10 (90%) susceptible persons with close contact will develop measles. The virus is transmitted by direct contact with infectious droplets or by airborne spread. The measles virus lives for up to two hours on surfaces. The disease is active and contagious in the airspace for two whole hours.

Enter the Measles Vaccine

During a Measles outbreak in 1954, physicians collected blood samples from affected students in Boston. They isolated the measles virus from a 13-year-old student’s blood and created a Measles vaccine. In 1963, the live Measles vaccine debuted in the United States. Five years later, the modern-day vaccine was introduced.

Measles is usually combined with mumps and rubella as part of the MMR vaccine. It is a very effective vaccine that protects over 97% of recipients (5). By 2000, the Centers for Disease Control and Prevention (CDC) declared measles eliminated. Historically, the development of the measles vaccine changed the scope of public health.

For the first time, prevention proactively saved lives. But now, with the advent of the anti-vaccination campaign, we are at risk for a revival of the disease that healthcare nearly eliminated.

Signs and Symptoms of Measles

Measles includes the onset of an elevated fever that may be as high as 105 degrees Fahrenheit (4). Other symptoms include:

• Malaise
• Cough
• Noninfectious nonallergic rhinitis (also known as coryza)
• Conjunctivitis
• Koplik’s spots
• Maculopapular rash

Koplik’s spots are unique to measles and highly suggestive of the disease. They occur two to three days before the rash. They are white, clustered lesions on the gums that resemble grains of salt.

The maculopapular rash appears approximately 14 days after exposure and spreads from head to trunk to the extremities. Those with measles are contagious from four days before they show symptoms until four days after the rash appears. In some cases, immunocompromised patients may not develop a rash. The rash usually disappears within one week (4).

Diagnosis

A diagnosis is made after evaluation of the signs and symptoms, in particular, a widespread skin rash that appears three to five days after exposure and lasts up to one week. The rash consists of red, itchy bumps. Measles is more likely to occur in unvaccinated children, primarily under five years old.

Once a diagnosis is suspected, measles is verified with laboratory confirmation. The lab tests that are performed are the measles antibodies (IgM) and measles RNA by real-time polymerase chain reaction (RT-PCR). To complete the laboratory tests, the nurse should collect a nasopharyngeal swab and take a serum sample. The serum sample is for public health implications, and diagnostic testing usually occurs in a specialty lab (4).

Complications

If measles is not identified and treated, the associated complications can be quite deadly. Possible complications include (4):

• Encephalitis
• Pneumonia
• Ear infection (Otitis media)
• Miscarriage or preterm labor in pregnant women
• Thrombocytopenia
• Blindness
• Severe diarrhea and dehydration

Personal Protective Equipment (PPE)

Because Measles is incredibly contagious, it is critical to adhere to all recommendations for isolation and the appropriate personal protective equipment (PPE). Patients with Measles should be placed on airborne precautions. Airborne precautions are used to prevent the spread of germs through the air (8). Other illnesses with airborne precautions include tuberculosis and chickenpox.

It is vital to place the patient on isolation precautions as soon as you suspect measles to minimize potential exposure to other staff and patients. Place patients in a negative pressure room and wear a fitted N-95 respirator to enter a room. A surgical mask is not appropriate, so a respirator must be worn.

Treatment

The treatment of measles is broken into different categories, depending on exposure and symptoms: (4)

-Post-exposure prophylaxis for asymptomatic patients who have been exposed to measles. If they are not properly vaccinated or unsure of their immunization status, they should be treated with an MMR vaccine within 72 hours or immunoglobulin within six days of exposure.

• Patients should receive the immunoglobulin if they are not vaccinated against measles and are unable to be vaccinated with the MMR vaccine in the cases of pregnancy, severe immunosuppression, or age less than one-year-old. They should not receive the MMR vaccine for six to eight months following the immunoglobulin administration.
• Patients should avoid public areas for 72 hours due to the contagious nature of the disease (e.g., hospitals, schools, and daycare).
• Immunoglobulin and the vaccine should never be given together as this process invalidates the vaccine. 

-Treatment after the confirmation of measles is individualized and may range from a vaccination, immunoglobulins, vitamin A, Ribavirin, or supportive care (9).

• Acetaminophen PRN for fever and myalgia (muscle aches or pains)
• Humidifier for cough and sore throat
• Rest and hydration
• Isolation for four days after the rash appears
• Educate patients that symptoms will last two to three weeks
• Vitamin A or Ribavirin may be given 

Measles Spread

Although the COVID-19 pandemic has showcased many polarized views on either the support or opposition of vaccinations, the “anti-vax” or “anti-vaccination” movements were around much before then with measles. 

These groups publicly shared views of wanting to eliminate vaccinations and believed that its benefits do not outweigh the overall risk of receiving them. However, evidence does not prove that the risks of vaccinations are significant, especially when compared to the risks of the diseases. 

Encouraging Vaccination Through Education

The best strategy to reduce the spread of measles is to encourage all patients and family members to receive all recommended vaccinations. One of the most important nursing interventions is education, and this is the perfect opportunity to educate your patients.

In 2014, families visiting Disneyland left with measles. The state of California later reported 159 cases of measles throughout the next several months. When looking at school data in that same year, only 70 percent of counties had the ideal herd immunity status of 95% vaccinated.

In response to this outbreak, California passed Senate Bill 277 that eliminated all personal belief and conditional vaccination exemptions before entering school. The law went into effect in 2016 and only allowed medical exemptions and required that all schools report the vaccination status of enrolled children. Officials in California found that by tightening the vaccine regulations, more children received vaccinations before entering kindergarten (6). In 2016, 97% of school districts met herd immunity guidelines.

When patients are discussing travel plans, it is an excellent opportunity to provide Measles education (6). Many patients are unaware that leaving the country puts them at risk for specific vaccine-preventable diseases, particularly when traveling to endemic countries.

It is also important that patients and families understand the concept of herd immunity. This is the indirect defense from infectious disease that happens when the majority of a population is immune to a specific infection. Herd immunity ensures that even when a person is not vaccinated, they receive protection because the people surrounding them are resistant to the disease and are unlikely to transmit it to them or harbor an outbreak. However, for herd immunity to be effective, 19 out of 20 people (95%) of the population must be vaccinated (7). When many people are immune, the chances of infection to the rest of the population are rare because it is unlikely an unvaccinated person will come in contact with an infected person.

There are medical conditions that make the vaccine unsafe to receive. New babies are at risk for many diseases until they are old enough to receive all vaccinations (5). Many people are at risk for infectious diseases because they are unable to receive the MMR vaccine. Other populations who should not be vaccinated include patients who are:

• Pregnant,
• An anaphylactic allergic response to a component in the MMR vaccine,
• Immunosuppressed or compromised,
• Recently received blood products,
• Suffering from active tuberculosis or other severe illness.

Lastly, many people are unaware of the risks of measles because they have never seen it. However, measles could become an endemic in the U.S. again if vaccine coverage decreases significantly and herd immunity is lost (4). It is critical to discuss this possibility with your patients so that they are aware of the significant risk of the anti-vaccination movement. Most patients and caregivers are unaware that Measles can result in life-threatening complications, such as pneumonia and encephalitis.

