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The following course content

Introduction   

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

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

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

What is Implicit Bias?

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

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

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

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

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

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

Implications

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

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

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

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

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

Exploring Areas of Bias

Culture

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

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

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

Maternal Health

One of the more obvious places that implicit bias has tainted the healthcare industry is in maternal health. Repeatedly, statistics show that Black women experience twice the infant mortality rate and nearly four times the maternal mortality rate of non-Hispanic white women during childbirth. Due to this severe prevalence, it is vital that we cover maternal health in this implicit bias training course.

Pregnancy and childbirth are natural processes, but they do come with inherent risks for both the mother and baby; but in a modern society, women should feel comfortable and confident in their care, not scared they won’t be treated properly or not survive. Home births among Black women are on the rise as they seek to avoid the biases of the hospital setting and maintain control over their own experiences (17).  

A few examples that showcase the hesitance a Black woman might have with birthing in a hospital setting might include a lack of health insurance leading to poorer general health before pregnancy, a lack of prenatal care, or a lack of care in the weeks following pregnancy. However, the discrepancies still exist at an alarmingly high rate even when looking at minority women with advanced education and high income, indicating that a more insidious culprit, such as implicit bias, is hugely responsible (17). In order for true change to come, this topic must be addressed in this implicit bias training. A few notes that indicate the prevalence of implicit bias in healthcare throughout history are listed below:  

1. Biological differences between white and black women date back to slavery, including the belief that Black women have fewer nerve endings, thicker skin, and thicker bones and therefore do not feel pain as intensely. This is an entirely false belief. Unfortunately, Black and Hispanic women statistically have their perceived pain rated lower by healthcare professionals and are offered appropriate pain management interventions less often than white peers.  
2. Complaints from minority patients that may indicate red flags for conditions such as preeclampsia or hypertension are often downplayed or ignored by healthcare professionals.  
3. Studies show healthcare professionals may believe minority patients are less capable of adhering to or understanding treatment plans and may explain their care in a condescending tone of voice not used with other patients. For example, one in five Black and Hispanic women report poor treatment during pregnancy and childbirth by healthcare staff. These patients are less likely to feel respected or like a partner in their care and may be non-compliant in treatment recommendations due to feeling this way, however, this just perpetuates the attitudes held by the healthcare providers (17).
   

Reproductive Rights

Branching off of maternal health, is reproductive justice. Biases surrounding the reproductive decisions of women may negatively impact the care they receive when seeking care for contraception or during pregnancy. While some of these inequities may be more profound for women of color, women of all races can be and are affected by biases surrounding reproduction, which is why it is being covered in this implicit bias training course. Examples of ways implicit bias may affect care include:  

Some healthcare professionals may believe there is a “right” time or way to become pregnant and feel pregnancy outside of those qualifiers is undesirable; this can stem from personal or religious beliefs. While healthcare staff are certainly entitled to hold these beliefs in their personal lives, if the resulting implicit biases are left unchecked, they can lead to attitudes and actions that are less compassionate when caring for their clients. Clients may feel shamed or judged during their experiences instead of having their needs addressed (7). Variables that may be perceived as unacceptable or less desirable include: 

• Age during pregnancy. Clinicians may feel differently about pregnant clients who are very young (teenagers) or even those who are in their 40s or 50s (7).  
• Marital status during pregnancy. Healthcare professionals may have beliefs that clients should be married when having children and may have bias against unmarried or single clients (7).  
• Number or spacing of pregnancies. Professionals may hold beliefs about how many pregnancies are acceptable or how far apart they should be and may hold judgment against clients with a large number of children or pregnancies occurring soon after childbirth.  
• Low income and minority women are more likely to report being counseled to limit the number of children they have, as opposed to their white peers (12).  
• Method of conception. Some healthcare professionals may have personal beliefs about how children should be conceived and may have negative opinions about pregnancies resulting from fertility treatments such as IVF or surrogacy (7).  

Personal or religious beliefs about contraception may also cause healthcare professionals to provide less than optimal care to clients seeking methods of birth control. 

• Providers may believe young or unmarried clients should not be given access to contraception  because they do not believe they should be engaging in sexual activity (7). 
• Providers, or even some institutions such as Catholic hospitals, may withhold contraception from clients as they believe it to be immoral to prevent pregnancy. 
• Providers may push certain types or usage of contraception onto clients that they feel should limit the number of children they have, even if this does not align with the desires of the client. This includes the use of permanent contraception such as tubal ligation (12).  
• Providers may provide biased information about types of contraception available, minimizing side effects or pushing for easier, more effective types of contraception (such as IUDs), despite a client’s questions, concerns, or contraindications (12). One study showed Black and Hispanic women felt pressured to accept a certain type of contraception based on effectiveness alone, with little concern to their individual needs or reproductive goals (12).  

Personal or religious beliefs about pregnancy termination may impact the care provided and counsel given to pregnant clients who may wish to consider termination. Providers who disagree with abortion on a personal level may find it difficult to provide clear and unbiased information about all options available to pregnant women or may have a judgmental or uncompassionate attitude when caring for clients who desire or have had an abortion (7).

Case Study

Alexandria is a 22 year old Hispanic woman who has always wanted a big family of 3-5 children. She met her current boyfriend in college when she was 19 and became pregnant shortly afterwards. It was an uneventful pregnancy, and Alexandria had a vaginal delivery to a healthy baby girl at 39 weeks. When that child turned 2, Alexandria and her partner decided they would like to have another baby. At 38 weeks' gestation, Alexandria was at a prenatal appointment when her provider brought up her plans for contraception after the birth. The provider suggested an IUD and stated it could be placed immediately after birth, could be left in for 5 years, and would be 99% effective at preventing pregnancy. Alexandria stated she had an IUD when she was 17 and did not like some of the side effects, mostly abdominal cramping, and that she also might like to have another baby before the 5-year mark. Her doctor stated, “all birth control has side effects, and this one is the most effective. You are so young, do you really want 3 children by age 25 anyway?” 

Where Change is Needed

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

On the individual level, efforts must focus on:  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Introduction

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

The most likely perpetrators for both student nurses and registered nurses were patients. However, physicians and male staff were most likely to be perpetrators of sexual harassment toward registered nurses (2). It is important to remember that sexual harassment is not limited to female registered nurses; male nurses are also at risk of experiencing sexual harassment in the workplace. Our Illinois sexual harassment training for nurses will help prepare you for any unfortunate potential experiences you may have with sexual harassment in your workplace.

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

Why are Nurses Vulnerable to Sexual Harassment?

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

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

What is Sexual Harassment?

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

Listed below are some common examples of potential sexual harassment:

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

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

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

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

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

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

Key Points for Sexual Harassment

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

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

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

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

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

Two Types of Sexual Harassment

Quid pro Quo

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

Hostile Work Environment

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

What Should Nurses Do If They Experience Sexual Harassment?

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

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

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

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

Reporting the issue is the next step.

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

1. Within Your Organization

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

2. Illinois Department of Human Rights

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

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

3. Law Enforcement

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

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

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

5. U.S. Equal Employment Opportunity Commission

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

Illinois Sexual Harassment Training for Nurses – Whistleblower Protections

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

Conclusion

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

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

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

This Illinois Alzheimer's and Dementia Training course is required for nurses who provide healthcare services and have direct patient interaction with indivuduals age 26 and older, as mandated by Public Act 102-0399, 20 ILCS 2105/2105-365.

Many times, individuals, family members, and healthcare workers misinterpret symptoms as they are related to dementia because it can be rather difficult to differentiate what is normal age-related memory loss versus early signs of dementia.  Many of us tend to become more forgetful as we age, and may need a bit longer to remember things, become distracted more easily, or have issues with multi-tasking.  Even though these changes are normal and typically occur during middle age, they can very well become a nuisance and even frustrating at times.  But, how can one know that these are normal and are not an early symptom and determinant of dementia?  For most individuals, these changes are a normal result of aging, but it is important to understand the differences so diagnosis can be accurate and efficient in treating these individuals who are dealing with dementia.  

Introduction   

We should be investing our efforts on observing and reporting any potential signs of underlying dementia.  The state of Illinois aims to improve early diagnosis and management and has implemented this Illinois Alzheimer's and Dementia Training for those caring for patients who are 26 and older. Early diagnosis of dementia leads to more effective treatment options and advanced decision making for interventions needed.  Accurate diagnosis of dementia is the ultimate key to proper treatment and both health care providers and caregivers need to provide empathy in caring with these individuals.  As part of reaching these goals, it will be necessary for all those caring for individuals with dementia to become more knowledgeable about dementia, proper care aspects, and the most effective approaches that need to be used with this vulnerable population.  In doing so, these practices will provide both the support and care needed to successfully care for those with dementia.  

What is Dementia versus Age-Related Memory Loss?

At one point or another in our lives, we have misplaced a set of keys, totally blanked on remembering someone’s name, forgot a phone number, or walked into a room to do or get something and forgot and then began wondering what you went in there for.  Even though memory lapses can be frustrating, most likely they are not cause for concern.  However, age-related memory changes are not the same issue as dementia.   

As one grows older, there are various physiological changes that can cause variations in brain functions that one typically doesn’t even think about.  A few examples of these are the process of the longer duration to both learn and to recall information, one is not as quick as he/she used to be, and it can sometimes take longer to recall events to mind.  Memory lapses typically have little impact on one’s daily activities and one’s ability to do what he/she wants to do.   

Dementia is marked by a persistent and often disabling decline in two or more intellectual abilities such a memory, judgment, language, and abstract thinking.  The chart below compares the normal age-related memory changes to those that may indicate dementia (5): 

Treatment and Care of Alzheimer's Disease

A goal of the Illinois Alzheimer's and Dementia Training is to educate nurses on treatment options for both Alzheimer's Disease and other types of dementia.

Pharmacological Interventions

Even though there is no cure for dementia or any disease-modifying agents that can fully combat Alzheimer’s disease and the related dementias, there are some medications that can assist with slowing down the progression of cognitive loss.  These medications are classified as anti-dementia drugs and can only be prescribed by a medical doctor.  Medications prescribed are given based on the type of dementia characterized by the individual.  It is important to note that the individual may experience side effects as with any medication and the medications used for dementia are typically expensive (4). 

Non-Pharmacological Interventions

There are various therapies used to support those diagnosed with dementia and to aid is assisting the nurses and/or family caregivers who are caring for these individuals.  Not all therapies work for each individual experiencing dementia, and it is important to work together as a team with both medical providers and family members to provide and offer the best individualized solution.  The types of non-pharmacological interventions are as follows (4): 

• Cognitive Stimulation  Therapy (CST) 
• Reminiscence Therapy 
• Validation Therapy 
• Reality Orientation 
• Physical Exercise 
• Multisensory Stimulation: Snoezelen Rooms 
• Aromatherapy 

Cognitive Stimulation Therapy (CST) 

Cognitive Stimulation Therapy is used for those individuals with mild to moderate dementia and the individual is invited to partake in therapeutic sessions with a trained practitioner that specializes in skills related specifically to individuals with dementia.  A session consists of themed activities that are designed to stimulate and engage the individual with dementia.  Some of the themes used may include topics such as money, current affairs, food, and clothing.  The sessions are typically held twice a week, beginning with 14 sessions followed by 24 maintenance sessions.  The key aspects focused on are person-centeredness, involvement, respect, inclusion, fun, choices, the use of reminiscence, and strengthening relationships (4). 

Reminiscence Therapy 

Reminiscence therapy allows a person with dementia to tap into his/her long-term memory and experience past memories that were pleasurable.  With this type of therapy, it has been considered one of the most popular and can be enjoyed by the individual with dementia, health service professionals, and relatives.  The therapy can be completed in several formats using life story work, simple or general reminiscence, and specific or special reminiscence (4).  

Validation Therapy 

Validation therapy attempts to use a practitioner to communicate with the person with dementia by showing empathy with his or her feelings and special meaning is displayed behind the person’s speech and behavior assisting the individual.  Validation therapy aims to validate the individual’s emotions by acknowledging one’s feelings and the aim to make the person with dementia as happy as possible, even though there may be misconceptions and misinterpretations.  It is important to keep in mind that if a demented individual is experiencing delusions or false beliefs which can cause added distress, validation therapy is not the best source of therapy (4).   

Reality Orientation 

With this type of therapy, it helps the individual with dementia by reminding him/her about the present.  Self-identity is reinforced and recognition about one’s surrounding environment is also emphasized.  The different forms used with reality orientation are calendars, reminder boards, and cueing and typically take place in groups or individually.  It is important to be mindful of the fact that the individual may have difficulty remembering current or recent events due to his/her cognitive impairment (4).   

Physical Exercise 

The act of exercising has been shown to benefit people with and without a cognitive impairment and has been found to be extremely beneficial to those who once led a very active life.  It is important to encourage individuals with dementia to participate in some form of physical activity and to make adaptations as needed once dementia progresses.  In formulation exercise programs for these individuals, attention should be given to the individual’s abilities, preferences, interests, and safety needs.  Physical activity has also been recognized for its effects on reducing depressive symptoms and behavioral disturbances such as aggression and agitation (4). 

Multisensory Stimulation: Snoezelen Rooms 

Multisensory stimulation are increasingly being used in long term residential care settings to help individuals with dementia who may be agitated or restless.  A Snoezelen room incorporates multiple sources of stimulation such as light, water color, fiber optics, contrasting textures, quiet music, and soft furnishings.  All of these features are meant to help relax the individual with dementia and can also enhance communication between the individual and his/her caregiver (4).  

Aromatherapy 

Aromatherapy is often used with individuals with dementia and the use of smells, massage, and bathing can stimulate pleasurable emotions for the individual with dementia.  Two of the most commonly used essential oils are lavender and a special type of balm.  Aromatherapy has proven in many trials to produce a decrease in agitation among these individuals with dementia (4). 

