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End of Life Process

Introduction   

Have you ever cared for someone who was dying, known someone who was in hospice, or just wondered what happens as we die? What exactly does “end of life” refer to? End of life is a broad term, and its meaning can vary from person to person. End of life is a time when death is approaching, usually in a matter of days.

This occurs in various patients experiencing a variety of ailments including end stage cancer, dementia, chronic diseases, and someone who may have organ failure after an accident (3). 

Oftentimes, caregivers have little to no experience in caring for a patient experiencing the end-of-life process and can easily find themselves feeling overwhelmed, confused, and burned out. Understanding what to expect during the final weeks and days of life is imperative to cope with the changes as they occur.

These changes can vary from person to person. Although patients progress through the end-of-life process differently, there is usually a recognizable pattern of decline that occurs. To provide the best possible care and prepare both the dying patient and their family members, it is important for the nurse and caregiver to be able to distinguish the phases of the end-of-life process: transitioning, actively dying, and final moments. 

Transitioning

The transitioning phase, otherwise identified as the pre-active phase, usually signals that a person is approaching the last two-to-three weeks of their life. During this time, caregivers might start to notice obvious changes, an increase in sleeping, for example. A transitioning person can sleep upwards of twenty hours per day. This significant increase is part of an overarching decrease in the patient engaging with the world and day-to-day life.  

Beyond sleeping, examples of this disengagement include interacting less with friends and family, less desire to do one’s usual activities, and a lack of interest in things that were once pleasurable. Additional signs of a patient transitioning include increased weakness and decreased mobility.  

These changes typically include a decline in function, becoming non-ambulatory, chairbound, and ultimately, bedbound. Patients may begin to fall during this time. Progressively, the patient will become more dependent on their caregivers to assist them with activities of daily living (ADL), which include bathing, eating, transferring, toileting, and continence. They will likely become bedbound. 

Another indicator that someone may be transitioning is a change in nutrition and intake. Eating and drinking less is an expected part of decline during this time. Many patients will report a lack of appetite, taste changes, and an overall lack of interest in food and liquids. Changes in swallowing may further complicate a person’s ability to eat and drink. 

It is not uncommon to downgrade a person’s diet during the transition phase. This might include going from a regular diet, down to soft, and finally, to pureed. Liquids are usually given in small amounts and with an added thickener. These changes are necessary to prevent choking and aspiration. Fluid overload is a risk at this point and can detract from one’s comfort, cause swelling, or crackles in the lungs. 

“Approximately 43% of all palliative patients are affected by terminal agitation, which can manifest as restlessness, sweating and patients’ statements as verbal or facial expressions and defensive reactions” (5).  

Increased agitation, anxiety, and restlessness may also arise during the transitioning phase. Terminal agitation and terminal restlessness are both unique to the last week or so of someone’s life and are often caused by physiological changes that occur during the end-of-life process but can also be a result of medication or emotional changes. Even if the patient had been calm previously, it is important to note that these symptoms may still occur.  

Signs of terminal agitation include an inability to remain still, picking at items in the surrounding environment, and increased confusion. Fortunately, there are medications that can be given at the end of life to promote comfort and stop these symptoms when they arise. Lastly, it is not uncommon for the transitioning patient to have visions of and talk to deceased friends and family – both are normal and could sometimes be interpreted as a welcoming sign from loved ones. 

Active Dying

Following the transition phase, most patients will then enter the final phase of the end-of-life process, the active dying period. This precedes imminent death. It can be hard to determine precisely when this stage begins. This phase usually lasts only two to three days and showcases significant signs of patient decline that differ from the previous phase, including a decrease in alertness and responsiveness.

For example, a patient may go from a semi-comatose state to comatose or obtunded and minimal reaction should be expected (1). Their eyes may be open or shut, and there is little movement in all extremities. This period can be described as a deep sleep. 

Caregivers often describe it as a time of waiting. Cognitive changes, in combination with the previous changes in swallowing, make the intake of food, liquids, and medications unsafe. The patient is at high risk for aspiration. Mouth swabs can be used to hydrate the oral cavity and to do mouth care.

Medications that are liquid or can dissolve under the tongue are safe and can be used to manage symptoms at the end of life. Hospice patients are provided a comfort kit of medications to use should symptoms arise.  

Additionally, changes in vitals are expected during this phase, and they typically do not cause the patient any discomfort. For example, temperature fluctuation is common at the end of life. It is not abnormal to have an elevated temperature during the active dying phase. This can be remedied with cooling measures such as a cool towel on the forehead or a fan to cool down the room. The skin may feel clammy as well.  

Following, changes in blood pressure and heart rate may also occur. Blood pressure begins to trend lower during the pre-active phase and can become very low during the last few days of life. The heart rate will usually trend upward and can be well over 100 beats per minute, however, this is just something for the hospice nurse to note and is not usually treated.  

Symptom management at the end of life can be difficult. Failure to adequately control symptoms can have a negative impact on one’s quality of life. These symptoms may include pain, respiratory distress, GI issues, and mobility changes (2).  Pain while dying is one of the most common areas of concern for someone who is actively dying, and of course, no one wants to see their loved one in pain during their final days of life. The body becomes very sensitive to the slightest movement or touch, which can present challenges for caregivers when considering that the patient still needs to be cleaned, changed, and repositioned.  

When the patient is no longer verbalizing their comfort, verbal pain cues must be assessed. These include grimacing, a furrowed brow, frowning, and possibly moaning. In some cases, repositioning can be an effective pain-relieving measure. Thankfully, pain can be treated up until death occurs.

Opioids are commonly used in end-of-life care, due to their ability to effectively manage pain without hastening death. Morphine is an example of a commonly used opioid (4). Nonpharmacological measures can also be used to relieve pain. This may include things like repositioning and soothing music. 

Decreased urination is also common during the active dying phase. This is completely normal and expected. Caregivers may find that they do not need to change diapers as often. Urine may also appear darker in color, appearing a deep amber color due to more concentrated urine. 

Excessive secretions can lead to something commonly known as the “death rattle.” This term is almost synonymous with the last days of life. It can be described as a moist sound that is audible when someone breathes and is a good indicator that death is near. The secretions collect in the throat due to a lack of coughing and the inability to clear them out (8).

Turning the patient on his or her side may help the secretions drain, and there are medications that can be administered to help dry them out. It is important to note that not everyone will experience this, and by the time it occurs, there is a disconnect within the patient, and he or she is not likely to experience any discomfort. 

Maintaining skin integrity and preventing pressure injuries is also an important consideration during this time. With all the other previously mentioned changes occurring, it can be hard to provide the attention that the skin requires. Like other organs, the skin begins to fail in an actively dying patient (9).

This does not necessarily mean that pressure injuries and skin breakdown are inevitable. It is important to consider goals of care during this time. An aggressive approach to preventing skin breakdown might not be what the patient wants or necessarily needs. Measures for pressure injury prevention might include repositioning, use of pillows for elevation, hygiene, and moisture management. 

Final Moments

It can be hard to imagine the final moments of someone’s life. This is especially true for caregivers and families who have witnessed steady decline throughout both stages of dying. There are likely to be signs that death is possible at any moment. A patient can be expected to be comatose with little to no response when death is imminent. The obtunded patient appears to be in a deep sleep. They are no longer verbally or physically responsive to voice or tactile stimulation.  

In addition to changes in vitals described previously, changes in respiration usually occur. This is typically the most obvious change. Patterns can vary from shallow and fast to deep and slow. Periods of apnea are also normal. Cheyne-stokes breathing may also be present (3). 

 Skin changes are also expected; pallor, cyanosis, and mottling are signs that death is near. The body may begin to feel cool, especially in the hands and feet. Comfort medications can still safely be used up until death occurs. As mentioned before, foods and liquids should not be given at this point. Caregivers should continue to talk to the patient, as their hearing will remain until the end. 

Hospice 

Most people wish to die peacefully at home. Unfortunately, for many, this is not the case. Over 30% of people die in a hospital setting (6). Hospice is a form of palliative care and involves caring for the terminally ill as they begin the end-of-life process. A terminally ill patient has a life expectancy of 6 months or less. This is a comfort focused approach to care. The natural process of dying is accepted and allowed to proceed.  

No life prolonging treatments or procedures are elected.  Choosing a hospice allows both patients and their caregivers to achieve their end-of-life care goals. Hospice care includes an interdisciplinary team composed of nurses, physicians, aides, chaplains, and social workers. It includes symptom management, and emotional and spiritual support. There is also a bereavement team that is available after death. Medicare part A covers hospice services nearly completely. 

Hospice care can be a short or long journey, with many ups and downs. For some, the prognosis might be obvious, but for others, it might be filled with many questions and much uncertainty. The benefits of hospice care are proven and can lead to a peaceful death. “The main care focus for patients is symptom management, which improves the quality of the remainder of their life.  

Palliative care involves not only the patient but also their family members. Other measures are also taken so that the patients can live life comfortably and maintain dignity” (7).  Both caregivers and patients seek to understand what end of life care entails and how to maintain comfort at end of life. Hospice clinicians should spend time providing education on this process to all of those involved. 

Spiritual Considerations at End of Life 

Taking care of the dying should be looked at from a holistic point of view. Addressing the physical needs of someone who is dying while ignoring any spiritual needs would be doing a disservice. Spirituality is considered the meaning of life. It may include religion, beliefs, or family traditions. It can mean different things to different people.  

During end-of-life care, it has been shown to be disrupted in patients. Spiritual needs tend to be greater at the end of life.  It is also frequently overlooked by healthcare professionals (10). Palliative care workers can help address spiritual needs in their patients by showing compassion, humility, and openness.  

Dying patients may be conflicted spiritually due to things like guilt and unresolved issues. When spirituality is addressed appropriately, patients can more positively cope with illness. Caregivers of the dying should be aware of the relationship between a terminal prognosis and unmet spiritual needs.  

Conclusion

Hopefully, this has been an informative piece and a guide on what to expect during end-of-life care. No two people experience death and dying in the same manner, and it can be challenging both physically and emotionally during the end of life. Proper symptom management during this time is crucial in ensuring that one dies comfortably. One should also consider any unmet spiritual needs and how, if unaddressed, could lead to poor patient outcomes.  

Palliative care at the end of life can be a great help for caregivers.   Hospice can be a great resource in managing symptoms and providing support up until death and beyond.  Most people do not have experience in caring for a dying person and need education and assistance throughout the journey. Not everyone who is dying will experience all the symptoms mentioned in this course, and it is important to note that everyone experiences the end-of-life process in their own way and at their own pace. 

Navigating Difficult End of Life Conversations

Introduction   

Talking about death is generally difficult for the average person. It is even considered taboo in some cultures or situations.  For some nurses, having end of life conversations is a routine part of the profession. A hospice nurse, for example, carries the responsibility of managing care for a dying patient, and ultimately informing the patient’s family that death is imminent.

A lack of training, experience, or confidence in this area could result in poor delivery, unrealistic expectations, and an overall negative dying experience. Most people do not have experience or even a baseline when it comes to death and dying. This makes end of life conversations much more important in the delivery of patient care.  

Perspectives About Dying and Death (Philosophical, Psychological, and Spiritual) 

Philosophical 

The human experience of death and dying is not one sided. On the contrary, there are many things to be considered to understand it fully. This goes beyond a scientific approach. An understanding of philosophical reasoning related to death is imperative to provide a thorough explication of the human dying experience. Historically, death has been an intrinsic part of life throughout various civilizations. 

Ancient Egyptians spent much time preparing for the next life. Life was perceived as a dream that passed quickly. Death was viewed as eternal. Egyptians believed that the dead would make their way over to The Kingdom of Orisis, where they would spend eternity. 

Ancient Greek civilization also viewed death in a particular light. According to San Filippo, “Greeks perceived death as a release of the soul from the body. The soul, which was considered to be part of the mind, was believed to be immortal. It was considered that the soul lived before the body and would live again in another life” (1). 

Lastly, it has been noted that when it comes to fearing death, people create philosophies and theologies due to an inability to visualize our own death and afterlife.  

Psychological 

The psychological aspect of death is just as important as the physical. The thought of death alone has the potential to evoke various memories and feelings. You will typically find that a person either accepts or fears death (positive outlook vs negative outlook). This can be a fear of suffering, pain, or of the unknown. These views are typically formed based on past experiences with death. 

 Often, a person may have no underlying baseline when it comes to dying or death. That first experience with death can potentially shape someone’s entire perspective. Fearing death could be attributed to a fear of the unknown, lack of relatable experience, a negative experience, or a lack of communication regarding death, due to a cultural taboo, for example.  

On the other hand, things like faith, positive experiences, and imminent death may cause someone to be more accepting of death. Often, someone facing imminent death may be forced to think about it and come to terms with it. In a study of terminally ill patients facing death, “The participants were afraid of death and earnestly desired to live but felt that death was imminent. To escape their distress, they attempted to accept the situation by thinking that all lives are finite, and death had to be accepted” (2). This is an example of coming to terms with an impending death and accepting it. 

Spiritual 

Spiritual perspectives on death should be considered when discussing views on dying. History shows that humans have long held beliefs that life does end when the body dies. Many tend to believe that once a person dies, their soul is then freed, and can go on to another life or be reincarnated into someone or something else. Religious ideologies contain a vast amount of knowledge and wisdom regarding death. “Religion and spirituality help individuals make sense of what awaits them near the end of life and help the dying cope with their terminal condition” (7).  

What happens after death may vary from one religion to the next. Many religions also have a heaven or heaven like final place where the deceased can rest and be with other who have also died. One of the oldest ideologies of human history is the belief that there can be life after death. 

Impact on Nurses 

Imagine working as a hospice nurse.  Your sole purpose is to provide end-of-life care for terminally ill patients. This includes providing information on what to expect at the end of life. At any given time, you have patients that could be imminently dying.  

You are a source of knowledge and comfort for a patient and their family during this time. In the end, you will likely be there when the patient takes their last breath. How can one prepare to handle this scenario time and time again? Should a nurse feel sadness for a patient that was expected to die, or should they emotionally separate themselves? 

The latter may prove hard to do. The reality is that nurses are frequently exposed to death and dying in a variety of settings. A patient’s dying process can be planned or not and this distinction may mean different things for different people. Typically, nurses are taught skills to help prevent death.  

This may be a hard thought process to overcome when the goal is not curative, but comfort focused. These patient interactions help to shape a nurse’s feelings on death and dying. “Nurses are frequently exposed to dying patients and death in the course of their work. This experience makes individuals conscious of their own mortality, often giving rise to anxiety and unease.  

Nurses who have a strong anxiety about death may be less comfortable providing nursing care for patients at the end of their life” (3).  This ‘death’ anxiety could lead to disastrous outcomes for both the nurse and the patient. Nurses should be aware of their own thoughts and attitudes towards death, and how these could affect their ability to provide patient care. 

Caring for the dying involves both skill and emotional support from nurses. Younger nurses and nurses with less experience with death may have greater difficulty caring for dying patients. End of life education and an introspective look at oneself are imperative when it comes to providing quality care. “Nurses’ professional experience is positively correlated with their position, professional level (rank), EOL care experience, competence in EOL, and another knowledge. 

 Nurses who have a positive attitude seem more likely to have more competence in dealing with patients’ symptoms at EOL and better knowledge of EOL care (3). The more palliative knowledge nurses had, the more competence they felt. Moreover, competence dealing with patients’ symptoms in EOL care was correlated with older nurses” (8). Positive conversations about death and dying usually lead to a positive dying experience. 

 To reach this point, nurses and other healthcare professionals need to know how to have these conversations. In a society that is so focused on the living, receiving education on death can be difficult. When death is perceived as a part of life, only then will people feel more comfortable talking about it.  

Communication Strategies 

Many people are uncomfortable talking about death and dying and tend to shy away from such conversations. This may also be true for nurses. Talking about death should not be a formidable task. Nurses should be able to comfortably implement these conversations in their practice when needed. Effective communication is imperative throughout a patient’s trajectory.  

Conversations about death and dying can impact patient care. “Research has shown that talking about and planning the EOL is important for how the final days in a patient’s life may play out and is associated with reduced costs as well as a higher quality of care in the final weeks of life” (4). In a society so focused on life, it may be difficult for nurses and other health professionals to obtain the skills needed to confidently speak with patients about death. 

To effectively talk to patients about death, nurses should first be willing to initiate and discuss the topic. There are important strategies to remember when talking about the end of life. “Qualitative research on the end of life has revealed that medical personnel should consider the following strategies when conducting EOLD: open and honest conversation, setting treatment goals, and balancing hope with reality” (13).  

Patients should also be encouraged to express their thoughts, fears, and to ask questions. It is also important to be honest and forward with patients. No “beating around the bush”. This means using words like “dying” and “death” while having these conversations.  

One communication strategy, VALUE, “recommends to value and appreciate statements of family members, acknowledge their emotions, as well as to listen and ask questions to understand who the patient was as a person” (9). Nurses should keep the following in mind: a patient’s comfort level with death, goals of care, expectations, and cultural factors. Having this knowledge will help to guide the conversation.  

Lastly, when a nurse feels confident and exhibits calmness while talking about death, a patient will more than likely feel the same way. 

Stages of Grief 

Nurses are not immune from experiencing grief or loss. We mourn personally and we mourn alongside our patients and their families. “Grief and loss are something that all people will experience in their lifetime. The loss may be actual or perceived and is the absence of something that was valued. An actual loss is recognized and verified by others while others cannot verify a perceived loss.  

Both are real to the individual who has experienced the loss. Grief is the internal part of the loss; it is the emotions related to the loss” (4). Grief allows a person to begin to deal with the pain associated with loss and to heal. There are five stages of grief which were identified in Dr. Elisabeth Kübler-Ross in her book Death and Dying.  

1. Denial: This stage Is not necessarily about denying that the loss happened. Instead, it is more about denying the feelings associated with the loss. Denial lets us face our feelings of grief. “As an individual is able to accept that this loss is their reality, they will be able to move into the healing process and denial will begin to diminish” (5). 
2. Anger: A grieving person may feel anger towards a variety of people associated with the loss. This is a normal and a necessary part of the healing process. “Under the anger is the individual’s pain. Anger provides structure, and that is better than preceding numbness. It can be a challenge for some to feel the anger; sometimes it is easier to try and suppress the anger. Feeling anger and addressing anger is part of the grieving process” (5). 
3. Bargaining: Grieving people may begin to say things to themselves like, “If this__, then this __”, or “I will do anything if you take the hurt away” (5). This stage may occur at any point in the grief process. Once this step is reached, the person can begin to move through the stages in different ways.  
4. Depression: This stage involves a realization that the situation is real. “Empty feelings come forward, and one’s grief moves in on a deeper level than before. This type of depression is not a sign of mental illness; although reaching out for help may be the right step. It is an appropriate response to a great loss. An individual may withdraw from their daily life activities, and they may feel a fog of   intense sadness” (4). Depression after a major loss is normal and necessary in the healing process.  
5. Acceptance: Entering this final stage does not mean one is completely okay with what has happened. In fact, one may never be as they once were prior to the loss. “Acceptance, as a stage, is about accepting that this is their new reality, and it is permanent. Life cannot go on as it once did, but through acceptance, life can and will go on” (5). Individuals in this stage must realize that change is necessary to adjust to the new normal. 

Not everyone experiences grief in the same way. Grief is a very personal experience that affects people in different ways. Nurses should be familiar with the stages of grief to be able to offer optimal patient care to grieving patients and their families. This includes recognizing signs of depression and possible suicidal ideation, providing empathy, compassion, education, and resources to those in need. 

End of Life Process 

Phases of Dying 

Although everyone experiences death differently and on their own terms, there are two main pathways that most people take before dying. The dying process can be broken up into two phases: the transitioning phase, and the actively dying phase. The amount spent in each phase varies from person to person. 

The transitioning phase usually begins 2-3 weeks prior to death. Major changes in function and the ability to do activities of daily life are observed during this time. Patients may even begin falling prior to entering this phase. Becoming bedbound is common as one will begin to spend most of their time sleeping. 

This means decreased responsiveness, less interest in normal activities and hobbies, decreased interaction with family and friends, and an overall decline in one’s interest in external factors. It is possible to be roused during this phase, but this may only be possible in short intervals. It is not uncommon for transitioning patients to speak to or about loved ones that have already passed away. They may even report seeing deceased family in the room with them (11). 

This should not be feared and is an important part of a person’s dying process. Incontinence may also begin during this time and briefs will be needed. Perhaps one of the most noticeable and difficult changes to witness, especially by friends and family, is changes in appetite. Patients will begin to show less interest in food and liquids. A greater difficulty swallowing will become apparent. “Refusal of food and fluid by a dying person is a common occurrence, particularly as the body slowly shuts down, and this may be the evidence signifying an actively dying process rather than starvation” (11). 

 Lastly, symptoms like restlessness, agitation, and pain may arise and detract from one’s comfort level. Although most patients will spend about two weeks transitioning, time can vary from days to weeks. The transitioning phase can also be skipped altogether, depending on the person. 

Once the transitioning phase has concluded, the actively dying phase will begin. Actively dying immediately precedes death. This phase is usually short, lasting about 48 hours. Once actively dying, death is imminent, and a patient is expected to pass away at any moment. This phase is markedly different from the previous phase, and symptoms tend to become more apparent. “The following five changes constitute objective evidence of the end of life: diminished daily living performance, decreased food intake, changes in consciousness and increased sleep quantity, worsening of respiratory distress, and end-stage delirium” (12). 

One key difference is one’s ability to response to tactile or verbal stimuli. The actively dying patient is obtunded and no longer responds to external forces.  There could be slight reactions, but nothing meaningful. This is a comatose state.  

There are many observable changes, including changes in vital signs. Blood pressure begins to drop, heart rate speeds up and eventually slow, respiratory rate picks up, and temperature may become elevated. Respiratory differences tend to be the most common observable changes. Cheyne-Stokes may occur, and the overall breathing pattern can be very irregular. Apnea is also common (11). 

Many patients experience what is known as the “death rattle”.  This very noticeable sound is due to an accumulation of secretions in the upper airway. This is a hallmark of the actively dying phase, but it is not experienced by everyone. “Death rattle is a strong predictor of imminent death, and nearly 80% of people die within 48 hours after its onset” (11).  

Skin changes also occur. The body may become cool to touch, cyanosis may develop in the nail beds of fingers and toes, and mottling can occur usually beginning in the lower extremities and later spreading to other parts of the body. Skin may also become very pale. Urine output will decrease and become concentrated as evidenced by an amber color. 

Nursing Assessment and Care 

Since there are so many drastic changes observed during the transitioning phase, proper education is crucial for caregivers. Nurses should reassure them that what the patient is experiencing is normal and to be expected. “At the end of life, most patients are in a state of lethargy, wherein their consciousness progressively declines, and sleep duration increases; therefore, it is necessary to provide appropriate explanations to patients and their families so that they can accept these symptoms as part of the natural end-of-life process” (12). 

Family members usually try to wake the sleeping transitioning patient and have them attempt activities that could be done in the past. This is dangerous for the pt and can lead to injuries and more agitation. Becoming bedbound is a major change and puts the patient at risk for pressure injuries and increased pain. Fragile skin combined with new episodes of incontinence are topics that should be discussed, and proper supplies should be used. 

Other potential barriers to a peaceful transitioning period are force feeding and aspiration. Nurses should provide education on what is acceptable and needed at this point. Patients will not die of hunger or lack of water. Allowing the patient to eat and drink small amounts is okay (12). 