Parent Education and Shared Decision Making

While many healthcare professionals have strong opinions regarding vaccination, using shared decision-making to further parental understanding of vaccinations is critical. It can be upsetting for parents to see their infant or child receive multiple injections. By opening the discussion of the risks and benefits, the nurse provides parents with essential information regarding vaccination. It is crucial that nurses have an open discussion and to acknowledge the concerns of patients and families.

Despite multiple immunizations in each visit until their second birthday, the CDC states that a healthy child’s immune system will not become overwhelmed by the vaccinations. There is a slight risk for side effects with immunizations such as severe allergy, disease, and death; but, most side effects are mild, like redness and swelling at the injection site (3). However, vaccine-preventable diseases can be fatal, and the benefits of the vaccine far outweigh the risks. The risks of becoming ill with measles are far worse than the risks associated with the vaccination (3). These are important points to make families aware of.

The U.S. Food and Drug Administration (FDA) ensures the safety, effectiveness, and availability of vaccines. Current vaccinations have each been evaluated by scientists and continually monitor for other side effects after FDA licensure. Any complications or adverse effects are tracked by the Vaccine Adverse Event Reporting System (VAERS). If the CDC and FDA find a link between a particular immunization and a specific side effect, they will weigh the benefits against the risks and update the safety information on the Vaccine Information Sheets (VIS) (3).

What is Asthma?

Asthma is a chronic disorder of the respiratory system that is characterized by four primary components: recurrent respiratory symptoms, bronchial hyper-responsiveness, airway obstruction, and inflammation (9).

Certain factors such as genetics, environment, socioeconomic status, smoking status, and race/ethnicity can increase the chances of developing asthma. Common triggers of asthma include allergens, pollution, cold air, stress, and exercise, among other irritants. All of these contribute to asthmatic reactions, and necessitate childhood asthma treatment.

Environmental factors trigger dendritic cells, which produce B and T cell lymphocytes, initiate IgE production of mast cells, eosinophil, and neutrophils. The end result of this cascade is bronchial inflammation.

These cells also activate Th2/Th1 cytokines which amplify the response of the smooth muscle walls leading to persistent inflammation and remodeling of the tissues (long-term) (9).

Summary 

A Word on Septic Shock 

Septic shock occurs in up to 15% of patients with sepsis (1). The management of the patient in septic shock hinges on prompt recognition of the patient’s deteriorating condition, and expeditious administration of antibiotic therapy coupled with infectious source control. Simultaneously, the failing organ systems must be supported through measures such as, fluid resuscitation, vasopressors, blood transfusions, respiratory support, and inotropic agents. You can find more details regarding the initial management of sepsis in the Surviving Sepsis Campaign guidelines. 

Septic Shock is defined as hypotension requiring intravenous vasopressors to maintain a MAP ≥65mmHg and serum lactate of >2mmol/L (1). 

Early Septic Shock 

• Hemodynamics à High Cardiac Output (CO) and Low Systemic Vascular Resistance (SVR)  
• Extreme vasodilation leading to an increase in cardiac output. This is the body‘s attempt to preserve peripheral vascular perfusion.  

Late Septic Shock 

• As shock progresses, myocardial performance diminishes and circulating blood volume is continually lost to the interstitial space, leading to a profound hypotensive state.  
• Sepsis–induced myocardial dysfunction may ensure. This results in a potentially reversible heart failure state due to myocardial depression.  

What Is a “Bundle“ and Why Are They Used? 

The Surviving Sepsis Campaign developed the internationally endorsed “sepsis bundle“ separately from their guidelines as a way to guide sepsis quality improvement (3).  

The bundles consist of various components of sepsis care: 

• fluid resuscitation 
• timely and appropriate antibiotic administration  
• blood cultures 
• and the use of serum lactate levels (4) 

The bundle elements were designed in such a way to be updated as new evidence emerged (3). In response to the most recent guidelines published in 2016, there has been a revised “hour-1 bundle“ as opposed to the previous 3 hour and 6–hour bundles (3) (5). 

Evidence has shown an association between compliance with bundles and improved survival in patients with sepsis and septic shock. In a multi-center, retrospective, observational study of adult patients with a hospital discharge diagnosis of severe sepsis or septic shock, overall mortality was lower in those who received bundle-adherent care (17.9%) when compared to those who did not (20.4%) (4). Interestingly, when the patients in the study were divided into subgroups by the suspected source of infection, there was only a statistically significant mortality benefit to bundle-adherent sepsis care in patients diagnosed with pneumonia (4).

1-Hour Bundle Components and Strategies to Expedite care 

The most critical change in the Surviving Sepsis Campaign bundles is that the previous 3-hour and 6-hour bundles are now combined into a single “hour-1 bundle“ with the intention of beginning resuscitation and management immediately upon presentation (3) (5). While more than one hour may be needed for patient resuscitation to be completed, the initiation should begin immediately upon suspicion that the patient may be presenting with sepsis. 

Measure lactate level.

Serum lactate level serves as a surrogate for direct tissue perfusion measurement (3). In the absence of oxygen – anaerobic metabolism ensues, and lactate levels rise. It often represents the degree of tissue hypoxia present, and increased levels are associated with worse outcomes. If the initial lactate is >2mmol/L, it should be re-measured within 2-4 hours and used to guide resuscitation with the goal of achieving a lactic acid <2mmol/L (3). 

Hospitals should have a threshold of ≥2mmol/L for a critical lactic acid value, which will prompt any abnormal value to be communicated to the provider. Consider having non-nursing personnel collect the lactate level so that the nursing staff is free to focus on other tasks. The re–collection of lactates >2 can be automated by many electronic order entry systems and will help reduce fallouts due to re-collection. Point of care lactate is now readily available which can be valuable. 

All critical lactate values should be communicated to both the nurse and the provider. Traditionally this has been done by a call to the nurse, who then notifies the provider. We suggest that the lab calls both the provider and the nurse directly to reduce the potential for error. 

Obtain blood cultures prior to antibiotics.

Blood cultures can become sterile within minutes of the first dose of an appropriate antibiotic (3). By obtaining cultures before administering antibiotics, there is a better opportunity to identify pathogens and therefore improve patient outcomes. Appropriate cultures include at least two sets of both aerobic and anaerobic cultures from two separate venipuncture sites. However, administration of antibiotic therapy should not be delayed past 1 hour in an effort to obtain cultures (3). 

Administration of broad-spectrum antibiotics.

Empiric broad-spectrum antibiotic therapy with one or more intravenous antimicrobials to cover all likely pathogens should be started immediately (3). Once a pathogen is identified, and sensitivities are established, the empiric antibiotics should be narrowed or discontinued if the patient is found not to have an active infection (3). 

Since time is of the essence when treating a patient presenting with sepsis, the empiric antibiotics should be kept in the on-unit medication storage for ease of access. Nurses should have immediate access to these medications. 

All orders for sepsis antibiotics should be ordered as STAT (for the first dose). The providers should be trained to enter antibiotics orders directly after examining patients, if possible. Delays in ordering obviously lead to a delay in medication delivery. The goal should be to have a culture that recognizes and treats sepsis as a medical emergency, just as a code stroke or myocardial infarction. 

Administer IV Fluid.

Early effective fluid resuscitation is critical for the stabilization of sepsis-induced tissue hypoperfusion and septic shock (3). Initial fluid resuscitation should begin immediately upon recognizing that a patient is presenting with sepsis and/or hypotension and elevated lactate (3). Fluid resuscitation should be completed within 3 hours of recognition. Current guidelines recommend that intravenous fluid resuscitation consists of 30 mL/kg bodyweight of crystalloid fluid (3). 