Common Types of Dementia

Alzheimer’s Disease  

The individual presents with symptoms such as memory loss and difficulty planning and performing routine tasks.  The symptoms are mild at first but progressively worsen.  Other symptoms noted may be confusion about person, place, and time, difficulty speaking and/or writing, losing things and unable to find them, showing poor judgment, and mood and personality changes (1). 

Vascular Dementia  

Individuals with this type of dementia have typically had a stroke and symptoms depend on which part of the brain is affected by the stroke.  The first signs noted with vascular dementia is poor judgment or difficulty planning, organizing, and making decisions.  Other noted symptoms are memory problems that disrupt the individual’s daily life, difficulty speaking and understanding speech, difficulty recognizing sights and sounds that used to be familiar, becoming confused or agitated easily, changes in mood and personality, and difficulty walking with increased falls (1).   

Dementia with Lewy Bodies (DLB) 

Lewy bodies consist of tiny microscopic deposits of a protein that form in some individual’s brains.  The deposits of the protein develop and form in the part of the brain called the cortex and the symptoms include difficulty thinking clearly, making decisions, or paying attention.  The individual also has problems with memory, experiencing hallucinations, unusual sleepiness during the day, periods of “blanking out” or staring, difficulty with movement including slowness, trouble walking, and the individual may have dreams where he/she acts out physically such as walking, talking, and kicking (1).   

Parkinson’s Disease Dementia 

Studies have shown that individuals with nervous system disorders experience this type of dementia an estimated 50-80% of the time.  Typically, the symptoms of dementia develop approximately ten years after a person is first diagnosed with Parkinson’s (1).   

Frontotemporal Dementia (FTD)  

Individuals with this type of dementia have developed cell damage in areas of the brain that control judgement, planning, emotions, movement, and speech.  These individuals may also experience behavior and personality changes, sudden lack of inhibition in social and personal situations, problems thinking of the correct words when speaking, and movement problems such as shakiness, muscle spasms, and balance problems (1).   

Huntington’s Disease 

In this disease, it is caused by a genetic defect that is typically passed from one family member to another.  The individual may have the gene for this disease at birth, but typically the symptoms do not usually start until the ages of 30-50.  The individual typically has difficulty with thinking and reasoning, memory, judgment, organizing, planning, and concentrating (1). 

Creutzfeldt-Jakob Disease  

In this type of dementia, a protein called prions cause normal proteins in the brain to begin developing into abnormal shapes.  This disease is a rare condition that leads to dementia symptoms that occur suddenly and quickly becomes worse.  The individual may experience memory and concentration problems, poor judgment, mood swings, confusion, sleep problems, depression, trouble walking, and twitching or jerking muscles (1).   

Normal Pressure Hydrocephalus  

A buildup of fluid in the brain is noted in this type of dementia and includes difficulty walking, concentrating, personality, and behavior changes.  In some cases, the extra fluid can be drained from the brain into the abdomen through a long, thin tube called a shunt (1).   

Wernicke-Korsakoff Syndrome 

A severe shortage of thiamin (vitamin B-1) is noted in this type of dementia and is noted most commonly in individuals who are long-term heavy drinkers.  The most common symptom noted is problems with memory, but typically one’s problem-solving and thinking skills are not affected (1).   

Assessment is a crucial factor in determining if dementia is present or if the signs and symptoms are an indicator of normal age-related memory loss.  Assessment is also the first identification to obtain the needed treatment for the individual and to offer services and support to the family members or caregivers.  The Illinois Alzheimer's and Dementia Training was enacted to prepare nurses for the management and care plans for both Alzeheimer's Diseae and the many types of dementia. To be adaquetly prepared, it is important to understand the different types, diagnosies, and care plans of each before implementing treatment.

Health systems are working to improve this area and to recognize the burden that is presented to caregivers caring for those with dementia.  There is a gap between the need for treatment, the active provisions for treatment, and educating families regarding the options that are available for treatment.  Many families seem to feel the burden is too great to care for his/her loved one with dementia independently.  Due to this reason, it is imperative that both physical and emotional support be offered.  Many times, families are not aware of the resources available for this population of individuals and they need assistance and education to evaluate the available options.  All of these factors should encourage the importance of increased support, health, and awareness among this vulnerable population.  

Effective Communication and Management of Care

As part of the Illinois Alzheimer's and Dementia Training, communication strategies are emphasized in order to provide an optimal care plan for patients and their caregivers in order to have the best possible outcomes.

When dealing with Alzheimer’s patients, it is imperative to offer simple, step-by-step instructions, repeat instructions and allow more time for a response, do not talk about the individual as if he/she isn’t there, and do not use “baby talk” or a “baby voice”.  Families and caregivers need to also know that management of care for a loved one with Alzheimer’s will be assisted by a support person such as a nurse, social worker, or other healthcare professional.  It is important that these resources are offered for families/caregivers caring for a loved one with Alzheimer’s.   

Case Study

Dorothy's Story

Dorothy is living with dementia, and has been receiving live-in care support since 2013. Before considering home care, Dorothy’s family was naturally worried about having a stranger in her home.  Their concerns soon lifted after meeting with their local care specialist and talking about what Dorothy needed, such as what food she liked and how having dementia affected her a day-to-day.  This helped us to find Magda, who has fit perfectly into Dorothy’s life. 

Dorothy says, “There really is no place like home, and with Magda’s support I am able to keep in touch with all of my friends and neighbors.  We visit church every week for the Sunday morning service, I can visit the shops and I also take part in a local knitting group. This really is one of the greatest joys of staying in my own home around people I know.” 

By helping her to do the activities that mean most, Magda has made such a difference in Dorothy’s life.  An experienced caregiver with plenty of care knowledge is present and what matters most to Magda is that Dorothy is happy. 

Dorothy says, “Live-in care means friendship, a sense of security and feeling comfortable in my own home. Having previously spent a brief but unhappy period of time in a care home, I am able to recognize how perfect my situation is now. I feel very lucky and comfortable; I have a true friend. Magda is going nowhere! I want this to continue forever” (2). 

Moving Forward: The Future for Individuals with Dementia

With increased awareness among this vulnerable population and the number of individuals diagnosed with dementia, the future for those caring for these individuals proves that advanced care and education needs which have both been a recent focal point have proven successful.  The information below details some highlights for the future that are seemingly optimistic (3):  

• Recent study from 1988 – 2015 has shown a 13 percent decreased per decade in the incidence of dementia in the United States and Europe 
• If trends continue, there could be 15 million fewer people living with dementia in high-income countries by 2040 
• Change is likely linked to increased heath education along with a better understanding of modifiable risk factors, such as diet and exercise 
• Experts stress the need for doctors, health care members, individuals, family members, and caregivers to develop healthy habits to lower one’s risk for developing dementia

Both small and large actions can be taken as a client care health advocate in order for positive results to be obtained.  First, volunteer or assist in a facility that offers services to these individuals, educate yourself and your immediate circle on the facts surrounding dementia, serve as a mentor, and receive the necessary education and training to pursue legislative advocacy.  Throughout the entire process of advocacy, these elements need to remain – confidentiality, purpose, equality, diversity, empowerment, and most importantly treating the individual with dementia with empathy, compassion, and respect.    

The care and treatment for those with dementia and the ones caring for these individuals certainly have the capability of improving if healthcare workers, family members, and caregivers are trained and educated on the symptoms, treatment options, and available resources to assist those caring for these individuals.   

Education is the ongoing key to becoming more aware of proper care and treatment options for individuals with dementia.  Increased knowledge and expertise in this area and serving as an advocate for these individuals by listening and representing the individual’s views must be in place in order for this population to receive the necessary and adequate care they each deserve.  Questions can be asked on the individual’s behalf in order to ascertain that necessary treatment options and support services are being offered.  It is also imperative to use a holistic approach with both the individual and the health care members, caregivers, and family members to maintain open communication, empathy, and compassion while developing the best plan of action for the individual.   

Introduction   

When we talk about culture, we often dive right into how to respectfully care for patients who are different than we are. However, let’s start with a different perspective. Imagine you are transferring to another nursing department/unit in your workplace. What might you expect during the orientation training period? Perhaps learning about the new patient population and their care needs? Maybe identifying where all the supplies and equipment are located? How about getting to know your new boss?

While not always a popular topic during orientation training, acclimating to the culture of the new department/unit is equally important. Many nurses are familiar with the workplace culture, but how might you describe it to someone who doesn’t work at your organization? If a workplace can have a culture, how do we truly define culture? How does this relate to patients?

As of January 1, 2025, all nurses in Illinois (LPN, RN, and APRN) are required to obtain continuing education (CE) training on Cultural Competency. This course will explore the expansive nature of culture and explain how you can use your understanding of culture to be culturally competent as a nurse practicing in Illinois. First, the course will outline the new CE requirement.

Illinois Cultural Competency Continuing Education Requirement

The State of Illinois now requires nurses and other registered/licensed health professionals to engage in continuing education on the topic of Cultural Competency to practice within the state as of January 1, 2025. This section will define terminology within the new law and detail the training requirements.

New Law Terminology

As you continue to read through this section, refer to the definition of the following terms as outlined in the new law: (1) Cultural Competency, (2) Health Professional, and (3) Statutorily Mandated Topics [7].

• Cultural Competency

According to the State of Illinois, cultural competency is “a set of integrated attitudes, knowledge, and skills that enables a health care professional or organization to care effectively for patients from diverse cultures, groups, and communities” [7].

• Health Professional

The new law applies to health care professionals in the state of Illinois, including nurses, medical providers, dentists, pharmacists, clinical psychologists, physical and occupational therapists, respiratory therapists, speech-language pathologists and audiologists, social workers, counselors, behavioral analysts, and nursing home administrators.

• Statutorily Mandated Topics

According to the State of Illinois, statutorily mandated topics are “continuing education training as specified by statute” [7]. These are CE topics in which you must receive training to renew your Illinois nursing license and practice within the state. Examples include Implicit Bias Awareness, Sexual Harassment Prevention, and now, Cultural Competency.

New Law Summary

The new law (Public Act 103-0531) is divided into two parts (Section 2105-370 and Section 2105-375) [7]. Part one details the new training requirements. Part two describes how often the new training must occur. 

• Section 2105-370: “Continuing Education; Cultural Competency”

For healthcare professional license or registration renewals occurring on or after January 1, 2025, a healthcare professional who has continuing education requirements must complete at least a one-hour course in training on cultural competency. A healthcare professional may count this one hour for completion of this course toward meeting the minimum credit hours required for continuing education.

• Section 2105-375: “Limitation on Specific Statutorily Mandated Training Requirements”

Notwithstanding any other provision of law, for health care professional license or registration renewals occurring on or after January 1, 2025, a health care professional whose license or registration renewal occurs every 2 years must complete all statutorily mandated topics within 3 renewal periods.

• • Illinois RN and APRN license renewals occur every 2 years, expiring May 31 of each even-numbered year [8]
  • Illinois LPN license renewal occurs every 2 years, expiring January 31 of each odd-numbered year [8]

Therefore, all nurses in Illinois must complete the Cultural Competency continuing education requirement within 3 renewal periods (or once every 6 years).

What is Culture?

Reflect on the word “culture.” What crosses your mind? Do you think of educational background? How about employment status? While it may be easy for some to think culture only refers to an individual’s ethnic/racial background, culture encompasses much more. Culture is defined as “a set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group” [3].

Culture is an identity and can be expressed in many ways, including [3]: 

• Ethnic/Racial Background 
• Language(s) Spoken 
• Religion and Spiritual Beliefs 
• Gender Identity 
• Socioeconomic Status 
• Age 
• Sexual Orientation 
• Geography 
• Educational Background 
• Life Experiences 
• Living Situation 
• Employment Status 
• Immigration Status 
• Ability/Disability

We can belong to many cultures at once. For this reason, when we ask someone about their culture, the answer can be quite complex. We might have multiple ways in which we culturally identify ourselves and this can change over time as culture is not fixed [3]. Your cultural identity can be ever-evolving. For example, you may adopt other groups’ beliefs or practices over time.

Ethnic/racial background, language, and religious/spiritual beliefs are often primarily associated with culture but as you can see, culture is expansive. Culture can also encompass occupations, hobbies, and interests (although these are often associated with the term subculture – a smaller group within a culture, like the “nursing culture”) [3]. Earlier we talked about workplace culture. This refers to the way you and your peers think and behave at work. Your current workplace culture may have existed for many years before your employment; therefore, these thoughts and behaviors may have been passed down.

As nurses, to truly grasp the concept of Cultural Competency, we must first understand the various expressions of culture so we can ensure our attitudes and behaviors are respectful of all aspects of a patient’s cultural identity. Reflect on the following case scenario.

Case Scenario 

A patient comes to the emergency room with an infected leg wound infection. The patient identifies themselves as part of the nomad community and shares they have been staying in hostels, renting rooms, and staying with family and friends over the past four years. The patient states they have a freelance virtual job, like to travel, and prefers not to have a home of their own. They are currently renting a room in a stranger’s home. The patient developed a chronic wound in the right leg caused by a spider bite that recently became infected. They state, “My room has a spider infestation and isn’t as clean, but it works for me right now.”

Cultural Sensitivity and Cultural Humility

Cultural Competency starts with cultural sensitivity and cultural humility – one is an awareness, and the other is an attitude.

Cultural Sensitivity

First, we must be aware that cultural differences exist in the first place. Then we must know that culture can affect the way we think and behave. The American Nurses Association defines cultural sensitivity as “being aware that cultural differences and similarities exist and affect values, learning, preferences and behaviors” [2][5]. This awareness helps us understand why a patient may respond to care in a particular way.  