This amount will decrease as the body starts shutting down. Ice chips can be used while the patient is still alert. Utilizing mouth swabs with water is enough to hydrate the oral cavity and keep the patient comfortable until the end. During this time, symptoms can seemingly come out of the blue.  

A once calm patient can become highly agitated in a short period of time. Medications should be added timely to ensure that the patient has a peaceful death.  Information on medication and interventions to control uncomfortable end of life symptoms like pain, agitation, and restlessness should be provided to caregivers. Hospice patients, for example, have a comfort kit with various medications to use during this time.  

Medications can be used as needed or scheduled to keep patients comfortable. (12). As the patient enters the actively dying phase and becomes less alert and aware, it is important that friends and family continue to talk to the patient and keep conversations positive around the patient. Hospice nurses, for example, are sure to tell caregivers that hearing is the last thing to go, so they should continue to speak to their loved one. Since vital signs start to become abnormal, reassurance is usually needed to keep family comfortable.  

Not all vital signs need to be taken in the final stages. Taking blood pressure, for example, could cause discomfort. Death education related to respiratory changes is imperative. “Abnormal breathing patterns such as shallow breathing sound become increasingly common starting 1 week before death” (12). 

Caregivers should be informed that breathing too fast or too slow at this point is not an emergency and there are things that can be done to promote comfort like applying oxygen, keeping the head of the bed upright, and keeping the room cool. Medications can also be given to decrease the death rattle. It should be noted that patients do not experience discomfort from the death rattle.  

Lastly, not having a bowel movement or passing urine during the last few days of life is normal and interventions are not needed. Education and support are especially important during the final phases of life. With their peaceful words and deep knowledge base, nurses can be instrumental in facilitating a peaceful death.  

Resources and Support 

Planning, coordinating, and executing quality end of life care can be challenging for health care workers. This period can also be one of the most challenging times for both patients and their loved ones. There are available resources for health care workers, patients, and their loved ones that provide information on end-of-life care. 

Hospice care is an invaluable resource and source of support. This is available to terminally ill patients with a life expectancy of 6 months or less.” Hospice care is the term given to the care provided when a patient is given a prognosis of death within 6 months, and they do not pursue curative treatments They focus on improving the quality of life which can mean many things” (10).   

Care can be provided in any setting that a patient calls home. The hospice team includes a medical director, registered nurse, chaplain, social worker, home health aide, and often a nurse practitioner. Symptoms and care can be managed at home with the help of covered medications, supplies, and medical equipment. Hospice allows patients to reach their goal of dying peacefully at home. A bereavement team also provides support during the process. (10?) 

Palliative care, another form of comfort care, can also be utilized to maintain comfort at the end of life. Unlike hospice, patients receiving palliative care do not need to have a life expectancy of 6 months or less. “Research found that timely EOL care discussions allowed family members to make use of hospice and palliative care services sooner and maximize their time with the patient” (6). 

Nurses should be educated in other end of life resource topics such as advanced directives, POLST (Physician Orders for Life Sustaining Treatment), and Durable Medical Power of Attorney. Looking ahead and having meaningful discussions regarding end-of-life planning can help prevent the stress of needing to address these things when death is imminent. 

Conclusion

End of life conversations have a profound impact on not only patient care, but also on the dying process itself. Research shows that when implemented appropriately, these conversations improve patient relationships with healthcare workers, lead to better outcomes, and allow for a more positive dying experience. Nurses play a critical role in end-of-life processes in many different settings. With education, practice, experience, and confidence, nurses can incorporate conversations about death and dying to provide quality care. 

GI Bleed: An Introduction

Introduction   

Gastrointestinal bleeding (GI Bleed) is an acute and potentially life-threatening condition. It is meaningful to recognize that GI bleed manifests an underlying disorder. Bleeding is a symptom of a problem comparable to pain and fever in that it raises a red flag. The healthcare team must wear their detective hat and determine the culprit to impede the bleeding.  

Nurses, in particular, have a critical duty to recognize signs and symptoms, question the severity, consider possible underlying disease processes, anticipate labs and diagnostic studies, apply nursing interventions, and provide support and education to the patient. 

Epidemiology  

The incidence of Gastrointestinal Bleeding (GIB) is broad and comprises cases of Upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB). GI Bleed is a common diagnosis in the US responsible for approximately 1 million hospitalizations yearly (2). The positive news is that the prevalence of GIB is declining within the US (1). This could reflect effective management of the underlying conditions.  

Upper gastrointestinal bleeding (UGIB) is more common than lower gastrointestinal bleeding (LGIB) (2). Hypovolemic shock related to GIB significantly impacts mortality rates. UGIB has a mortality rate of 11% (2), and LGIB can be up to 5%; these cases are typically a consequence of hypovolemic shock (2).  

Certain risk factors and predispositions impact the prevalence. Lower GI bleed is more common in men due to vascular diseases and diverticulosis being more common in men (1). Extensive data supports the following risk factors for GIB: older age, male, smoking, alcohol use, and medication use (7).  

We will discuss these risk factors as we dive into the common underlying conditions responsible for GI Bleed.  

Etiology/ Pathophysiology

Gastrointestinal (GI) bleeding includes any bleeding within the gastrointestinal tract, from the mouth to the rectum. The term also encompasses a wide range of quantity of bleeding, from minor, limited bleeding to severe, life-threatening hemorrhage.

We will review the basic anatomy of the gastrointestinal system and closely examine the underlying conditions responsible for upper and lower gastrointestinal bleeding.

Let's briefly review the basic anatomy of the gastrointestinal (GI) system, which comprises the GI tract and accessory organs. You may have watched The Magic School Bus as a child and recall the journey in the bus from the mouth to the rectum! Take this journey once more to understand the gastrointestinal (GI) tract better.

The GI tract consists of the following: oral cavity, pharynx, esophagus, stomach, small intestine, large intestine, and anal canal (5). The accessory organs include our teeth, tongue, and organs such as salivary glands, liver, gallbladder, and pancreas (5). The primary duties of the gastrointestinal system are digestion, nutrient absorption, secretion of water and enzymes, and excretion (5, 3). Consider these essential functions and their impact on each other.

This design was created on Canva.com on August 31, 2023. It is copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

As mentioned, gastrointestinal bleeding has two broad subcategories: upper and lower sources of bleeding. You may be wondering where the upper GI tract ends and the lower GI tract begins. The answer is the ligament of Treitz. The ligament of Treitz is a thin band of tissue that connects the end of the duodenum  and the beginning of the jejunum (small intestine); it is also referred to as the suspensory muscle of the duodenum (4). This membrane separates the upper and lower GI tract. Upper GIB is defined as bleeding proximal to the ligament of Treitz, while Lower GIB is defined as bleeding beyond the ligament of Treitz (4). 

Upper GI Bleeding (UGIB) Etiology 

Underlying conditions that may be responsible for the UGIB include: 

• Peptic ulcer disease 

• Esophagitis 
• Foreign body ingestion 
• Post-surgical bleeding 
• Upper GI tumors 
• Gastritis and Duodenitis 

• Varices 
• Portal hypertensive gastropathy (PHG) 
• Angiodysplasia 
• Dieulafoy lesion 
• Gastric antral valvular ectasia 

• Mallory-Weiss tears 
• Cameron lesions (bleeding ulcers occurring at the site of a hiatal hernia 
• Aortoenteric fistulas 
• Hemobilia (bleeding from the biliary tract) 
• Hemosuccus pancreaticus (bleeding from the pancreatic duct) 

(1, 4, 5, 8. 9) 

Pathophysiology of Variceal Bleeding. Variceal bleeding should be suspected in any patient with known liver disease or cirrhosis (2). Typically, blood from the intestines and spleen is transported to the liver via the portal vein (9). The blood flow may be impaired in severe liver scarring (cirrhosis). Blood from the intestines may be re-routed around the liver via small vessels, primarily in the stomach and esophagus (9). Sometimes, these blood vessels become large and swollen, called varices. Varices occur most commonly in the esophagus and stomach, so high pressure (portal hypertension) and thinning of the walls of varices can cause bleeding within the Upper GI tract (9). 

Liver Disease + Varices + Portal Hypertension = Recipe for UGIB Disaster 

Lower GI Bleeding (LGIB) Etiology

• Diverticulosis
• Post-surgical bleeding
• Angiodysplasia
• Infectious colitis
• Ischemic colitis
• Inflammatory bowel disease
• Colon cancer
• Hemorrhoids
• Anal fissures
• Rectal varices
• Dieulafoy lesion
• Radiation-induced damage

(1, 4, 5, 9)

Unfortunately, a source is identified in only approximately 60% of cases of GIB (8). Among this percentage of patients, upper gastrointestinal sources are responsible for 30–55%, while 20–30% have a colorectal source (8).

Laboratory and Diagnostic Testing

Esophagogastroduodenoscopy (EGD) and colonoscopy identify the source of bleeding in 80–90% of patients (4). The initial clinical presentation of GI bleeding is typically iron deficiency/microscopic anemia and microscopic detection of blood in stool tests (6).

The following laboratory tests are advised to assist in finding the cause of GI bleeding (2):

• Complete blood count
• Hemoglobin/hematocrit
• International normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (PTT)
• Liver function tests

Low hemoglobin and hematocrit levels result from blood loss, and blood urea nitrogen (BUN) may be elevated due to the GI system's breakdown of proteins within the blood (9).

The following laboratory tests are advised to assist in finding the cause of GI bleeding:

• EGD (esophagogastroduodenoscopy)- Upper GI endoscopy
  • Clinicians can visualize the upper GI tract using a camera probe that enters the oral cavity and travels to the duodenum (9)
• Colonoscopy- Lower GI endoscopy/ (9)
  • Clinicians can visualize the lower GI tract.
• CT angiography
  • Used to identify an actively bleeding vessel

Signs and Symptoms 

Clinical signs and symptoms depend on the volume/ rate of blood loss and the location/ source of the bleeding. A few key terms to be familiar with when evaluating GI blood loss are overt GI bleeding, occult GI bleeding, hematemesis, hematochezia, and melena. Overt GI bleeding means blood is visible, while occult GI bleeding is not visible to the naked eye but is diagnosed with a fecal occult blood test (FOBT) yielding positive results of the presence of blood (5). Hematemesis is emesis/ vomit with blood present; melena is a stool with a black/maroon-colored tar-like appearance that signifies blood from the upper GI tract (5). Melena has this appearance because when blood mixes with hydrochloric acid and stomach enzymes, it produces this dark, granular substance that looks like coffee grounds (9). 

Mild vs. Severe Bleeding  

A patient with mild blood loss may present with weakness and diaphoresis (9). Chronic iron deficiency anemia symptoms include hair loss, hand and feet paresthesia, restless leg syndrome, and impotence in men (8). The following symptoms may appear over time once anemia becomes more severe and hemoglobin is consistently less than 7 mg/dl: pallor, headache, dizziness from hypoxia, tinnitus from the increased circulatory response, and the increased cardiac output and dysfunction may lead to dyspnea (8). Findings of a positive occult GI bleed may be the initial red flag. 

A patient with severe blood loss, which is defined as a loss greater than 1 L within 24 hours, hypotensive, diaphoretic, pale, and have a weak, thready pulse (9). Signs and symptoms will reflect the critical loss of circulating blood volume with systemic hypoperfusion and oxygen deprivation, so that cyanosis will also be evident (9). This is considered a medical emergency, and rapid intervention is needed. 

Stool Appearance: Black, coffee ground = Upper GI; Bright red blood = Lower GI. 

History and Physical Assessment

History

A thorough and accurate history and physical assessment is a key part of identifying and managing GI bleed. Remember to avoid medical terminology/jargon while asking specific questions, as this can be extremely helpful in narrowing down potential cases. It is a good idea to start with broad categories (general bleeding) then narrow to specific conditions.

Assess for the following:

• Previous episodes of GI Bleed
• Medical history with contributing factors for potential bleeding sources (e.g., ulcers, inflammatory bowel disease, liver disease, varices, PUD, alcohol abuse, tobacco abuse, H.pylori, diverticulitis) (3)
• Contributory medications (non-steroidal anti-inflammatory drugs (NSAIDs, anticoagulants, antiplatelet agents, bismuth, iron) (3)
• Comorbid diseases that could affect management of GI Bleed (8)

Physical Assessment

1. Head to toe and focused Gastrointestinal, Hepatobiliary, Cardiac and Pancreatic
2. Assessments
   Assess stool for presence of blood (visible) and anticipate orders/ collect specimen for occult blood testing.
3. Vital Signs

Signs of hemodynamic instability associated with loss of blood volume (3):

• Resting tachycardia
• Orthostatic hypotension
• Supine hypotension
• Abdominal pain (may indicate perforation or ischemia)
• A rectal exam is important for the evaluation of hemorrhoids, anal fissures, or anorectal mass (3)

Certain conditions place patients at higher risk for GI bleed. For example, patients with end-stage renal disease (ESRD) have a five times higher risk of GIB and mortality than those without kidney disease (2).

Treatment and Interventions

Treatment and interventions for GIB bleed will depend on the severity of the bleeding. Apply the ABCs (airway, breathing, circulation) prioritization tool appropriately with each unique case. Treatment is guided by the underlying condition causing the GIB, so this data is too broad to cover. It would be best to familiarize yourself with tools and algorithms available within your organization that guide treatment for certain underlying conditions. Image 2 is an example of an algorithm used to treat UGIB (8). The Glasgow-Blatchford bleeding score (GBS) tool is another example of a valuable tool to guide interventions. Once UGIB is identified, the Glasgow-Blatchford bleeding score (GBS) can be applied to assess if the patient will need medical intervention such as blood transfusion, endoscopic intervention, or hospitalization (4).

Unfortunately, there is currently a lack of tools available for risk stratification of emergency department patients with lower gastrointestinal bleeding (LGIB) (6). This gap represents an opportunity for nurses to develop and implement tools based on their experience with LGIB.

(8) 

The first step of nursing care is the assessment. The assessment should be ongoing and recurrent, as the patient's condition may change rapidly with GI bleed. During the evaluation, the nurse will gather subjective and objective data related to physical, psychosocial, and diagnostic data. Effective communication is essential to prevent and mitigate potential risk factors.

Subjective Data (Client verbalizes)

• Abdominal pain
• Nausea
• Loss of appetite
• Dizziness
• Weakness

Objective Data (Clinician notes during assessment)

• Hematemesis (vomiting blood)
• Melena (black, tarry stools)
• Hypotension
• Tachycardia
• Pallor
• Cool, clammy skin

Nursing Interventions

Ineffective Tissue Perfusion:

1. Monitor vital signs frequently to assess blood pressure, heart rate, and oxygen saturation changes.
2. Obtain IV access.
3. Administer oxygen as ordered.
4. Elevate the head of the bed (support venous return and enhance tissue perfusion).
5. Administer blood products (packed red blood cells, fresh frozen plasma) as ordered to replace lost blood volume.

Acute Pain:

1. Assess the patient's pain (quantifiable pain scale)
2. Administer pain medications as ordered.
3. Obtain and implement NPO Orders: Allow the GI tract to rest and prevent further irritation while preparing for possible endoscopic procedures.
4. Apply heat/cold therapy for comfort.

Risk for Decreased Cardiac Output

1. Assess the patient's heart rate and rhythm. (Bleeding and low cardiac output may trigger compensatory tachycardia.) (9)
2. Assess and monitor the patient's complete blood count.
3. Assess the patient's BUN level.
4. Monitor the patient's urine output.
5. Perform hemodynamic monitoring.
6. Administer supplemental oxygenation as needed.
7. Administer intravenous fluids as ordered.
8. Prepare and initiate blood transfusions as ordered.
9. Educate and prepare the patient for endoscopic procedures and surgical intervention as needed.

Risk for Deficient Fluid Volume:

1. Monitor intake and output.
2. Maintain hydration.
3. Administer intravenous fluids as ordered.
4. Monitor labs, including hemoglobin and hematocrit, to assess the effectiveness of fluid replacement therapy.
5. Educate the patient on increasing oral fluid intake once the bleeding is controlled.
6. Vital signs
7. Assess the patient's level of consciousness and capillary refill time to evaluate tissue perfusion and response to fluid replacement.
8. Collaborate with the healthcare team to adjust fluid replacement therapy based on the patient's response and laboratory findings.

Nursing Goals / Outcomes for GI Bleed:

• The patient's vital signs and lab values will stabilize within normal limits.
• The patient will be able to demonstrate efficient fluid volume as evidenced by stable hemoglobin and hematocrit, regular vital signs, balanced intake and output, and capillary refill < 3 seconds.
• The patient will exhibit increased oral intake and adequate nutrition.
• The patient will verbalize relief or control of pain.
• The patient will appear relaxed and able to sleep or rest appropriately.
• The patient verbalizes understanding of patient education on gastrointestinal bleeding, actively engages in self-care strategies, and seeks appropriate support when needed.

Case Study

Mr. Blackstool presents to the emergency department with the following:

CHIEF COMPLAINT: "My stool looked like a ball of black tar this morning."

He also reports feeling "extra tired" and "lightheaded" for 3-5 days.

HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old tractor salesman who presents to the emergency room complaining of the passage of black stools, fatigue, and lightheadedness. He reports worsening chronic epigastric pain and reflux, intermittent for 10+ years.

He takes NSAIDS as needed for back, and joint pain and was recently started on a daily baby aspirin by his PCP for cardiac prophylaxis. He reports "occasional" alcohol intake and smokes two packs of cigarettes daily.

PHYSICAL EXAMINATION: Examination reveals an alert and oriented 65-YO male. He appears anxious and irritated. Vital sips are as follows. Blood Pressure 130/80 mmHg, Heart Rate 120/min - HR Thready - Respiratory Rate - 20 /minute; Temperature 98.0 ENT/SKIN: Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity is noted. The parotid glands appear full.

CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals a regular rhythm with an S4. No murmur is appreciated. Peripheral pulses are present but are rapid and weak.

ABDOMEN/RECTUM: The waist shows a rounded belly. Bowel sounds are hyperactive. Percussion of the liver is 13 cm (mal); the edge feels firm. Rectal examination revealed a black, tarry stool. No Dupuytren's contractions were noted.

LABORATORY TESTS: Hemoglobin 9gm/dL, Hematocrit 27%, WBC 13,000/mm. PT/PTT - normal. BUN 46mg/dL.

Discuss abnormal findings noted during History and Physical Examination; Evaluate additional data to obtain possible diagnostic testing, treatment, nursing interventions, and care plans.

Conclusion

After this course, I hope you feel more knowledgeable and empowered in caring for patients with Gastrointestinal bleeding (GIB). As discussed, GIB is a potentially life-threatening condition that manifests as an underlying disorder. Think of gastrointestinal bleeding as a loud alarm signaling a possible medical emergency. Nurses can significantly impact the recognition of signs and symptoms that determine the severity of bleeding and underlying disease process while also implementing life-saving interventions as a part of the healthcare team. As evidence-based practice rapidly evolves, continue to learn, and grow your knowledge of GIB. 

Constipation Management and Treatment

Introduction   

In the realm of healthcare, where every aspect of patient well-being is meticulously tended to, constipation is a condition that often remains in the shadows. Often dismissed as a minor inconvenience, constipation is a prevalent concern that can have significant repercussions on the health and comfort of hospitalized and long-term care patients (8).  

Imagine a scenario where a middle-aged patient, recently admitted to a hospital for a non-related condition, is experiencing discomfort due to constipation. Despite the patient's hesitation to bring up this seemingly "embarrassing" topic, a skilled nurse takes the initiative to initiate an open conversation.  

By actively listening and empathetically addressing the patient's concerns, the nurse alleviates the discomfort and also plays a crucial role in preventing potential complications. This scenario exemplifies the pivotal role that nurses play in the comprehensive management of constipation. 

Envision a long-term care facility where an elderly resident's mobility is limited, leading to a sedentary lifestyle. As a result, this individual becomes more susceptible to constipation, which could potentially lead to more severe issues if left unattended. Here, the nurse's expertise in identifying risk factors and tailoring interventions comes into play.  

By suggesting gentle exercises, dietary adjustments, and adequate hydration, the nurse transforms the resident's daily routine, ensuring a healthier digestive tract and enhanced overall well-being. 

Through the above scenarios, it becomes evident that constipation is not merely a minor inconvenience but a legitimate concern that warrants attention. As the first line of defense in patient care, nurses are uniquely positioned to identify, address, and holistically prevent constipation.  

Nurses possess the knowledge and skills to create a profound impact on patient lives by acknowledging and addressing this issue. This course aims to equip nurses with an in-depth understanding of constipation, enabling them to be proactive vigilant advocates for patient comfort, bowel health, and overall well-being. 

Epidemiology  

To truly comprehend the significance of constipation in healthcare settings, it's essential to grasp its prevalence and impact. Statistics reveal that constipation holds a prominent spot in healthcare challenges, with up to 30% of patients in hospitals and long-term care facilities experiencing this discomfort (4). This means that in a unit with 100 patients, nearly a third of them might be grappling with constipation-related issues.  

Even though constipation transcends demographics, elderly patients, who are a substantial part of long-term care settings, are more susceptible to constipation due to factors like decreased mobility, altered dietary habits, and medication use. Understanding this demographic predisposition is crucial for nurses as it guides their vigilance in recognizing and managing constipation among this vulnerable group. By unraveling its prevalence and its penchant for affecting diverse patient groups, nurses can step into their roles armed with knowledge, ready to make a tangible difference in patient lives. 

Etiology/Pathophysiology  

Embarking on the journey to comprehend constipation's root causes and underlying mechanisms offers a fascinating glimpse into the intricate workings of the digestive system. The digestive system is a well-orchestrated symphony where even a slight disruption can lead to a discordant note, constipation being one such note.  

Constipation arises from an intricate interplay of factors. Lifestyle choices, such as physical inactivity, dietary habits, and even medication use, can disturb the symphony of digestion. These disruptions impact the stool's consistency, its journey through the intestines, and the efficiency of water absorption.  

Some examples of how lifestyle choices can cause constipation include the following: 

• The digestive tract, like a finely tuned instrument, requires regular movement to maintain its rhythm and balance. Without physical activity to nudge food along, its journey through the digestive process slows down, potentially leading to constipation. 
• Mismanagement of water absorption in the colon can also contribute to constipation. Excess absorption of water in the colon can turn the stool hard and dry, making it a formidable challenge to pass.  
• When fiber is lacking in the diet, stool encounters resistance and sluggishness, akin to a symphony losing its guiding rhythm. This lack of fiber can lead to constipation, underscoring the importance of dietary choices in maintaining a harmonious digestive process (10). 

Understanding the above dynamics empowers nurses to decode the origins of constipation and tailor interventions that restore the harmonious rhythm of the digestive orchestra. Just as a conductor guides a symphony to its crescendo, nurses can orchestrate the path to relief and comfort for patients grappling with constipation. 

Signs and Symptoms  

Constipation's signs and symptoms are the stars that guide nurses toward effective management. Infrequent bowel movements, excessive straining, abdominal discomfort, and bloating are like constellations, revealing the narrative of digestive imbalance. 

Recognizing the constellation of signs and symptoms becomes the compass guiding nurses toward effective care. Just as a seasoned sailor navigates by the stars, nurses navigate constipation's landscape by deciphering the cues that patients present. 

Research by Anderson and Brown (1) reveals that patients grappling with constipation often experience infrequent bowel movements as a telltale sign. Nurses, armed with this insight, recognize that infrequent bowel movements warrant vigilant assessment and timely interventions. 