Providers should communicate the need for intravenous fluids verbally to the nursing staff and place orders into the order entry system directly after examining patients. The patient should have 2-3 large–bore IVs placed to facilitate the administration of IV fluids and IV antibiotics without sacrificing the timing of one or the other. Oftentimes, placing a central line takes anywhere from 15-30 minutes and will delay overall patient care during the first minutes. If additional venous access is needed, it is advisable to wait until the patient is stabilized so long as adequate, reliable IV access is obtained. 

Apply vasopressors.

A critical part of sepsis resuscitation is restoring perfusion to the vital organs. If a patient‘s blood pressure does not return to normal after the initial fluid resuscitation, then vasopressors should be initiated to maintain a mean arterial pressure (MAP) of >/= 65 mmHg (3). If a patient has profound hypotension and the decision is made by the medical team to initiate vasopressor therapy, there is no need to wait to initiate until central access is obtained (3). Vasopressors can be infused through a large–bore peripheral IV safely for a short amount of time (3). 

Within the ER and ICUs, there should be easy access to vasopressors, specifically norepinephrine, vasopressin, and epinephrine, in the event that a patient needs a vasopressor started. Additionally, institutions should have standing protocols for nurses to initiate a vasopressor if a patient is consistently hypotensive despite adequate fluid resuscitation. This will save vital time by allowing the nurse to use their clinical judgment and restore vital organ perfusion quickly and efficiently while awaiting provider guidance. 

Code Sepsis 

Despite bundle care and the diligent work of healthcare providers and beside nurses alike, many hospitals have identified an opportunity to save lives and reduce suffering through early sepsis detection, compliance with current standards of care, and determining the appropriate level of care. 

The Emergency Department Code Sepsis Project focuses on timely implementation of the SSC care bundle to reduce mortality and costs and to ensure appropriate level of care placement. By activating a ‘code sepsis,’ it allows not only doctors and nurses to be aware of the urgency at hand but also pharmacists, respiratory therapists, lab technicians, nursing support staff, and unit secretaries. 

In some facilities, a ‘code sepsis‘ is worked into the rapid response team’s framework. For example, if a nurse screens a patient for SIRS criteria and the patient meets the criteria, a page can be sent out from the patient‘s current floor. This will mobilize the appropriate resources to facilitate swift and effective resuscitation. 

The multidisciplinary nature of the code sepsis project creates a strong sense of teamwork centered around applying best evidence-based practice, mobilizing resources, avoiding procedure variability, and improving patient care and safety (6). 

Hospitals that are struggling to meet sepsis measures should consider the addition of a “code sepsis“ or “sepsis response team“. 

Each organization should strive for a culture that treats sepsis with the same urgency as any other medical emergency. Much of the delay in treatment with sepsis is due to a lack of standardized processes. Hospitals should work to develop sepsis protocols and sepsis response teams to increase compliance with bundles and decrease mortality. 

Conclusion 

With sepsis being the number one killer of hospitalized patients in America and the number 1 cause of pediatric deaths, especially in developing countries, knowledge of the entire healthcare team, with an emphasis on nurses is imperative to decrease this statistic and provide expedited care to our patients to save lives. As a nurse, having the knowledge to recognize early symptoms of sepsis and act accordingly to prevent the progression, it will allow you increase care and improve patient morbidity and mortality.  

Chest Tubes Nursing Care

Introduction

Chest tube nursing care and placement is common procedure in many hospitals, yet nurses consistently rank them as one of the most overwhelming drains to care for.

A malfunction in a chest tube can be deadly for a patient in a matter of minutes. Many hospitals have recognized them as a common source of error and patient harm. For these reasons it is imperative that nurses understand how chest tubes function and how to care for them. In this course we will discuss the anatomy, indications, and care of chest tubes.

The ancient Greeks were the first to record techniques used to drain the pleural space (1). Though the process and equipment have evolved over the centuries, the basic principles  of chest tubes nursing care have not changed (1). Today, thoracostomy tube (more commonly known as a chest tube) placement continues to be a very common procedure.

Chest tubes are utilized for a variety of reasons, ranging from emergent placement to routine use after an elective surgery (1). They can be placed just about anywhere– the bedside, the operating room (OR), and interventional radiology.

Most nurses will encounter chest tubes at some point during their career– perhaps frequently, depending on where you work. Thus, it is essential for nursing staff to feel comfortable with chest tube management. Unfortunately, like anything else in healthcare, chest tubes are at risk for complication. Chest tubes nursing care is critical to overall health. Quick identification of potential complications could be the difference between life and death. This course aims to expand your knowledge and increase confidence in chest tube management.

Chest Tubes Nursing Care Basics – What Is a Chest Tube?

Licensed and retrieved from Adobe Stock

Let’s start with a quick refresher on the structure of our lungs. First comes skin (obviously). Beneath that is a layer of subcutaneous tissue, followed by muscle. Then we come to the ribs, which form the basic protective cage that holds our lungs, heart, and some very important blood vessels. Between each rib from top to bottom is a vein, artery, nerve, and more muscle (2). Behind the ribs lies the first layer of the pleural space, called the parietal pleura (2).

This membrane lines the entire chest cavity. Then comes the pleural space, which measures about 15-20 microns wide in its normal state (2). On the other side of the pleural space lies the visceral pleura, which is a membrane that covers the lungs, and then finally the lungs themselves (2).

What this means is that in a normal person, a small potential space exists between the lungs and the chest cavity, called the pleural space. When the pleural space becomes compromised and fills with extra fluid or air, the precarious negative pressure balance that keeps the lungs inflated is disrupted, forcing lung tissue to collapse.

A chest tube comes to the rescue. Known officially as a thoracostomy tube, the chest tube is a hollow plastic tube that is carefully placed by a licensed provider. The tube is driven through the outer skin and muscle, between two ribs and past the parietal pleura to rest inside the pleural space.

Its purpose is to drain the excess fluid or air out of the pleural space so the affected lung can reinflate. The tube is attached to a drainage system to facilitate the movement of the abnormal fluid/air out of the plueral chest. The tube remains in place until the fluid/air is removed, the lung is reinflated, or becomes nonfunctional (3).

According to chest tube nursing care experts, chest tubes are generally divided into three categories based on size and method of insertion: large bore, small bore, and tunneled.

Large Bore (Blunt Dissection Technique)

Generally greater than 20Fr in size, large bore chest tubes are placed using the blunt dissection technique (3). A quick aside here: the size “Fr” refers to “French” or the actual french word “Charrière”, which is the name of the frenchman who invented the sizing (3). The sizing is based on the diameter of a tube, with 1Fr = ⅓ mm (for example, a 12Fr tube is 4mm, 12÷3=4).

The blunt dissection technique requires a skin incision large enough to fit a finger (3). A clamp or forceps is used to bluntly dissect intercostal tissues. The tube is inserted and held in place with heavy suturing (3). This technique is more invasive. It also comes with some risks, including damage to surrounding structures, tube misplacement, bleeding, and increased pain.

Small Bore (Seldinger Technique)

Small bore chest tubes are generally less than 14Fr in size. They are placed using the Seldinger technique, which involves using an introducer needle to get access into the pleural space (3). A guidewire is threaded through the needle and the needle is removed. Then the chest tube is threaded over the wire and the wire is pulled out, leaving only the chest tube. The tube is held in place with a suture and/or adhesive dressing. Advantages include a smaller incision, less pain, and it’s less invasive (3). Conversely, they are more prone to blockage because they are smaller (3).