For example, a patient may refuse a medical treatment based on a spiritual belief, such as holistic healing. If the nurse is aware that spirituality can play a significant role in a patient’s medical decision-making, the nurse may be more likely to respect the patient’s choice. Cultural sensitivity allows the nurse to respect the patient’s right to autonomy (the right to make their own medical decisions regardless of the nurse’s beliefs).  

Cultural sensitivity also involves how you communicate with patients/families from diverse cultural backgrounds. While your communication (both verbal and body language) may be reflective of your cultural background, it may be considered offensive to some patients. In this case, it’s less about changing who you are and more about being aware that your communication may be insensitive. When communication is not culturally sensitive, the risk of miscommunication increases which may result in adverse events or poor adherence to treatment [Brooks].

Cultural Humility

You may be familiar with some aspects of a patient’s cultural identity, such as sexual orientation, based on past encounters with patients who shared the same identity, personal study about sexual orientations, or personal experiences you may have had outside of the workplace. While knowledge is power, cultural humility is the acknowledgment that you do not know everything about a patient’s culture. 

The American Nurses Association defines cultural humility as “a humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot know everything about other cultures, and approach learning about other cultures as a life-long goal and process” [2][5].  

As mentioned earlier, a patient may hold certain cultural beliefs but adopt other groups’ beliefs and practices as well. You may be unaware of the patient’s evolving cultural beliefs as they are unique to each patient. Additionally, your patient may hold many other cultural identities that you may be unfamiliar with. Culture isn’t a one-size-fits-all all. Think back on the example of the patient who culturally identifies as a nomad. How much do you know about the nomad community? What questions might you have for the patient about their lifestyle? What parts of nomadism are interesting or confusing to you? How might a nurse’s lack of cultural humility influence the care they provide to patients who identify as nomads?

Cultural sensitivity and cultural humility are foundational to cultural competency as a nurse. Knowing everything there is to know about a patient’s culture is not necessary to become culturally competent. Cultural competency is a life-long process and simply being willing to learn and evaluate your own culture and biases is key.

Cultural Demographics in Illinois

As discussed, part of cultural sensitivity is having an awareness of the existence of diverse cultures. To provide culturally sensitive care to patients, nurses must be aware of the various cultures that exist in their area of practice.

Let’s take a look at some cultural demographics in Illinois.

Ethnic/Racial Background [16]:

• White – 76%  
• Hispanic or Latinx – 19%  
• Black or African American – 15%  
• Asian – 6%  
• American Indian and Alaska Native – 1%

Ancestry [15]: 

• German – 17%  
• Irish – 11%  
• English – 7%  
• Polish – 6%  
• Italian – 5%  
• French (except Basque) – 1% 
• Sub-Saharan African – 1%  
• Scottish – 1% 
• Norwegian – 1%

Language(s) Spoken [15]: 

• English – 76% 
• Spanish – 14% 
• Other Indo-European languages – 6% 
• Asian and Pacific Islander languages – 3%  
• Other languages – 1%

Religion and Spiritual Beliefs [11]:

• Feel a sense of spiritual peace and well-being at least several times a year – 80% 
• Feel a sense of wonder about the universe at least several times a year – 73% 
• Participate in meditation at least several times a year – 53% 
• Christian – 71% 
• Agnostic – 4% 
• Atheist – 3% 
• Jewish – 2% 
• Muslim – 1% 
• Buddhist – 1% 
• Hindu – 1%

Age [15][16]: 

• Under age 5 – 5% 
• 5 to 14 years old – 12% 
• 15 to 17 years old – 4%  
• 18 and older – 78%  
• 65 and older – 17%

Sex/Gender [16]: 

• Assigned female at birth – 51% 
• Assigned male at birth – 49%

Sexual Orientation [10]:

• Adult residents who identify as LGBTQ* (Lesbian, Gay, Bisexual, Transgender, Queer) – 4%

Educational Background [15]:

• High school – 25% 
• Some college, no degree – 19% 
• Associates degree – 8% 
• Bachelor’s degree – 23% 
• Graduate or professional degree – 16%

Living Situation [15][16]: 

• Married couple family household – 45% 
• Female householder, no spouse present – 29% 
• Male householder, no spouse present – 19% 
• In poverty – 12%  
• Moved from a different state – 2% 
• Moved from abroad – 1%

Civilian/Veteran Status [15]:

• Veteran – 5%

Employment Status [12][15]:

• Private-owned company workers – 68% 
• Local, state, and federal workers – 13%  
• Private not-for-profit workers – 10%  
• Self-employed – 9%  
• Unemployed – 5%

Ability/Disability [6][15]:

• Have a disability – 12% 
• Have a disability under age 65 – 7%  
• Ambulatory difficulty – 6% 
• Cognitive difficulty – 5% 
• Hearing difficulty – 3% 
• Self-care difficulty – 3% 
• Vision difficulty – 2%

*The “Q” in LGBTQ can also include those who are “questioning.” Additionally, sometimes a “+” is added at the end to include other orientations [3]

As you can see from the statistics, the State of Illinois is culturally diverse. The world as a whole is becoming increasingly diverse. All nurses must be equipped with the tools necessary to provide culturally sensitive care that respects the dignity and human rights of all patients. The first right of the Patient Bill of Rights is the “right to considerate and respectful care” [3].

The Code of Ethics for Nurses and the Standards of Nursing Practice – both developed by the American Nurses Association – also outline the importance of providing care that is respectful of patients’ cultural differences. This care must be bias-free. This is not optional. It is a requirement as long as you hold a nursing license and practice in your state. This is why Cultural Competency training is so important.

Cultural Competency

Now that we have defined culture, reviewed cultural demographics in the State of Illinois, and outlined your responsibility in providing culturally sensitive care, we can bring it all together and apply cultural competency to practice in everyday interactions with patients/families. As mentioned earlier, the State of Illinois defines cultural competency as “a set of integrated attitudes, knowledge, and skills that enables a health care professional or organization to care effectively for patients from diverse cultures, groups, and communities.” Essentially, cultural competency is a skill. Just as you may be competent in starting an IV or placing a urinary catheter, you can be competent in effectively caring for patients from diverse cultural backgrounds.

In this section we will discuss:

• Cultural Influences on Care 
• Culturally Safe Environments 
• Cultural Negotiation 
• Benefits of Cultural Competency

You can also apply the skills you learn in this section to your interactions with your peers/coworkers from diverse cultural backgrounds.

How Culture Influences Care

As aforementioned, cultural sensitivity is an understanding that cultural differences exist and can affect our thoughts and behaviors.

The following are ways a patient’s cultural background may influence their decisions about medical care or treatment [3]:

• Perception of Illness

This may include beliefs about the cause of illness, how diseases are healed or treated, and pain perception.

• Necessity and Type of Medical Care

This can include beliefs about holistic care / alternative medicine versus contemporary medicine, religious restrictions, the necessity of health insurance, or mistrust of the medical field.

• Patient Spokesperson

This might include beliefs about who can speak on behalf of the patient or become the durable power of attorney (i.e., only the patient’s spouse). This can also include the level of family involvement.

• Nutritional Habits

This can include the type of meal (i.e., Kosher, Vegetarian, Vegan, Fasting, etc.), times to eat meals, who prepares the meal, or how the food is prepared (i.e. Halal foods).

Learning about various health-related cultural beliefs can be motivated by cultural knowledge and/or cultural desire. Cultural knowledge refers to the process of seeking out information about cultural health beliefs/values to understand patients better [3]. Cultural desire refers to the internal motivation and commitment to develop cultural awareness [3]. Familiarity with various cultural beliefs surrounding medical care and treatment is highly beneficial as a nurse as it can help you develop and strengthen your level of cultural sensitivity. However, what happens when a patient’s cultural beliefs interfere with care? Reflect on the following case scenario.

Case Scenario

A patient on the medical-surgical unit is recovering from diabetic ketoacidosis. During the assessment, the patient tells the nurse they prefer to eat their own home-prepared meals because the hospital does not have culturally diverse food options on the menu. They state that they asked their family to bring in home-cooked meals instead. The patient describes the type of foods they eat at home, which are very high in carbohydrates. The nurse recognizes the patient’s home-cooked meals do not align with the diet ordered by the provider (carbohydrate-controlled) and may interfere with the patient’s healing process.

To address the scenario, the nurse should:

1. Inquire. Ask the patient if they understand the importance of consuming the ordered diet and how not doing so can negatively affect their health.
2. Teach. Teach the patient about their disease process, the benefits of consuming a carbohydrate-controlled diet, and the risks associated with consuming a high-carbohydrate diet. Patients may not be entirely aware of how their actions may affect their health, so nurses should ensure patients are provided basic education on how to manage their disease effectively. The nurse should also include the family in the teaching session and employ the teach-back method to ensure everyone understands the information.
3. Inform. Speak to the provider about the issue. The provider may speak with the patient as well or consult a specialist, such as a dietician/nutritionist or diabetic educator, to come up with a plan that works best. The nurse should also be aware that a patient’s cultural beliefs can influence their perception of authority figures (note: this awareness is part of cultural sensitivity). The patient may trust advice from a provider over a nurse. The nurse should involve a supervisor and/or ethics committee/representative if needed.
4. Respect. If the patient still chooses against the ordered diet and the nurse has ensured the patient truly understands the benefits and risks of their decision, the nurse should respect the patient’s decision, document the situation, and involve the appropriate team members to keep the patient safe (i.e., delegate to unlicensed assistive personnel to notify the nurse if family members bring in outside food).

Culturally Safe Environments

Part of cultural competency is creating a safe space for patients to share their cultural beliefs without feeling judged. This is referred to as a “culturally safe environment” [3]. In the example above, the nurse can create a culturally safe environment in the inquiry step. Inquiring about the patient’s background, preferences, beliefs, and values surrounding medical care/treatment can make patients feel comfortable sharing as it displays curiosity, interest, and/or concern. Standardized patient admission forms and the patient assessment area of the electronic medical record may include culturally specific questions that can guide the nurse’s inquiry.

Creating a culturally safe environment also involves evaluating your own cultural beliefs and potential biases so that you do not judge patients based on cultural differences. Bias is a human trait stemming from an individual’s personal experiences and need to make sense of the world [14]. It involves both stereotypes (categorizing others by age, gender, ethnicity/race, etc.) and attitudes (positive or negative feelings directed towards others) [14]. You may be aware (explicit) or unaware (implicit) of the biases you may have.

Nurses can challenge themselves by engaging in cultural encounters. A cultural encounter is a process in which you directly engage in face-to-face cultural interactions with patients from culturally diverse backgrounds to change your existing beliefs about a cultural group [3]. This is a self-motivated action to prevent possible stereotyping as biases can inhibit your ability to provide culturally sensitive care.

Cultural Negotiation

Cultural negotiation is the process of coming to a mutual agreement on how to deal with competing interests of the care/treatment plan and the patient’s cultural needs [3]. In the example above, cultural negotiation may occur during the teaching and inform steps. The nurse should attempt to accommodate the patient as much as possible while ensuring the accommodations do not significantly alter the care/treatment plan [3].

Keep in mind that cultural negotiation is a collaborative process. Teamwork between the nurse, the patient, the provider, a supervisor, a dietician/nutritionist, and an ethics committee/representative (if needed) are key. The solution may be to ask the dietary department (with the support of a dietician) to prepare special meals that follow diet order although these food items aren’t listed on the menu. Another solution may be to allow the patient’s family to only bring certain types of home-cooked food items that comply with the diet order, but the food must be brought to the nurse first for confirmation before the patient can consume it. The goal is to “meet the patient halfway” so to speak.

Benefits of Cultural Competency

Now that we have discussed how to apply cultural competency to practice in nursing, we will conclude the course by recognizing your efforts and contributions. Facing your own biases and being open to learning about other cultures is not always an easy task. Your efforts to provide culturally sensitive care increase patient satisfaction and can make them feel considered and respected [4]. This is great, but whether you realize it or not you are making an even greater contribution to patients.

Culturally sensitive care contributes to positive patient outcomes and reduced health disparities [3][4]. Health disparities occur when socially disadvantaged groups experience preventable differences in the burden of disease, injury, violence, or opportunities related to unequal distribution of social, political, economic, and environmental resources [13]. These social disadvantages are based on factors such as poverty, inadequate access to health care, or educational inequalities [13].

Cultural competency is also beneficial for the delivery of high-quality care in today’s diverse complex healthcare system [9]. Culturally sensitive care is by definition a facet of high-quality care. In 2011, the Institute of Medicine (IOM), now the National Academy of Medicine, outlined six domains of quality healthcare.

Health systems nationwide use this six-domain guide as a model to determine if the care they provide is of the highest quality possible. The sixth domain of the IOM’s Six Domains of Healthcare Quality identifies equitable care as high-quality care. The IOM’s definition of equitable care is “care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status” [1].

In summary, the benefits of cultural competency include: 

• Patient satisfaction 
• Positive patient outcomes 
• Reduced health disparities 
• Provision of high-quality care

Conclusion

Cultural Competency training has been shown to improve the knowledge and attitudes of health professionals [9]. Hopefully, this course has broadened your understanding of culture and provided you with tips and tools to challenge your own potential biases, strengthen your level of cultural competence, and effectively care for the residents of Illinois and any other region in which you practice.

Introduction

Flap surgeries can be a critical treatment for various wounds to provide bulk tissue. It is a tad more detailed than skin grafts, as it involves a circulatory supply from a donor site to a recipient site. It is important to recognize what flap surgery entails, the indications, and types of flap surgeries. Nurses should be knowledgeable on care plans and assessment for flap surgery, positioning techniques, patient education topics, and how to identify possible complications such as infection or flap dehiscence. Are you ready to dive into the interesting course topic of flap surgery?

Flap Surgery: What is it?