Excessive straining, much like tugging at sails in adverse winds, emerges as another hallmark of constipation (6). Patients' tales of discomfort during bowel movements point to an underlying imbalance. Nurses adeptly interpret this discomfort as a call for action, initiating strategies that ease the passage of stool and restore harmony to the digestive symphony. 

Discomfort serves as an indicator of the digestive system's struggle to find its equilibrium. Nurses, like skilled navigators, probe further, discerning the nuances of the discomfort to tailor interventions that address its root cause (11). 

Bloating is another symptom. Research by Smith and Williams (9) illuminates the link between constipation and bloating. This connection heightens nurses' vigilance, prompting them to delve into patients' experiences and offer relief from the discomfort. 

Pharmacological/Non-Pharmacological Treatment 

Constipation management encompasses a harmonious blend of pharmacological and non-pharmacological strategies. Just as a symphony thrives on a balanced ensemble, nurses can orchestrate a symphony of relief and comfort by selecting the right interventions for each patient's unique needs. Through this holistic approach, nurses play a pivotal role in restoring the digestive symphony to its harmonious rhythm. 

Pharmacological 

As nurses step into the realm of constipation management, they encounter a diverse array of strategies that can harmonize the digestive symphony. Picture a pharmacist's shelf adorned with an assortment of medications, each with a specific role in alleviating constipation. 

Fiber supplements work by increasing stool bulk and promoting regular bowel movements. They're gentle and mimic the natural process, ensuring a harmonious flow. 

Osmotic laxatives introduce more water into the stool, creating a balanced blend of moisture, preventing dry and challenging stools, and facilitating movement.  

Stimulant laxatives stimulate bowel contractions, hastening the stool's journey through the digestive tract. They're like the energetic beats that invigorate a symphony, leading to a rhythmic and effective passage. 

Lastly, stool softeners ensure that the stool is neither too hard nor too soft, striking the perfect balance. They act by moistening the stool, making it easier to pass without straining. By introducing this harmony, stool softeners contribute to patient comfort. 

Non-pharmacological 

Beyond the realm of medications lies an equally vital avenue: non-pharmacological interventions. Nurses can craft a holistic care plan, carefully considering dietary adjustments and lifestyle modifications as the foundation. Examples of non-pharmacological interventions include the following: 

A diet rich in fiber guides the stool's journey with ease. Nurses can educate patients on incorporating fruits, vegetables, and whole grains, ensuring a harmonious flow through the intestines. 

Engaging in regular physical activity not only stimulates bowel movements but also enhances overall well-being. Nurses can encourage patients to integrate movement into their routines, contributing to a dynamic and efficient digestive process. 

Relaxation techniques play a vital role in constipation management. Nurses can provide guidance on techniques like deep breathing or gentle abdominal massages that soothe the digestive tract, facilitate a smoother passage, and transform discomfort into relaxation. 

Complications 

Constipation complications can disrupt the symphony of health. Nurses, armed with knowledge and interventions, become conductors of comfort, guiding patients toward a harmonious journey free from discomfort and dissonance. Through their skilled care, nurses harmonize the symphony of patient well-being, preventing complications and promoting relief. Examples of complications include the following. 

Hemorrhoids 

These are swollen blood vessels around the rectal area that cause pain, itching, and even bleeding during bowel movements. Nurses can educate patients about preventive measures, such as adequate fiber intake, staying hydrated, and avoiding straining during bowel movements. 

Anal Fissure 

This is a small tear in the anal lining that can cause pain and bleeding, disrupting daily life. Nurses can gently guide patients toward hygiene practices and proper self-care, restoring comfort and preventing further disruption. 

Fecal Impaction 

Here, the stool accumulates, creating an obstruction that can be likened to an unexpected pause in flow. This impaction causes severe discomfort and can even lead to bowel obstruction. Nurses should be attentive to patients at risk of fecal impaction, promptly intervening with measures such as stool softeners, gentle digital disimpaction, and regular bowel assessments.  

Rectal Prolapse 

This protrusion of the rectal lining is a disruptive problem that not only causes physical discomfort but also emotional distress. Nurses can empower patients by educating them about the importance of managing constipation and preventing rectal prolapse.  

Nausea and Vomiting 

The buildup of waste and toxins can trigger these unsettling symptoms. Nurses should be vigilant, recognizing these cues as a sign of digestive imbalance. Collaborating with healthcare teams, nurses can address the underlying constipation, restoring harmony and alleviating discomfort. 

Bowel Obstruction 

This is a medical emergency. Patients experience severe abdominal pain, bloating, and the inability to pass stool or gas. Nurses should be well-equipped to recognize these symptoms and act swiftly, seeking immediate medical intervention.  

Prevention  

Prevention is composed of dietary choices, hydration, exercise, and lifestyle awareness. Nurses, as conductors of preventive care, guide patients toward a harmonious journey of well-being. By embracing preventive measures, patients become active participants in the symphony of their health, ensuring that the digestive rhythm remains soothing and uninterrupted. Sample preventive measures include the following: 

Dietary Adjustments 

Nurses can educate patients about the importance of incorporating fiber into their diets. Picture a patient's plate adorned with vibrant fruits, vegetables, and whole grains — these fiber-rich choices act as the brushstrokes that create a smooth flow through the digestive system.  

Hydration 

Like the gentle spray that keeps a garden vibrant, staying adequately hydrated ensures the digestive landscape remains fluid and inviting. Nurses can encourage patients to drink sufficient water, allowing the stool's journey to be as effortless as the water's flow.  

Exercise 

Nurses can guide patients in incorporating regular physical activities like brisk walks, or gentle stretching into their daily routines, creating a rhythm that enhances bowel motility and overall well-being. Movements, much like instrument tuning before a performance, prepare the digestive system for optimal function.  

Lifestyle Awareness 

Nurses can educate patients about the importance of timely bowel movements and creating a comfortable environment for digestion. Patients can cultivate their well-being by avoiding prolonged periods of sitting and adopting healthy toileting habits.  

Patient Education 

Nurses can provide insights into the importance of fiber-rich foods, hydration, and movement. By empowering patients with knowledge, nurses equip them with the tools needed to prevent constipation and maintain digestive well-being.   

Nursing Implications 

Nurses are instrumental in managing constipation and improving patient outcomes. Nurses should be skilled in assessing patients for constipation risk factors, communicating effectively about symptoms, and tailoring interventions to individual patient needs. Collaborating with other healthcare professionals to develop comprehensive care plans is essential. Examples of useful nursing skills include: 

Holistic Assessment 

Nurses are vigilant observers, attuned to the nuances of patient well-being. Like skilled detectives, nurses delve into patients' histories, medications, and lifestyles, identifying constipation risk factors. Holistic assessments allow nurses to understand the unique backdrop against which constipation may unfold. Armed with this knowledge, nurses can tailor interventions that resonate with each patient's needs (12). 

Effective Communication 

Envision a nurse as a skilled communicator, bridging the gap between patient concerns and medical insights. Like a translator, nurses help patients express their symptoms and experiences, ensuring nothing gets lost in translation. Effective communication not only nurtures trust but also facilitates accurate assessment, enabling nurses to identify constipation-related cues and initiate timely interventions (14). 

Collaboration with Multidisciplinary Teams 

Consider a care setting where the patient's well-being is a collective effort, much like an orchestra composed of diverse instruments. Nurses collaborate with physicians, dietitians, physical therapists, and other healthcare professionals to ensure a harmonious approach to constipation management. This interdisciplinary collaboration ensures that each note of patient care resonates in unison, creating a symphony of comprehensive well-being (7). 

Patient-Centered Care Plans 

Imagine nurses as architects of care plans, designing blueprints that reflect patients' unique needs and preferences. Just as architects tailor a building to its occupants, nurses craft patient-centered care plans that incorporate dietary preferences, lifestyle routines, and individualized interventions. This tailored approach ensures that patients feel heard and empowered in their constipation management journey (13). 

Education and Empowerment 

Envision nurses as educators, empowering patients with knowledge that transforms them into active participants in their care. Much like a guide, nurses navigate patients through the maze of constipation management strategies, ensuring clarity and understanding. By imparting information about dietary choices, hydration, exercise, and self-care, nurses equip patients with the tools needed to harmonize their digestive well-being (2). 

Continuous Monitoring and Evaluation 

Imagine nurses as diligent conductors, continuously assessing the rhythm of constipation management. Just as a conductor listens to every note, nurses monitor patients' responses to interventions, ensuring their effectiveness. Regular evaluation allows nurses to fine-tune strategies, ensuring that the symphony of constipation management remains harmonious and effective (5). 

Compassionate Support 

Envision nurses as compassionate companions on the patient's constipation management journey. Like trusted friends, nurses offer emotional support, addressing patients' concerns and fears with empathy. This compassionate approach fosters a sense of security and trust, enabling patients to navigate the challenges of constipation with resilience and a sense of camaraderie (3). 

Conclusion

Constipation is a significant concern that impacts the comfort and well-being of hospitalized and long-term care patients. Nurses' proactive role in identifying, managing, and preventing constipation is essential for promoting patient health. By employing a combination of pharmacological and non-pharmacological interventions, nurses can significantly enhance patient comfort and quality of life.  

Envision nurses as educators who share the symphony of knowledge with patients, empowering them to become proactive partners in their well-being. With insights about dietary choices, hydration, exercise, and relaxation techniques, patients become active participants in the harmony of their digestive health. 

Think of nurses as vigilant observers, continuously assessing the rhythm of constipation management, listening to every note, monitoring patient responses, and adjusting interventions to ensure a harmonious and effective approach.  

Finally, visualize nurses as compassionate companions on the constipation management journey. They offer unwavering support, much like friends sharing the weight of challenges. This compassionate presence fosters trust, comfort, and a sense of unity, creating a symphony of emotional well-being alongside physical relief. 

As this course concludes, let us remember that constipation management is not just about alleviating discomfort but about orchestrating a symphony of care that encompasses every aspect of the patient’s experience.  

By blending knowledge, empathy, and skill, nurses elevate constipation management from a routine task to a transformative experience. With this newfound understanding, nurses are prepared to guide patients toward a harmonious symphony of relief, comfort, and overall well-being. 

Spinal Cord Injury: Bowel and Bladder Management

Introduction   

Imagine one day you are able to walk and take care of your own needs. Now, imagine one week later you wake up no longer able to walk, feel anything below your waist, or hold your bowels.  

This is a reality for many people who sustain spinal cord injuries. Managing changes in bowel and bladder function is one of many challenges that people with spinal cord injuries and their families or caregivers face.  

This course will provide learners with the knowledge needed to assist patients who have spinal cord injuries with bowel and bladder management to improve the quality of life in this group.

Spinal Cord Injuries: The Basics

Spinal Cord Function 

Before defining a spinal cord injury, it is important to understand the function of the spinal cord itself. The spinal cord is a structure of the nervous system that is nestled within the vertebrae of the back and helps to distribute information from the brain (messages) to the rest of the body [1].  

These messages result in sensation and other neurological functions. While it may be common to primarily associate the nervous system with numbness, tingling, or pain, nerves serve an important purpose in the body’s function as a whole.

Spinal Cord Injury Definition 

When the spinal cord is injured, messages from the brain may be limited or entirely blocked from reaching the rest of the body. Spinal cord injuries refer to any damage to the spinal cord caused by trauma or disease [2]. Spinal cord injuries can result in problems with sensation and body movements.  

For example, the brain sends messages through the spinal cord to muscles and tissues to help with voluntary and involuntary movements. This includes physical activity like running and exercising, or something as simple as bowel and bladder elimination.  

Spinal Cord Injury Causes 

Spinal cord injuries occur when the spinal cord or its vertebrae, ligaments, or disks are damaged [3]. While trauma is the most common cause of spinal cord injuries in the U.S., medical conditions are the primary causes in low-income countries [4] [2]. 

Trauma 

• Vehicle accidents: Accounts for 40% of all cases [2] 
• Falls: Accounts for 32% of all cases [2] 
• Violence: Includes gun violence and assaults; accounts for 13% of all cases [2] [5] 
• Sport-related accidents: Accounts for 8% of all cases [2] 

Medical Conditions 

• Multiple Sclerosis (MS): Damage to the myelin (or insulating cover) of the nerve fibers [1] 
• Amyotrophic Lateral Sclerosis (ALS): Lou Gehrig’s disease, damage to the nerve cells that control voluntary muscle movements [1] 
• Post-Polio: Damage to the central nervous system caused by a virus [1] 
• Spina Bifida: Congenital defect of the neural tube (structure in utero that eventually forms the central nervous system) [1] 
• Transverse Myelitis (TM): Inflammation of the spinal cord caused by viruses and bacteria [1] 
• Syringomyelia: Cysts within the spinal cord often caused by a congenital brain abnormality [1] 
• Brown-Sequard Syndrome (BSS): Lesions in the spinal cord that causes weakness or paralysis on one side of the body and loss of sensation on the other [1] 
• Cauda Equina Syndrome: Compression of the nerves in the lower spinal region [1] 

Spinal Cord Injury Statistics 

According to the World Health Organization, between 250,000 and 500,000 people worldwide are living with spinal cord injuries [4]. In the U.S., this number is estimated to be between 255,000 and 383,000 with 18,000 new cases each year for those with trauma-related spinal cord injuries [6]. 

Age/Gender 

Globally, young adult males (age 20 to 29) and males over the age of 70 are most at risk. In the U.S., males are also at highest risk, and of this group, 43 is the average age [2].  

While it is less common for females to acquire a spinal cord injury (2:1 ratio in comparison to males), when they do occur, adolescent females (15-19) and older females (age 60 and over) are most at risk globally [4].  

Race/Ethnicity 

In the U.S. since 2015, around 56% of spinal cord injuries related to trauma occurred among non-Hispanic whites, 25% among non-Hispanic Black people, and about 14% among Hispanics [6].  

Mortality 

People with spinal cord injuries are 2 to 5 times more likely to die prematurely than those without these injuries (WHO, 2013). People with spinal cord injuries are also more likely to die within the first year of the injury than in subsequent years. In the U.S., pneumonia, and septicemia – a blood infection – are the top causes of death in patients with spinal cord injuries [6]. 

Financial Impact 

Spinal cord injuries cost the U.S. healthcare system billions each year [6]. Depending on the type, spinal cord injuries can cost from around $430,000 to $1,300,000 in the first year and between $52,000 and $228,000 each subsequent year [6].  

These numbers do not account for the extra costs associated with loss of wages and productivity which can reach approximately $89,000 each year [6]. 

Spinal Cord Injuries: Types and Complications

Four Levels of the Spinal Cord 

• Cervical (vertebrae C1 – C8): Neck; controls the back of the head down to the arms, hands, and diaphragm 
• Thoracic (vertebrae T1 – T12): Upper mid-back; controls the chest muscles, many organs, some back muscles, and parts of the abdomen 
• Lumbar (vertebrae L1 – L5): Lower back; controls parts of the lower abdomen, lower back, parts of the leg, buttocks, and some of the external genital organs 
• Sacral (vertebrae S1 – S5): Lower back; controls the thighs down to the feet, anus, and most of the external genital organs 

Types of Spinal Cord Injuries 

Spinal cord injuries may be classified by level and degree of impairment. There are four types of spinal cord injuries [5]. 

Injury Level 

• Tetraplegia or Quadriplegia: Injury at the cervical level; loss of feeling or movement to the head, neck, and down. People with this type of spinal cord injury have the most impairment. 
• Paraplegia: Injury at the thoracic level or below; limited or complete loss of feeling or movement to the lower part of the body.  

Impairment 

• Incomplete spinal cord injury: Some sensation and mobility below the level of injury as the spinal cord can still transmit some messages from the brain. 
• Complete spinal cord injury: Total loss of all sensation and mobility below the level of injury. Spinal cord injuries of this type have the greatest functional loss. 

Spinal Cord Injury Complications 

Complications from spinal cord injuries can be physical, mental, or social, and can impact overall quality of life. There are six common complications of spinal cord injuries [2]. 

Depression 

Studies show that 32.9% of adults with disabilities experience frequent mental distress [7]. Mental distress may be related to functional limitations, chronic disease, and the increased need for healthcare services.  Up to 37% of people with spinal cord injuries develop depression [2]. 

Pressure injuries 

People with spinal cord injuries may have problems with circulation and skin sensation– both risk factors for pressure injuries. Some may be bedridden or wheelchair-bound which also places them at risk for pressure injuries. Up to 80% of people with spinal cord injuries will have a pressure injury during their lifetime and 30% will have more than one [2].  

Spasticity 

Around 65% - 78% of people with spinal cord injuries have spasticity [2]. Spasticity is uncontrolled muscle tightening or contraction. The damage from spinal cord injuries causes misfires in the nervous system leading to twitching, jerking, or stiffening of muscles. 

Autonomic dysreflexia 

In some people with spinal cord injuries, a full bladder or bowel distention can cause a potentially dangerous condition called autonomic dysreflexia. The full bladder or bowel triggers a sudden exaggerated reflex that causes an increase in blood pressure. This condition is also associated with a severe headache, low heart rate, cold skin, and sweating in the lower body [8]. 

Respiratory problems 

If the diaphragm function is affected, as with cervical spinal cord injuries, there may be breathing difficulties. People with lumbar spinal cord injuries can even have respiratory problems as the abdominal muscles are used to breathe. 

Sexual problems 

Due to changes in muscle function and depending on the degree of damage, people with spinal cord injuries may have problems with arousal and climax due to altered sensations and changes in sexual reflexes.  

Changes in bowel and bladder function 

Many people with spinal cord injuries lose bowel control. Bowel problems can include constipation, impaction, and incontinence. They may also have problems with urination, for example, urinary retention. 

Bowel and Bladder Dysfunction in Spinal Cord Injuries 

This section will cover the normal function of the bowel and bladder, and the types of bowel and bladder dysfunction that occurs in patients with spinal cord injuries.

Normal Bowel and Bladder Function 

In normal bowel and bladder function, when the rectum or bladder fills with stool/urine and presses on area nerves (stimulation), the message is sent to the spinal cord which sends it to the brain. The brain gives the person the “urge” feeling, allowing an option to control the elimination or not.  

Whatever decision the person makes, the brain sends the message back to the spinal cord, which in turn sends a message to the elimination muscles (anal and bladder sphincters) to either relax or stay closed until the person is ready. In people with spinal cord injuries, the messages are limited or blocked, leading to problems with bowel and bladder control [9] [10].  

Bowel Dysfunction with Spinal Cord Injuries 

Reflex hypertonic neurogenic bowel occurs when a rectum full of stool presses against area nerves sending a message to the spinal cord, but it stops there. The message never makes it to the brain, so the person never gets the urge.  

As a result, a reflex is set off, prompting the spinal cord to send a message to the anal muscle (sphincter) instead, causing it to relax and release the stool. This condition leads to bowel incontinence and usually occurs in spinal injuries at the cervical and thoracic levels [9] [10]. 

Flaccid hypotonic bowel occurs when area nerves are also stimulated by a full rectum, but the message does not even reach the spinal cord, so there is no reflex. The anal sphincter is always in a relaxed state.  

As a result, the bowels simply empty when they are full, and this can occur at any time without the person having the ability to control it. This condition results in bowel incontinence and can lead to constipation as the patient does not have the urge and may not have the ability to push. This condition usually occurs in spinal injuries at the lumbar level [9] [10]. 

Bladder Dysfunction with Spinal Cord Injuries 

Reflex neurogenic bladder occurs when the bladder automatically starts to contract after filling with a certain amount of urine. The person has no urge to go as the messages are either limited or blocked from reaching the brain, therefore leading to loss of bladder control. Similar to reflex hypertonic neurogenic bowel, the full bladder triggers are nerves that set off a reflex, prompting the spinal cord to send messages to the bladder releasing urine outside of the person’s control [9] [10]. 

Acontractile bladder occurs when the bladder loses muscle tone after a spinal cord injury, lessening its ability to contract, leading to bladder distention, and dribbling of urine. People with this condition need to use urinary catheters to help empty the bladder [9]. 

The Nurse’s Role in Bowel and Bladder Management 

This section will cover how nurses can assess, intervene, and teach when caring for patients with spinal cord injuries who have bowel and bladder dysfunction.

Nurse Assessments 

When caring for patients with spinal cord injuries, nurses should obtain a detailed bowel and bladder history including diet, fluid intake, medications, and elimination patterns/habits [11]. Many of these patients may already manage their own bowel and bladder care at home.  

If so, the nurse should obtain the patient’s current regimen and communicate the information to the physician. The physician may choose to continue the regimen or adjust as needed based on the patient’s current illness/condition.  

Questions the nurse can ask the patient: 

• What does your typical diet consist of? 
• How much fluid do you drink on a daily basis? 
• How often do you have a bowel movement or urinate? 
• Do you schedule your bowel movements with assistance from medications? 
• Are there certain body positions or things you do to help you pass stool more easily?
• How often do you use an intermittent urinary catheter for bladder relief? 
• How much time do you spend on your bowel and bladder regimens? 
• Do you care for all of your elimination needs or does someone help you? 
• How does your bowel and bladder dysfunction affect your quality of life? 

Some assessments may be observed. For example, nurses may notice that the patient has a surgically placed permanent suprapubic urinary catheter or colostomy (when the bowel is cut somewhere above the level of the rectum and diverted to the outside of the abdomen). 

Nurse Interventions 

Since many patients with spinal cord injuries have problems with bowel and bladder function, elimination must be scheduled. Nurses can help by implementing bowel and bladder programs and providing education and support to patients, families, or caregivers.  

Regimens 

Follow the patient’s home bowel and bladder regimen (as ordered). This may include maintaining intermittent catheterization every few hours or administering suppositories daily.  

For patients who do not have a regimen already or wish to modify their current one, encourage them to pay attention to how often they urinate and pass stools, elimination problems, foods that alleviate or worsen the problem, and medications or other things that help. This can be done through a diary. 

Dietary Considerations 

Educate patients on the importance of a fiber-rich diet to avoid constipation. Patients should also be made aware that high-fat foods, spicy foods, and caffeine can alter gut dynamics and lead to bowel incontinence episodes [12]. 

Fluid Intake 

Some patients may avoid drinking enough water to avoid bladder complications (e.g., frequent incontinent episodes) [12]. However, nurses should educate patients on the importance of adequate fluid intake to prevent constipation. Patients should be made aware that bladder and bowel elimination regimens go hand in hand. 

Bladder Elimination 

For bladder dysfunction, help patients perform intermittent urinary catheterization as needed or place a temporary urinary catheter (as ordered). 

Bowel Elimination 

For bowel dysfunction, administer ordered suppositories and laxatives to help the bowels move (use suppositories in conjunction with the level of sensation the patient has near the anus/rectum) [9]. Changes in body position may help as well.  

While many of these interventions may not work in some patients with spinal cord injuries, bowel irrigation (water enemas) may be helpful [11]. Surgical placement of a colostomy may be indicated if all other measures have failed [11]. 

Emotional Support 

Ensure privacy and sensitivity during all elimination care as patients may experience embarrassment or frustration. 

Education for Families or Caregivers 

Provide education to families or caregivers on the importance of helping patients stay consistent with their elimination regimen, follow diet and fluid intake recommendations, and comply with medication orders.  

Referrals 

Inform the physician if interventions are not effective or if the patient, family, or caregiver has a special need (e.g., counselor or dietician). Refer patients and families or caregivers to support groups as needed.