The decision to use a small or large bore chest tube is made by the provider. For the treatment of most pneumothoraces, research shows that small bore chest tubes are as effective as larger tubes and may be less painful (4). Large bore tubes are recommended to treat traumatic pneumothorax due to the need for removal of blood and air (4). In the past, providers used large bore chest tubes to drain thick fluid like blood and pus, but more recent research suggests that small bore chest tubes are also effective if they remain patent and are properly maintained (4).

Tunneled (Indwelling)

(Retrieved from Cleveland Clinic Journal of Medicine, 2016)

Indwelling chest tubes are indicated for long-term chest drainage, primarily as a treatment for malignant pleural effusion (3). These tubes consist of a special catheter equipped with a cuff that remains under the skin and acts as an infection barrier (3). The Seldinger technique is used to get access into the pleural space, along with a “peel-away” dilator that allows the tube to be tunneled under the skin. Two small incisions are required for placement. A special vacuum bottle is attached periodically to collect the drainage (3).

Current Practice in Chest Tubes Nursing Care

Bedside chest tube placement has become increasingly routine. Thus, bedside nursing staff may be directly involved with the initial chest tube placement (5).

The nurse may be asked to gather the necessary supplies for placement, ensure patient consent is obtained, and assist with patient education regarding the procedure (5). The nurse may assist the provider during the procedure by participating in a pre-procedure “time-out” and monitoring the patient’s vital signs, comfort, and response to the procedure. Afterward, the provider will order a chest x-ray to verify placement and to confirm the absence of complications from the chest tube insertion. As always, the nursing staff is responsible for ensuring any post-procedure orders are carried out.  

Once the chest tube is in place, verified by x-ray, and attached to a drainage device, nurses are tasked with monitoring the patient and the drainage device. This would include monitoring vital signs as directed, observing for pain and signs of infection, and assessing the tube and drain system (5). An important part of monitoring includes recording the amount and color of chest drainage. How often this is done depends on nursing judgement, facility policy and the provider’s written orders.  

Perhaps the most intimidating aspect of chest tube management is ensuring proper function. It is the nurse’s job to look for signs that there may be a problem. Rest assured, these signs and symptoms will be discussed in detail later in the course.  

There will also be orders for the nurse to change any dressings and provide necessary wound care. This includes routine observation of the chest tube insertion site. Depending on how long the chest tube is in place, nurses may also have to change out the drainage system if it becomes full of fluid.  

Patients with chest tubes may ambulate, if appropriate, and travel to other departments within the hospital for other procedures. Chest tubes nursing care staff (most nurses) are responsible for ensuring the chest tube is properly packed up and stowed away for every adventure. This includes removing the chest tube from suction if suction is ordered and leaving the drainage system lower than the patient’s chest. Remember, it’s okay, the water seal will keep anything from entering the patient during transport and/or the procedure.

Indications for Chest Tube Placement

A chest tube may be indicated for the following reasons: pneumothorax/hemothorax, pleural effusion, empyema, chylothorax, and post-operatively after cardiac/thoracic surgery (1).

Pneumothorax/Hemothorax

A pneumothorax, also known as a “lung collapse”, occurs when the normal negative pressure gradient within the lungs is compromised (6). Air is introduced into the pleural space where it is not welcome. A pathway to the pleural space may form on the inside of the body when lung tissue is damaged. The connection typically forms at the airway or alveoli (the little air sacs in the lungs that encourage gas exchange) (6).

For example, a patient with COPD or chronic bronchitis may develop enlarged, weakend alveoli called blebs that are prone to rupture. When this happens, air flows into the pleural space because of the difference in pressure, forcing the lung tissue to shrink or collapse in response to the expanding pleural space (6).

A pneumothorax may also occur from an outside source if an abnormal connection forms between the pleural space and the chest wall (6). For example, during a lung biopsy, a needle is introduced into the lungs from the outside. Sometimes a pathway forms, allowing air from the environment to flow into the chest. In an attempt to equalize the pressure, air rushes into the pleural space.

A pneumothorax may also be spontaneous in a condition known as primary spontaneous pneumothorax (PSP) (6). PSP usually occurs in tall, thin young men between the ages of 10-30 (6). The risk is significantly increased with current or past smoking (6).

Finally, a hemothorax is diagnosed when blood becomes trapped within the pleural space. It often occurs with pneumothorax. Hemothorax may result from trauma, abnormal coagulation, spontaneously, or after certain medical treatments (such as a biopsy) (7).

Symptoms of pneumothorax and hemothorax include acute chest pain and shortness of breath (dyspnea). The pain may be worse during inhalation and localized to the affected side (6). The degree of dyspnea is often proportional to the size of pneumothorax (bigger pneumo = more pain), but not always- a small percentage of people are asymptomatic (6).

Licensed and retrieved from Adobe Stock

Pleural Effusion

In a healthy person, the pleural space contains a small amount of serous fluid (about 5-10 ml) that is secreted by the parietal pleura and reabsorbed by the lymphatic system (8). When this carefully balanced system is disrupted, extra fluid can accumulate, known as a pleural effusion.

Pleural effusion is the result of leaky capillaries. Capillaries leak for two reasons: changes in pressure or damage to the vessels themselves (8). Congestive heart failure and cirrhosis are the two most common causes of pressure changes. Capillary damage is most commonly caused by pneumonia, pulmonary embolism, cancer, and GI disease (8).

Pleural effusion in the pediatric population usually stems from congenital heart disease, pneumonia, and cancer (8).

Large right-sided pleural effusion Licensed and retrieved from Adobe Stock

Empyema

Empyema is the development of infected, purulent fluid inside the pleural space (8). Pneumonia is the usual suspect, but empyema can also form from a lung abscess, bronchopleural fistula (an abnormal tract/pathway between the bronchus and the pleural space), esophageal perforation, or complications of trauma and surgery (8).

The development of empyema may begin with just a small amount of extra, sterile fluid that accumulates in the pleural space (8). When an infectious agent is introduced, inflammation brings white blood cells and even more fluid. Eventually, the infected material can grow into the pleural walls and cause tissue thickening, prohibiting lung expansion (8).

Purulent drainage associated with empyema can be thick and therefore difficult to drain. Fibrinolytics (medicines that dissolve blood clots) can be directly administered through the chest tube into the pocket of infection to help break it down and improve drainage (2). tPA is the medication of choice. A small amount of tPA is diluted in saline and infused through the chest tube, which is clamped for a while (1-2 hours) before drainage is resumed (2). The dose may be repeated if necessary.

Symptoms for pleural effusion and empyema include dyspnea, pleuritic chest pain, cough, fever & chills if infection is present, and weight loss. If a large volume of fluid collects, cardiac function may be impaired: the heart cannot pump effectively if there is no room (8).

Post-Operative

Chest tubes are often placed after heart or lung surgery because of the risk for developing pleural effusion or pneumothorax during recovery. They are inserted while the patient is still sedated prior to leaving the operating room.

In chest tubes nursing care, chest tubes are routinely placed following open heart surgery, including cardiac bypass and valve replacements. They are also indicated in major thoracic surgeries, such as pneumonectomy, lobectomy, lung transplants, segmentectomy, and wedge resection.