Flap surgery involves removing healthy, live tissue from one location of the body and transporting it to another area that needs it for healing purposes. Flap surgeries are commonly used to transfer this healthy tissue to areas of lost skin, fat, muscle movement, and/or skeletal support (9). A tissue flap has its own system for vascularization and does not depend on the recipient’s wound bed to perfuse the donor tissue, which differs from non-vascularized skin grafts (8). Essentially, a flap is tissue with a substantiated blood supply that is transferred from a donor site to a recipient site. If the flap surgery was a party, the damaged host site would send out an invite saying “BYOB- Bring Your Own Blood-Supply!”

The flap continues to be fed by the same blood supply from where it was taken, until new blood vessels grow from the recipient site and the wound heals completely. The recipient site is called the primary defect and the wound that is created by cutting, lifting, or sliding the flap to fill the primary defect is called the secondary defect (8). The base, or pedicle, of the flap is the tissue that remains attached to the skin adjacent to the defect, it contains the vascular supply required for initial flap survival (8).

Surgeons have used skin flaps to repair wounds and tissue damage for centuries. The term “flap” was derived from the Dutch word “flappe” during the 16th century (8). Around 700 B.C., the Sushruta Samhita (an ancient text on surgery and medicine) first documented a technique of reconstructing a large nasal tip defect with a flap of cheek tissue (8). New techniques are constantly being developed to meet various needs. Flap surgeries are used for a variety of wounds from pressure ulcers to breast reconstruction following mastectomy.

Types of Flap Surgeries 

Flap surgeries are classified in the following ways: (9) 

• Blood supply  

• Type/composition of tissue  

• Distance of the healthy site from the recipient tissue  

• Locations of donor and recipient tissue 

• Movement 

Figure 1: Classification of Flaps 

Classification by Blood Supply 

Flaps can be named based on the supply of blood. The understanding of the circulation of blood to the donor tissue is critical when describing the type of flap. The terms random and axial are used to categorize the blood supply. 

• Random Flaps 

• Not based on a specific vessel 

• Uses subdermal plexuss (network of blood vessels between the deep reticular portion of the dermis and subcutaneous fat tissue beneath it) (7) 

• Axial Flaps 

• Single, direct cutaneous artery in the axis of the flap 

• Named according to the pathway 

Classification by Tissue Type 

Flaps can be named according to their composition. The tissue composition may be skin, fascia, muscle, bone, nerve, cartilage, or a combination. Fascia is the thin lining of connective tissue that surrounds and holds each blood vessel, bone, nerve fiber, and muscle in place (7). Cutaneous refers to the layers of skin. Pedicle flaps are those that are still attached to the original site and the other end is moved to cover the recipient area; a free flap is an area of tissue completely removed from one part of the body and surgically placed in another area (8). 

Common flaps: (5) 

• Skin Flap: Skin and superficial fascia 

• Fascio-cutaneous Flap: Skin and deeper layer of deep fascia 

• Fascial Flap: Deep fascia only 

• Muscle Flap: Muscle only 

• Myo-cutaneous Flap: Muscle and skin 

• Osteomyocutaneous Flap: Muscle, bone, and skin 

• Bone Flaps: Bone (vascularized) 

• Innervated Flaps: Flaps that contain a motor or sensory nerve and function 

Fascio-cutaneous Flap  

This flap includes the skin, subcutaneous tissue, and the underlying deep fascia (5). The musculocutaneous perforators or direct septocutaneous branches of major arteries act as vascular supply (5). Perforator flaps are named based on their location, arterial supply, or the muscle of origin. The indications for fasciocutaneous flaps are based on its advantages of being more simple, reliable, thin, and easily mobilized (8). These flaps can come from many potential donor sites (8). 

Muscle Flap 

Muscle tissue can be used as donor tissue in flap surgery. Surgeons may utilize the benefits of flap surgery in wound closure following major surgeries. For example, median sternotomy (vertical inline incision through the sternum of the chest) is the most commonly used approach for cardiac surgery (6). Cardiac surgeons face the risk of deep sternal wound infections following surgery, which is associated with significant morbidity and mortality rates. The use of soft tissue flaps for sternal closure is helpful for patients with extensive tissue deficits after debridement (6). It can be used for immediate or delayed closure. Options for donor tissue for sternal flap closure include the pectoralis major, rectus abdominis, and latissimus dorsi muscles, or an omental flap (6).  

Remember, flaps are transplanted with blood supply intact, so it’s important to know the supply. For instance, if tissue from the pectoralis major muscle is used, the nurse must recognize that this muscle’s primary and secondary blood supply is the thoracoacromial artery and perforators from the internal mammary artery (6). 

Musculocutaneous Flap 

This type of flap, which includes muscle and skin layers, is often used when the area to be covered needs more bulk and an increased blood supply. Musculocutaneous flap surgery is frequently used to rebuild a breast after a mastectomy (5). 

Bone Flap 

A bone flap is comprised of bone with a vascular supply. An example of this flap surgery is for a surgical site infection (SSI) following a craniotomy; in this procedure, operative debridement occurs, and the bone flap is removed, cleaned, and replaced (4). An alternate therapy for this is titanium cranioplasty (implant instead of native bone flap), which has similar outcomes. 

Classification by Location and Movement 

• Local flap: Donor tissue is located next to the area receiving the tissue; the skin remains attached at one end to allow the blood supply to be left intact (5). 

• Regional flap: Donor tissue is a section that is attached by a specific blood vessel.  

• Distant flap: Donor and recipient tissues are distally located from each other. This flap surgery involves detaching and reattaching skin and blood vessels from one site of the body to another site; microsurgery is used to connect the blood vessels (5).  

Figure 2: Example of Flap Type 

The movement of the flap is also used to describe flap surgery. You may hear terms such as advancement, sliding, rotation, and pivotal. Sliding flaps is when the tissue is moved or "slid" directly into the adjacent defect without "jumping" over other tissue (5).  Advancement flaps are considered simple movements for local flaps and fall within the group of sliding flaps. Pivotal (geometric) flaps include rotation, transposition, and interpolation (5). Local, random pattern flaps are common for the reconstruction of cutaneous defects. 

Image 1: Image of a local flap surgical procedure to cover nasal tip defect/wound (9) 

Indications for Surgery 

There is an incredible breadth of possibilities for flap reconstructive surgery, from small, skin-only defects to large, multi-tissue defects. There is a wide range of etiologies, such as traumatic, oncological, and congenital (9). The transferred tissue flap can contain multiple types of tissue, including skin, muscle, nerve, fascia, and bone (9). The larger the volume of tissue transferred, the greater the need for perfusion. A common indication is the need for a large bulk of tissue. Flaps are helpful when wounds are large, complex, or need large amounts of tissue for closure.  

General Indications: 

• Protection of the greater vessels 

• Correction of congenital defect 

• Abdominal wall reconstruction 

• Deep, gaping wounds 

• Reconstruction after tumor excision 

• Trauma 

• Debridement procedure to remove infected or necrotic tissue 

• Venous ulcers (non-healing) 

• Pressure ulcers (non-healing) 

• Breast reconstruction 

• Rhinoplasty 

• Scar Revision 

• Skin Cancer 

• Burns 

Each type of wound has unique indications. Commonly, skin flap surgery is required when a wound is too big for the edges to be brought together directly, so the flap covers the area and depth of the wound (10).

Risks versus Benefits 

Flap survival depends on factors of blood flow, angiogenesis (formation of new blood cells), vascularization, edema, wound closure tension, postoperative complications (hematoma/seromas) and infection (8). Before the initial incision, the flap is fully vascularized and viable, but once the flap is raised, it is immediately ischemic. The tissue can survive up to 12 to 13 hours of avascularity at 37°F and many research studies have proven it is viable even longer (8). This time is invaluable to preserve the tissue. Sufficient blood flow through attachment of the base of the flap is essential in the initial 24 to 48 hours after surgery (8). There is a risk for loss of tissue with no meaningful contribution to the needed area, along with a new wound. This risk reminds me of a neighbor who once removed carpet from a closet to patch carpet in a bedroom, only to find the cutting was too small and they were left with two gaping carpet holes.  

There is also risk for bleeding, infection, or necrosis at both sites. A recent study found that more than 27% of patients will experience a minor complication (wound dehiscence, infection, fistula, and donor-site problems) after surgery, and 6% of patients will suffer a major complication (flap failure, pneumonia, and cerebrovascular accidents) following surgery (11). Chronic flap complications can also be aesthetic in nature; include scarring, contracture, color/texture mismatch, and lack of hair growth. Patients may experience pain or numbness at the sites on a chronic basis as well (9). 

Most flap surgeries are considered safe with a low complication rate, and surgeons report that flap surgery is not avoidable in certain circumstances. However, the surgery preparation itself and anesthesia presents considerations for elderly patients or those with heart disease, uncontrolled diabetes, smokers, or bleeding disorders (2). Nutrition is a key factor in these surgical procedures. Poor nutritional status has been linked with a greater incident of negative outcomes (11). The healthier the patient is before surgery increases, the chances of reduced complications, so glucose control and weight management are examples of risk reduction strategies. 

Preparing for Surgery 

Patients undergoing flap surgery need an abundance of education on what to expect throughout this procedure. There are many opportunities to optimize patient outcomes before going to the operating room. Preoperative education, for example, has been suggested to have an important, positive effect on clinical outcomes (11). Many patients are also experiencing other issues, such as cancer diagnoses, poor circulation, comorbidities, bed sores, among others. Taking time to holistically prepare each patient is essential.  

Addressing Comorbidities and Other Conditions 

Multiple studies have found an increased surgical complication rate in patients with diabetes mellitus, older age, female gender, malnutrition, anemia, and nicotine intake (11). Prior to surgery, the goal is to improve and optimize the modifiable conditions as much as possible, for instance, reduction in nicotine or improvement in glucose control and anemia. Further, patients with advanced cancer can have hypothyroidism affecting postoperative healing if left uncorrected (11). Non-modifiable factors such as a history of radiotherapy, age, advanced cancer stage, or chronic kidney disease, cannot be altered prior to surgery, but can guide care planning and education following the surgery. 

Adequate nutrition before and after flap surgery has been demonstrated in numerous studies to improve outcomes. An estimated 35% of patients with head and neck cancers present in a state of malnutrition, and the Enhanced Recovery After Surgery (ERAS) Society recommends that all patients undergo a comprehensive preoperative nutritional assessment and consult with nutritionist (11). Improved nutrition status can hopefully yield enhanced wound healing problems and reduction in risk of infection. 

Lab assessment is key to preparation before flap surgery. An example is assessment for anemia prior to surgery. Patients who are anemic at the time of free flap surgery have been found to have poor outcomes (11). Remember, hemoglobin transporting the oxygen to the sites of flap insertion and removal is vital to the survival of the flap. Preoperative hemoglobin values below 10 g/dL have historically been a significant predictor of flap failure and thrombosis (11). A hematocrit level of 30 to 40% with normovolemic hemodilution is ideal to optimize patient outcomes.  

Blood transfusions during or following surgery impacts flap success as well.  Transfusion can increase blood viscosity and immunosuppression, thus leading to decreased blood flow and flap compromise from poor perfusion (11). Studies also show a link between blood transfusions and increased wound infections (11). Steps and treatments should be taken prior to surgery to improve anemia or blood component abnormalities to give these patients a greater chance for successful flap surgery. 

Preoperative considerations should include: (9) 

• Patient age  

• Diabetes status 

• Smoking history 

• Atherosclerosis 

• Peripheral vascular disease 

• Steroid use 

• Previous surgeries 

• The extent and location of the defect 

Providing Preoperative Instructions 

A lack of education, difficulty in understanding complex medical information, fear and anxiety about the surgery, and language barriers are some of the challenges a patient for surgery may have. Patients may also have limited access to reliable health resources or be unable to recall important information due to stress or preoperative medications. As a result, they may not be fully informed about the surgical process, potential risks, and postoperative care.  

Preoperative education list: 

• Assess the patient’s level of understanding. 

• Each facility should have a preoperative teaching program with specific content on surgery, but you must assess if the patient understands this information. 

• Review specific pathology and anticipated surgical procedure.  

• Verify that consent has been obtained / signed. 

• Informed surgical choices and consent for the procedure is required, not only a signature. 

• Use resource teaching materials, and audiovisuals as available on flap surgery and implement an individualized preoperative teaching plan.  

• Preoperative or postoperative procedures and expectations, output (urinary and bowel) changes to expect following surgery, dietary considerations, anticipated intravenous (IV) lines and tubes (nasogastric [NG] tubes, drains, and catheters). 

• Preoperative instructions: NPO guidance prior to surgery, shower or skin preparation, medications to take and hold, prophylactic antibiotics or anticoagulants, anesthesia premedication. 

• Discuss postoperative pain management plan and options.   

• Some patients may expect to be pain-free or are hesitant to take narcotic agents. 

• Provide education and encourage practice of coughing and deep breathing. 

• Confirm and recheck the surgery schedule, patient identification band, chart, and signed operative consent for the surgical procedure. 

• Offer pastoral spiritual care or counseling. 

Post-Operative Considerations 

This section will cover assessment, drains, positioning, and negative pressure wound therapy during the post-operative period. 

Assessment 

Frequent monitoring of free flaps in the acute postoperative period is important. It is strongly recommended that flap assessments are performed at least hourly for the first 24 hours postoperatively, then continued at a reduced increment for the duration of the patient's hospitalization (11). Each facility should have standing orders for flap assessment based on the directive of the surgeon or regulatory body.  