Support Groups and Resources 

Christopher and Dana Reeve Foundation 

Christopher Reeve – an actor who was left paralyzed after an equestrian accident – and his wife Dana’s legacy lives on through their foundation, an organization that advocates for people living with paralysis [13].  

Miami Project to Cure Paralysis 

In response to his son, who acquired a spinal cord injury during college football, NFL Hall of Famer Nick Buoniconti and world-renowned neurosurgeon Barth A. Green, M.D. started a research program aimed at finding a cure for paralysis and discovering new treatments for many other neurological injuries and disorders [14]. 

National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) 

The National Institute on Disability, Independent Living, and Rehabilitation Research, a part of the U.S. Department of Health and Human Services’ Administration for Community Living, helps people with disabilities integrate into society, employment, and independent living [15].  

Paralyzed Veterans of America (PVA)  

A group of World War II veterans who returned home with spinal cord injuries, started this organization to support those with spinal cord injuries and dysfunction. Today, the organization focuses on quality health care, research and education, benefits, and civil rights to affected veterans [16].  

United Spinal Association 

The United Spinal Association supports people with spinal cord injuries and those in wheelchairs. The organization advocates for disability rights like access to healthcare, mobility equipment, public transportation, and community support. Support groups can be found on their website [17).  

Conclusion

Spinal cord injuries can have devastating effects on patients and their families. Management of basic bodily functions like bowel and bladder elimination should be made as easy as possible for these patients.

When nurses learn how to effectively help patients with spinal cord injuries better manage their own bowel and bladder regimens, quality of life and health outcomes may be improved for this group.

Pressure Injury Prevention, Staging and Treatment

Introduction   

When hearing the term HAPI, what comes to mind? The fact is, HAPI may not necessarily generate happy thoughts. Hospital-acquired pressure injuries (HAPIs) are a significant problem in the U.S. today. In fact, pressure injuries in general – whether acquired in a hospital or not – are a global problem.

Many articles have noted that staging and differentiating pressure injuries can be overwhelming for nurses [9]. The purpose of this course is to equip learners with the knowledge needed to reduce pressure injuries, resulting complications, financial risk, and associated death. The information in this course will serve as a valuable resource to nurses from all specialties and backgrounds.

What is a pressure injury?

The National Pressure Injury Advisory Panel (NPIAH) defines pressure injuries as “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device” [17]. Pressure injuries can present as intact or opened skin and can be shallow or deep. Pressure injuries can be quite painful for patients and may require extensive treatment.

Prior to 2016, pressure injuries were termed “pressure ulcers.” However, since ulcer implies “open skin,” the NPIAH changed it to “pressure injury” as the skin is not always open with some of these injuries [22][25].

What causes a pressure injury to develop?

Pressure 

Intense and/or prolonged pressure on the patient’s skin and/or tissue can cause compromised blood flow and decreased sensation [7]. This can occur when patients lay or sit on a bony prominence for an extended period of time [16].  

Bony prominences are areas where you can easily feel a bone underneath the skin or tissue when palpating. These can include the heels, hips, elbows, and tailbone. Approximately two-thirds of all pressure injuries occur on the hip and buttocks area [7]. 

Friction and Shear 

Friction and shear often happen when patients slide down in bed, for example, when the head of the bed is raised. Although “friction and shear” are often used together, there is actually a difference between the two.  

While friction occurs when skin is dragged across a coarse surface (leading to surface-level injuries), shearing occurs when internal bodily structures and skin tissue move in opposite directions (leading to deep-level injuries) [10]. Shearing is often associated with a type of pressure injury called deep tissue injury (occurring in the deeper tissue layers rather than on the skin’s surface) [10].

[24] 

What are risk factors for developing a pressure injury? 

There are numerous risk factors for pressure injuries – some of which may not be directly related to the skin. These risk factors can be categorized as either intrinsic factors (occurring from within the body) or extrinsic (occurring from outside of the body) [2][13]. 

Intrinsic Risk Factors 

- Poor skin perfusion (e.g., peripheral vascular disease or smoking) 

- Sensation deficits (e.g., diabetic neuropathy or spinal cord injuries) 

- Moist skin (e.g., urinary incontinence or excessive sweating) 

- Inadequate nutrition (particularly poor protein intake) 

- Poor skin elasticity (e.g., normal age-related skin changes) 

- End of life/palliative (leads to organ failure including the skin) 

- Limited mobility (i.e., bedridden, or wheelchair-bound) 

Extrinsic Risk Factors 

- Physical and chemical restraints (leads to limited mobility) 

- Undergoing a procedure (laying down for extended periods of time) 

- Length of hospital stay (for HAPIs) 

- Medical devices (can lead to medical device-related pressure injuries)

Statistical Evidence 

This section will cover pressure injury statistics both globally and nationally. This section will also cover the impact pressure injuries have on healthcare.

What is happening on a global scale? 

In a global study, researchers found that the prevalence (all cases) and incidence (new cases) of pressure injuries in 2019 were 0.85 million and 3.17 million, respectively – numbers that have decreased over time [23][25]. Numbers were disproportionately high in high-income North America, Central Latin America, and Tropic Latin America [25]. Numbers were lowest in Central Asia and Southeast Asia. The report revealed that although numbers are high overall, they are much lower than what they were predicted to be, which may be attributed to better prevention and treatment initiatives.

What is happening nationally? 

In the U.S., 2.5 million people develop pressure injuries each year [1]. This number does not account for the many people trying to manage pressure injuries on their own at home (i.e., when family acts as the caregiver).  

HAPIs in particular are a growing problem. The most recent data on hospital-acquired conditions in the U.S. shows that from 2014 to 2017, HAPIs increased by 6% (647,000 cases in 2014 to 683,000 in 2017) [6]. Each year 60,000 patients in the U.S. die as a direct result of pressure injuries [1]. 

How do pressure injuries impact healthcare? 

Pressure injuries can be quite costly to the healthcare system. These injuries can lead to persistent pain, prolonged infections, long-term disability, increased healthcare costs, and increased mortality [1].  

In the U.S., pressure injuries cost between $9.1 - $11.6 billion per year [1]. These injuries are complex and can be difficult to treat [7]. Often requiring an interdisciplinary approach to care, the costs of one pressure injury admission can be substantial. Individual care for patients with pressure injuries ranges from $20,900 to $151,700 per injury [1]. Not to mention, more than 17,000 lawsuits are related to pressure injuries every year [1].  

Due to the significant impact that these injuries have on healthcare, prevention and accurate diagnosis is imperative.

Staging and Diagnosis 

The section will cover the staging, varying types, and diagnosis of pressure injuries.  

What is the difference between wound assessment and staging? 

Pressure injury staging is more than a basic wound assessment. Wound assessment includes visualizing the wound, measuring the size of the wound, paying attention to odors coming from the wound, and lightly palpating the area on and/or around the wound for abnormalities. Pressure injury staging, however, involves determining the specific cause of injury, depth of skin or tissue damage, and progression of the disease.  

What are the six stages of pressure injuries? 

According to NPIAP guidelines, there are six types of pressure injuries – four of which are stageable [14]. 

[16] 

Stage 1 

In Stage 1 pressure injuries, there is intact skin with a localized area of non-blanchable erythema (pink or red in color), which may appear differently in darkly pigmented skin. Before visual changes are noted, there may be the presence of blanchable erythema or changes in sensation, temperature, or firmness. Stage 1 pressure injuries do not have a purple or maroon discoloration (this can indicate a deep tissue pressure injury). 

Stage 2 

In Stage 2 pressure injuries, there is partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent an intact or opened serum-filled blister. Fat (adipose) and deeper tissues are not visible. Granulation tissue, slough (soft moist material, typically yellow or white), and eschar (hard necrotic tissue, typically black in color) are not present. Stage 2 injuries cannot be used to describe wounds associated with moisture-only, skin chaffing, medical adhesives, or trauma. 

Stage 3 

In Stage 3 pressure injuries, there is full-thickness loss of skin, in which fat is visible in the injury, and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be noted. The depth of tissue damage is dependent on the area of the wound. Areas with a significant amount of fat can develop deep wounds.  

Undermining (burrowing in one or more directions, may be wide) and tunneling (burrowing in one direction) may be present. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar covers the extent of tissue loss, this would be considered an unstageable pressure injury, not a Stage 3. 

Stage 4 

In Stage 4 pressure injuries, there is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the wound. Slough and/or eschar may be visible. Rolled wound edges, undermining, and/or tunneling are often present. The area where the wound is present will determine the depth. As with stage 3 pressure injuries, if slough or eschar covers the extent of tissue loss, this would be considered an unstageable pressure injury. 

Unstageable 

In unstageable pressure injuries, there is full-thickness skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because it is covered by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.  

Deep Tissue Injury 

In deep tissue pressure injuries (also termed: deep tissue injuries or DTIs), there is intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.  

Pain and temperature changes often precede skin color changes. Discoloration may appear differently in darker-pigmented skin. The injury may resolve without tissue loss or may worsen quickly and open up, revealing the actual extent of tissue injury. Deep tissue pressure injuries should not be used to describe vascular, traumatic, neuropathic, or dermatologic conditions.  

What are other types of pressure injuries? 

Mucosal Membrane Pressure Injury 

Mucosal membrane pressure injuries are found on mucous membranes with a history of a medical device in use at the location of the injury. For example, a wound on the inside of a nostril from a nasogastric tube would be considered a mucosal membrane pressure injury. Due to the anatomy of the tissue, mucosal membrane pressure injuries cannot be staged [18]. 

Medical Device-Related Pressure Injury 

Medical device-related pressure injuries, often associated with healthcare facilities, resulting from the use of devices designed and applied for diagnostic or therapeutic purposes [15]. The resulting pressure injury typically conforms to the pattern or shape of the device which makes identification easier. The injury should be staged using the staging system.  

Hospital Acquired Pressure Injury (HAPI) 

While the general hospital setting places patients at a 5% to 15% increased risk of developing a pressure injury (HAPI), patients in the intensive (or critical) care unit in particular have an even higher risk [17]. Critical care patients typically have serious illnesses and conditions that may cause temporary or permanent functional decline. There is also evidence that pressure injuries in this setting can actually be unavoidable.  

The NPIAP defines “unavoidable” pressure injuries as those that still develop after several measures by the health provider have been taken. These measures include when the provider has (a) evaluated the patient’s condition and pressure injury risk factors, (b) defined and implemented interventions consistent with standards of practice and the patient’s needs and goals, and (c) monitored and evaluated the impact of interventions [20]. There are certain situations in which a critical care patient may have a higher risk of developing unavoidable pressure injuries.  

In one study of 154 critical care patients, researchers found that 41% of HAPIs were unavoidable and those who had a pressure injury in the past were five times more likely to develop an unavoidable pressure injury during their stay [20]. The study also found that the chance of developing an unavoidable HAPI increased the longer patients stayed in the hospital – a 4% risk increase each day.  

How are pressure injuries diagnosed? 

Diagnosing a pressure injury is done by simply staging the injury. The health provider may stage the injury or rely on the nurse’s staging assessment before giving the final diagnosis and initiating treatment. There are tests that may be ordered to help identify the early stages of a developing injury.  

For example, subepidermal moisture assessment (SEM) scanners may help to identify tissue changes early on in patients with darker skin tones [8]. Tests may also be ordered to determine the extent of the damage, disease, or infection caused by a pressure injury. A magnetic resonance imaging test (MRI) can be used to determine if the infection in a stage 4 pressure injury has spread to the bone. 

Prevention and Treatment 

This section will cover various strategies that can be used to prevent and treat pressure injuries. 

What are some ways to prevent pressure injuries? 

Preventing pressure injuries takes more than just one nurse repositioning a patient every two hours. It involves a combination of strategies, protocols, and guidelines that facilities can implement across various departments, specialties, and care team members. The NIAPH recommends the following prevention strategies [19]. 

Risk assessment 

Facilities should use a standardized risk assessment tool to help identify patients at risk for pressure injuries (i.e., the Braden or Norton Scale). Rather than using the tool as the only risk assessment strategy, risk factors should be identified by other means (for example, by gathering a detailed patient history).  

Risk assessments should be performed on a regular basis and updated as needed based on changes in the patient’s condition. Care plans should include risk assessment findings to address needs. 

Skin Care 

Monitoring and protecting the patient’s skin is vital for pressure injury prevention. Stage 1 pressure injuries should be identified early to prevent the progress of disease. These include looking at pressure points, temperature, and the skin beneath medical devices.  

The frequency of assessments may change depending on the department. Ideally, assessments should be performed upon admission and at least once daily. Skin should also be cleaned promptly after incontinence episodes. 

Nutritional Care 

Tools should be used that help to identify patients at risk for malnutrition. Patients at risk should be referred to a registered dietician or nutritionist. Patients at risk should be weighed daily and monitored for any barriers to adequate nutritional intake. These may include swallowing difficulties, clogged feeding tubes, or delays in intravenous nutrition infusions. 

Positioning and mobilization 

Immobility can be related to age, general poor health, sedation, and more. Using offloading pressure activities and keeping patients mobile overall can prevent pressure injuries. Patients at risk should be assisted in turning and repositioning on a schedule. Pressure-relieving devices may be used as well. Patients should not be positioned on an area of previous pressure injury. 

Monitoring, training, and leadership 

Current and new cases of pressure injuries should be documented appropriately and reported. All care team members should be educated on pressure injury prevention and the importance of up-to-date care plans and documentation.  

All care team members should be provided with appropriate resources to carry out all strategies outlined. Leadership should be available to all care team members for support (this may include a specialized wound care nurse or wound care provider). 

How are pressure injuries treated? 

There is no one way to treat a pressure injury. Management of pressure injuries involves a specialized team of care providers and a combination of therapies that aim to target underlying factors and prevent complications [7]. Depending on the stage of the wound and skin risk factors, providers may order specific types of treatments.  

Some pressure injury treatments may include the following [7]. 

- Wound debridement – a procedure in which necrotic tissue is removed from a wound bed to prevent the growth of pathogens in the wound, allowing for healing 

- Antibiotic therapy (topical or systemic) 

- Medicated ointments applied to the wound bed (e.g., hydrogels, hydrocolloids, or saline-moistened gauze to enable granulation tissue to grow and the wound to heal) 

- Nutritional therapies (e.g., referrals to dieticians) 

- Disease management (e.g., controlling blood sugar in diabetes) 

- Pain medications 

- Physical therapy (to keep the patient active) 

The Nurse’s Role 

The section will cover the nurse’s role in preventing pressure injuries and the progression of disease.  

What is the nurse’s role in pressure injury prevention? 

Based on NPIAH guidelines, the Agency for Healthcare Research and Quality (AHRQ) – an agency that monitors pressure injury data for the U.S. – breaks down quality initiatives for preventing pressure injuries in a three-component care bundle [2].  

A care bundle is a combination of best practices that when used together, can lead to better patient outcomes [2]. The care bundle includes skin assessments, risk assessments, and care planning. Nurses should follow the guidelines listed under each component. 

Standardized pressure injury risk assessment 

- Use risk assessment tools and processes to identify patients at risk 

- Do not rely on tools only, use your own judgment as well (tools are meant to guide the assessment) 

- Update risk scores at least once daily and if patient’s condition changes 

- Document findings in the medical record 

- Communicate findings to other staff involved for continuity of care (e.g., informing another nurse during patient handoff reporting) 

Comprehensive skin assessment 

- Identify any pressure injuries that may be present 

- Determine whether there are other areas of skin breakdown or factors that may predispose the patient to develop a pressure injury (e.g., moist skin) 

- Identify other skin issues 

- Perform assessments at regular intervals 

- Document findings in the medical record 

- Communicate findings to other staff involved in care so that appropriate changes can be reported (e.g., informing the nursing assistant) 

- Ask colleague to confirm findings for accuracy (i.e., two-nurse skin checks) 

Care planning and implementation to address areas of risk 

- Create care plans that include each skin risk factor (e.g., nutrition, mobility, and moisture) 

- Update care plans as often as needed if there are any changes in the patient’s condition 

- Evaluate whether care plan was effective by assessing patient response to interventions 

-  Individualize care plans for each patient based on risk assessment scores and other observed risks 

- Identify patient learning needs and implement teaching as needed 

- Document care plan in the medical record 

- Communicate care plan to other staff involved for continuity of care (e.g., informing another nurse during patient handoff reporting) 

How can nurses prevent medical device-related pressure injuries?

The NPIAP outlined best practices to prevent medical device-related pressure injuries in various settings including general care, long-term care, critical care, and pediatric care [20]. The following strategies apply across all settings. 

- Choose the correct size of medical device for the individual. 

- Cushion and protect the skin with dressings in high-risk areas (e.g., nasal bridge). 

- Inspect the skin under and around the device at least daily (if not medically contraindicated).  

- Rotate sites of oximetry probes.  

- Rotate between O2 mask and prongs (if feasible).  

- Reposition devices (if feasible).  

- Avoid placement of device over sites of prior or existing pressure injury OR directly under the patient.  

- Be aware of edema under the device and the potential for skin breakdown. 

- Change rigid C-collar to softer collar when medically cleared (for critical care settings).

How can nurses identify pressure injuries in patients with darker skin tones? 

Research suggests that it may be difficult to note early changes that can lead to the development of a pressure injury in patients with darker skin tones – for one, blanching may not be as visible [8]. This places the patient at a greater risk for the advancement of disease as early identification may be challenging.  

In order to appropriately identify pressure injuries in patients with darker skin tones, nurses should use unique strategies. The NIPAH offers these recommendations for nurses to help accurately identify pressure injuries in this group [8]. 

Identification tips 

- Clean the suspected area beforehand 

- Compare the area to surrounding unaffected areas 

- Compare the area to the opposite laterality if possible (i.e., right versus left elbow) 

- Compare the area to unaffected areas in a different location (i.e., upper back versus chest) 

- Look for differences in skin tautness 

- Look for shining skin changes 

- Palpate for changes in skin temperature 

How can nurses quickly differentiate between pressure injury stages? 

Correct staging of pressure injuries is vital as treatment is determined by the extent of damage, disease, or infection. First and foremost, wounds should be gently cleaned prior to staging as drainage or debris can be mistaken for fat or bone within the wound bed [14].  

Nurses can quickly differentiate between stages by asking these simple easy-to-understand starter questions. A more detailed assessment should follow. 

- Stage 1 versus Stage 2: Is the skin intact? 

Rationale: The skin is always intact in Stage 1. The skin is always open in Stage 2 (or there may be an intact blister present). 

- Stage 2 versus Stage 3: Is the wound bed pink or beefy red? 

Rationale: The wound bed is pink or beefy red in Stage 2. In Stage 3, the wound bed has structures within that may be discolored. 

- Stage 3 versus Stage 4: Does the wound bed contain soft or firm structures? 

Rationale: The wound bed contains softer structures in Stage 3. The wound bed contains firmer structures in Stage 4.* 

- Unstageable versus Stageable: Is any part of the wound bed hidden? 

Rationale: The wound bed is not entirely exposed in an unstageable. The wound bed is exposed in a stageable that is open. 

- Intact DTI versus Stage 1: Is the discoloration light or dark? 

Rationale: The discoloration is dark in a DTI. The discoloration is much lighter in Stage 1. 

- Open DTI versus Stage 2: Is the discoloration in or around the wound bed dark? 

Rationale: There is dark discoloration in or around the wound bed in an open DTI. In stage 2, the discoloration is much lighter (if even present). 

*Nurses should familiarize themselves with the appearance of the various structures that may be present in a wound like fat, fascia, bone, tendon, ligament, etc. Most importantly, nurses should consult the wound care team or health provider if a stage cannot be determined. 

What should patients know? 

Facilities can use the NIAPH prevention strategies to devise teaching plans for patients [19]. Nurses should educate patients and families/caregivers on risk factors, signs and symptoms, prevention tips, and the importance of following through with treatment.  

Nurses should also teach patients to advocate for their own health in order to avoid progression of disease. Here are important tips to teach at any point during the patient’s stay. These tips can apply to nurses working in a variety of settings. 

- Tell the nurse or provider of your medical conditions (needed to identify risk factors) 

- Tell the nurse or provider if you notice any numbness or tingling in your body (potential risk for sensory deficits) 

- Tell the nurse or provider if you have a loss of appetite or trouble eating (potential risk for malnutrition) 

- Clean yourself well after using the restroom (maintains skin integrity) 

- Tell the nurse or provider if you need to use the restroom or need help with cleaning yourself (maintains skin integrity) 

- Tell the nurse right away if you have an incontinence episode (maintains skin integrity) 

- Take all prescribed medications (may include necessary antibiotics or wound-healing medications) 

- Reposition yourself in bed often or tell the nurse if you need help doing so (reduces immobility risk) 

- Tell the nurse or provider if you notice a new discolored area on your skin, or an open area (potential new or worsening pressure injury) 

- Tell the nurse or provider if you notice any changes to your wound (potential worsening pressure injury) 

Quality Improvement 

This section will cover the quality improvement measures in place to reduce pressure injuries. 

What is a pressure injury quality improvement initiative? 

Quality improvement involves setting goals (or initiatives) and standards of care. The goal of quality improvement is to improve patient outcomes at a systematic level where everyone involved is on the same page.  

Although possibly unaware, all care team members are involved in quality improvement. Nursing leaders design, manage, and evaluate program initiatives. Staff nurses and other care team members follow protocols that are often developed from these initiatives.  

The Pressure Injury Prevention Program is a guide designed by the AHRQ to help health facilities implement a structured pressure injury prevention initiative based on quality improvement [12]. Facilities can use the guide as a training toolkit to implement a new quality improvement program [5].  

Initiative Goals: 

- Reduced pressure injury rates 

- Reduced adverse events related to pressure injuries 

- Reduced costs associated with pressure injuries 

- Reduced lawsuits related to pressure injuries 

Ways facilities can implement a prevention program: 

- Address the overall objectives of the prevention program 

- Identify the needs for change and how to redesign practice 

- Develop goals and plans for change 

- Use the NIAPH pressure injury prevention recommended practices 

- Establish comprehensive skin assessment protocols 

- Standardize assessments of pressure injury risk factors 

- Incorporate risk factors into individualized care planning 

- Establish clear staff and leadership roles 

What are some pressure injury quality measures? 

Quality measures are tools that measure a system’s healthcare goals and/or ability to provide high-quality care [11]. In simple terms, quality measures are specific ways that systems (governments, states, organizations, etc.) can show how they are making progress in meeting goals. The AHRQ highlights the following three ways the U.S. measures its progress.  

Number of HAPIs 

The AHRQ measures the number of HAPIs per year. The most recent data is from 2014 to 2017 [6].

Rate of HAPIs per admission 

The AHRQ measures the number of HAPIs per admission related to age groups. The number is measured as a “rate,” meaning the number of HAPIs per 1,000 hospital admissions. The most recent evidence is from 2017 [4]. 

Costs of HAPIs 

Another quality measure is HAPI costs. While the AHRQ does not measure costs of HAPIs every single year, the most recent data is from 2017 [3].  

Deaths related to HAPIs 

Patient mortality rates related to HAPIs are a quality measure (calculated per 1,000 pressure injury cases). The most recent data is from 2017 [6]. 

Conclusion

 Pressure injuries are complex conditions that can lead to poor patient outcomes and a burdened healthcare system. The best strategy in the care of patients with pressure injuries or those at risk is prevention.  

However, preventing these injuries involves more than individual nurses taking specific steps. Prevention of pressure injuries involves a team effort from all members of the care team and a systemic plan for improvement.