Patients with chest trauma may require a chest tube in the presence of pneumothorax or hemothorax.

Potential Complications

When preparing a patient for chest tube placement, it is important to be aware of potential complications. Chest tubes can be lifesavers but they are not without risk: when placed at the bedside or during an emergency, it is essentially a blind procedure.

Injury to Surrounding Structures

Gastrointestinal Tract

Although rare, it is possible to for chest tubes to be placed beneath the diaphragm into the abdominal cavity. Insertion into the abdominal cavity poses risk for injury of the stomach, bowel, liver, spleen and other abdominal structures (1).

Though the overall risk is <1%, a third of all chest tubes that find their way into the abdomen result in injury to the patient (1). Signs of abdominal placement include the presence of stomach contents within the tube or peritonitis (1). An x-ray would confirm that the chest tube is located below the diaphragm. Inserting the chest tube no lower than the 5th intercostal space helps prevent this problem (1).

Diaphragm

Many chest tubes are placed at the bedside without imaging guidance. Improper placement poses a risk for injury to the diaphragm (1). Laceration, perforation, and muscle injury are the most common injuries (1). Certain conditions increase the risk of diaphragmatic injury, including diaphragm paralysis, late pregnancy, obesity, ascites, and abdominal tumors (1).

Lungs

The lungs are at highest risk of injury during chest tube placement, especially if a patient suffers from decreased lung compliance or pleural adhesions (1). Lung injury is commonly missed because it cannot be visualized on imaging and patients may be asymptomatic (1).

A rare complication of chest tube placement is infarction of the lung. Excessive suction causes aspiration of lung tissue into the chest tube, leading to infarction and tissue death (1). Providers must also beware of lung perforation and accidentally puncturing the pulmonary artery (as evidenced by rapid blood loss, massive hemoptysis, shortness of breath, tachycardia and hypotension) (1).

Cardiac Structures

If the chest tube is advanced too far, the tip may rest too close to the mediastinum, resulting in compression of nearby structures (1). Although rare, it can lead to hemodynamic instability (1). There have also been cases of penetration of cardiac structures.

Other Potential Complications

Pain

Some pain is associated with chest tube placement. At the very least, providers will provide local anesthetic to numb the area while the tube is inserted. Sometimes, patients are also given IV pain medicine or sedation during placement. Patients may also experience pain while the chest tube is in place, so providers will often prescribe PRN analgesia to improve comfort. Some studies have suggested that large bore chest tubes are generally more painful than smaller ones (4). Remember to encourage mobility. A patient’s pain will need to assessed, managed, and controlled.

Fistula

Bronchopleural fistula is both an indication for and potential complication of chest tube placement (1). A fistula is an abnormal pathway or tract that forms between two structures, in this case between the pleural space and the bronchial tree. A chest tube may benefit a patient if a bronchopleural fistula already exists (1). However, if a fistula forms as a result of the chest tube itself, it is associated with high morbidity and mortality (1). Patient symptoms of fistula include dyspnea, hypotension, cough, and persistent air leak (1). Timely chest tube removal can help prevent the formation of a fistula because it limits tube erosion (1).

Bleeding

Providers must be careful when placing chest tubes because the space between each rib contains a vein, artery, and nerve (1). Although rare, cases of hemorrhage and death have been reported as a result of chest tube placement. Luckily, abnormal bleeding is usually apparent right away. However, early diagnosis can be missed if the tube compresses the artery in such a way that it prevents any bleeding while in place (3).

Recurrent Pneumothorax

One of the worst complications is recurrent pneumothorax, simply because it means the chest tube has failed. A new pneumothorax is more likely to occur when the tube is pulled too early and the lung has not properly re-expanded (1). It can also be caused by an air leak or if air enters the pleural space during tube removal (1). If the recurrent pneumothorax is small and the patient is asymptomatic, it can typically be managed with follow up imaging and close observation. Otherwise, the chest tube will have to be reinserted.

Patient Considerations for Chest Tubes Nursing Care

When considering chest tube placement, it is important to evaluate the patient. Because the indications for chest tubes range from routine post-op care to life threatening emergency, the presentation of these patients varies significantly. In all cases, patient or family consent is paramount and should be obtained prior to the procedure.

The only exception to this is a true emergency, the process for which is outlined in your facility’s policies (all the more reason to be familiar with policy!).

Contraindications in chest tube placement should be considered as part of a risk/benefit analysis. For example, there are no contraindications for using chest tubes in the treatment of tension pneumothorax (1).

Tension pneumothorax is a medical emergency. It occurs when a pneumothorax or hemothorax becomes so severe that air can no longer escape from the pleural space. The pressure increases within the chest and forces the mediastinum (heart, great vessels, etc.) to shift out of the way, compressing the remaining unaffected lung.

These patients are at high risk of going into shock or cardiac arrest. Signs and symptoms of tension pneumothorax include decreased breath sounds, hypotension, tachycardia, hypoxia, and tracheal deviation to the contralateral side of tension pneumothorax (16). A tension pneumothorax can be diagnosed from a bedside ultrasound or chest x-ray (16).  

Relative contraindications to chest tube placement include abnormal coagulation or infection at the insertion site (2). Abnormal coagulation puts the patient at higher risk of bleeding. The parameters for placement will vary between facilities, but generally speaking, prospective patients should have an INR < 1.5 and platelets > 50,000 (2).

Infection at or near the insertion site increases the risk of infection in the chest cavity (3). In many cases, an alternate insertion site is available and should be utilized. For patients seeking elective or semi-elective chest tube placement, these relative contraindications should be resolved prior to placement, if possible.

A chest tube is considered elective if the patient is stable. The American College of Chest Physicians (ACCP) guidelines state that a patient is clinically stable with a respiratory rate less than 24 breaths/min, pulse rate 60-120 beats/min, normal blood pressure, and oxygen saturation greater than 90% on room air (6).

The ACCP recommends that all patients with a large pneumothorax (great than 3 cm apical length) get a chest tube (6). Ultimately, the ordering provider will decide if a patient requires a chest tube as an elective procedure or an emergency.

Chest Tubes Nursing Care Basics – Where Are Chest Tubes Placed?

As previously mentioned, there are several different techniques used to place chest tubes: the blunt dissection technique for large bore tubes, Seldinger technique for small bore tubes, and the Seldinger technique with a peel-away dilator for tunneled chest tubes. Interestingly, these chest tube techniques can be performed just about anywhere: the OR, IR, and the patient’s bedside.

Operating Room

Chest tubes are usually placed in the OR after cardiothoracic surgery. The tube should be positioned no lower than the 5th intercostal space along the midaxillary line to avoid injury to the diaphragm (1). The second intercostal space at the midclavicular line is an alternate site. However, it is never the first choice because the tube must be driven through the pectoralis muscle (ouch) and it is more likely to produce an ugly scar (3).

Mediastinal chest tubes are commonly placed after cardiac surgery to facilitate drainage of blood and other fluid from the pericardial and pleural spaces (1). The goal is to prevent cardiac tamponade and pleural effusion. These tubes are easy to identify because they emerge from the mediastinum.

Interventional Radiology (IR)

Interventionalists have the advantage of using imaging to assist with chest tube placement. Ultrasound, CT and fluoroscopy (live x-ray) may be used. Imaging allows the provider to observe the chest tube as it enters the body, which helps ensure proper placement.