In addition to conventional assessments of flaps (physical exam of flap warmth, turgor, capillary refill, color, and Doppler assessment of the vascular pedicle), many adjuncts have been developed including implantable Dopplers to assess blood flow (11). Assessments should include a head-to-toe physical assessment and a focused wound assessment. A focused cardiovascular (circulation and perfusion) and integumentary assessment is appropriate. Review of lab work indicative of healing status, hemodynamics, and infection should be a priority. Standard post-operative assessments following anesthesia, such as respiratory and orientation, should be performed according to facility protocol. 

Assess circulation of the flap: 

• Color of the flap (dusky, blue, pink, pale) 

• Warmth 

• Dry/Intact? Leaking Fluids? 

• Changes in size 

• Edema 

• Indications of hematoma (sutures over the flap pulling apart, or palpable crepitus beneath the skin) 

Assess amount and type of exudate (drainage): (3) 

• Amount (scant, small/minimal, moderate, or large/copious)  

• Color and thickness: (7) 

• Sanguineous: fresh bleeding  

• Serous: clear, thin, watery plasma 

• Serosanguinous: serous drainage with small amounts of blood noted 

• Purulent: thick and opaque; color can be tan, yellow, green, or brown (this is an abnormal finding and should be reported to physician or wound care provider) 

Use of Doppler to assess deeper circulation of flap: (11) 

• Color duplex ultrasound 

• Near-infrared spectroscopy 

• LASER Doppler flowmetry 

• Implantable Doppler (useful for buried flaps) 

Assess circulation distal to the flap: 

• Capillary refill 

• Color  

• Temperature 

• Pulses  

• Edema 

Drains 

Drains may be used for removal of fluid around both the donor and recipient surgical areas to enhance healing (7). 

Patients may have the following drains after flap surgery: 

• Jackson Pratt (JP) drains 

• JP drains are closed-suction devices that remove fluids from the surgical sites. 

• JP drains contain a flexible bulb that has a plug that can be opened to remove collected fluid.  

• Each time fluid is removed from the JP drain, the nurse should squeeze the air out of the bulb and replace the plug before releasing the bulb.  

• This suction creates a vacuum that pulls fluid into the drainage tubing and bulb. 

• Penrose drains: 

• A Penrose drain is a soft, flexible tube inserted into the surgical site that drains fluid away from the wound bed (7).  

• Nurses should assess the drain and express fluid when appropriate to prevent accumulation. 

Positioning 

The goal of positioning following flap surgery is to promote and improve tissue perfusion. Positioning and elevation of the flap recipient will promote venous return and reduce fluid accumulation to improve tissue perfusion. Activity, exercise, and repositioning improve tissue perfusion. Massage of the erythematous area is avoided because damage to the capillaries and deep tissue may occur (10). Patients should never lay on the wound and extremities should never “dangle” (if the donor or recipient site is on the extremities). Positioning may require creativity when there are multiple drains, NG tube, wound therapy devices, IV tubes, and multiple dressings. Positioning should be free of restrictive clothing and flap sites should be visible for assessment of dressings. It is imperative for the surrounding skin to be sanitary and free of debris.  

Negative Pressure Wound Therapy 

Negative pressure wound therapy (NPWT) is typically used for soft-tissue salvage after the development of complications after flap surgery. For example, NPWT may be applied if an infection occurs in the donor or recipient flap. Immediate postoperative application of NPWT over the flap coverage is not as common (2). However, nurses should be aware of this treatment, the application, and its mechanisms of action. 

NPWT is also known as a wound vac. NPWT uses 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 systems consist of a sterile foam sponge applied to the wound bed, a semi-occlusive adhesive cover, a fluid collection system or cannister, and the suction pump (1). The foam sponge is applied to the wound and covered. A fenestrated tube is embedded in the foam, 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). 

Figure 3. Negative Pressure Wound Therapy Visual 

Home Care and Patient Education 

Educating clients and caregivers about wound care and skin integrity empowers them to actively care for their flap sites. With proper wound cleaning, dressing changes, and preventive measures, individuals can confidently perform their own self-care and enhance the healing process. The use of pamphlets, printouts, websites, and referrals to specialists will give the patients a stronger foundation of knowledge. 

• Wound Assessment  

• Teach the patient and caregiver about skin and wound assessment, ways to monitor for signs and symptoms of infection, complications, and proper healing. 

• Signs of Infection 

• Signs of a localized wound infection include redness, warmth, tenderness, and abnormal purulent drainage around the wound. 

• Importance of proper nutrition, hydration, and methods to maintain tissue integrity 

• Adequate caloric intake and balance of protein and essential vitamins has been shown to improve the healing of flaps (3). 

• Dressing changes, wound cleansing, and hand hygiene 

• Methods to prevent skin breakdown 

• The flap surgery is often for the treatment of a deep pressure wound, so education is needed on impaired skin integrity due to friction. 

• Common areas: Sacrum, heels, elbows. 

• Avoidance of raising the head of bed often, causing weight to be applied to sacrum. 

• Importance of turning, mobility, and ambulation 

• Pain management 

• Medications 

• Heat/cold therapy applications and precautions 

• Negative Pressure Wound Therapy devices (wound vac) 

• Home healthcare is applicable for these devices and should be changed by a certified individual, but patients should be aware of basic care and troubleshooting. 

• Drain maintenance 

• Showering restrictions 

• Reduction of stress and tension at wound site 

• Avoid constipation, strenuous movements, and lifting 

• Restrictions vary for location of flaps and per surgeon instructions 

• Follow-up appointments 

Flap Dehiscence or Loss 

Flap dehiscence is a complication in which the incision made to either the donor or recipient site reopens. A flap loss refers to the flap not re-establishing blood flow and surviving, leading to necrosis of the tissue. As we mentioned earlier, the survival of the flap is impacted by blood flow, new vascularization and tissue formation, edema, wound closure tension, postoperative complications (hematoma/seromas), and infection (8).   

Prevention Strategies 

Nurses should apply their basic knowledge on causes of wound dehiscence. Factors that influence dehiscence risk include the ability to synthesize collagen, strength of suture material, closure technique, and stress on the incision, such as coughing, strenuous movement, or obesity (7). Consider areas that have greater stress and tension, such as the abdomen. Dehiscence is most common following abdominal flap surgeries (7). NPWT has been shown to be a great preventative measure for wound dehiscence as studies found a roughly 50% reduction in stress and tension at the incision site with its use (7). This reduction in stress is attributed to the reduction in subcutaneous fluid accumulation and enhanced healing time.  

The location of the flap surgical sites will impact prevention. For example, immobilization and stabilization devices are unique to sites such as the abdomen, chest, extremities, and sacral region. Infection prevention measures for wounds are essential for nursing care. Incisions from flap procedures also have a higher chance of opening if the wound becomes infected (7). Prevention of hematomas is also meaningful, including the use of blood thinners. However, the safety precautions for blood thinners is different for each client. 

Management and Treatment 

It is estimated that 80% of free flaps can be salvaged if dehiscence or compromise is recognized early enough (11). As we mentioned, it is more common for flaps that are removed from (or applied to) the abdomen to open. The following terms describe the depth: 

• Superficial dehiscence: the skin wound alone opens, but the rectus sheath remains intact. 

• Full thickness dehiscence: the rectus sheath fails to heal and “bursts,” with protrusion of abdominal content. 

• This commonly occurs secondarily to intra-abdominal pressure (example: ileus) or poor surgical technique. 

The treatments for flap compromise will be determined by the provider once a cause is identified. Treatment may be a return to the operating room for additional surgical intervention or a simple evacuation of hematoma through suctioning.  

Recovery 

The focus of recovery is the healing and thriving of the flap site and surgical wounds. The time of flap healing varies, and some may heal much quicker than others. There are four phases of wound healing to recognize: hemostasis, inflammatory, proliferative, and maturation (7). 

• Hemostasis. This phase begins immediately after surgery when platelets release growth factors that alert various cells to start the repair process.  

• Inflammatory. This process involves vasodilation so that white blood cells in the bloodstream can move into the wound to begin cleaning the wound bed. Signs include edema and erythema.  

• Proliferative. This phase generally begins a few days after the injury and includes capillary repair and growth, granulation tissue formation, collagen formation, and wound contraction (7). 

• Maturation. During this phase, collagen continues to be created to strengthen the wound and fill in the wound gaps. 

The healing process can be enhanced in many ways, including nutrition therapy, topical agents, compression therapy, and hyperbaric oxygen therapy (HBOT). The recovery process for flap surgery will include management of pain and discomfort, disturbance of body image, impaired skin integrity, swelling, bruising, and gastrointestinal upset.  

Outcomes for recovery should be measurable and achievable. Each patient will have unique recovery goals, integrating comorbidities and psychosocial aspects.  

Examples of Patient Outcomes following flap surgery: (3) 

• Patient safety: Patient will be able to attain safety by maintaining intra- and extra-cellular environment. 

• Healing of wounds: Wounds should heal properly, complications will be prevented or maintained 

• Management of pain 

• Prevention of further damage or skin breakdown 

Conclusion

As discussed throughout this course on flap surgery, nurses are a key team member in the care and survival of flaps. Hopefully you now understand what flap surgery is, the indications, and types of flap surgeries. Critical knowledge includes pertinent assessment, drain or NPWT management, patient teaching, and prevention and management of possible complications.

Introduction   

Diabetic ketoacidosis is considered one of the most life-threatening complications of diabetes mellitus. More importantly, it is also one of the most preventable complications of diabetes. Through proper education and empowerment of persons with diabetes to self-manage this chronic medication condition, the overall mortality rates associated with this complication have steadily declined in the United States. An interdisciplinary team approach (including medical providers, social workers, case managers, and community resources) has been proven to reduce recurrences of DKA in vulnerable populations. (2)

Definition

DKA, or diabetic ketoacidosis, is defined as the potentially life-threatening medical condition that occurs in people with diabetes. While it usually occurs in persons with type 1 diabetes mellitus, who are dependent on daily insulin injections, it may also occur in individuals with type 2 diabetes for a variety of reasons (underlying physiologic stress, such as an acute infection or trauma, or uncontrolled blood glucose levels and missed routine diabetic medications).

In an acute case of diabetic ketoacidosis, the body is not producing enough insulin to move glucose into the cell for energy, and the liver then begins to break down fat for fuel instead, producing ketones. This buildup of ketones in the body results in ketoacidosis. Left untreated, diabetic ketoacidosis can lead to a diabetic coma and eventual death. (3)

Epidemiology

Epidemiology is the study of how often a disease process occurs in different populations. By studying the rates of occurrence, epidemiologists are able to evaluate treatment options and develop long term strategies to lower the risk of ongoing or recurrent disease related episodes.

Diabetic ketoacidosis is currently a leading cause of both morbidity and mortality in children with Type 1 diabetes. It usually occurs at the time of the initial diagnosis in as much as 30-40 percent of the children in the United States alone. In children living with a confirmed Type 1 diabetes condition (previously diagnosed), these percentages decrease to average rates of 6-8 percent annually.

The drastic reduction of such occurrences is believed to be directly related to ongoing patient and family education and medication adherence. Diabetic ketoacidosis is potentially life-threatening, but it is for the most part, also preventable. Throughout this educational offering, key components of patient education in diabetic self-management, including reducing the risk of diabetic ketoacidosis, will be discussed (4) (5).

By comparison, other countries, challenged by annual income, healthcare access, cost management, and food insecurity, do not fare so well. Various studies were funded by the Leona M. and Harry B. Helmsley Charitable Trust, and the Juvenile Diabetes Research Foundation Ltd. Several countries included in these studies were deemed “LLMIC” (low and low middle-income countries). Countries, including Haiti, Ethiopia, Senegal, Nepal, and Tanzania, to name a few were found to have inadequate supplies, medications, and equipment to both initially diagnose, and successfully manage diabetes mellitus long term. Critical items necessary for the treatment and stabilization of acute diabetic ketoacidosis were in even shorter supply. These barriers to treatment resulted in delayed or missed diagnosis, increased overall complication rates and premature deaths.

“Evidence from single-center studies suggest that DKA in new-onset T1D is more common in LLMICs compared to upper and upper-middle income countries, with rates ranging from 62.2 to 77.1% in Nigeria, 69.8% in South Africa, and 92.1% in Sudan. In comparison, in upper and upper-middle income countries in North America and Europe the rates range from 14.7% (Denmark) to 42.0% (France”). (6)

Ongoing education of healthcare professionals and patients/families alike, coupled with availability of and easy access to self-management medications, and monitoring equipment, positively affect DKA related health outcomes and quality of health and well-being.

The development of insulin delivery systems (insulin pumps) has further positively impacted the rate of DKA occurrence. Patient comfort, ongoing education, streamlined medication delivery and enhanced monitoring systems have afforded patients with diabetes a better understanding of their condition and empowered them to successfully self-manage their health conditions. While reported rates of DKA in previously diagnosed persons with T1DM were 6.3% in one study, that number decreased to 2.2% at 3 years out.

Ongoing improvements in closed insulin delivery systems medication continues to improve (lower) DKA occurrence rates, when compared to those previously using multiple daily injection therapy. The development of continuous glucose monitoring (CGM) devices, in addition to insulin delivery systems, provides for early detection and treatment of both hypoglycemia and hyperglycemia. The addition of remote app devices further allows constant monitoring and two-way communication between patients, family members, and even healthcare providers.

Sadly, the population identified as being at highest risk for DKA is that of children who are uninsured/underinsured, lacking the insurance coverage for many closed delivery medication systems as well as specialty care (pediatric endocrinology) provider access.

The acute complications associated with DKA account for a high percentage of premature deaths in T1DM patients under the age of 30 years old. (7) Given these statistics of prevalence and incident rates, DKA is an ever-increasing global concern which is best addressed and managed through ongoing, patient specific disease management education.