Negative Pressure Wound Therapy (Wound Vac)

Introduction   

Negative pressure wound therapy (NPWT), also known as a wound vac, can be a powerful tool in combatting acute and chronic wounds. It relies on generating a negative pressure on the surface of a difficult wound to promote wound healing.

The goal of this course is to develop an understanding of mechanism of action of NPWT, discuss appropriate nursing assessment of these wounds, evaluate adjunct treatment options and troubleshooting support tips.

We will review basic concepts of the integumentary system and the normal wound healing process to support the rationale of NPWT.

Definition

Negative pressure wound therapy (NPWT) is the application of sub-atmospheric pressure to help reduce inflammatory exudate and promote granulation tissue in an effort to enhance wound healing (4). The idea of applying negative pressure therapy is that once the pressure is lower around the wound, the gentle vacuum suction can lift fluid and debris away and give the wound a fighting chance to heal naturally.

NPWT has a long and interesting history. The idea of suctioning fluid from wounds as therapy is not a new concept. The process was first called “cupping” and was described in Ebers Papyrus around 500 BC; historians tell us that a form of wound suction was used around 1000 BC in China, 600 BC in Babylon and Assyria, and in 400 BC by Greeks who heated copper bowls over wounds to remove blood and fluids (5).

Modern medicine has built upon a very old concept. Thankfully, nurses have a slightly easier tool in NPWT devices than heating copper bowls.

Indications for Use 

Negative pressure wound therapy is widely used for the management of both acute and chronic wounds. This therapy is helpful for a broad range of wounds, from pressure ulcers to closed surgical incisions.  

The system is now implemented routinely for open wounds, such as open fractures, fasciotomies, diabetic foot ulcers, and infected wounds. Delayed wound healing and difficult wounds are seen more commonly in elderly patients and those with comorbidities (1).  

It’s important to review the basic anatomy of our integumentary system, types of wounds, and barriers to healing to understand the usefulness of NPWT. 

Basic Anatomy of Integumentary System 

Our integumentary system is considered the body’s largest organ. Our skin acts as a shield against heat, light, bacteria, infection, and injury. Other functions include body temperature regulation, storage of water and fat, sensory function, prevention of water loss, and a basic storage compartment for the organs (6).  

The skin is made up of 3 layers. Each layer has unique functions: 

1. Epidermis 

1. Dermis 

1. Subcutaneous fat layer (hypodermis) 

The epidermis is the thin outer layer of our skin, it contains squamous cells, basal cells, and melanocytes (gives skin its color). The dermis is the middle layer of skin, it contains blood vessels, hair follicles, sweat glands, nerves, lymph vessels, fibroblasts, and sebaceous glands (6). It is important to remember that the dermis contains nerves and nerve receptors. 

The subcutaneous fat layer is the deepest layer of skin and is made up of a network of collagen and fat cells; this layer conserves the body's heat and protects the body from injury by acting as a shock absorber (6).

This design was created on Canva.com on September 28, 2023. It is copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

Types of Wounds 

Negative pressure wound therapy is primarily used to treat complex wounds that are non-healing or at risk of non-healing. It is also indicated for acute wounds when the wound cannot be closed due to the risk of infection, active infection, skin tension, or swelling (7).  

Closure or skin grafting of acute wounds, such as open fractures or burns, are at high risk for infection due to microorganisms becoming trapped in the soft tissue leading to abscess development.  

Examples of possible wounds to apply NPWT (1):  

• Diabetic foot ulcers 
• Bed sores 
• Skin graft fixation  
• Burns 
• Crush injuries 
• Sternal/abdominal wound dehiscence  
• Fasciotomy wounds 
• Animal bites 

• Frostbite 

Barriers to Healing 

Age 

• Increased risk of tearing and shearing due to thinning of epidermis and decrease in elastin 
• Phases of healing are prolonged 
• Increased risk of dehiscence as the dermis has slower contractility 
• Skin more susceptible to bacterial growth and infections as pH becomes more neutral with age  

Co-morbidities 

• Cardiopulmonary Disease 

• Oxygen-transport pathways are affected 
• O2 necessary for wound healing 

• Diabetes Mellitus 

• High glycemic levels predispose patients to infection 
• Microvasculature and neuropathic components of DM increase the risk for impaired healing  
• Poor glycemic control can increase the risk of ulceration and delayed healing 

• Immune-suppressing conditions (Cancer, HIV, immunosuppressive therapy, immunosuppression syndrome) 

• Inflammatory phase (immunology) is impaired 
• Increased risk for infection 

Impaired Perfusion and Oxygenation 

• Peripheral Vascular Impairment 

• Proper perfusion is required for growth of new tissue and immunological responses of the tissue. 
• Arterial insufficiency (blood flow to extremities) leads to necrosis or lack of response to edema. 

Neurological Impairment  

• Peripheral neuropathy 

• Complication related to DM, alcoholism, chemotherapy 
• Loss of neuronal signaling and transmission 
• Loss of the sensory ability to recognize and react to sensations of touch, pressure, temperature, pain. Example: patient leaving foot on hot surface because there was no pain sensation, leading to burn wound. 

• Spinal cord injury 

Mechanism of Action 

The mechanism of action is dependent on applying negative pressure, which is below atmospheric pressure, to the wound. This pressure allows the gentle vacuum suction to lift fluid and exudate away from the wound to enhance healing (3).  

The vacuum is gentle because powerful suction would remove newly formed tissue as well. The mechanism of action is not only in removing fluid and debris from the tissue, but the pressure causes stimulation of the growth of granulation tissue at a macroscopic and microscopic level.  

The porous foam shrinks in size with the application of negative pressure and exerts strain on the wound bed, which leads to macro- and micro-deformation of the wound (3). Microdeformation is simply a term used to describe microscopic tissue cell reactions. This reaction can be compared to a battery jump-start of a car; the stimulation causes the battery to engage. 

NPWT systems consist of a sterile foam sponge, a semi-occlusive adhesive cover, a fluid collection system or canister, and a suction pump (1). The foam sponge is applied to the wound and covered. A fenestrated tube is embedded in the foam and the wound is sealed with adhesive tape to make it airtight, and the machine delivers continuous or intermittent suction, ranging from 50 to 125 mmHg (1). 

This design was created on Canva.com on October 1, 2023. It is copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

Proper application of the NPWT is important for the mechanism of action to be effective. Research supports that NPWT is effective at creating a stable wound environment, reduces inflammation and bacterial load, improves tissue perfusion, and stimulates granulation tissue and angiogenesis (1).  

Imagine you want to plant a garden in a swampy location, you would first need to divert the water and algae from the land, cover it with a greenhouse with consistent heat and pressure, and cultivate the soil for optimal growth. Similarly, NPWT creates the most ideal conditions possible for tissue regeneration.  

Contraindications 

NPWT would be contraindicated for the following: 

• Wounds involving untreated osteomyelitis. 
• Wounds that have exposed blood vessel 
• Wounds with exposed nerves, anastomotic sites, or organs 
• Wounds including open joint capsules 
• Malignant wounds 
• Wounds with necrotic tissue; it is recommended to excise first 

The following wounds could benefit from NPWT, but caution should be given (5): 

• Wounds with visible fistula 
• Wounds with exposed bone or tendon 

• The bone or tendon should be isolated from direct pressure  

• Patient with clotting disorders or that are taking anticoagulants, due to an increased risk of bleeding. 
• Compromised microvascular blood flow to the wound bed. 

Assessment 

A focused assessment should be done for patients with NPWT devices in place, both on the machine settings, the dressing, and the wound itself. Thorough documentation of the wound is essential to see the progression of wound healing. 

Suction Device Settings: 

• Continuous or intermittent 
• Pressure Setting: Range of pressure settings from -40mmHg to -200mmHg, which can be tailored for different types of wounds (7). This is set by the medical provider. 

Laboratory assessment is meaningful in wound care. Labs can be used to assess oxygenation or indicators of infection (6). 

Dressing Assessment 

The appearance of the NPWT and dressing should be clean, dry, intact, and sealed. The tubing should not be twisted or kinked, and the clear adhesive dressing should not be wrinkled or overlapping. Please see below an example of the appropriate appearance of a dressing. 

Wound Assessment: 

• Anatomic location 
• Type of wound  
• Degree of tissue damage 
• Description of wound bed 
• Wound size 
• Wound edges and surrounding skin 
• Signs of infection 
• Pain 

Anatomical Location  

Anatomical terms and numbering should be used to make sure the location of each wound is documented. Patients often have more than one wound, so the treatment needs to be specified for each wound.  

Wound Base 

Assess the color of the wound base. Healthy granulation tissue appears pink and moist due to the new capillary formation. The appearance of slough (yellow) or eschar (black) in the wound base should be documented and communicated to the health care provider (1).  

This tissue may need to be removed to optimize healing. If any discoloration or duskiness of the wound bed or wound edges are identified, the suction should initially be reduced or switched off (7).  

Type and Amount of Exudate 

Assess the color, thickness, and amount of exudate (drainage) The amount of drainage from wounds is categorized as scant, small/minimal, moderate, or large/copious.  

Terms are used when describing exudate: sanguineous, serous, serosanguinous, and purulent (6).  

• Sanguineous: fresh bleeding  
• Serous: Clear, thin, watery plasma 
• Serosanguinous: Serous drainage with small amounts of blood noted 
• Purulent: Thick and opaque. The color can be tan, yellow, green, or brown. This is an abnormal finding and should be reported to a physician or wound care provider. 

Wound Size  

Wounds should be measured on admission, wound vac dressing changes, or as needed for abnormal events. Many healthcare facilities use disposable, clear plastic measurement tools to measure the area of a wound.  

Consistent measurement is vital to the assessment of wound healing. 

• Measure the greatest length, width, and depth of the wound in centimeters 
• Examples of wound classification tools: 

• NPUAP staging system for pressure injuries 
• Payne-Martin classification system for skin tears 
• CEAP (clinical, etiologic, anatomic, and pathophysiology) system for venous ulcers 

Tunneling or Undermining 

Tunneling is when a wound has moved underneath the skin, making a “tunnel.” The depth of tunneling can be measured by gently inserting a sterile, cotton-tipped applicator into the tunnel and noting the length from the wound base to the end of the tract (7). Undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge.  

Healing Process 

It is important to recognize the entire process of normal wound healing. There are four phases of wound healing: hemostasis, inflammatory, proliferative, and maturation (6).  

Hemostasis begins immediately after injury, involving platelet aggregation and activation of clotting factor (6). A platelet “plug” is formed as fibrinogen converts to fibrin and binds to itself. Vasoconstriction occurs at this time, decreasing blood loss and allowing clot formation.  

The inflammatory phase begins right after the injury and the injured blood vessels leak and cause localized swelling. The swelling, warmth, pain, and redness present during this stage of wound healing are related to the release of white blood cells, growth factors, nutrients, and enzymes to help control bleeding and prevent infection (6).  

The proliferative phase of wound healing involves “rebuilding” with new tissue made up of collagen and extracellular matrix; granulation tissue is built stronger with proper oxygen and nutrients.  

Key nursing knowledge: Dark granulation tissue can indicate infection, ischemia, or poor perfusion. The maturation phase of wound healing is when collagen is remodeled, aligns along tension lines, water is reabsorbed so the collagen fibers can lie closer together and cross-link, and the wound fully closes (1). 

There are three types of wound healing: primary intention, secondary intention, and tertiary intention.  

Primary intention means that the wound healing is supported by sutures, staples, glue, or otherwise closed so the wound heals beneath the closure (6).  

Secondary intention must happen when the edges of a wound cannot be approximated, or “brought together,” so the wound heals with the production of granulation tissue from the bottom up (6).  

Wounds that heal by secondary intention are at higher risk for infection, so contamination prevention is essential. Pressure ulcers are an example of wounds that heal by secondary intention.  

Tertiary intention refers to a wound that needs to remain open, often due to severe infection. Wounds with secondary and tertiary intention have longer healing times (2). 

Alternatives when NPWT fails 

• Hyperbaric Oxygen Therapy (HBOT): 

• HBOT is a treatment in which the wound is exposed to pure oxygen in a pressurized chamber to enhance wound healing (3). 

• Bioengineered Tissue:  

• Skin grafting or bioengineered tissue to promote tissue growth and healing.  
• Skin grafts are considered as a treatment option if a wound is so large that it can’t close on its own. In this procedure, skin is taken from another part of your body – usually your thigh – and transplanted onto the wound (2). 
• Some grafts are made from human cell products and synthetic materials. Studies have shown that these increase the chances of poorly healing venous leg ulcers closing faster. (2) 

• Electrical Stimulation Therapy:  

• Electrical stimulation therapy applies electrical currents to stimulate wound healing and tissue generation (4). It may be used to treat chronic wounds or pressure ulcers. 

Adjunct Treatment Options 

When selecting an adjunctive therapy for wound management, the patient's medical history, overall health, co-morbidities, ambulation status, psychosocial aspects, environmental factors, and the specific needs of the wound should all be considered. Each patient is unique, and an individualized care plan is the goal.  

Treatment of the underlying contributing disorder will be essential. For example, a patient with uncontrolled diabetes that has led to poor circulation can benefit from glycemic control.  

Take a look at the larger, holistic picture. It can be helpful for the healthcare team to create a concept map of problems that contribute to the wound. 

Topical Agents and Dressings 

Various creams, ointments, or dressings can promote wound healing and prevent infection. One example is silver-based products, which are commonly used in reducing bacterial burden and treating wound infection (4). 

Nutrition Therapy for Wound Healing 

Patients with wounds would benefit from nutrition consultation and ongoing support.  

Nutrients from foods help the body build and repair tissue and fight infection. An increase in calories and protein is important, as well as blood sugar control for diabetics.  

Vitamins C, D, B-6, B-12, folate, and others aid in repairing tissues (6). Minerals such as iron, magnesium, calcium, zinc, and others support the cardiovascular system making sure cells have enough oxygen, the nervous system, and immunological function (6). 

‍ 

Compression Therapy 

Compression therapy uses pressure to reduce swelling and improve blood flow to the wound. There are common compression devices or stockings available. It is frequently used to treat venous leg ulcers (6). 

Hyperbaric Oxygen Therapy (HBOT) 

HBOT can also be used as an adjunct treatment in which the patient breathes pure oxygen in a pressurized chamber to increase the amount of oxygen in the blood, which enhances wound healing (3). 

Troubleshooting Tips 

You may encounter complications with the wound dressing or the wound vac equipment. The most common complications associated with NPWT are pain, bleeding, and infection (7).  

The wound therapy relies on an adequate seal similar to a regular vacuum, so a loss of suction can result in ineffective treatment. If loss of seal occurs, the nurse should assess the seal around the wound dressing and note if the transparent adhesive sealant tape has either been misapplied or has come off due to poor contact with the underlying skin.  

A loss of suction could also result from incorrect placement of the suction drain tube, loss of battery power, blockage of the suction drain tube, or if the suction device is full of output (7). Sometimes the location of the wound leads to difficulty in keeping the dressing seal in place; for example, the abdomen or near joints, so movement can misplace the dressing and break the seal. Patient education is key to maintaining proper suction. 

Troubleshooting Tips: 

• Confirm the machine is on and set to the appropriate negative pressure. 
• Make sure the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure. 
• Assess the negative pressure seal and check for leaks. 
• Check for kinks in the tubing and make sure all clamps are open. 
• Avoid getting the machine wet. 

• Assess the drainage chamber to make sure it is filling correctly and does not need changing. 
• Address alarm issues: 

• Canister may be full 
• Leak in the system  
• Low/dead Battery 

• The device should not be turned off for more than two hours without ordered discontinuation. 

• If the device is off, apply a moist dressing and notify the provider immediately. 

Case Study 

Mr. Smith is a 59-year-old male presented to his primary care provider and referred to general surgery; diagnosed with lymphedema and multiple, copiously draining ulcerations on the left lower extremity.  

The patient presented with lymphedema and multiple ulcerations on the left lower extremity with copious amounts of drainage. This is an ongoing, worsening issue for over 8 months and has failed to respond to compression, foam dressings, or hydrocolloid dressing.  

The hospitalist has ordered surgical consultation, who scheduled debridement of the wounds and application of a wound vac following the procedure; Negative pressure wound therapy (NPWT) orders in place.  

CHIEF COMPLAINT: "The sores on my feet are draining more and I can no longer go to work because my boots do not fit on my foot.” He also reports a loss of appetite, chills, and loss of sensation to his left lower extremity.  

HISTORY OF PRESENT ILLNESS: Patient is a 59-year-old truck driver who has previous medical history of DM Type II, hypertension requiring use of anti-hypertensive medication, and hyperlipidemia (non-compliant with medication regimen). He takes NSAIDS as needed for back and joint pain and was recently started on a daily baby aspirin by his PCP for cardiac prophylaxis. He denies alcohol intake. He reports smoking a pack of cigarettes per day. 

PHYSICAL EXAMINATION: Examination reveals an alert and oriented 59-YO male. He appears anxious and irritated. Vital sips are as follows. Blood Pressure 155/90 mmHg, Heart Rate 120/min - HR Thready - Respiratory Rate - 20 /minute; Temperature 98.0  

ENT/SKIN: Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity is noted. Wound: 3 cm x 2 cm x 1 cm wound to lateral LLE. Wound base is dark red with yellow-green drainage present. Removed 4 x 4 dressing has a 5 cm diameter ring of drainage present. The surrounding skin is red, warm, tender to palpation, and with a dusky appearance to the entire LLE.  

CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals a regular rhythm with an S4. No murmur is appreciated. Peripheral pulses are present but are rapid and weak. A positive Stemmer sign was noted and palpable pedal pulses with mild symptoms of venous insufficiency were noted. 

ABDOMEN/RECTUM: The abdomen reveals a rounded abdomen. Bowel sounds are present.

Conclusion

Hopefully, upon completion of this course, you feel empowered and curious about the use of negative pressure wound therapy (NPWT). Wound vacs can be a powerful tool in combatting acute and chronic wounds, it is a well-documented concept throughout history.

The nurse should be knowledgeable on the integumentary system makeup and types of wounds this therapy is indicated for. The mechanism of action of NPWT is critical knowledge when assessing the healing of a wound. Adjunct treatment options and troubleshooting support tips are also meaningful in the care of patients with NPWT.

Nutritional Interventions to Promote Wound Healing

Introduction   

The medical field is an ever-evolving and constantly changing arena. Advances in technology and an increased understanding of how the body works have produced newer and better procedures and techniques in healing. These initiatives, as innovative as they may be, still depend on the body’s ability to heal itself as the foundation of the recovery process.  

In turn, the body needs proper nutrition to support the healing process within itself. Nutrition is often overlooked by nurses even though it is arguably the most critical aspect of physical healing. 

Factors That Impact Wound Healing 

Wound healing is a complex process. There are a myriad of factors that impact the body’s ability to heal and recover from an injury. Comorbidities, genetic disorders, medications, and, in some cases, disease treatments (chemotherapy, radiation, steroids, etc.) can all have the potential to slow, change, or interfere with normal wound healing (2). For this course, we will discuss a few of the more common factors that nurses will undoubtedly come across during their practice. 

Diabetes 

It is estimated that this growing, global disease will impact forty million people by the year 2030. It has been proven that diabetes is responsible for more than one hundred changes in wound healing.  

These alterations have been seen across all four phases of wound healing. Platelet activation, epithelialization, collagen deposition, and granulation tissue formation are among the alterations that take place with diabetes. Worsening renal function/failure and peripheral vascular disease as a result of diabetes also affect the wound-healing process (2). 

Renal Failure 

Though most patients who have chronic kidney disease or renal failure also have multiple comorbidities that cause the renal problem, renal failure does, independently, bring a risk of diminished wound healing. Tissue edema, delayed granulation, chronic inflammation, and decreased vessel formation are all ways that renal failure impacts wound healing.  

Hemodialysis, a life-sustaining treatment of chronic renal failure, adds fuel to the fire when it comes to risks of diminished wound healing. Protein and water-soluble vitamins and nutrients are lost through the dialysis process. This includes zinc and iron and will lead to deficiencies in these needed nutrients. Further, patients on hemodialysis and patients who receive a kidney transplant as treatment for renal failure are both at higher risk for developing infections (2).  

Smoking 

Smoking causes multiple alterations within the body at the molecular level that affect normal wound healing. Vasoconstriction caused by smoking worsens wound ischemia. The highly documented negative impact that smoking has on wound healing has led physicians to decline some elective surgeries due to the risk of poor wound healing (2). 

Infection 

It is not fully understood how infection alters wound healing. It is believed to be a multifactorial process that has a range of properties that can be progressive in nature; infection-necrosis-sepsis-death. The bacteria create an environment where the collagen that repairs the injured tissue is destroyed (2). 

Obesity 

Obesity complicates virtually every disease process including normal wound healing. Wound healing complications due to obesity include increased rates of infection, hematomas, and dehiscence. Local hypoxia is also a complication that impacts wound healing (2). 

Age 

Aging also has an impact on wound healing. During the aging process, the skin loses elasticity, thickness, and water content. There is also a decrease in the skin’s blood vessels as it ages, reducing the capacity for oxygenation and nutrients. Wound closure becomes slower with aging; by age forty, the amount of time for an identical wound to heal doubles from age twenty. After the age of fifty, dermal collagen decreases by one percent per year (2). 

Malnutrition 

Malnutrition or undernutrition has a variety of effects on wound healing. Good nutrition is essential for proper wound healing and the overall recovery of the body after an injury.  

Malnutrition can lead to the loss of immune function which will affect the body’s response to infection. With malnutrition, the skin becomes thin and frail thus more apt to develop wounds. Pressure wounds are also more likely as fat deposits over pressure points become depleted. The lack of energy during malnutrition leads to immobility, increasing the possibility of wounds. Collagen synthesis is also decreased (5).

Phases of Wound Healing 

Once again, wound healing is a complex process. From a simple pin prick to a stage-four decubitus ulcer, the wound healing process itself remains the same. The body will go through the four phases of wound healing to repair the damage.  

Hemostasis 

The first phase of wound healing is hemostasis. Whether by surgery or trauma, the body attempts to achieve hemostasis at the time of the injury. The intrinsic and extrinsic coagulation cascades are activated by the body.  

Vasoconstriction takes place while platelet aggregation occurs to form a fibrin clot. This is all in an effort of the body to stop the bleeding to bring about hemostasis. As the platelets arrive at the site of injury, cytokines and growth factors are released by the platelets to initiate the inflammation process (3) (4) (5). 

Inflammation 

Inflammation is the second phase of wound healing. It starts once hemostasis has been re-established. During this phase, the previous vasoconstriction reverses and the vessels dilate.  

This brings blood to the injury site along with neutrophils, macrophages, monocytes, and other inflammatory cells. Phagocytosis is initiated and the wound is cleansed by the removal of bacteria. The wound site will swell and there may be some restrictions in mobility to the affected area (3) (5). 

Proliferation 

Phase three is proliferation. In this phase, rebuilding of the wounded tissue begins. The number of fibroblasts increases and begins to build a collagen network and prepare the wound base for new granulation tissue.  

At the same time, new blood vessels are created; a highway for oxygen and nutrients to be supplied to the site. By the end of this phase, the foundation will have been laid for full epithelialization (3) (5). 

Remodeling 

The final phase of wound healing is remodeling. Epithelialization is in full swing once granulation tissue has filled the wound. This process stimulates skin integrity restoration.  

Scar tissue is formed as proteins such as collagen and elastin along with keratinocytes are produced. The wound closes and begins to strengthen and appear “normal”; it may take a couple of years for the site to return to its fully functional pre-injured status (3). 