When placing a chest tube for the treatment of pneumothorax, the provider often uses fluoroscopy for guidance. The pneumothorax is visualized on the monitor while the tube is positioned. Using the Seldinger technique, the final catheter is threaded over the wire to rest in the pleural space.

Interventional radiologists are commonly enlisted to place drainage tubes for the management of empyema or lung infection (8). CT is the modality of choice because it allows better visualization of surrounding structures than fluoroscopy. The provider will take frequent CT scans while a wire is guided into place, then thread the catheter over the wire into the infection (8). Small bore tubes have been shown to be effective in the drainage of thicker fluids, like pus (4).

Finally, approximately 50% of cancer patients develop malignant pleural effusion (8). Malignant pleural effusion is recurrent, usually due to diseased pleura, obstructed lymph channels, or atelectasis (8). Breast, lung, lymphoma, ovarian, and gastric cancers have been known to cause malignant effusion (8). At first, these recurrent effusions may be treated with thoracentesis, a procedure in which the interventional radiologist positions a small catheter into the pleural space, where it remains temporarily to allow pleural fluid to drain. After drainage has ceased, the catheter is removed and a dressing is applied.

Over time, malignant effusions require drainage more frequently, which can be hard on the patient (8). Thoracentesis provides only short term relief of symptoms. Tunneled chest tubes are a more long term alternative for malignant pleural effusion. The catheter contains a special cuff and is tunneled under the skin to minimize the risk of infection. Prior to placement, the interventional radiologist will use ultrasound to locate the effusion.

Bedside

Providers often insert chest tubes at the bedside. After discussing the risks and benefits of the procedure with the patient, providers should obtain informed consent. Nursing staff would be required to assemble the appropriate supplies and be available to assist as needed. Full aseptic technique is required, so medical staff should wear gowns, gloves, masks and use sterile drapes (3).

Chest tube insertion is made much simpler if the patient is positioned appropriately. The head of the bed should be raised to 45-60 degrees with the patient resting in the supine position and slightly rotated. The ipsilateral arm is placed behind the neck or head so it is out of the way, providing easy access to the chest (ipsilateral meaning “same side”).

For posterior fluid collections, the patient should sit on the side of the bed with the provider standing behind (3). The position can be made more comfortable by allowing the patient to rest his or her arms upon a side table. Bedside ultrasound will allow the provider to visualize any fluid collections.

Note: In all cases, post-procedure x-ray is required as soon as possible to confirm chest tube placement and to verify the presence or absence of complications from the insertion. 

Large right-sided pneumothorax

Notice the lack of parenchymal (lung) markings on your left side. Remember that chest radiographs are flipped, thus this is the patient’s right side. This lack of lung marking is due to a pneumothorax- thus the lung is compressed by air in the pleural space. 

Licensed and retrieved from Adobe Stock

Chest Tube Drainage Systems

After a chest tube is in place, it must be attached to a drainage system to facilitate the removal of excess fluid and promote lung reinflation. There are four basic types of drainage systems: Heimlich valves, three-compartment systems, digital systems, and vacuum bottles.

Heimlich Valve

A Heimlich valve is a one-way valve shaped a bit like a thin cylinder that attaches to the distal end of the chest tube. It is called a one-way valve because air is permitted to flow only one direction: out.

The valve itself is composed of a rubber flutter that occludes with inspiration to prevent air from entering the chest. The flutter opens during exhalation to allow the trapped air to escape the pleural space. The pneumothorax shrinks slowly over time with each breath. Heimlich valves are more commonly used for ambulatory patients when suction is not required (3). Its small size allows patients to move freely. Figure 1 is an example of a Heimlich valve (11).

(Figure 1)

Three-Compartment System

The most commonly used drainage systems are three-compartment systems, such as Atrium® and Pleur-evac®.

Like the name suggests, they contain three interconnected chambers: the collection chamber, water seal chamber, and a suction chamber. The collection chamber fills with air or fluid that drains from the chest tube. The water seal uses a column of water to prevent air from flowing into the pleural space with inhalation (3). Finally, the suction chamber allows the provider to adjust the level of suction against the chest tube.

If needed, the drainage system is attached to a wall regulator to apply active suction (3). Alternatively, these drainage systems can also be set to drain by gravity if the device is positioned below the chest (3). These drain systems require careful observation for air leaks. Figure two is a drawing of a three-compartment system (11).

Figure 2: Drainage system

Digital Drain System

A more modern approach to chest tube management, digital systems use a computer to monitor drainage, air leaks, and pleural pressure (3). All measurements are calculated internally and displayed on a screen. They do not require wall suction, so patients may ambulate with ease (3). Because they are more compact and basically manage themselves, some patients are discharged with their chest tube in place, resulting in shorter hospital stays overall (3). Digital systems are typically used for patients who develop a pneumothorax after thoracic surgery.

Vacuum Bottle

Remember, tunneled catheters are commonly used to drain recurrent pleural effusions associated with malignancy. Instead of constant suction and drainage, pleural fluid is allowed to accumulate and then drained periodically as needed. Frequency of drainage ranges from occasionally to multiple times a week. The tunneled catheters are equipped with a special one-way valve that opens and drains when a vacuum bottle is attached (3).

Nurse Roles and Responsibilities: How to Manage Chest Tubes

It is the responsibility of the nursing staff to monitor chest tubes and report any potential malfunction. Because chest tube patients may reside in virtually any hospital department (or even as an outpatient), it is essential that nurses feel comfortable around them. Chest tube management includes observing and maintaining the insertion site, recording output, and managing the drainage system.

Observe the Patient

Perhaps most importantly, the nurse should observe the patient. Check vital signs as ordered by the provider or facility policy. Assess for pain. Some discomfort is expected after chest tube placement. Provide pain medicine as needed. Auscultate breath sounds frequently and encourage deep breathing, especially during the post-procedure period. Diminished breath sounds, changes in vital signs and increased work of breathing could indicate the re-accumulation of air or fluid in the pleural space.

Maintain the Insertion Site. Chest tubes are commonly sutured to the skin to hold the tube in place. The insertion site is covered with a dressing to protect the area. Dressing changes occur as ordered by the provider or are dictated by facility policy. Most chest tubes require an occlusive dressing, meaning the dressing should adequately cover the site and be well-secured, which reduces the risk of developing an air leak (1). Expect to change the dressing if it becomes soiled. Chest tubes nursing care nurses should observe the insertion site frequently for signs of infection, including fever, redness at or around the site, swelling, warmth, and purulent drainage.

Although they are sutured in place, there is a risk for dislodging the chest tube if it is pulled too hard. Securing the tube to the patient’s side with a piece of tape is one way to reduce the risk of dislodgement (9). Advise the patient to ask for help when getting out of bed.

Record Output. The nursing staff is also in charge of observing and recording chest tube output. The frequency of recording the output is dictated by nursing judgment and written orders from the provider or facility policy. Drainage fluid is often bloody, serosanguinous (pink), or purulent, depending on the reason it was inserted. Whatever the color, it should lighten in color and lessen its drainage amount over time. The most common type of drainage system is the three-compartment system, such as the Pleur-evac® or Atrium®. All drainage is contained within this system, meaning the container cannot be emptied. Instructions vary between facilities, but it is common practice to document the amount of drainage directly onto the container by marking the level of output with a pen or marker. When full, the drain system is removed and a new, clean one is attached. Check your facility policy of when to call the physician for excessive drainage. Always call the physician for excess drainage when there is a change in the patient’s vitals signs or signs of a worsening condition. 