The prognosis for DKA worsens in the presence of coma, hypotension and in the presence of severe (chronic and acute) comorbidities. Yet, with early identification, ongoing education, and improved glucose monitoring/treatment options, DKA, often life threatening, is also highly preventable. The goal, therefore, is to ensure all patients with diabetes mellitus are given equal opportunity to access both the education and materials necessary to successfully monitor their health condition. (8)

Pathophysiology

Diabetic ketoacidosis occurs when the body is under stress and responds with an increase in catecholamines, cortisol and growth hormones. The release of such hormones decreases the ability of insulin, further increasing insulin resistance and resulting in serum hyperglycemia. Without cellular glucose for energy the body then begins to break down fat and protein for energy, resulting in increased levels of serum ketones. The combination of hyperglycemia and ketosis, as well as dehydration and various electrolyte imbalances, form the basis of diabetic ketoacidosis. (9)

While it is believed that the omission of insulin (nonadherence/ noncompliance, or mechanical failure of insulin delivery systems) accounts for the largest percentage of DKA admissions, other factors may be responsible for the development of this condition. Any disease process that increases insulin resistance, impairs insulin secretion, or interferes with carbohydrate metabolism may contribute to the onset of acute diabetic ketoacidosis in a vulnerable, health compromised patient.

Clinical Signs and Symptoms

Diabetic ketoacidosis is caused by the underlying presence of hyperglycemia, ketoacidosis and ketonuria. Early signs and symptoms may include any of the following:

• Generalized weakness and fatigue.
• Nausea and vomiting
• Diffuse abdominal pain.
• Decreased appetite and anorexia.
• Decreased/ altered levels of consciousness, such as mild disorientation and confusion.
• Dry skin and mucus membranes and decreased perspiration
• Tachycardia (increased heart rate) and tachypnea (increased respiratory rate)
• Acetone/ketone smell on breath
• Significant weight loss (usually a rapid onset in the newly diagnosed Type 1 diabetes mellitus patients)
• A patient history of noncompliance with prescribed insulin therapy (due to coexisting medical issues in which patient may have intentionally stopped insulin due to decreased food/fluid intake), costs factors (unable to afford prescribed therapy) and missed insulin doses (mechanical failure of the patient’s current insulin delivery system).

Additional signs and symptoms may be present, related to the patient’s age. While an adult patient would be able to verbalize symptoms, a child may not be able to do so, especially in cases where the diagnosis of T1DM is done during their initial presentation to an emergency department for suspected DKA.

In all cases, there may be other factors (illness, injury, medication side effects) that cause DKA to occur; thus, thorough examination and diagnostic testing must be done in all cases prior to initiation of treatment. Likewise, discharge planning and ongoing follow-up care must be patient specific to address behaviors and treatments required for optimal health maintenance.

Teens/Young Adults

In the teenager/ young adult population, the following symptoms may occur: (11)

• Increases in urination, thirst, and appetite.
• Unintentional/ unexplained weight loss despite increases in food and fluid intake.
• Changes in energy level (increased fatigue)
• Vision changes

Please note that normal growth and development stages/patterns in a teenager/young adult will influence glucose metabolism (related to hormone levels).

Young Children

In the young children’s population, symptoms usually strike suddenly and, unlike the adult population, are usually not related to a specific lifestyle or dietary practice. Most children present with the following symptoms:

• Increased urination
• Increased thirst
• Fatigue
• Vision problems (blurred vision)
• Acetone/ketone “fruity smell” on breath
• Unexplained weight loss, often despite appearing to eat (and drink) more.
• Changes in mood and behavior

Infants/Toddlers

In the infant/toddler population, symptoms may present as follows:

• Increased food and fluid intake (always appearing thirsty despite normal fluid intake)
• Frequent urination (in the potty-trained child, this may present as a new onset of bed wetting behaviors)
• Increasing fatigue and changes in normal activity levels
• Unexplained weight loss despite increased food and fluid intake
• Increased occurrences in diaper rashes (suspected increase in yeast infection)
• Fruity/acetone smell to breath
• Unusual behavior (child specific)

Etiology

Etiology: Causes of Diabetic Ketoacidosis

Hyperglycemia and low insulin levels lead to diabetic ketoacidosis. Common causes include the following:

• Acute illness, altering a person’s intake of food or drink, makes glucose management more difficult. This is a two-fold situation. The person with diabetes, recognizing the change in their normal food/fluid intake may also choose to intentionally decrease/skip their routine diabetic medications to avoid episodes of hypoglycemia.
• Insufficient levels of insulin due to the demands of normal growth and development patterns in children and young adults.
• Missed insulin doses (intentional decision to take inadequate doses, inadvertently held doses, inaccurate dose amounts, clogged insulin pump tubing).

Other causes of DKA, unrelated to insulin dose administration, are thought to be related to increased stress levels (inflammation/ infection) and normal hormone disruption, physiologic stressors. Persons with Type 2 diabetes may experience DKA due to prolonged, untreated hyperglycemia. (12), (13)

• Myocardial infarction
• Neurological stroke
• Motor vehicle accident with physical injuries (inflammatory response to blunt force/penetrating trauma)
• Abuse of alcohol and illegal drugs
• Medication side effects (diuretic and corticosteroid *use) see below
• Severe or prolonged illness (such as pneumonia and urinary tract infection/ urosepsis/wound infections)

Etiology: Precipitating Factors

Common precipitating factors for diabetic ketoacidosis include the following (14):

• Poor compliance with prescribed insulin therapy (intentional, nonintentional)
• Infections (especially T2DM in the elderly/ adult population)
• Newly diagnosed diabetes (especially T1DM in the pediatric/juvenile population)
• Physiologic based stressors, including coronary syndrome, cerebral vascular accidents, ischemic injuries, shock like states, chronic alcoholism, illicit drug use and certain antipsychotic medications.

Etiology: Diabetic Ketoacidosis and Corticosteroid Use

Diabetic ketoacidosis is related to long term corticosteroid usage. yperglycemia has been reported in a large percentage of patients who are using corticosteroids long term, often as high as “64-71%”. The elevated glucose levels combined with the ongoing physiologic stressors warranting use of these medications, increases the risk of DKA. The benefit/risk of using these medications long term must be assessed, especially in patients with pre-existing metabolic risk factors. Ongoing patient monitoring is essential to lower the risk of long-term complications. (15) (16).

Risk factors that “may” increase the likelihood of developing type 2 diabetes after long term steroid usage include the following:

• Overweight (BMI 25.0 -29.9 percent) / obesity (BMI 30 percent or above)
• History of gestational diabetes
• History of polycystic ovarian syndrome
• History of family members with type 2 diabetes

Treatment

Emergency Treatment

The initial or emergency treatment of diabetic ketoacidosis may require complex, frequent monitoring, often necessitating an intensive care admission. The following generic guidelines refer to intensive care nursing management. Please refer to your specific organization for nursing protocols related to DKA management. Many facilities have strict admission guidelines to ensure the appropriate use of intensive care resources. With respect to patients with DKA, suitable ICU admissions may include the following:

• A newly diagnosed diabetic during an episode of DKA
• Any infectious disease condition that triggers an episode of DKA
• An episode of DKA occurring concurrently with a physiologic stressor event (acute myocardial infarction, cerebrovascular accident/stroke)

The goals of emergency treatment of diabetic ketoacidosis are multifactorial and listed below. Interventions will include, but not be limited to, insulin intravenous infusions, hourly vital sign monitoring (or more frequent), and hourly glucose checks.

• Treatment/correction of dehydration with IV fluids
• Treatment of hyperglycemia with insulin therapy
• Treatment of electrolyte imbalances
• Treatment/correction of acid-base imbalance

Initial/Emergency treatment of DKA includes (20):

• Initial assessment and stabilization ABC airway, breathing and circulation.
• Aggressive fluid therapy to restore circulating volume.
• Isotonic saline IV infusion
• IV with dextrose component once glucose level 200-250mg/dl

Laboratory Findings

The following laboratory ranges provide a generic overview of normal ranges and abnormal findings associated with DKA (17) (18) (19). The confirmation of acute diabetic ketoacidosis is dependent on both laboratory findings as well as patient assessment. Please refer to your specific medical organization (unit specific) for further guidance and treatment parameters.

• Serum potassium levels: Normal range (3.5 to 5.0 mEq/L) hyperkalemia range approximately 5.0 to 5.5mEq/L. 
• Serum sodium levels: Normal range (137 to 142 mEq/L) severe hyponatremia range approximately 125mEq/L or lower; severe hypernatremia range above 145mE/L 
• Serum Amylase level: Normal range (40 to 140 units per liter) (U/L); may be elevated in cases of pancreatitis/ pancreatic inflammation, which may coexist with DKA 
• Serum Lipase level: Normal range (0-160 units per liter) (U/L); may be elevated in cases of pancreatitis/ pancreatic inflammation, which may coexist with DKA 
• Serum Osmolality level: Normal range 275-295 mOsm/kg: may be elevated to between 300-320 mOsm/kg in DKA       
• Arterial blood gas analysis: Arterial ph below 7.3 (normal range 7.35-7.45)   
• Anion Gap: Normal 4-12 mEq/L ; levels above  > 10 may indicate existing acidosis in DKA 
• Serum glucose level (normal fasting below 100mg/dl). Hyperglycemia range above 250mg/dl 
• Serum ketone level (normal negative); serum ketones detected in blood; usually greater than 5mEq/L       
• Serum bicarbonate level (normal 22-29 mEq/l); usually less than 18mEq/L  
• Anion gap level (normal 4-12mmol/L); usually greater than 12 mmol/L)

To rule out physiologic stressors associated with the development of DKA (systemic infections, acute myocardial infarction, pneumonia, urosepsis), refer to your medical organization (unit specific) guidelines regarding these additional diagnostics:

• Serial blood and wound cultures
• Serial EKG and Troponin levels
• Sputum cultures and sensitivity
• Urinalysis and culture with sensitivity
• Chest Xray

Fluid Resuscitation Guidelines

The American Diabetes Association (ADA) recommends the following initial fluid resuscitation in the adult population; additional boluses may be required after each hourly reassessment: (21). Please refer to your unit specific guidelines regarding fluid boluses, and fluid resuscitation. Caution in use with patients with preexisting heart failure, kidney failure or other medically indicated “fluid restrictions”.

0.9% SC (Sodium Chloride Solution) initially as a 15–20 mL/Kg bolus for hemodynamic resuscitation

• then 250–500 mL/h of fluid until glucose is normalized (usually faster than DKA resolution) 
• then 150–250 mL/h until DKA resolution  
• For the replenishment, 0.45% SC (Sodium Chloride Solution) unless hyperglycemia-corrected hyponatremia is present.

In the pediatric population, fluid resuscitation boluses are indicated in children who present with the following symptoms: (22)

• Dry mucus membranes 
•  Poor skin turgor 
•  Lethargy; altered level of consciousness. 
• Nausea and vomiting 
• Tachycardia and tachypnea 
• Kussmaul type respirations (deep and labored respiratory breathing patterns)

Fluid recommendation: 10–20 mL/kg bolus of isotonic saline given over 30–60 mins.

Insulin Therapy and Acute Diabetic Ketoacidosis

Intravenous use of insulin is preferred in patients with acute diabetic ketoacidosis, as subcutaneous absorption of insulin would most likely be ineffective in light of dehydration.

Intravenous continuous infusion of insulin at a rate of at 0.14 U/kg/hour or

Insulin bolus of 0.1U/kg, followed by insulin continuous infusion at a rate of 0.1U/kg/hour.

Hourly (or more frequent glucose checks) with a decrease in insulin delivery dose when glucose level is 250mg/dl or less. At this time, insulin dose is further decreased to 0.05 or 0.1U/kg hourly until DKA is resolved. 

• Patients, once stabilized and deemed able to eat, can be transitioned to subcutaneous insulin administration and routine glucose monitoring (point of care/ POC glucometers)

Laboratory Tests Guidelines Therapy Goals

• Serum glucose levels below 200mg/dl 
• Serum bicarbonate level greater than 15mEq/L 
• Serum potassium level 4.0 -5.0 mEq/L 
• Venous pH greater than 7.30  
• Anion gap equal to/less than 12eEq/l. (23)

Electrolyte Imbalance (Hyperkalemia-> Hypokalemia)

Serum potassium levels are usually high/elevated due to the cellular changes occurring as the result of acidosis and decreased insulin. Electrolyte replacement should be monitored very closely in diabetic ketoacidosis. During the rehydration/ volume restoration phase and insulin administration, extracellular potassium shifts back into the intracellular space (causing hypokalemia). In addition, insufficient insulin levels may deplete various serum electrolytes; thus, frequent serum electrolyte levels with appropriate intravenous replacement ensure proper cellular activity.

Treatment-Related Complications

• Hypoglycemia (blood glucose levels below 70mg/dl); treat; accordingly, patient should be transitioned to subcutaneous insulin injections when serum glucose level 200-250mg/dl, and patient is able to tolerate oral intake.
• Hypokalemia (blood potassium levels below 3-3.4 mmol/L); intravenous therapy to include potassium supplements; oral supplements as tolerated once patient transitions to diabetic diet.
• Cerebral edema

Cerebral Edema

Cerebral edema, or brain swelling, occurs for a variety of conditions (brain tumors, blunt trauma, inflammatory conditions, and even infections). Diabetic ketoacidosis and hyponatremia can cause cerebral edema. (24) Cerebral edema is the leading cause of mortality in children. A normal ICP (intracranial pressure) reading is 7-15mmHG; an increased reading in excess of 20-25mmHG, coupled with the following symptoms, may be indicative of cerebral edema.

Initial symptoms of cerebral edema may include the following:

• Headache 
• Visual changes (double vision (diplopia) or blurred vision) 
• Changes in speech/ ability to talk/ personality. 
• Nausea and vomiting 
• Changes in level of consciousness (lethargy-> unresponsiveness) 
• Changes in respirations/ difficulty breathing

Symptoms that may indicate worsening of cerebral edema. 