How Does Nutrition Impact Healing? 

Nutrition is, perhaps, the most important underlying aspect of wound healing. The mechanism of wound healing and the role nutrition plays in that process is very complex.  

Adding nutritional interventions to the wound healing care plan is generally low cost and will increase the probability of a full recovery. Nutrition is essential for all phases of the healing process. It is the foundation of wound healing.  

The malnourished patient will have difficulty progressing through the wound healing phases. Proper nutrition will also help prevent wounds such as pressure ulcers from developing in the first place.  

Understanding which nutrients are needed through the phases of wound healing will help to devise a nutritional plan of care. Energy is required in all the phases of wound healing and is only made possible through proper nutrition (3). 

Common Deficiencies 

Nutrients and proteins are the building blocks of life. They are needed for growth, maintenance, and healing of the body. Many types of nutrient deficiencies greatly impact the healing process. Here, we will discuss some of the more common nutrient deficiencies. 

Iron 

Iron plays a key role in the synthesis of hemoglobin. Hemoglobin delivers oxygen throughout the body; oxygen is required through all phases of wound healing. Iron deficiencies can lead to anemia and decreased tissue perfusion. An iron deficiency will also affect protein synthesis, macrophage function, and overall wound strength (3) (6). 

Vitamin A 

When it comes to wound healing, vitamin A quickens collagen synthesis and the overall inflammatory phase. A deficiency in vitamin A decreases collagen production, epithelization, and tissue granulation (9). 

Vitamin B 

There are eight vitamins included in the vitamin B complex. Each of the eight vitamins has its own daily recommended intake. Vitamin B promotes cell proliferation and promotes normal metabolism. In the presence of a wound, some dietitians promote doubling the daily recommended intake of the B vitamins (3). 

Vitamin C 

Vitamin C (ascorbic acid) assists with iron absorption. It is also essential in the process of collagen formation. Without vitamin C, the immune response cannot take place as needed. There are many sources of vitamin C readily available for everyday consumption (6). 

Zinc 

Zinc is used through all phases of the wound-healing process. It is used to initiate and modulate enzyme function throughout the wound healing phases. It affects immunity and assists in fibroblast proliferation and collagen production. It is also needed for granulation tissue formation (5) (6). 

Amino Acids 

Protein and amino acids are another set of nutrients that are highly essential in wound healing. The blood’s most abundant amino acid, glutamine, provides the body’s preferred energy source, glucose. Increased levels of glutamine have been shown to help with wound strength and increase the levels of mature collagen.  

Generally, the body is able to produce enough glutamine for regular function. In times of stress on the body, such as a wound, glutamine is sought out in the diet. Arginine assists in modulating the collagen deposits, increases new vessel formation, and aids in wound contraction (3). 

Special Considerations 

Tube Feedings 

Patients who use tube feedings or enteral feedings are in a unique situation when it comes to wound healing and nutrition. Once a proper nutrition assessment has been performed, a tailor-made nutrition-rich diet can be formulated and administered directly into the gut.  

Studies have shown that different formulas with supplemental nutrients have increased the ability of the body to heal faster than those without supplements. With tube feedings, patients don’t need to prefer the taste of one formula over another as it is delivered through the tube.  

The amount of formula can also be adjusted as the patient’s needs change. Though some formulas may have side effects such as diarrhea, the overall benefits usually outweigh such side effects (8). 

Chronic and Terminal Illness 

Autoimmune, inflammatory, and cancers are among the chronic and terminal diseases that are under special consideration when it comes to wound healing. These types of diseases can interrupt the immune/inflammatory response of the body thus prolonging the phases of wound healing.  

When a wound develops on a patient who is immunocompromised, there is a higher incidence of wound infection which will delay wound healing. In many of these diseases, there may be circulatory issues that decrease the body’s ability to provide the affected area with nutrient-rich blood.  

Chronic illnesses often decrease the patient’s energy levels. This can lead to immobility and increases the risk of wounds developing.  

Further, for many of these types of issues, the treatment itself can have adverse effects on wound healing. Chemotherapy, radiation therapy, and immunosuppressants all decrease the body’s ability to heal and increase the rates of infection in wounds (2). 

Supplements 

Nutritional supplements have been shown to improve wound healing and recovery outcomes. It is important that the supplements are given under the supervision of a provider as too much of some nutrients can have a detrimental effect on wound healing.  

A proper nutrition screening should be performed on all patients with wounds so that the nutrition plan can be tailored to the individual patient. These improvements to wound healing with nutritional supplementation differ based on the type of wound and the overall health of the patient.  

The patient should be monitored and reassessed regularly by a dietitian. Again, there is no cookie-cutter supplement regimen.  

Another factor to consider with supplements is the ease of following the supplement regimen. Hard to swallow pills or foul-tasting food/liquids may have a negative impact on the patient’s ability to adhere to the supplement regimen.  

Allowing the patient to choose (with the input of the provider) the method of supplement delivery along with a choice of flavors will help increase compliance with the prescribed regimen (1). 

Patient Education 

Throughout the entire wound healing process, patient education is a must. Not only is it important so that the patient can make an informed decision about their care, but the patient should understand what is going on with their bodies.  

Education fuels compliance. A comprehensive nutrition assessment will not only provide a baseline of the patient’s nutritional status but will also help identify gaps in the patient’s understanding.  

This is where the education can be focused to best help the patient meet their wound healing goals. Education must include which foods contain which nutrients, the amount of these foods to eat, and which foods will interact with the absorption processes of the nutrients.  

Discussing normal daily requirements and the requirements needed during wound healing is also needed (1). 

Conclusion

Nutrition plays a key role in wound healing. There are many factors that affect the body’s ability to acquire and use the needed nutrients. One of the most important considerations that we as healthcare providers need to put into practice is determining a patient’s nutritional status.  

A nutritional assessment should be done on patients with wounds so that a proper plan of care can be developed. Often, nutrition is an afterthought when in reality it is the foundation on which other treatments should be built upon.  

Once this has been established, the patient’s plan of care can be implemented and must include nutritional education. Needed supplements to increase the patient’s ability to heal can be added or removed as necessary when the reassessments have been completed. 

Ostomy Management

Introduction   

Newton's law of gravity states: what goes up, must come down; similarly, the normal human gastrointestinal system has a law that what goes in, must come out. When disease inhibits the normal process, ostomy procedures are a life-saving intervention.

There are around one million people living with an ostomy or continent diversion in the US, and approximately 100,000 ostomy surgeries are performed annually in the US (1). We will build a stronger understanding of various types of ostomies, indication for the need, site selection, stoma care, complications, and patient education.

Types of Ostomies

An ostomy is a surgically created opening that reroutes stool or urine from the abdomen to the outside of the body through an opening called a stoma (9). The term stoma refers to the portion of the bowel that is sutured into the abdomen (9).

When you look at a stoma, you are looking at the lining (the mucosa) of the intestine. The color is similar to the mucosa inside your mouth and cheek. Throughout various healthcare environments, you may hear the terms ostomy or stoma interchangeably. The purpose of an ostomy is to bypass a diseased portion of the gastrointestinal tract that is not functioning properly or has been removed (2).

Ostomies are placed proximal to the diseased area, comparable to building a dam in a river to stop the flow of fluid and divert it somewhere else. An ostomy can be temporary or permanent.

There are three most common types of ostomies: ileostomy, colostomy, and urostomy (9). We will discuss these types, but it is important to recognize that gastrostomy, jejunostomy, duodenostomy, and cecostomy procedures are also done.

1. Ileostomy: A stoma is attached at the end of the small intestine (ileum) to bypass the colon, rectum, and anus.
2. Colostomy: A stoma is attached to a portion of the colon to bypass the rectum and anus.
3. Urostomy: A stoma is attached to the ureters (the tubes that carry urine from the kidney to the bladder) to bypass the bladder.

Ileostomy

The small intestine has three parts that are compact and folds over itself: the duodenum, jejunum, and the ileum. An ileostomy has a stoma attached and created from the ilium. The ileum is the final and longest segment of the small intestine (9).

The ileum terminates at the ileocecal valve, which controls the flow of digested material from the ileum into the large intestine and prevents the backup of bacteria into the small intestine (9). If a patient has this type of ostomy, the colon distal to the ostomy has a form of disease or disorder such as cancer. There are two main types of ileostomies, loop, and end ileostomy.

Loop ileostomy

In a loop ileostomy, a loop of the small bowel is lifted and held in place with a rod due to resection or repair to the distal bowel (Will). This ostomy is technically two stomas joined together (4). Loop ileostomies are typically temporary and will be closed or reversed through an operation in the future.

End ileostomy

In an end ileostomy, the ileum is surgically separated from the colon, the colon is removed or left to rest, and the end of the ileum is brought to the surface through the abdomen to form a stoma. Although end ileostomies are sometimes temporary and later rejoined, they are usually permanent (9).

Colostomy

A colostomy may be formed as an ascending, transverse, descending, or sigmoid colostomy (9). It is named according to the location of placement. An end colostomy is constructed from the ascending, transverse, descending, or sigmoid colon and has one opening for fecal elimination.

Loop Colostomy

The creation of a loop stoma takes a loop of the colon (usually the transverse colon) and pulls it to the outside of the abdominal wall (9). In this type of ostomy, the entire bowel is not dissected but left mostly intact.

End Colostomy

In end colostomies, the proximal end of the colon is dissected and pulled out of the abdominal cavity, which becomes the stoma (9). Additional procedures may involve repairing or removing portions of the distal colon or rectum.

Urostomy

Kidneys have an important job of filtering waste and excess fluid from your blood. This process creates urine, which then travels from the kidneys to the bladder through tubes called ureters (8). If the bladder is damaged or diseased, ostomies are a life-saving method of creating safe passage for the urine.

A urostomy is a surgical opening in the abdominal wall that redirects urine away from a bladder that’s diseased, has been injured, or isn't working properly (8). The bladder is either bypassed or removed (called a cystectomy) during surgery. Following the surgery, urine exits the body through a stoma.

Indication for Ostomy Placement

Gastrointestinal Tract Ostomy

- Cancer

- Colorectal

- Rectal

- Trauma/ Injury

- Significant Disorders

- Crohn’s disease

- Ulcerative Colitis

- Diverticulitis

- Bowel perforation from a ruptured diverticulum or abscess

- Bowel obstruction

- Infection (9)

Urinary Tract Ostomy

- Bladder Cancer

- Neurogenic bladder disease (damage to the nerves that control the bladder)

- Birth defects

- Chronic inflammation of the bladder (9)

Site Selection

Wound, ostomy, and continence nurses (WOCN) play a vital role in site selection. Patients should have a pre-operative consultation prior to surgery. During this consultation, the nurse acts as an advocate and educator to prepare these patients for the physical and emotional path ahead of them. A significant amount of time should be spent with the patient before surgery to determine a stoma incision site (exit of ostomy).

It is important to make the presence of the ostomy (and collection bag) as comfortable as possible, striving to reduce the hindrance to ease movements and ability to wear their typical clothing (9). Studies show that preoperative education and stoma site marking has been directly responsible for improving quality of life and decreasing peristomal skin and pouching complications (4).

Site Assessment:

Locate positions for a site within the rectus muscle (4).

Observe the abdomen in various positions sitting, standing, or lying down.

Ask the patient about the types of clothing they wear most often. Examples: Level of pants (low, high), use of belts, dresses, etc. (9)

Determine a location that is visible to the patient, as they will need to see the site well for stoma care.

Avoid skin or fat folds (folds increase chances of leakage)

Avoid scars, bony prominences, and the umbilicus (4).

Post-operative Care

Post-operative care following ostomy placement is vital. The post-operative nurse assigned to this patient should read the surgery documentation to determine the type of procedure performed, intraoperative findings, type of stoma created, any advanced diseases, and unexpected events during surgery (2).

The nurse should be aware of the level of invasiveness; was this a laparoscopic, robotic, or open surgery? This type of surgery can have an impact on the post-op care plan and length of stay (2). Teaching can begin as soon as they are able to comprehend and focus on understanding new skills.

The stoma will gradually decrease in size over the weeks following the surgery. For a patient with a new ostomy, postoperative assessments should be done per facility protocol and the stoma should be inspected at least every 8 hours (9).

Note the type of closure (staples, sutures, liquid bonding agent), presence of abdominal drains, and presence of urinary catheter (C2). Assess for pain and address accordingly with repositioning, cold/heat therapy, and ordered pain medications. Assess for bowel sounds. Palpate the abdomen and note firmness and tenderness levels. Document strict Intake and Output for these patients.

Stoma Assessment:

Note the Appearance/ Color: The stoma should be pink to red in color, moist, and firmly attached to the surrounding skin (9). If the stoma appears bluish, it indicates inadequate blood supply; if the stoma appears black, necrosis has occurred. Immediate notification is needed from the provider, as the need to return to surgery will be assessed.

- Note the Presence of edema.

- Note the Surrounding skin

- Note any Ostomy Discharge

- Amount

- Color / Consistency

- Note any Bleeding

- Monitor for rupture or leakage.

Diet

Once bowel sounds and activity return, the patient’s diet may resume (2). Typically, patients are offered clear liquids to determine their ability to tolerate fluids. Nurses should encourage the patient to chew thoroughly, eat small frequent meals, and ambulate frequently to assist in gas movement and peristalsis (2).

Stoma Care

Nursing Consideration / Reminders

Ostomy pouching system needs to be changed every 4 to 7 days, depending on the patient and type of pouch.

Patients should be encouraged to participate in stoma care. Instruct the patient to empty the pouch when it is one-third to one-half full as they become heavy and more prone to spilling or leaks.

Table 1. Ostomy Change Procedure SAMPLE (Always check with your agency policy)

Complications

Ostomy Leakage

One of the most common and troublesome complications is leakage (4). Proper preoperative site selection (away from skin folds) is important. Patient education on proper techniques and supplies can aid in the prevention of leakage.

Educate patients on the risks of changing the ostomy too often. Frequent appliance changes lead to pain and frustration, as well as financial expenses on supplies (4). Leakage is more common in the early postoperative period but can also develop with weight changes later.

Interventions involve thickening the stool with antidiarrheals to form more solid excretion and pouching techniques to bolster the height of the stoma off of the peristomal skin (4). Helpful tips also include heating the appliance with a hair dryer before application, lying flat for several minutes following application, making sure the peristomal skin is dry before application, and the possible use of a fine dusting of stomal powder and skin sealant prior to application (4). Leakage is frustrating for patients, so support and encouragement is vital.

Mucocutaneous Separation

The stoma is sutured to the skin of the abdomen with absorbable sutures during surgery (4). Mucocutaneous separation is a complication that can occur if the sutures securing the stoma become too tight or if blood flow to the area is restricted (9). This complication requires appropriate treatment because the pouch leakage will occur from the open pocket.

The goal of treatment is to keep this open pocket covered properly until the wound heals on its own and closes. Appropriate covering of the opening can include an absorbent product such as an alginate, followed by a cover dressing such as a hydrocolloid, which is covered with the ostomy pouch (4).

Early High Ostomy Output

Early high ostomy output (HOO) is defined as ostomy output greater than fluid intake occurring within 3 weeks of stoma placement, which results in dehydration (4). This is more common with ileostomies (4). Strict Input and Output records are a vital nursing intervention. The most important treatment for this complication is hydration to prevent renal failure, which is typically done intravenously (4).

The site of a patient’s colostomy will impact the consistency and characteristics of the excretion. The natural digestive process of the colon involves the absorption of water, which causes waste from the descending colon to be more formed. Waste from an ileostomy or a colostomy placed in the anterior ascending colon will be a bit more loose or watery (2).

Peristomal Skin Issues

Irritant Contact Dermatitis (ICD) is the most common peristomal skin complication following ostomy placement (9). ICD is characterized by redness; loss of epidermal tissue; pain; and open, moist areas.

Newer and inexperienced patients and caregivers will increase the size of the pouching system opening to get a better seal and stop leakage (2) However, this only contributes to more skin breakdown and irritation. Patients may also develop a fungal rash, have allergic rashes to the ostomy appliance, or folliculitis (4).

Patient Education

Patient education is a key aspect is caring for a patient with an ostomy, this process begins prior to surgery and remains constant throughout encounters. If you have not received specialized training on wound and ostomy care, you should reach out to the Wound, Ostomy and Continence Nurse (WON) within your healthcare setting to become involved if they are not already.

However, each nurse has a meaningful impact on discussing and managing expectations for life with an ostomy, including stoma care, complications, managing ostomy output, maintaining pouching appliances, and resources. Patients may feel inadequate and uneasy about caring for their stoma.

Nurses need to meet the unique learning needs of each patient and caregiver, providing education in verbal information, written pamphlets, online resources, videos, and demonstrations. The United Ostomy Associations of America, Inc. (UOAA), is a nonprofit organization that serves as an excellent resource for information, support, advocacy, and collaboration for those living with ostomies.

Nurses should be aware there is an “Ostomy and Continent Diversion Patient Bill of Rights” (PBOR) that outlines the best practices for providing high-quality ostomy care during all phases of the surgical experience (1). There are numerous national resources for patients, as well as community-based and online ostomy support groups. 

Promotion of Body Image and Self-Esteem

Ostomy surgery can have a major impact on how patients perceive themselves. A person’s body image is how they see themselves when they look in the mirror or how they picture themselves in their mind.

There are stigmas surrounding ostomies, such as being odorous, unhygienic, and unattractive due to the stoma, but the truth is that ostomies save lives and make life possible. Positivity should surround the conversation. Confirmations such as beauty, strength, celebration, and hope are meaningful.

Ways to become involved in celebrating ostomies:

- Become familiar with the United Ostomy Associations of America (UOAA) and their initiatives.

https://www.ostomy.org/ostomy-awareness-day/

National Ostomy Awareness Day on October 7, 2023

Worldwide Virtual Run for Resilience Ostomy 5k

- Social Media Sites

Celebrate Body Positivity for those with ostomies

Intimacy Encouragement

Conclusion

Ostomy care is an essential nursing skill. If you are caring for a patient with an ostomy, remember that this is a major life-altering event and condition. Reflect on ways to provide individualized care by understanding various types of ostomies, site selection, stoma care, complications, and patient education. Empower and encourage these ostomy patients’ confidence in themselves.

Diabetes Management Updates

Introduction   

Diabetes Mellitus (DM), also known as diabetes, is a condition in which the body develops high levels of blood glucose due to the inability to produce insulin or for the cells to use insulin (1) effectively. If left untreated or mismanaged, it can lead to health complications such as heart disease, chronic kidney disease, blindness, nerve damage, oral and mental health problems (1)(15).  

There are several classifications of DM, and the following will be discussed: T1DM, T2DM, gestational diabetes, and idiopathic diabetes. 

Classifications of Diabetes

Type 1 Diabetes Mellitus (T1DM)  

T1DM is formerly known as juvenile diabetes or insulin-dependent diabetes and usually occurs in children and young adults (1). Although, it can also occur at any age and accounts for 5 – 10% of cases. T1DM develops when one’s own immune system attacks and destroys the beta cells that produce insulin in the pancreas (6).     

Type 2 Diabetes Mellitus (T2DM)  

T2DM, formerly known as adult-onset diabetes or non-insulin-dependent diabetes, develops because of the body's inability to use insulin effectively. It is the most common type of diabetes and mainly occurs in adults aged 30 years and older (1). However, it is also becoming common in children and young adults due to obesity. It accounts for 90% of the population diagnosed with diabetes (6).   

Gestational Diabetes 

Gestational Diabetes occurs during pregnancy and in women who have never had a previous diagnosis of diabetes. It is a result of pregnancy hormones that are produced by the placenta or because of the insufficient use of insulin by the cells (1). Gestational diabetes can be temporary or in some cases can become chronic. It is also likely that children whose mothers have gestational diabetes can develop diabetes later in life (6).  

Prediabetes 

Prediabetes, also referred to as impaired glucose tolerance, is a stage when a person is at risk of developing diabetes. If well managed through proper diet management and exercise, this can help with the prevention or delay of type 2 diabetes (1).  

Other Forms of Diabetes 

Other forms of diabetes include monogenic diabetes syndrome, diabetes from the removal of the pancreas or damage to the pancreas from disease processes such as pancreatitis or cystic fibrosis, and drugs or chemical-induced diabetes from glucocorticoids used to treat HIV/Aids or organ transplant (1) (6).  

Statistical Evidence/Epidemiology 

Diabetes is now ranked as the 8th leading cause of death in the United States (6). There is no known cure for diabetes. It is one of the fastest-growing chronic diseases and the most diagnosed noncommunicable disease. It is also one of the leading causes of chronic kidney disease, adult blindness, and lower limb amputations (6).   

In 2019, it was estimated that 37.3 million American adults have diabetes, which equals 11.3% of the population (4). Of those, 41% were men and 32% were women. 28.7 million were diagnosed with diabetes, and 8.5 million were undiagnosed.  

There are 96 million American adults who are prediabetic, which means they are at risk of developing diabetes, but their blood glucose levels are not high enough to be diagnosed with diabetes (5).  

Most of the population that is pre-diabetic is 65 years old or older. Type 2 diabetes accounts for 90% to 95% of cases (5). The risk of developing diabetes increases with age.  

The prevalence of diabetes is much higher in both black and Hispanic/Latino adult men and women. Men are more likely to develop diabetes compared to women. Due to the rise in obesity in younger adults, there has been an increase in the number of new cases of diabetes in black teens (4).  

The figure below represents trends in incidence of type 1 and type 2 diabetes in children and adolescents 2002–2018; results show the incidence of type 2 diabetes has significantly increased (4)

Etiology and Pathophysiology 

In normal glucose metabolism, blood glucose is regulated by the two hormones insulin and glucagon (11). Insulin is secreted by the beta cells in the Islet of Langerhans in the pancreas and glucagon is secreted by the alpha cells in the pancreas.  

When there is an increase in blood glucose, the function of insulin is to reduce blood glucose by stimulating its uptake in the cells. Glucose is stored as glycogen in the liver and muscles or as fat in the adipose tissues. When blood glucose levels start to fall, glucagon promotes the release of glycogen from the liver, which is used as a source of energy in the body (8) (13).   

When there is a deficiency of insulin or a decreased response of insulin on the targeted cells in the body, it leads to hyperglycemia (high blood glucose). Meaning that the glucose that remains in the blood is not able to get to the cells. Diabetes develops mainly because of lifestyle and genetic factors (13).

T1DM 

The etiology is not well understood, though it is thought to be influenced by both environmental and genetic predispositions that are linked to specific HLA alleles. T1DM is considered an autoimmune disorder that is characterized by T-cell-mediated destruction of the pancreatic B-cells (13).  

As a result, this leads to complete insulin deficiency and ultimately hyperglycemia, which requires exogenous insulin. The rate of destruction of the pancreatic B-cell-specific disorder is known to develop rapidly in infants and children or gradually in adults (8)(13). 

T2DM 

The etiology of T2DM is characterized by decreased sensitivity to insulin and decreased secretion of insulin. Insulin resistance occurs due to the disruption in the cellular pathways that result in a decreased response in the peripheral tissues, particularly the muscle, liver, and adipose tissue.  

T2DM diabetes can progress slowly and asymptomatically over a period. Obesity and age can play a key role in the homeostatic regulation of systemic glucose because they influence the development of insulin resistance, which affects the sensitivity of tissues to insulin. Therefore, most patients with type 2 diabetes are overweight or obese 7) (8).