Manage Drain Systems

Heimlich Valve. Nurses should assess that the Heimlich valve is securely attached to the distal end of the chest tube. The one-way flutter valve allows air to leave the chest but prevents air from seeping back inside. It does not require suction, so the patient may move around freely. Heimlich valves do not possess a true collection chamber, rather, any drainage will freely leak from the distal end of the valve. Thus, the Heimlich valve is not the system of choice for patients with significant drainage.

Three-Compartment System. Again, these are the most commonly used systems. They should be positioned below the patient’s chest at all times. The nurse is responsible for monitoring the three compartments: collection chamber, water seal, and suction. As discussed above, the nurse will simply document the drainage any drainage that collects in the collection chamber.

The water seal serves two functions: to prevent outside air from flowing into the chest and the detection of air leaks. An air leak within a chest tube may indicate a serious problem. The water seal should be easy to find. When the water seal is functioning correctly, the water level will fluctuate (rise and fall) with breathing. If the nurse observes intermittent or constant bubbling within the water seal, an air leak is present (1). The most severe type of leak is a continuous air leak which is observed throughout the entire respiratory cycle. All air leaks need to be reported to the physician immediately and the patient needs to be reassessed for further signs of respiratory distress. Digital draining systems are able to quantity the leak and display dynamic real-time pleural pressures (12). A persistent air leak can be caused by either an alveolar-pleural fistula or bronchopleural fistula (12). 

Chest tubes often require suction to help gently pull excess fluid and air from the body. Three-compartment systems are equipped with a dial that allows staff to set the level of suction, usually between 0 and -40 cm H2O. The provider’s orders or facility policy will dictate the level at which suction should be set. Part of the nurse’s assessment is verifying that the suction dial is set correctly. Additionally, nursing staff should check that the suction tubing is connected securely to the wall suction regulator.

Digital Drain System. Thanks to technology, digital drain systems are pretty easy to manage. The device collects and displays all of its data to the nurse, including the amount of drainage, intrapleural pressure, and the presence of any air leak. It simply needs to be recorded.

Tunneled Catheters. Tunneled catheters should be clamped unless they are being drained. These catheters contain a one-way valve that will not open unless a vacuum bottle is attached. Tunneled catheters are usually managed at home by a willing family member or trained home health provider, thus the patient and family may require extensive education prior to discharge.

Clamping the Tube. With the exception of tunneled catheters, as a general rule, chest tubes should not be clamped unless it is necessary to replace the drain system or it is ordered by the provider (9). If an air leak is present, a clamped tube can lead to tension pneumothorax (9). There is no need to clamp a chest tube during patient transportation or ambulation. If the drainage system is positioned below the chest as indicated, it will continue to drain with gravity after suction is turned off (9).

Chest Tubes Nursing Care Troubleshooting: When to Call the Doctor

Like anything else, chest tubes are prone to complications. It is essential for nurses to be able to identify a malfunctioning tube quickly and know when to alert the provider. A worsening pneumothorax can lead to a longer hospital stay for the patient, or at worst tension pneumothorax and death.

Tube/Drain Malfunction

Chest tubes should be assessed regularly by nursing staff. The chest tube must be well-connected to the drainage system and wall suction (if necessary). If the chest tube becomes disconnected from the drainage system, the two ends should be cleaned well with an antiseptic, like alcohol pads, prior to being reconnected (1). You can also stick the open end of the chest tube into a bottle of sterile water or saline to quickly create a water seal (13). Do not clamp the tube in case there is an air leak, as the patient could develop a tension pneumothorax (1). If the tube is completely pulled out from the patients’ chest, immediately apply pressure and apply a sterile petroleum impregnated gauze over the site and call the physician immediately (13). 

Infection

Infection is always a risk when a foreign body is present. Because chest tubes allow direct access into the chest cavity, it is essential to watch closely for any signs of infection. Infection may develop at the insertion site or inside the chest cavity (empyema/abscess).

Signs of infection at the insertion site include fever, redness, swelling, warmth, or purulent drainage. The site needs to be kept clean and soiled dressings should be replaced quickly and efficiently.

Chest tube patients that also have pleural effusions are at higher risk of developing empyema (1). Chest tubes are considered a “clean contaminated” procedure, meaning the chest cavity is accessed cleanly, but a risk for contamination remains as long as the tube is in place (1). The risk of empyema after chest tube insertion is as high as 25% in some populations. A nurse might suspect the development of empyema/abscess if the patient exhibits symptoms of infection: fever, tachycardia, respiratory distress and purulent drainage from the chest tube. A prompt call to the provider is warranted.

Kinks & Clots

The smaller the chest tube, the more likely it is to become clogged or kinked. Sometimes it is easy to spot a problem with a simple inspection of the entire apparatus. Pay particular attention to areas of the tubing covered with tape, such as the insertion site or taped connections. Straighten out the the tubing when patients are lying in bed or sitting in the chair.

Pay close attention to the drainage system. A digital system or three-compartment syndrome will alert you if there is a problem. A digital system will literally sound the alarm in the event of a kink or clot because it monitors pressures. Three-compartment systems are not fitted with alarms, so they require closer observation to detect an issue. Earlier, it was mentioned that it is normal for the water seal in three-compartment systems to fluctuate with breathing or coughing. If the water seal is not fluctuating with breath, you may have a kink or clot. The water seal is not fluctuating because the tube cannot drain past the blockage.

Kinks are easy to fix: simply straighten out the tube or resolve kinked connections. Clots can be a little more difficult to handle. Luckily, ⅔ of clots resolve themselves (1). Historically, providers have used techniques such as milking or stripping the tube to help remove clots. The use of these procedures is questionable. Prophylactic milking/stripping has not shown any tendency to prevent clots from forming (1). Also, these techniques have actually been shown to cause harm by increasing pressure within the pleural cavity, resulting in increased bleeding, tissue entrapment, and dysfunction of the left ventricle (1). Thus, tube milking and stripping should probably be avoided altogether.

What do you do if you see a clot then? If the clot is located in the drain system tubing, simply replace the system. Attach a new Pleur-evac® or Atrium® system and remove the affected tubing. If that doesn’t resolve the problem, notify the provider. Chest tubes can also become kinked inside of the patient, so the provider may order a chest x-ray to confirm proper tube placement (2).

Loss of Suction

Loss of Suction. Ensure that the drain tubing is securely attached to the wall suction regulator and that the tubing is unclamped. The regulator should be turned on. Check that the suction dial on the drain system is set to the appropriate suction setting and that the suction is continuous, not intermittent. If all connections are appropriate, the wall regulator or drain system is malfunctioning and should be replaced. Maintaining appropriate suction is critical, as too little suction will prevent lung re-expansion, while too much suction can damage lung tissue (9). 

Drain System Malfunction

The best course of action is to replace the drain system and re-assess the problem. If it was truly an issue with the drain system it should resolve by replacing it.

Air Leak

The easiest way to assess for an air leak is to observe the drainage system. Again, a digital system will alarm if it detects a problem. With a three-compartment system, an air leak will cause intermittent or constant bubbling within air-leak detection compartment of the water seal. Air leaks are a concern because they allow air to flow back into the pleural space (1). The whole point of the chest tube is to get the air out of the chest. Air leaks can occur in a couple places: at the insertion site or within the tubing/drain system (1).