• decorticate and decerebrate posturing. 
• cranial nerve palsies  
• fluctuating level of consciousness 
• sustained heart rate deceleration, 
• increased vomiting, headache, and lethargy 

Confirmation Testing: 

• CT (Computerized Tomography) scan 
• MRI Magnetic Resonance Imaging

Treatment for DKA Related Cerebral Edema

When cerebral edema is confirmed by radiologic testing, the administration of Mannitol (or hypertonic sodium) is recommended as follows (25) (26):

• 0.5-1 g/kg intravenous mannitol may be given over the course of 20 minutes and repeated if no response is seen in 30-120 minutes.  
• If no response to mannitol occurs, hypertonic saline (3%) may be given at 5-10 mg/kg over the course of 30 minutes. 
• Additional treatments may be warranted, including diuretics, corticosteroids, and possible surgical intervention (to prevent herniation syndrome).

Nursing Care and Management

Nursing Care: Patient Placement

Initial/hourly (or more frequent) assessment to include the following:

Due to the frequency of monitoring and medication administration during the acute phase of DKA, patients are usually placed in the Intensive Care Unit. ICU treatment often includes hourly physical assessments (intake, output, neurological assessment, vital signs; frequent laboratory testing (glucose testing); and rapid identification of complications (cerebral edema, hypoglycemia, hypokalemia).

Transfer to a step-down unit usually occurs when the patient is fully awake, tolerating oral intake (both solid food and liquids), vital signs are stable, and fluid and electrolyte replacements are complete. The average timeline may be 1-2 clinical days. The focus of care now shifts to discharge planning, patient education, and ongoing management.

Nursing Care: Acute Phase

• Monitoring of vital signs, level of consciousness/ neurological status, urine output
• Administration of IV fluids as ordered.
• Frequent blood glucose assessment and insulin administration

Nursing Care: Patient Education, Discharge Planning, and Follow-up Care

• Compliance with medications, healthy diet, glucose monitoring, sick day management
• Signs and symptoms of infection
• Importance of follow-up care with primary medical provider/endocrinologist
• Lifestyle behavior changes (smoking cessation, physical activity, healthy diet)
• Medical Alert ID bracelet or wallet insert regarding chronic medical conditions and medication.
• Coordination of follow-up care to ensure ongoing medical support, educational services and financial assistance when appropriate (medical provider, endocrinologist, pharmacist, social worker/ case management services, DSMES classes) (27)

Patient Education

Diabetes Self-Management Education and Support (DSMES)

The Centers for Disease Control and Prevention offer a Diabetes Self-Management Education and Support Toolkit on their website available to the public, designed for various health organizations/ community organizations and others interested in educating persons with diabetes to live a healthier lifestyle. Studies have shown that people who receive such education have better overall health and wellbeing. Despite these studies, a very low percentage of those qualified to receive such services access them. Check out the link below for more information.

• DSMES Program Review: https://www.cdc.gov/diabetes/dsmes/index.html
• DSMES Tooliit: https://www.cdc.gov/diabetes/dsmes-toolkit/index.html

Additional Resources

The following websites are being provided to assist the healthcare professional in accessing appropriate diabetes related information, including insulin coverage, food insecurities, food bank locations, and DSMES information. https://diabetes.org/

The American Diabetes Association provides information on prediabetes, Type 1, and Type 2 diabetes, as well as gestational diabetes. Included on their website are sections on medications, support groups, diet and activity, advocacy efforts, and prevention efforts. https://www.jdrf.org/

The Juvenile Diabetes Research Foundation is a global organization for Type 1 diabetes mellitus. The site offers information on all things T1DM, including sections for those newly diagnosed, those interested in fundraising, research and clinical trials, daily diabetes management, volunteer opportunities, and access to local chapters worldwide. From the healthcare provider perspective, this website offers continuing education programs and pdf downloads for patient specific education. https://getinsulin.org/

The Get Insulin website provides information for persons with diabetes to access affordable insulin coverage. The site also offers information and guidance on health insurance plans, an insulin related newsletter, and external links to food sources (for patients with food insecurity issues) https://www.feedingamerica.org/find-your-local-foodbank

The Feeding America website enables persons with food insecurities to access food banks in their area, according to state location and zip code.

Patient Education and Follow-up Care (DSMES)

DSMES, or Diabetes Self-Management Education and Support, is the gold standard when it comes to patient education on this chronic medical condition. The goal of this education is to educate and empower the patient to successfully manage their medical condition, in efforts to lower the risk of long term, lifetime complications. DSMES is considered an ongoing process, and is recognized as an integral part of patient education at various critical points in their lifetime:

• At time of initial diagnosis
• During all patient medical appointments and routine follow-up care
• At time of onset for newly diagnosed complications
• Anytime a patient expresses concern over current diabetic management challenges.

Medicare and Medicaid

Medicare (Medicare Part B) and Medicaid plans currently offer the following coverage for diabetes related education (28):

• 10 hours of education (combined individual and group training) for an initial diagnosis of diabetes
• 2 hours of follow-up training annually after initial training completion

Qualifying Labs for DSMES

In general, a patient must be diagnosed with type 1, type 2, or gestational diabetes to qualify for DSMES, such as:

• Fasting Blood glucose of 126 mg/dL on 2 separate occasions
• 2-hour Post-Glucose Challenge of ≥200 mg/dL on 2 separate occasions
• Random Glucose Test of >200 mg/dL with symptoms of unmanaged diabetes

DSME Contents Overview

• Diabetes disease process pathophysiology and treatment to increase risk reduction for long term complications.
• Healthy eating includes meal planning, food label reading, carbohydrate counting, and strategies for eating out.
• Physical activity includes the benefits of activity as they related to better weight control, sleep habits and stress reduction.
• Medication usage overview to include medication administration, side effects, storage and cost issues.
• Blood glucose monitoring and management to include proper use of monitoring devices and associated equipment cleaning/repair.
• Prevention of complications (early detection, treatment, acute and chronic complications such as kidney disease and nerve damage; proper foot care)
• Healthy coping strategies to include stress reduction, effective self-management behaviors, and symptom recognition (hypoglycemia/hyperglycemia)
• Sick day management includes intake/output monitoring, over the counter medication usage, carbohydrate counting, ketone assessment, fever control and when to seek emergency services.
• Problem solving to include diabetes management during emergencies (power outages, flooding, tornados, hurricanes)

For more DSMES information visit: https://www.cdc.gov/diabetes/dsmes/dsmes-living-with-diabetes.html

Safety Considerations (Sick Day Management)

Successful management (prevention) of diabetic ketoacidosis requires patient education and empowerment in managing situations where glucose levels may be elevated and/or insulin levels (doses) are substandard (29).

There are many situations that can put a patient at risk for the development of DKA, including the following (29):

• Illness (acute and chronic), affecting normal food and fluid intake which negatively affects glucose management.
• Missed medication (insulin therapy) due to a clogged insulin pump tubing, a malfunctioning insulin pump, partial doses/skipped doses of insulin (whether related to costs, cognition, or mental health issues {diabetes distress}),
• Medication side effects
• Concurrent use of alcohol or drugs
• Physiologic stress (heart attack, stroke, physical injury)

Patient Education: Sick Day Management

Home treatment/ self-care (30)

The importance of preplanning cannot be understated. All persons with diabetes should have adequate supplies at home, to address an acute illness, including medications to treat basic symptoms before they escalate. These medications may include over the counter medications to treat pain, nausea, vomiting, diarrhea, as well as adequate supplies to manage their diabetes (alcohol prep pads, syringes, prescription medications).

In addition, it is important to stock up on diabetic friendly foods and drinks to maintain nutrition and hydration levels during an acute illness. Such items might include sports drinks, soft drinks, instant cooked cereals, puddings, soups. In the event that a patient cannot eat their regular meals, the goal is to eat or drink 50 grams of carbohydrate every 4 hours to maintain glucose levels.

Sick Day Management Guidelines

• Monitor glucose levels every 4 hours.
• Stay hydrated – 4 to 6 ounces of fluid every ½ hour to prevent dehydration.
• Daily weight
• Temperature checks (rule out underlying infection)
• Current medication compliance- do not stop taking insulin or diabetic oral agents ** notify provider immediately if you choose to stop medications.

Seek emergency care for the following signs/ symptoms:

• Persistent vomiting/diarrhea to the point that you cannot tolerate any food or fluid intake for several hours
• Ongoing glucose levels above 240mg/dl
• The presence of moderate/high levels of ketones in urine
• Unexplained weight loss during an illness
• Any difficulty breathing
• Fruity/acetone smell on breath
• Changes in gait/balance/ vision

Research Findings

Research: Diabetes Distress and Burnout

Diabetes is a 24/7/365 chronic medical condition. Unlike many conditions that are simply managed with lifestyle changes or a single, once a day medication regimen, diabetes mellitus requires lifelong, around the clock commitment. Whether diet, activity, or medication management, a person with diabetes may easily feel overwhelmed by even the basic requirements for self-management. (31)

Ongoing health challenges, comorbid medical conditions, medication and diet cost issues and family dynamics can all affect a person’s ability to successfully manage any health condition. When emotions (sadness, anger, hostility, frustration, and even fear) become overwhelming, diabetic distress (a feeling of defeat) can often occur. Without prompt, patient specific interventions (mental health services, financial assistance, self-management education), these feeling will progress to diabetic burnout, and increase the risk of unhealthy habits (poor medication adherence and overall glycemic control). (32)

Diabetes distress can easily progress to diabetes burnout without appropriate ongoing medical treatment and mental health interventions. When a person with diabetes reaches the point of burnout, they often appear to disconnect from their routine healthcare, exhibiting indifference towards their overall health and well-being. They may become both mentally and physically exhausted from the daily requirements of this chronic medical condition. At this point, it is not uncommon to observe a person’s total disregard for their ongoing medical treatments, daily medications, routine self-care, and more. Missed medications, missed medical appointments, poor dietary intake, and a visible lack of basic hygienic practices are cause for concern.

A multidisciplinary approach to treating suspected diabetic distress and burnout is highly encouraged. From ongoing education, physical and mental health assessments, and enrollment in therapies (individual therapy sessions, and support groups), the person with diabetes needs a supportive environment in which to become empowered in the self-management of their disease progress. In doing so, it is believed that health outcomes are optimal, and the risk of long-term complications is lowered. (33)

Reserach: Diabulimia

Bulimia nervosa is a potentially life-threatening eating disorder characterized by episodic binge eating of large amounts of food, followed by forced vomiting and possibly laxative use to then “purge” the food. These alternating behaviors are the result of a person fearful of weight gain and willingness to lose weight in unhealthy ways. (34) (35)

Diabulimia is a serious, life threatening eating disorder affecting persons with Type 1 diabetes. Through intentional restricted/ limited use of prescribed insulin, weight loss occurs. This eating disorder is more common in young female adolescents and young adults. (34) (35)

Signs and symptoms may include the following (34) (35):

• Unexplained weight loss
• Hemoglobin A1C > 9
• Multiple episodes of DKA
• Unfilled insulin prescriptions, missed diabetes related medical appointments,
• Expressed fear of insulin related weight gain
• Anxiety related to body image
• Obsessive interest in calories and dieting

Research: Insulin Affordability

For many persons with diabetes, the perceived noncompliance with therapy (on behalf of the healthcare professional) is actually that of a cost related issue. Many persons cannot afford ongoing therapies related to management of this chronic medical condition. In attempts to “cut costs”, patients have admitted to skipping certain medications, cutting medications in half, reducing prescribed doses of insulin, and purchasing poorer quality, less expensive foods (that are often lacking in nutritional value). Poorly controlled / uncontrolled diabetes heightens the risk of both acute and chronic complications.

In an attempt to ensure accessibility and affordability of insulin therapy to persons with diabetes, the Inflation Reduction Act of 2022 in part ensures that persons with diabetes on Medicare pay no more than $35 for a month’s supply of insulin product under their prescription drug coverage. Similar drug coverage benefits were also extended to many state-based insurance plans. (36)

In addition, most Medicaid insurance plans, as well as private insurance companies have now enacted reduced insulin costs/ cost sharing programs. Finally, for patients with no insulin costs benefits, many national insurance providers offer free/ reduced cost insulin through their patient assistance program. For a comprehensive list of these resources, please see the following website link (American Diabetes Association): https://diabetes.org/tools-resources/affordable-insulin

Research: Insulin Delivery Systems

With the creation of advanced insulin delivery /monitoring devices (insulin pumps, and continuous glucose monitoring devices), the person with diabetes is afforded a more streamlined process to control their chronic medical condition. Most patients using such devices report better glucose control {“time in range”}, meaning the time their blood glucose levels remained in an acceptable range, ease of portability (of supplies), increased comfort (no more finger sticks), and decreased rates of anxiety, depression and distress.

The following website links represent various insulin delivery devices. Consider making a resource book containing various delivery devices for your specific unit (or hospital organization). Many have 24/7 customer service representatives available if you need to trouble shoot a device suspected of malfunctioning or require additional staff/patient educational resources.

This list contains a variety of websites but is not all inclusive. If you are caring for a patient with an insulin delivery device in place, please contact that specific company for more directions on its usage, removal, replacement parts and more.

Examples of insulin delivery devices:

• Makers of the MiniMed 780G System and the MiniMed 630G system: https://www.medtronic.com/us-en/healthcare-professionals/products/diabetes/insulin-pump-systems.html
• Makers of the Omnipod 5 and the Omnipod DASH Insulin Management System: https://www.omnipod.com/
• Quick overview of various insulin pumps currently on the market: https://consumerguide.diabetes.org/collections/pumps

Case Studies

Case Study #1

A 3-year-old female child is sent, by ambulance, from her local pediatrician’s office with reports of increased lethargy, increased thirst and appetite, and new onset of bedwetting (child had stopped wearing diapers at age 2.5 years). Parents report that the child’s appetite appears increased lately, but pediatrician noted several pounds weight loss since last visit.