Diagnostic and Screening tools 

There are a variety of tests that are used to diagnose and monitor diabetes. These vary based on the type of symptoms that a patient may have. Diagnosis of DM requires at least two abnormal test results, which should include fasting glucose and A1C. The tests should be one of two from the same sample or two abnormal test results drawn on different days (3). 

The recommended diagnosis guidelines for diabetes must be based on the following criteria: 

• Fasting Plasma Glucose (FPG) concentration with results greater than 126 mg/dL. This test involves measuring blood glucose at a single point. To have accurate results, the test should be conducted after one has had nothing to eat or drink for at least 8 hours (3). 
• Glycated hemoglobin (Hb A1C) is indicative of the average levels of blood glucose in a period of two to three months. Results greater than 6.5% mean diagnosis of diabetes. This blood test does not require fasting. The A1C test is not suitable for pregnant women or those who have certain blood conditions (anemia) - NIDDK. This test should only be used for prediabetes screening (3). 
• Oral Glucose Tolerance Test (OGTT): prior to conducting this test, an FPG level needs to be measured. One must ingest 75 grams of glucose liquid. Thereafter, their glucose level is measured 2 hours after they have taken the liquid. Test results greater than 200 mg/dL are indicative of diabetes. This test is commonly used in pregnant women (3). 
• Random plasma glucose of 200 mg/dL. This test is suitable when one has symptoms of hyperglycemia, which are polydipsia, polyuria, and polyphagia (3).  

Screening 

Screening is generally recommended for adults aged 45 or older regardless of present risk factors. The updated recommendation guidelines for prediabetes screening include adults 35 years and older who are overweight or obese (3).  

Screening for Prediabetes 

Prediabetes is associated with the impairment of blood glucose levels between 100 – 125 mg/dL. The diagnosis of prediabetes should be confirmed with glucose testing when there is impaired glucose tolerance with plasma levels between 140 – 199 mg/dL 2 hours after one has ingested 75g of oral glucose. A1C levels of prediabetes are between 5.7% to 6.4% (3). 

Screening for Pregnant women 

It is recommended that all pregnant women between 24 – 28 weeks be screened for gestational diabetes to avoid missing those that are at risk. A positive 3-hour OGTT test of greater than 140 mg/dL meets the criteria for diagnosis (3).  

Medication Management 

Monitoring of blood glucose levels in patients is useful in determining the effectiveness of antidiabetic medication. To achieve better patient outcomes, it is important to recognize individual needs (11).  

It is recommended that the approach to medication management should be based on each patient's hyperglycemic index and should include the following: the presence of comorbidities, risk of hypoglycemia, vascular disease, life expectancy, and disease duration (3).   

When the management of diabetes cannot be achieved through diet and exercise alone, oral antidiabetic agents are the preferred treatment (14). Oral antidiabetics can help maintain and achieve glycemic goals for patients who are diagnosed with T2DM) (10)(14).  

Diabetes Education and patient engagement is essential to managing diabetes (11). There are several classes of anti-diabetic medication. Below are some of the most utilized antidiabetic medications (9)(14).  

Biguanides 

Metformin is the only medication in this category. 

• It is considered the 1st line of treatment in patients with T2DM unless contraindicated. 
• Metformin helps to decrease hepatic glucose production.  

• Decreases intestinal absorption of glucose by improving insulin sensitivity. Must be titrated initially to minimize adverse effects. 
• Avoided in clients with chronic kidney disease.  
• Side effects: Lactic acidosis, hypoglycemia. 

GLP 1- Receptor Agonists (RAs) 

Mimics glucagon-like peptide 1 (GLP -) hormone. Binds to GLP-1 receptors stimulate glucose-dependent insulin release and delay gastric emptying, which increases satiation.  

• Known to have cardiovascular benefits. 
• Can be taken orally or subcutaneously.  
• Special considerations: Can cause weight loss, GI side effects such as nausea, vomiting and diarrhea, dehydration, increased satiation (fullness), acute pancreatitis, and reactions at the injection sites.  
• Some labels may require renal dose adjustment.  
• GLP - 1 RAs should be considered before starting clients on insulin to help reduce A1C then oral antihyperglycemic medications are not effective in treating diabetes.  

Sulfonylureas 2nd generation 

Stimulates insulin release in pancreatic beta cells.  

• Risk for prolonged hypoglycemia. Therefore, it should be avoided with the concurrent use of insulin.  
• Can cause weight gain.  
• Can cause photosensitivity.  
• Avoid use in clients with sulfa allergies and photosensitivity.  
• Avoid use in clients with chronic kidney disease and liver disease.   

Dipeptidyl Peptidase (DPP) - 4 inhibitors 

Prevents DPP-4 enzymes from breaking down to GLP-1 hormone.   

• Neutral weight.  
• Monitor for acute pancreatitis, which can cause joint pain.  
• May require renal dose adjustment with these brands: Saxagliptin (Onglyza), Sitagliptin (Januvia), and Alogliptin. Linagliptin does not require dose adjustment.  

Sodium-Glucose transporter - 2 (SGLT-2) inhibitors 

Reduce the reabsorption of glucose by up to 90%, therefore promoting the exclusion of glucose from the body.  

• Known to have cardiovascular benefits for clients with cardiovascular disease.  
• Use with caution in clients with increased risk of fractures.  
• Avoided in clients with diabetic ketoacidosis and those prone to have frequent urinary tract infections.  
• This medication should be avoided in clients with pure poor kidney function due to volume depletion and hypotension.  
• There’s also a risk for Fournier gangrene.  

Thiazolidinediones 

Pioglitazone and rosiglitazone can help reduce insulin resistance which promotes improved sensitivity to insulin. As a result, it can help reduce the A1C levels.  

• Can cause weight gain.  
• Potential risk for heart failure when taking thiazolidines (brands: pioglitazone, rosiglitazone). 
• Generally, it is not recommended for clients with renal impairment as medication has the potential to cause fluid retention.  
• Risk for bone fractures, bladder cancer, and increased LDL cholesterol (rosiglitazone).  

• Thiazolidines do not cause hypoglycemia and can be used in combination with other antidiabetic medications including insulin. 

Insulin therapy 

Insulin therapy is commonly recommended for patients with T1DM. It can be used to help prevent the development and progression of diabetes (2). The ideal insulin regimen should be tailored based on individual needs and glycemic targets to better contend with physiological insulin replacement to maintain normoglycemia. Insulin therapy is also recommended for patients with hemoglobin A1c of greater than 9% - 10% and when symptoms of hyperglycemia are present (3).  

Other Diabetes Interventions 

The automation of glucose monitoring devices and insulin delivery systems is revolutionizing glucose management mainly because it promotes lifestyle flexibility and improved glucose management (2). 

• Glucose Monitoring Devices- these devices are ideal for clients who are on insulin regimens and may become the standard for assessing glycemic controls in clients with DM (7). 
• Continuous Glucose Monitoring (CGM)- devices that are inserted subcutaneously and measure interstitial blood glucose levels. CGMs are devices that are used to provide glucose readings, trends, and alerts to the user in real-time to inform diabetes treatment decisions. (2)(3) 

• Importance- CGM is recommended for all patients with diabetes who receive treatment with intensive insulin therapy, defined as three or more insulin injections per day for all individuals with hypoglycemia (frequent, several, nocturnal) (3).  
• Known to reduce hyperglycemia and A1C levels. 

• Insulin Pump Therapy- also known as Continuous Subcutaneous Insulin Infusion (CSII) has had notable advances over the years. CSII is recommended for those with type 1 diabetes, although in recent studies, conventional CSII is also recommended for use in T2DM patients (2)(3). CSII is a small computer that is programmed to deliver fast-acting insulin continuously to the body using mechanical force via a cannula that is inserted under the skin (2).  

• It is more precise and flexible in insulin dosing. 
• Known to improve glycemic control.  
• Cheaper than using Multi-Dose Insulin. 

• Automated Insulin Delivery Systems (AIDS) - This is a diabetes management system that utilizes an insulin pump in conjunction with an integrated CGM and computer software algorithm (3).  

• Advantages: precision and flexibility with insulin dosing. 
• Recommended for T1DM: Achieve glycemic targets with less burden. 

Upcoming Research  

Islet cell transplant has been a biological solution to help treat patients with T1DM due to poor graft survival rates. Future research will focus on manipulating the beta cells in the pancreas to make them more viable. Other treatments that have been recently made available include incretins and Amylin which improve the absorption of insulin in the body (1).  

• The development of other types of insulin that can be administered by inhalation.  
• The development of immunosuppressant drugs that will help treat T1DM. 

Conclusion

Diabetes is a complex disease that requires a multi-disciplinary and patient-centered approach to help with effective management. Regular and early screening are necessary for those at risk for developing diabetes. Most importantly, ease and access to choices of managing diabetes are necessary.

Controlled Substances

Introduction   

Pain is complex and subjective. The experience of pain can significantly impact an individual’s quality of life. According to the National Institute of Health (NIH) (40), pain is the most common complaint in a primary care office, with 20% of all patients reporting pain. Chronic pain is the leading cause of disability, and effective pain management is crucial to health and well-being, particularly when it improves functional ability. Effective pain treatment starts with a comprehensive, empathic assessment and a desire to listen and understand. Nurse Practitioners are well-positioned to fill a vital role in providing comprehensive and empathic patient care, including pain management (23).

While the incidence of chronic pain has remained a significant problem, how clinicians manage pain has significantly changed in the last decade, primarily due to the opioid epidemic. This education aims to discuss pain and the assessment of pain, federal guidelines for prescribing, the opioid epidemic, addiction and diversion, and recommendations for managing pain.

Definition of Pain

Understanding the definition of pain, differentiating between various types of pain, and recognizing the descriptors patients use to communicate their pain experiences are essential for Nurse practitioners involved in pain management. By understanding the medical definition of pain and how individuals may communicate it, nurse practitioners can differentiate varying types of pain to target assessment.

According to the International Association for the Study of Pain (27), pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or terms of described such in damage.” The IASP, in July 2020, expanded its definition of pain to include context further.

Their expansion is summarized below:

• Pain is a personal experience influenced by biological, psychological, and social factors.
• Pain cannot be inferred solely from activity in sensory neurons.
• Individuals learn the concept of pain through their life experiences.
• A person’s report of an experience in pain should be respected.
• Pain usually serves an adaptive role but may adversely affect function and social and psychological well-being.
• The inability to communicate does not negate the possibility of the experience of pain.

Types of Pain

Pain originates from different mechanisms, causes, and areas of the body. As a nurse practitioner, understanding the type of pain a patient is experiencing is essential for several reasons (23).

• Determining an accurate diagnosis. This kind of pain can provide valuable clues to the underlying cause or condition.
• Creating a treatment plan. Different types of pain respond better to specific treatments or interventions.
• Developing patient education. A nurse practitioner can provide targeted education to patients about their condition, why they may experience the pain as they do, its causes, and treatment options. Improving the patient's knowledge and control over their condition improves outcomes.

Acute Pain

Acute pain is typically short-lived and is a protective response to an injury or illness. Patients are usually able to identify the cause. This type of pain resolves as the underlying condition improves or heals (12).

Chronic Pain

Chronic pain is diagnosed when it continues beyond the expected healing time. Pain is defined as chronic when it persists for longer than three months. It may result from an underlying disease or injury or develop without a clear cause. Chronic pain often significantly impacts a person's physical and emotional well-being, requiring long-term management strategies. The prolonged experience of chronic pain usually indicates a central nervous system component of pain that may require additional treatment. Patients with centralized pain often experience allodynia or hyperalgesia (12).

Allodynia is pain evoked by a stimulus that usually does not cause pain, such as a light touch. Hyperalgesia is the effect of a heightened pain response to a stimulus that usually evokes pain (12).

Nociceptive Pain

Nociceptive pain arises from activating peripheral nociceptors, specialized nerve endings that respond to noxious stimuli. This type of pain is typically associated with tissue damage or inflammation and is further classified into somatic and visceral pain subtypes.

Somatic pain is most common and occurs in muscles, skin, or bones; patients may describe it as sharp, aching, stiffness, or throbbing.

Visceral pain occurs in the internal organs, such as indigestion or bowel spasms. It is more vague than somatic pain; patients may describe it as deep, gnawing, twisting, or dull (12).

Neuropathic pain

Neuropathic pain is a lesion or disease of the somatosensory nervous system. Examples include trigeminal neuralgia, painful polyneuropathy, postherpetic neuralgia, and central poststroke pain (10).

Neuropathic pain may be ongoing, intermittent, or spontaneous pain. Patients often describe neuropathic pain as burning, prickling, or squeezing quality. Neuropathic pain is a common chronic pain. Patients commonly describe allodynia and hyperalgesia as part of their chronic pain experience (10).

Affective pain

Affective descriptors reflect the emotional aspects of pain and include terms like distressing, unbearable, depressing, or frightening. These descriptors provide insights into the emotional impact of pain on an individual's well-being (12).

Case Study

Mary Adams is a licensed practical nurse who has just relocated to town. Mary will be the utilization review nurse at a local long-term care facility. Mary was diagnosed with Postherpetic Neuralgia last year, and she is happy that her new job will have her mostly doing desk work and not providing direct patient care as she had been before the relocation. Mary was having difficulty at work at her previous employer due to pain. She called into work several times, and before leaving, Mary's supervisor had counseled her because of her absences.

Mary wants to establish primary care immediately because she needs ongoing pain treatment. She is hopeful that, with her new job and pain under control, she will be able to continue a successful career in nursing. When Mary called the primary care office, she specifically requested a nurse practitioner as her primary care provider because she believes that nurse practitioners tend to spend more time with their patients.

Assessment

The assessment effectively determines the type of treatment needed, the options for treatment, and whether the patient may be at risk for opioid dependence. Since we know that chronic pain can lead to disability and pain has a high potential to negatively affect the patient's ability to work or otherwise, be productive, perform self-care, and potentially impact family or caregivers, it is imperative to approach the assessment with curiosity and empathy. This approach will ensure a thorough review of pain and research on pain management options. Compassion and support alone can improve patient outcomes related to pain management (23).

Record Review

Regardless of familiarity with the patient, reviewing the patient's treatment records is essential, as the ability to recall details is unreliable. Reviewing the records can help identify subtle changes in pain description and site, the patient's story around pain, failed modalities, side effects, and the need for education, all impacting further treatment (23).

Research beforehand the patient's current prescription and whether or not the patient has achieved the maximum dosage of the medication. Analysis of the patient's past prescription could reveal a documented failed therapy even though the patient did not receive the maximum dose (23).

A review of documented allergens may indicate an allergy to pain medication. Discuss with the patient the specific response to the drug to determine if it is a true allergy, such as hives or anaphylaxis, or if the response may have been a side effect, such as nausea and vomiting.

Research whether the patient tried any non-medication modalities for pain, such as physical therapy (PT), occupational therapy (OT), or Cognitive Behavioral Therapy (CBT). Note any non-medication modalities documented as failed therapies. The presence of any failed therapies should prompt further discussion with the patient, family, or caregiver about the experience. The incompletion of therapy should not be considered failed therapy. Explore further if the patient abandoned appointments.

Case Study

You review the schedule for the week, and there are three new patient appointments. One is Mary Adams. The interdisciplinary team requested and received Mary's treatment records from her previous primary care provider. You make 15 minutes available to review Mary's records and the questionnaire Mary filled out for her upcoming appointment. You see that Mary has been diagnosed with Postherpetic Neuralgia and note her current treatment regimen, which she stated was ineffective. You write down questions you will want to ask Mary. You do not see evidence of non-medication modalities or allergies to pain medication.

Pain Assessment

To physically assess pain, several acronyms help explore all the aspects of the patient's experience. Acronyms commonly used to assess pain are SOCRATES, OLDCARTS, and COLDERAS. These pain assessment acronyms are also helpful in determining treatment since they include a character and duration of pain assessment (23).

Inquire where the patient is feeling pain. The patient may have multiple areas and types of pain. Each type and location must be explored and assessed. Unless the pain is from a localized injury, a body diagram map, as seen below, is helpful to document, inform, and communicate locations and types of pain. In cases of Fibromyalgia, rheumatoid arthritis, or other centralized or widespread pain, it is vital to inquire about radiating pain. The patient with chronic pain could be experiencing acute pain or a new pain site, such as osteoarthritis, that may need further evaluation and treatment (23).

Inquire with the patient how long their pain has been present and any associated or known causative factors. Pain experienced longer than three months defines chronic versus acute pain. Chronic pain means that the pain is centralized or a function of the Central Nervous system, which should guide treatment decisions.

To help guide treatment, ask the patient to describe their pain. The description helps identify what type of pain the patient is experiencing: Allodynia and hyperalgesia indicate centralized pain; sharp, shooting pain could indicate neuropathic pain. Have the patient rate their pain. There are various tools, as shown below, for pain rating depending on the patient's ability to communicate. Not using the pain rating number alone is imperative. Ask the patient to compare the severity of pain to a previous experience. For example, a 1/10 may be experienced as a bumped knee or bruise, whereas a 10/10 is experienced on the level of a kidney stone or childbirth (23).

Besides the 0-10 rating scale and depending on the patient's needs, several pain rating scales are appropriate. They are listed below.

The 0-5 and Faces scales may be used for all adult patients and are especially effective for patients experiencing confusion.

The Defense and Veterans Pain Rating Scale (DVPRS) is a five-item tool that assesses the impact of pain on sleep, mood, stress, and activity levels (20).

For patients unable to self-report pain, such as those intubated in the ICU or late-stage neurological diseases, the FLACC scale is practical. The FLACC scale was initially created to assess pain in infants. Note: The patient need not cry to be rated 10/10.

(21).

Assess contributors to pain such as insomnia, stress, exercise, diet, and any comorbid conditions. Limited access to care, socioeconomic status, and local culture also contribute to the patient's experience of pain (23). Most patients have limited opportunity to discuss these issues, and though challenging to bring up, it is compassionate and supportive care. A referral to social work or another agency may be helpful if you cannot explore it fully.

Assess for substance abuse disorders, especially among male, younger, less educated, or unemployed adults. Substance abuse disorders increase the likelihood of misuse disorder and include alcohol, tobacco, cannabis, cocaine, and heroin (29).

Inquire as to what changes in function the pain has caused. One question to ask is, "Were it not for pain, what would you be doing?" As seen below, a Pain, Enjoyment, and General Activity (PEG) three-question scale, which focuses on function and quality of life, may help determine the severity of pain and the effect of treatment over time.

(21).

Assess family history, mental health disorders, chronic pain, or substance abuse disorders. Each familial aspect puts patients at higher risk for developing chronic pain (23).

Evaluate for mental health disorders the patient may be experiencing, particularly anxiety and depression. The Patient Health Questionnaire (PHQ4) is a four-question tool for assessing depression and anxiety.

In some cases, functional MRI or imaging studies effectively determine the cause of pain and the treatment. If further assessment is needed to diagnose and treat pain, consult Neurology, Orthopedics, Palliative care, and pain specialists (23).

Case Study

You used OLDCARTS to evaluate Mary's pain and completed a body diagram. Mary is experiencing allodynia in her back and shoulders, described as burning and tingling. It is exacerbated when she lifts, such as moving patients at the long-term care facility and, more recently, boxes from her move to the new house. Mary has also been experiencing anxiety due to fear of losing her job, the move, and her new role. She has moved closer to her family to help care for her children since she often experiences fatigue. Mary has experienced a tumultuous divorce in the last five years and feels she is still undergoing some trauma.

You saw in the chart that Mary had tried Gabapentin 300 mg BID for her pain and inquired what happened. Mary explained that her pain improved from 8/10 to 7/10 and had no side effects. Her previous care provider discontinued the medication and documented it as a failed therapy. You reviewed the minimum and maximum dosages of Gabapentin and know Mary can take up to 1800mg/day.

During the assessment, Mary also described stiffness and aching in her left knee. She gets a sharp pain when she walks more than 500 steps, and her knee is throbbing by the end of the day. Mary rated the pain a 10/10, but when she compared 10/10 to childbirth, Mary said her pain was closer to 6/10. Her moderate knee pain has reduced Mary's ability to exercise. She used to like to take walks. Mary stated she has had knee pain for six months and has been taking Ibuprofen 3 – 4 times daily.

Since Mary's pain is moderate, you evaluate your options of drugs for moderate to severe pain.

Opioid Classifications and Drug Schedules

A comprehensive understanding of drug schedules and opioid classifications is essential for nurse practitioners to ensure patient safety, prevent drug misuse, and adhere to legal and regulatory requirements. Nurse practitioners with a comprehensive understanding of drug schedules and opioid classifications can effectively communicate with colleagues, ensuring accurate medication reconciliation and facilitating interdisciplinary care. Nurse practitioners’ knowledge in facilitating discussions with pharmacists regarding opioid dosing, potential interactions, and patient education is essential (49).

Drug scheduling became mandated under the Controlled Substance Act. The Drug Enforcement Agency (DEA) Schedule of Controlled Drugs and the criteria and common drugs are listed below.

(Pain Physician, 2008)

Listed below are drugs classified by their schedule and mechanism of action. "Agonist" indicates a drug that binds to the opioid receptor, causing pain relief and also euphoria. An agonist-antagonist indicates the drug binds to some opioid receptors but blocks others. Mixed antagonist-agonist drugs control pain but have a lower potential for abuse and dependence than agonists (7).

(41).

Commonly Prescribed Opioids, Indications for Use, and Typical Side Effects

Opioid medications are widely used for managing moderate to severe pain. Referencing NIDA (2023), this section aims to give healthcare professionals an overview of the indications and typical side effects of commonly prescribed Schedule II opioid medications, including hydrocodone, oxycodone, morphine, Fentanyl, and hydromorphone.

Opioids are derived and manufactured in several ways. Naturally occurring opioids come directly from the opium poppy plant. Synthetic opioids are manufactured by chemically synthesizing compounds that mimic the effects of a natural opioid. Semi-synthetic is a mix of naturally occurring and man-made (35).

Understanding the variations in how an opioid is derived and manufactured is crucial in deciding the type of opioid prescribed, as potency and analgesic effects differ. Synthetic opioids are often more potent than naturally occurring opioids. Synthetic opioids have a longer half-life and slower elimination, affecting the duration of action and timing for dose adjustments. They are also associated with a higher risk of abuse and addiction (38).

Hydrocodone

Mechanism of Action and Metabolism

Hydrocodone is a Schedule II medication. It is an opioid agonist and works as an analgesic by activating mu and kappa opioid receptors located in the central nervous system and the enteric plexus of the bowel. Agonist stimulation of the opioid receptors inhibits nociceptive neurotransmitters' release and reduces neuronal excitability (17).

• Produces analgesia.
• Suppresses the cough reflex at the medulla.
• Causes respiratory depression at higher doses.

Hydrocodone is indicated for treating severe pain after nonopioid therapy has failed. It is also indicated as an antitussive for nonproductive cough in adults over 18.

Available Forms

Hydrocodone immediate release (IR) reaches maximum serum concentrations in one hour with a half-life of 4 hours.  Extended-release (ER) Hydrocodone reaches peak concentration at 14-16 hours and a half-life of 7 to 9 hours. Hydrocodone is metabolized to an inactive metabolite in the liver by cytochrome P450 enzymes CYP2D6 and CYP3A4. Hydrocodone is converted to hydromorphone and is excreted renally. Plasma concentrations of hydromorphone are correlated with analgesic effects rather than hydrocodone.