If an air leak is observed in the water seal chamber, the next step is to find out where it is coming from. This is one case where clamping the tube (temporarily, of course) can help diagnose a problem. First, clamp the tube close to the patient (10). If bubbling within the water seal continues, this means there is a leak in the tubing or drain system. Although made of strong material, these drain systems are not infallible. Tubing can be cut or damaged accidentally, and it may not be easy to spot. Assess the tubing for cuts or holes. Ensure all connections are secure, as loose connections are an easy way for air to sneak inside. Replace the drain system if the tubing or container is damaged.

On the other hand, if you clamp the tube and the air leak disappears from the water seal, this means air is leaking near the patient (10). In this case, the leak stems from the insertion site or somewhere inside the chest (10). An air leak at the insertion site occurs because the dressing is insufficient or the hole is too big. This is why an occlusive dressing is a must. Apply new petroleum gauze and cover with a sterile, occlusive dressing at the site where the tube enters the skin (10). This prevents air from leaking into the chest at the skin.

Unfortunately, sometimes the skin site is too large relative to the tube itself, meaning the tube is too small for the skin incision that was created (1). The tube should fit snugly into the skin incision, without gaps. If you suspect the skin incision is too large, notify the physician. Often, a simple stitch can tighten any loose skin at the insertion site (1).

Finally, if you have accounted for all of the potential problems listed above and an air leak remains, the problem is likely inside the chest (10). Potential causes of persistent air leak include residual pneumothorax, pleural injury, a malpositioned chest tube, or fistula (10). Notify the provider right away if all attempts to resolve an air leak have failed.

Tube Dislodgement

Sometimes, the tube comes out despite every precaution. It may be pulled out partially or completely. After a partial removal of the tube, quickly and calmly secure the tube to the patient with a new dressing and tape. Obtain a set of vital signs and assess for pain and any new symptoms, such as shortness of breath or dyspnea. Notify the provider immediately. Follow up imaging (usually an x-ray) may be ordered to determine chest tube location and assess for any residual pneumothorax.

If the tube is pulled completely out, put on gloves and quickly cover the insertion site with your hand to prevent air from flowing into the chest (10). Stay with the patient and call for help. When help arrives, ask a coworker to get the necessary supplies for a new occlusive dressing: petroleum gauze, dry sterile gauze, and tape. Apply the dressing and notify the provider immediately. If the patient is in distress, call for help. Remember, chest tubes can be placed at the bedside pretty quickly in an emergency. And try to stay calm!

Under normal circumstances, chest tubes are removed once drainage has ceased, breath sounds return to normal, and/or imaging shows a resolution of the pneumothorax (9).

Chest Tubes – Frequently Asked Questions

Why raise the arm for chest tube insertion?  

Regardless of the patient’s position, sitting up, or lying in a supine position (preferred), the patient’s arm on the side of the chest tube insertion should be abducted and flexed with the hand above the head to expose the proper area of insertion. The main reason to place the patient in this position is to ensure easy access to the chest for clean and proper insertion.  

How to change a chest tube dressing: 

Most chest tubes require an occlusive dressing meaning the dressing should adequately cover the site and be well-secured, therefore reducing the risk of developing an air leak.  

1. Gather necessary materials:
   – Sterile gloves
   – Abd pad or drain sponge
   – 4×4 gauze
   – Xeroform gauze
   – ChrloraPrep
   – Tape   
2. Wash your hands with soap and water and don sterile gloves.  
3. Open the packaging of materials so you can grab the materials as you need them while maintaining sterility.   
4. Remove the patient’s old dressing. Inspect the chest tube site for redness, skin breakdown, suture condition, drainage amount and color, and if air leaks are present.  
5. Remove old gloves, and don new gloves.  
6. Clean the site with ChloraPrep. Begin at the insertion site and move outward. Repeat the process additionally and allow the site to thoroughly dry.   
7. Place the Ceroform gauze to create an air-tight seal at the insertion site.  
8. Split the 4×4 dressing and place it around the patient’s chest tube. Apply two additional 4×5 sponges over the previous layer of dressing that covers the chest tube.   
9. Apply tape over the dressing – some like to use foam tape. Note the time, date, and initial of the nurse changing the dressing.   
10. Remove you gloves and wash your hands thoroughly.  

This is an example of a dressing change. Some institutions have hospital policies related to chest tube dressings. Please use this as a guide and not as fact. Always follow hospital institutional protocol.   

How is it determined which chest tube to use?  

The decision to use a small or large-bore chest tube is made by the provider. Research shows that small-bore chest tubes are as effective as larger chest tubes for the treatment of most pneumothoraxes and may be less painful. Large bore chest tubes are recommended to treat traumatic pneumothorax due to the need for the removal of blood and air.  

When a patient is experiencing shortness of air, and you notice the chest tube is clamped, what do you do?  

Unclamp the chest tube and monitor the patient. If the shortness of air does not improve, call the provider, and obtain a chest X-ray. 

Conclusion

Chest tubes are a life-saving intervention for the patient with pneumothorax, hemothorax, chylothorax, pleural effusion, empyema/infection, and also those recovering from major cardiothoracic surgery. The technique for chest tube placement depends on the size: large tubes are placed using the blunt dissection technique and small tubes are inserted with the Seldinger technique. Radiologists use the Seldinger technique and a peel-away dilator to insert tunneled chest tubes.

Both small bore and large bore chest tubes are effective in treating pneumothorax, hemothorax, empyema/infection, and preventing complications after surgery. The size of the tube really depends on provider preference. There are advantages and disadvantages to either size. Large bore tubes are less likely to form kinks or clots, but may be more painful. Small bore chest tubes are less invasive, but form clots much more easily. Tunneled chest tubes are a great way to provide a palliative care to patients suffering recurrent malignant pleural effusions.

While there are no true contraindications for chest tube placement, a few relative complications exist. Sometimes, chest tube placement is a true emergency, such as the need to treat a tension pneumothorax. In these cases, the benefits outweigh the risks. For more stable patients of chest tube nursing care, providers should ensure that consent is obtained and the patient’s blood is coagulating appropriately prior to chest tube insertion.

When possible, patients and their families should be aware of potential risks with chest tube placement. Bleeding, damage to surrounding structures, bronchopleural fistula, recurrent pneumothorax, and pain are some potential complications of initial chest tube placement.

Chest tubes may be placed in the OR, IR, or even at the bedside. Once inserted, the tube should be connected to a drainage system to pull air out of the chest and prevent air from returning to the pleural space. Types of drainage systems include Heimlich valves, three-compartment systems, digital systems, and vacuum bottles for tunneled catheters.

Nurses are responsible for chest tube management after insertion. Roles and responsibilities include monitoring and recording drain output while continually assessing for signs of infection, air leaks, suction loss, or drainage system dysfunction. The ability to quickly identify a malfunctioning tube is essential for protecting our patients. Often, a problem found within chest tubes nursing care is solved with a quick fix, like replacing the drainage system if the tubing becomes damaged. However, persistent questions and concerns require a prompt call to the provider.

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 & 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 readmissions 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.  

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 and 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 

• 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 the 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 in those Diagnosed with Alzheimer‘s  

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).  

Caregiving  

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.  

Ways to cope 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 

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