Hydrocodone is formulated for oral administration into tablets, capsules, and oral solutions. Capsules and tablets should never be crushed, chewed, or dissolved. These actions convert the extended-release dose into immediate release, resulting in uncontrolled and rapid release of opioids and possible overdose.

Dosing and Monitoring

Hydrocodone IR is combined with acetaminophen or ibuprofen. The dosage range is 2.5mg to 10mg every 4 to 6 hours. If formulated with acetaminophen, the dosage is limited to 4gm/day.

Hydrocodone ER is available as tablets and capsules. Depending on the product, the dose of hydrocodone ER formulations in opioid-naïve patients is 10 to 20 mg every 12 to 24 hours.

Nurse practitioners should ensure patients discontinue all other opioids when starting the extended-release formula.

Side Effects and Contraindications

Because mu and kappa opioid receptors are in the central nervous system and enteric plexus of the bowel, the most common side effects of hydrocodone are constipation and nausea (>10%).

Other adverse effects of hydrocodone include:

• Respiratory: severe respiratory depression, shortness of breath
• Cardiovascular: hypotension, bradycardia, peripheral edema
• Neurologic: Headache, chills, anxiety, sedation, insomnia, dizziness, drowsiness, fatigue
• Dermatologic: Pruritus, diaphoresis, rash
• Gastrointestinal: Vomiting, dyspepsia, gastroenteritis, abdominal pain
• Genitourinary: Urinary tract infection, urinary retention
• Otic: Tinnitus, sensorineural hearing loss
• Endocrine: Secondary adrenal insufficiency (17)

Hydrocodone, being an agonist, must not be taken with other central nervous system depressants as sedation and respiratory depression can result. In formulations combined with acetaminophen, hydrocodone can increase the international normalized ratio (INR) and cause bleeding.  Medications that induce or inhibit cytochrome enzymes can lead to wide variations in absorption.

The most common drug interactions are listed below:

• Alcohol
• Benzodiazepines
• Barbiturates
• other opioids
• rifampin
• phenytoin
• carbamazepine
• cimetidine,
• fluoxetine
• ritonavir
• erythromycin
• diltiazem
• ketoconazole
• verapamil
• Phenytoin
• John’s Wort
• Glucocorticoids

Considerations

Use with caution in the following:

• Patients with Hepatic Impairment: Initiate 50% of the usual dose
• Patients with Renal Impairment: Initiate 50% of the usual dose
• Pregnancy: While not contraindicated, the FDA issued a black-boxed warning since opioids cross the placenta, and prolonged use during pregnancy may cause neonatal opioid withdrawal syndrome (NOWS).
• Breastfeeding: Infants are susceptible to low dosages of opioids. Non-opioid analgesics are preferred.

Pharmacogenomic: Genetic variants in hydrocodone metabolism include ultra-rapid, extensive, and poor metabolizer phenotypes. After administration of hydrocodone, hydromorphone levels in rapid metabolizers are significantly higher than in poor metabolizers.

Oxycodone

Mechanism of Action and Metabolism

Oxycodone has been in use since 1917 and is derived from Thebaine. It is a semi-synthetic opioid analgesic that works by binding to mu-opioid receptors in the central nervous system. It primarily acts as an agonist, producing analgesic effects by inhibiting the transmission of pain signals (Altman, Clark, Huddart, & Klein, 2018).

Oxycodone is primarily metabolized in the liver by CYP3A4/5. It is metabolized in the liver to noroxycodone and oxymorphone.  The metabolite oxymorphone also has an analgesic effect and does not inhibit CYP3A4/5. Because of this metabolite, oxycodone is more potent than morphine, with fewer side effects and less drug interactions. Approximately 72% of oxycodone is excreted in urine (Altman, Clark, Huddart, & Klein, 2018).

Available Forms

Oxycodone can be administered orally, rectally, intravenously, and as an epidural. For this sake, we will focus on immediate-release and extended-release oral formulations.

• Immediate-release (IR) tablets
• IR capsules
• IR oral solutions
• Extended-release (ER) tablets

Dosing and Monitoring

The dosing of oxycodone should be individualized based on the patient's pain severity, previous opioid exposure, and response. Initial dosages for opioid naïve patients range from 5-15 mg for immediate-release formulations, while extended-release formulations are usually initiated at 10-20 mg. Dosage adjustments may be necessary based on the patient's response, but caution should be exercised. IR and ER formulations reach a steady state at 24 hours and titrating before 24 hours may lead to overdose.

Regular monitoring is essential to assess the patient's response to treatment, including pain relief, side effects, and signs of opioid misuse or addiction. Monitoring should include periodic reassessment of pain intensity, functional status, and adverse effects (Altman, Clark, Huddart, & Klein, 2018).

Side Effects and Contraindications

Common side effects of oxycodone include:

• constipation
• nausea
• sedation
• dizziness
• respiratory depression
• respiratory arrest
• hypotension
• fatal overdose

Oxycodone is contraindicated in patients with known hypersensitivity to opioids, severe respiratory depression, paralytic ileus, or acute or severe bronchial asthma. It should be used cautiously in patients with a history of substance abuse, respiratory conditions, liver or kidney impairment, and those taking other medications that may interact with opioids, such as alcohol (4).

It is also contraindicated with the following medications and classes:

• Antifungal agents
• Antibiotics
• Rifampin
• Carbamazepine
• Fluoxetine
• Paroxetine

Considerations

• Nurse practitioners should consider the variations in the mechanism of action for the following:
• Metabolism differs between males and females: females have been shown to have less concentration of oxymorphone and more CYP3A4/5 metabolites.
• Infants have reduced clearance of oxycodone, increasing side effects.
• Pediatrics have 20-40% increased clearance over adults.
• Reduced clearance with age increases the half-life of oxycodone.
• Pregnant women have a greater clearance and reduced half-life.
• Impairment of the liver reduces clearance.
• Cancer patients with cachexia have increased exposure to oxycodone and its metabolite.
• Maternal and neonate concentrations are similar, indicating placenta crossing (4)

Morphine

Mechanism of Action and Metabolism

Morphine is a naturally occurring opioid alkaloid extracted from the opium poppy. It was isolated in 1805 and is the opioid against which all others are compared. Morphine binds to mu-opioid receptors in the brain and spinal cord, inhibiting the transmission of pain signals and producing analgesia. It is a first-line choice of opioid for moderate to severe acute, postoperative, and cancer-related pain (8).

Morphine undergoes first-pass metabolism in the liver and gut. It is well absorbed and distributed throughout the body. Its main metabolites are morphine-3-glucuronide and morphine-6-glucuronide. Its mean plasma elimination half-life after intravenous administration is about 2 hours. Approximately 90% of morphine is excreted in the urine within 24 hours (8).

Available Forms

Morphine is available in various forms, including.

• immediate-release tablets
• extended release tablets
• oral IR solutions
• injectable solutions
• transdermal patches

Dosing and Monitoring

Morphine is hydrophilic and, as such, has a slow onset time. The advantage of this is that it is unlikely to cause acute respiratory depression even when injected. However, because of the slow onset time, there is more likelihood of morphine overdose due to the ability to “stack” doses in patients experiencing severe pain (Bistas, Lopez-Ojeda, & Ramos-Matos, 2023).

The dosing of morphine depends on the patient's pain severity, previous opioid exposure, and other factors. It is usually initiated at a low dose and titrated upwards as needed. Monitoring pain relief, adverse effects, and signs of opioid toxicity is crucial. Reevaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or of dose escalation. General recommendations for initiating morphine (Bistas, Lopez-Ojeda, & Ramos-Matos, 2023).

Prescribe IR opioids instead of ER opioids.

Prescribe the lowest effective dosage, below 50 Morphine Milligram Equivalents (MME) /day.

Side Effects and Contraindications

Because morphine binds to opioid receptors in the brain and spinal cord, is metabolized in the liver and gut, and has a slow onset, the following side effects are common:

• Constipation
• Nausea
• Vomiting
• Sedation
• Dizziness
• Respiratory depression
• Pruritis
• Sweating
• Dysphoria/Euphoria
• Dry mouth
• Anorexia
• Spasms of urinary and biliary tract

Contraindications of morphine are:

• Known hypersensitivity or allergy to morphine.
• Bronchial asthma or upper airway obstruction
• Respiratory depression in the absence of resuscitative equipment
• Paralytic ileus
• Risk of choking in patients with dysphagia, including infants, children, and the elderly (8)

Concurrent use with other sedating medications: Amitriptyline, diazepam, haloperidol, chlorpromazine

Morphine interacts with the following medications:

• Ciprofloxacin
• Metoclopramide
• Ritonavir

Considerations for Nurse Practitioners

Assess for medical conditions that may pose serious and life-threatening risks with opioid use, such as the following:

• Sleep-disordered breathing, such as sleep apnea.
• Pregnancy
• Renal or hepatic insufficiency
• Age >= 65
• Certain mental health conditions
• Substance use disorder
• Previous nonfatal overdose

Fentanyl

Mechanism of Action and Metabolism

Fentanyl is a synthetic opioid more potent than morphine and was approved in 1968. Fentanyl is an agonist that works by binding to the mu-opioid receptors in the central nervous system. This binding inhibits the transmission of pain signals, resulting in analgesia. Fentanyl is often used for severe pain management, particularly in the perioperative and palliative care settings, or for severe pain in patients with Hepatic failure (8).

It is a mu-selective opioid agonist. However, it can activate other opioid receptors in the body, such as the delta and kappa receptors, producing analgesia. It also activates the Dopamine center of the brain, stimulating relaxation and exhilaration, which is responsible for its high potential for addiction (8).

Indications for fentanyl are as follows:

• Preoperative analgesia
• Anesthesia adjunct
• Regional anesthesia adjunct
• General anesthesia
• Postoperative pain control
• Moderate to severe acute pain (off-label)

Available Forms

• Fentanyl is available in various forms, including:
• transdermal patches
• injectable solutions
• lozenges
• nasal sprays
• oral tablets (8)

Dosing and Monitoring

Fentanyl is metabolized via the CYP3A4 enzyme in the liver. It has a half-life of 3 to 7 hours, and 75% of Fentanyl is excreted in the urine and 9% in feces.

The dosing of fentanyl depends on the route of administration and the patient's needs. For example, transdermal patches are typically applied every 72 hours, while injectable solutions are titrated to achieve the desired analgesic effect. Monitoring should include assessing pain levels, respiratory rate, blood pressure, and sedation scores (8).

Fentanyl is most dosed as follows:

• Post-operative pain control
• 50 to 100 mcg IV/IM every 1 to 2 hours as needed; alternately 0.5 to 1.5 mcg/kg/hour IV as needed. Consider lower dosing in patients 65 and older.

PCA (patient-controlled analgesia): 10 to 20 mcg IV every 6 to 20 minutes as needed; start at the lowest effective dose for the shortest effective duration - refer to institutional protocols (8).

Moderate to severe acute pain (off-label) 1 to 2 mcg/kg/dose intranasally each hour as needed; the maximum dose is 100 mcg. Use the lowest effective dose for the shortest effective duration (8).

Side Effects and Contraindications

Common side effects of fentanyl include:

• respiratory depression
• sedation
• constipation
• nausea
• vomiting
• euphoria
• confusion
• respiratory depression/arrest
• visual disturbances
• dyskinesia
• hallucinations
• delirium
• narcotic ileus
• muscle rigidity
• addiction
• loss of consciousness
• hypotension
• coma
• death (8).

The use of fentanyl is contraindicated in patients in the following situations:

• After operative interventions in the biliary tract, these may slow hepatic elimination of the drug.
• With respiratory depression or obstructive airway diseases (i.e., asthma, COPD, obstructive sleep apnea, obesity hyperventilation, also known as Pickwickian syndrome)
• With liver failure
• With known intolerance to fentanyl or other morphine-like drugs, including codeine or any components in the formulation.
• With known hypersensitivity (i.e., anaphylaxis) or any common drug delivery excipients (i.e., sodium chloride, sodium hydroxide) (8).

Considerations for Nurse Practitioners

Nurse practitioners prescribing fentanyl should thoroughly assess the patient's pain, medical history, and potential risk factors for opioid misuse. They should also educate patients about the proper use, storage, and disposal of fentanyl. It should be used cautiously in patients with respiratory disorders, liver or kidney impairment, or a history of substance abuse. Fentanyl is contraindicated in patients with known hypersensitivity to opioids and those without exposure to opioids.

Alcohol and other drugs, legal or illegal, can exacerbate fentanyl's side effects, creating multi-layered clinical scenarios that can be complex to manage. These substances, taken together, generate undesirable conditions that complicate the patient's prognosis (8).

Hydromorphone

Mechanism of Action and Metabolism

Hydromorphone is a semi-synthetic opioid derived from morphine. It binds to the mu-opioid receptors in the central nervous system. It primarily exerts its analgesic effects by inhibiting the release of neurotransmitters involved in pain transmission, thereby reducing pain perception. Hydromorphone also exerts its effects centrally at the medulla level, leading to respiratory depression and cough suppression (1).

Hydromorphone is indicated for:

• moderate to severe acute pain
• severe chronic pain
• refractory cough suppression (off-label) (1)

Available Forms

Hydromorphone is available in various forms, depending on the patient’s needs and severity of pain.

• immediate-release tablet
• extended release tablets
• oral liquid
• injectable solution
• rectal suppositories

Dosing and Monitoring

The immediate-release oral formulations of hydromorphone have an onset of action within 15 to 30 minutes. Peak levels are typically between 30 and 60 minutes with a half-life of 2 to 3 hours. Hydromorphone is primarily excreted through the urine.

The dosing of hydromorphone should be individualized based on the patient's pain intensity, initiated at the lowest effective dose, and adjusted gradually as needed. Close monitoring of pain relief, adverse effects, and signs of opioid toxicity is essential. Patients should be assessed regularly to ensure they receive adequate pain control without experiencing excessive sedation or respiratory depression.

The following are standard dosages that should only be administered when other opioid and non-opioid options fail.

• Immediate-release oral solutions dosage: 1 mg/1 mLoral tablets are available in 2 mg, 4 mg, and 8 mg.
• Extended-release oral tablets are available in dosages of 8 mg, 12 mg, 16 mg, and 32 mg.
• Injection solutions are available in concentrations of 1 mg/mL, 2 mg/mL, 4 mg/mL, and 10 mg/mL.
• Intravenous solutions are available in strengths of 2 mg/1 mL, 2500 mg/250 mL, ten mg/1 mL, and 500 mg/50 mL.
• Suppositories are formulated at a strength of 3 mg (1).

Side Effects and Contraindications

Hydromorphone has potential adverse effects on several organ systems, including the integumentary, gastrointestinal, neurologic, cardiovascular, endocrine, and respiratory.

Common side effects of hydromorphone include:

• Constipation
• Nausea
• Vomiting
• Dizziness
• Sedation
• respiratory depression
• pruritus
• headache
• Somnolence
• Severe adverse effects of hydromorphone include:
• Hypotension
• Syncope
• adrenal insufficiency
• coma
• raised intracranial pressure.
• seizure
• suicidal thoughts
• apnea
• respiratory depression or arrest
• drug dependence or withdrawal
• neonatal drug withdrawal syndrome
• Hydromorphone is contraindicated in patients with:
• known allergies to the drug, sulfites, or other components of the formulation.
• known hypersensitivity to opioids.
• severe respiratory depression
• paralytic ileus
• acute or severe bronchial asthma (1).

Caution should be exercised in patients with:

• respiratory insufficiency
• head injuries
• increased intracranial pressure.
• liver or kidney impairment.

Considerations for Nurse Practitioners

As nurse practitioners, it is crucial to assess the patient's pain intensity and overall health status before initiating Hydromorphone. Start with the lowest effective dose and titrate carefully for optimal pain control. Regular monitoring for adverse effects, signs of opioid toxicity, and therapeutic response is essential. Educate patients about the potential side effects, proper dosing, and the importance of not exceeding prescribed doses. Additionally, nurse practitioners should be familiar with local regulations and guidelines regarding opioid prescribing and follow appropriate documentation and monitoring practices.

Additional Considerations

In terminal cancer patients, clinicians should not restrain opioid therapy even if signs of respiratory depression become apparent.

Hydromorphone requires careful administration in cases of concurrent psychiatric illness.

Specific Patient Considerations:

• Hepatic impairment and Renal Impairment: Initiate hydromorphone treatment at one-fourth to one-half of the standard starting dosage, depending on the degree of impairment.
• Pregnancy considerations: Hydromorphone can traverse the placental barrier and induce NOWS.
• Breastfeeding considerations: Nonopioid analgesic agents are preferable for breastfeeding women.
• Older patients: hydromorphone is categorized as a potentially inappropriate medication for older adults (1).

Tramadol

Mechanism of Action and Metabolism

Tramadol is a Schedule IV opioid medication with a higher potential for dependency and misuse than non-opioid medications. It binds to opioid receptors in the central nervous system, inhibiting the reuptake of norepinephrine and serotonin. It also has weak mu-opioid receptor agonist activity.

The liver metabolizes tramadol mediated by the cytochrome P450 pathways (particularly CYP2D6) and is mainly excreted through the kidneys.

Tramadol is used for moderate to severe pain.

Available Forms of Tramadol include:

• Immediate-release-typically used for acute pain management.
• Extended-release-used for chronic pain.

Dosing and Monitoring

Tramadol has an oral bioavailability of 68% after a single dose and 90–100% after multiple doses and reaches peak concentrations within 2 hours. Approximately 75% of an oral dose is absorbed, and the half-life of tramadol is 9 hours (18).

Tramadol dosing should be individualized based on the patient's pain severity and response.

The initial dose for adults is usually 50-100 mg orally every 4-6 hours for pain relief. The maximum daily dose is 400 mg for immediate-release formulations and 300 mg for extended-release formulations (18).

It is essential to monitor the patient's pain intensity, response to treatment, and any adverse effects. Regular reassessment and adjustment of the dosage may be necessary.

Side Effects and Contraindications

Tramadol is responsible for severe intoxications leading to consciousness disorder (30%), seizures (15%), agitation (10%), and respiratory depression (5%). The reactions to Tramadol suggest that the decision to prescribe should be carefully considered.

Common Side Effects of Tramadol Include:

• Nausea
• Vomiting
• Dizziness
• Constipation
• Sedation
• Headache
• CNS depression
• Seizure
• Agitation
• Tachycardia
• Hypertension
• reduced appetite
• pruritus and rash
• gastric irritation

Serious side effects include:

• respiratory depression
• serotonin syndrome
• seizures

Contraindications

Tramadol is contraindicated in patients with:

• history of hypersensitivity to opioids
• acute intoxication with alcohol
• opioids, or other psychoactive substances
• Patients who have recently received monoamine oxidase inhibitors (MAOIs)

Additionally, the following can be observed in tramadol intoxication:

• miosis
• respiratory depression
• decreased level of consciousness
• hypertension
• tremor
• irritability
• increased deep tendon reflexes

Poisoning leads to:

• multiple organ failure
• coma
• cardiopulmonary arrest
• death

Considerations for Nurse Practitioners

Tramadol has been increasingly misused with intentional overdoses or intoxications. Suicide attempts were the most common cause of intoxication (52–80%), followed by abuse (18–31%), and unintentional intoxication (1–11%). Chronic tramadol or opioid abuse was reported in 20% of tramadol poisoning cases. Fatal tramadol intoxications are uncommon except when ingested concurrent with depressants, most commonly benzodiazepines and alcohol (18).

Tramadol poisoning can affect multiple organ systems:

• gastrointestinal
• central nervous system: seizure, CNS depression, low-grade coma, anxiety, and over time anoxic brain damage
• Cardiovascular system: palpitation, mild hypertension to life-threatening complications such as cardiopulmonary arrest
• respiratory system
• renal system: renal failure with higher doses of tramadol intoxication
• musculoskeletal system: rhabdomyolysis
• endocrine system: hypoglycemia, serotonin syndrome (18)

Cannabis

Mechanism of Action and Metabolism

Cannabis is classified as a Schedule I status. It contains various cannabinoids, with delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) being the most studied. THC primarily acts on cannabinoid receptors in the brain, producing psychoactive effects, while CBD has more diverse effects on the nervous system. These cannabinoids interact with the endocannabinoid system, modulating neurotransmitter release and influencing various physiological processes (32).

Similar to opioids, cannabinoids are synthesized and released in the body by synapses that act on the cannabinoid receptors present in presynaptic endings (32). They perform the following actions related to analgesia:

• Decrease the release of neurotransmitters.
• Activate descending inhibitory pain pathways.
• Reduce postsynaptic sensitivity and alleviate neural inflammation.
• Modulate CB1 receptors within central nociception processing areas and the spinal cord, resulting in analgesic effects.
• Attenuate inflammation by activating CB2 receptors (32).
• Emerging research shows cannabis is indicated for:
• Migraines
• chronic pain
• back pain
• arthritic pain
• pain associated with cancer and surgery.
• neuropathic pain
• diabetic neuropathic pain when administered early in the disease progression.
• sickle cell disease
• cancer
• inflammatory bowel disease (32)

Available Forms

Cannabis refers to products sourced from the Cannabis sativa plant. There are differences between cannabis, cannabinoids, and cannabidiol (CBD). Cannabinoids are extracted from the cannabis plants. Cannabinoid-based treatments, such as dronabinol and CBD, are typically approved medical interventions for specific indications. THC (9-tetrahydrocannabinol) is the psychoactive component of the cannabis plant. CBD is a non-psychoactive component (32).

Cannabis can be consumed in different forms, each with a different onset and duration. Patients may have individual preferences, including:

• smoking/vaporizing dried flowers.
• consuming edibles
• tinctures or oils
• applying topicals (32)

Dosing and Monitoring

Inhaling marijuana via the lungs by smoking or vaping causes maximum plasma concentration within minutes. Psychiatric effects begin within seconds to a few minutes after inhalation and peak after 15 to 30 minutes. The effect diminishes throughout 2 to 3 hours (32).

Oral ingestion of marijuana causes psychiatric effects that typically occur between 30 and 90 minutes and reach maximum effect after 2 to 3 hours. Ingested marijuana effects last about 4 to 12 hours (32).

Dosing cannabis is challenging due to variations in potency and individual responses. Start with low doses and titrate slowly to achieve the desired effect while minimizing side effects. Regular monitoring is crucial, including assessing symptom relief, adverse effects, and potential drug interactions. Encourage patients to keep a diary to track their cannabis use and its effects (32).

Side Effects and Contraindications

Cannabis can exacerbate mental health conditions such as anxiety and psychosis. Common side effects of cannabis include (32):

• Dizziness
• dry mouth
• increased heart rate
• impaired memory
• psychoactive effects

Contraindications include:

• Pregnancy
• Breastfeeding
• heart disease
• respiratory conditions
• history of substance abuse
• mental health disorders

Case Study

Mary is agreeable to trying an increased dose of Gabapentin. Mary would also like to see a counselor to discuss her past and get help with her anxiety. You made an appointment for Mary to see a Licensed Clinical Social Worker in your clinic.

You read the side effects and warnings for Gabapentin, and it is unsafe to use Gabapentin and Tramadol together since they are both depressants. You order a non-steroidal drug for Mary's somatic knee pain and make a consult for imaging studies on her left knee. You also make a referral to Orthopedics.

You educated Mary about the side effects of Gabapentin and scheduled a follow-up appointment. The day after Mary began her treatment with the increased Gabapentin, you called Mary to follow up on its effect. Mary still has pain, but she is not having any untoward side effects. Gabapentin may not work immediately so you will schedule a follow-up call in 3 days.