• Based on these signs and symptoms alone, what is your initial diagnosis for this child?
• What are your priority nursing interventions for this child?
• How would you assess hydration status on a 3-year-old child?

The child is diagnosed with new onset Type 1 Diabetes and stabilized in the Emergency Department. The parents of this child are visibly distraught over the diagnosis, stating “no one in our family is diabetic; this can’t be happening”.

• What are some of the initial nursing patient/family education areas you could address at this time?
• What are some in hospital consultations that should be considered for this patient and her family?
• What are some community resources you have in your area that you could offer this family?

Case Study #2

A 78-year-old female, with a previous history of CVA, is transferred to your facility from a local nursing home for evaluation of fever and hyperglycemia. The nursing home staff reported the patients’ blood glucose level was 400mg/dl earlier today and her WBC count was 14,500. Upon arrival, the patient is unresponsive, with a temperature 102F , her glucose is 350mg/dl, with +ketones (moderate) and a urinalysis (indwelling catheter) confirms a UTI.

Patient past medical history includes old CVA, T2DM.

• Based on these signs and symptoms alone, what is your initial diagnosis for this patient?
• What diagnostic studies would be warranted in light of hyperglycemia, fever, urinary tract infection, and altered level of consciousness?
• What questions would you ask the nursing home staff, in light of this patient’s initial presentation?
• When this patient is stabilized for transfer back to the nursing home, what information should be included in the discharge instructions/ transfer of care?

Case Study #3

A 60-year-old male present to the Emergency Department with an Acute Myocardial Infarction.

Patient past medical history includes borderline hypertension, and prediabetic HgbA1C 5.8.

The patient was found to have severe coronary artery disease and received Coronary Artery Bypass Graft x 3. During the immediate post operative recovery phase, he receives insulin therapy to control glucose levels >300mg/dl. He is eventually sent home on insulin therapy, pending follow-up with his cardiologist as well as a new consultation for an endocrinologist.

At the time of discharge, the patient is adamant that he was “prediabetic and could easily control my glucose levels with diet alone”; he doesn’t understand how he is now “an insulin diabetic”.

• What are key points in nursing education for this patient, regarding his new “diabetic status”
• How would you explain to the patient the connection between his myocardial infarction, bypass surgery, and currently elevated glucose levels?
• What nursing interventions can you provide PRIOR to discharge to assess his comfort level with insulin injections and glucose monitoring?
• What community resources are available to your patient for a new diagnosis of diabetes?
• The patient wants to know when he can stop the insulin injections. What is your response?

Successful management of acute diabetic ketoacidosis requires resuscitation with intravenous fluids and insulin therapy, replacement of electrolytes and early identification of any events (medical, surgical, and psychological) that contributed to this medical emergency. With the continued increase in diagnosis of diabetes, and ongoing challenges in healthcare costs and coverage, chronic medical conditions will continue to burden the already overwhelmed healthcare arena. By educating and empowering patients to self-manage their disease process, we can lower the risk of long-term complications and improve health outcomes worldwide.

Conclusion

The International Diabetes Federation reports that, in 2021, approximately 10.5 % of the global adult population (ages 20-79 years old) has diabetes, and that nearly 50% of this population are unaware that they are living with this chronic condition. Left untreated, the rates of long-term, nonreversible complications are quite alarming. (37) By the year 2045, it is projected that 1 in every 8 persons (approximately 12.5 %) will be living with diabetes. This will equate to an increase of 46 percent, with nearly 783 million people being affected. This single health condition will represent staggering health expenditures and increased mortality and morbidity associated rates worldwide.

Diabetes ketoacidosis continues to be a potentially life-threatening complication for persons with diabetes. DKA is also, in most cases, a highly preventable condition, with early identification and treatment. The importance of ongoing, patient specific education to address all aspects of diabetes self-management is a key factor in lowering the occurrence of DKA. Dr William Polonsky, a licensed clinical psychologist and certified diabetes educator, is the President of the Behavioral Diabetes Institute in San Diego, California. With regards to the importance of patient education and empowerment, he said the following:

“Well-controlled diabetes is the leading cause of nothing!” Dr William Polonsky. (38)

As healthcare professionals, we have the responsibility to ensure that our patients with diabetes are afforded the education and ongoing support necessary for them to successfully manage their specific disease process. In doing so, we positively impact patient satisfaction, improve medication adherence rates, and lower the risk of long-term complications.

Introduction   

Heart disease is an umbrella term encompassing a range of cardiovascular conditions, and stands as the leading cause of death worldwide, claiming millions of lives. Both heart disease and stroke are types of cardiovascular disease. The impact of heart disease transcends individual health, posing a significant economic burden through reduced labor and workforce participation. In 2018, the mean labor income losses were $13,463 for heart disease and $18,716 for stroke. Total labor income losses were estimated at $203.3 billion for heart disease and $63.6 billion for stroke [1].  

Heart disease manifests in various forms, each with its unique characteristics and implications. Coronary artery disease, the most common type, arises from the buildup of plaque in the coronary arteries [2]. This narrowing can restrict blood flow to the heart, causing symptoms such as chest pain or shortness of breath [2]. Other prevalent forms include heart failure, rhythm abnormalities, heart valve defects, and congenital heart defects [4]. These conditions can lead to a spectrum of complications, including heart attacks, strokes, and heart failure, significantly impairing quality of life and survival [3]. By understanding the underlying mechanisms, risk factors, and clinical presentations of heart disease, participants will gain a deeper understanding of the disease's impact on the cardiovascular system and overall health.  

Prevention, the cornerstone of combating heart disease, will be a central focus. Participants will explore lifestyle modifications that play a pivotal role in reducing the risk of heart disease, including diet, physical activity, weight management, smoking cessation, and stress reduction. Identification and management of risk factors, such as high blood pressure, high cholesterol, and diabetes, is prioritized. 

Types of Heart Disease  

Heart disease encompasses a spectrum of conditions, each with unique underlying mechanisms and dietary management strategies [5]. Coronary artery disease (CAD), heart failure (HF), hypertensive heart disease (HTN), and arrhythmias constitute a significant portion of these prevalent ailments. Coronary artery disease (CAD) is the most common type of heart disease [6]. The four main types of cardiovascular disease (CVD) include coronary heart disease, stroke, peripheral arterial disease, and aortic disease [7].  Cerebrovascular disease is the second most common type of heart disease [7]. Other forms of heart disease include congenital heart disease, heart valve disease, cardiomyopathy, pericardial disease, arrhythmia, and aortic dissection.  

Congenital heart disease (CHD) 

Congenital heart disease (CHD) is the most common type of birth defect, affecting about one in 100 babies born in the United States [8]. CHDs can range from mild to severe and can affect the heart's structure, function, or both [8].  

Heart Valve Disease 

Heart valve disease is a condition in which one or more of the heart valves are damaged or diseased which causes blood to flow backward through the valves, damaging the heart and other organs [9]. Heart valve disease affects 2.5% of the U.S population and can be caused by several factors, including infection, injury, and aging [9].  

Heart Failure 

Heart failure is a condition in which the heart's weakened pump fails to meet the body's demands for blood and oxygen, leading to a range of debilitating symptoms including fatigue, shortness of breath, swelling, chest pain, palpitations, weight gain, swelling in the ankles, legs, and abdomen, bloated or hard stomach, dry hacking cough, and nausea [10][11]. More than six million adults in the U.S. have heart failure [10].  

Cardiomyopathy 

Cardiomyopathy represents a collection of diverse conditions of the heart which makes it weaker and less able to pump blood. Cardiomyopathy can be caused by several factors, including infection, toxins, and genetic disorders [12]. Due to the potential for underdiagnosis, estimates of cardiomyopathy prevalence can vary. It is estimated that up to one in 500 adults may be affected by this condition [13].  

Pericardial Disease 

Pericardial disease is a condition that affects the pericardium, the sac that surrounds the heart [14]. This can cause inflammation, infection, or scarring of the pericardium, which can interfere with the heart's ability to function. Pericardial disease can manifest as acute pericarditis, pericardial effusion, cardiac tamponade, or constrictive pericarditis [14].  

Arrhythmia 

Arrhythmia is a cardiac disorder characterized by an abnormal heart rhythm, manifesting as tachycardia (excessively rapid heartbeat), bradycardia (abnormally slow heartbeat), or irregular heartbeat patterns [15]. These irregularities can induce symptoms such as palpitations, dizziness, and syncope (fainting episodes) and can arise from various etiologies, including underlying heart conditions, electrolyte imbalances, and adverse effects of certain medications [15].  

One in 18 people, or five percent of the U.S. population has an arrhythmia with afib (atrial fibrillation) being the most common [16].  

Aortic Dissection 

Aortic dissection is a rare, life-threatening condition in which the inner layer of the body’s main artery (aorta), tears [17]. This can cause blood to leak between the layers of the aorta, which can weaken the artery and cause it to rupture. Aortic dissection can be caused by several factors including high blood pressure, atherosclerosis, and connective tissue disorders [17]. Aortic dissection affects about 30 in one million people each year and more than 13,000 die each year [18]. Aortic dissection is most common in individuals over the age of 60 and if not treated, the tear can worsen, ripping the outer layer of the aorta, allowing blood to escape the artery [17] [18]. As many as 40 percent of individuals who suffer from an aortic dissection die, and the risk of death increases by 3-4 percent every hour the condition is left untreated [18]. 

Epidemiology/Statistical Evidence  

Heart disease is a global health crisis, with an estimated 17.9 million deaths attributed to cardiovascular diseases in 2019, representing 32% of all global deaths [19]. This significant number reflects the pervasive nature of heart disease, affecting individuals of all ages, socioeconomic backgrounds, and ethnicities. The distribution and determinants of heart disease plays a pivotal role in understanding the prevalence. Heart disease varies across regions, with higher rates observed in high-income countries compared to low-income countries [20]. However, the burden of heart disease is shifting, with a growing trend in low-income countries due to rapid urbanization, lifestyle changes, and increasing exposure to risk factors [20].  

Epidemiology: Modifiable and Non-Modifiable Risk Factors 

Epidemiological studies with data from 61 cohort studies, encompassing 12.7 million person-years of follow-up and 56,000 fatalities from coronary heart disease (CHD) and stroke revealed a consistent and graded increase in CVD risk. The risk was associated with higher baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels beyond the usual thresholds of 115 and 75 mmHg. A 20-mmHg elevation in SBP and a 10 mmHg increase in DBP was associated with a two-fold higher risk of CVD [21].  

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in individuals with type 2 diabetes mellitus (T2DM). This increased risk stems from a complex interplay of traditional and non-traditional risk factors that contribute to the initiation and progression of atherosclerosis, a pathological process characterized by the buildup of plaque within artery walls [22].  

The epidemiology of heart disease involves recognizing the associated risk factors. These can be categorized into modifiable and non-modifiable factors. Modifiable risk factors include hypertension, high cholesterol, smoking, obesity, diabetes, physical inactivity, and poor diet [23]. Non-modifiable risk factors include age, gender, and family history [23]. According to the American Heart Association (AHA), the likelihood of developing CVD in U.S. men and women is 40% between the ages of 40 and 59, 75% between 60 and 79, and 86% for those over the age of 80 [24].  

Statistics on Ethnic/Racial Minorities 

Patients from minority groups with acute coronary syndrome (ACS) are at an increased risk of heart attack (MI), readmission to the hospital, and death from ACS [25]. Black/African Americans are at 30% increased risk of heart disease and death from heart disease and double the risk of stroke with a higher risk of developing heart failure [25]. Among Asian Americans /Pacific Islanders, coronary artery disease (CAD) manifests earlier in life and affects a larger proportion of the population compared to other ethnic groups [25]. Overall CVD rates are lower among non-White Hispanic individuals. Among Hispanic subgroups, Puerto Rican Americans exhibit the highest HTN-related death rates [25]. Heart failure incidence among Hispanics falls between that of African Americans and non-Hispanic whites [25].  

Epidemiology: Genetic and Environmental Factors 

The development of heart disease is influenced by a complex interplay of genetic and environmental factors [26]. Major risk factors include sustained high blood pressure placing excessive strain on the heart, increasing the risk of heart failure, stroke, and other complications [27]. Elevated levels of low-density lipoprotein (LDL) cholesterol can accumulate in arteries, narrowing and reducing blood flow to the heart [28].  

Diabetes mellitus, characterized by high blood sugar levels that damage blood vessels and nerves throughout the body, increases the risk of heart disease and stroke [29]. Tobacco contributes to atherosclerosis – the buildup of plaque in arteries – through a cascade of mechanisms that lead to atherosclerosis, including thrombosis, insulin resistance, dyslipidemia, vascular inflammation, abnormal vascular growth, angiogenesis, and impaired endothelial repair and regeneration [30] [50].  

Obesity and excess abdominal fat can increase the risk of heart disease by elevating blood pressure, cholesterol levels, and blood sugar levels [27]. A lack of regular physical activity contributes to obesity, high blood pressure, and other risk factors for heart disease [31]. A family history of heart disease increases an individual's risk, indicating a genetic predisposition to the condition [32].  

Prevention Strategies 

Prevention for heart disease begins with addressing modifiable risk factors with an emphasis on diet, exercise, smoking cessation, and stress management. Prevention also involves regular health screenings.  

Key prevention strategies include: 

• Adopting a Heart-Healthy Diet consisting of fruits, vegetables, and whole grains, and limiting saturated and trans fats, sodium, and added sugars [33].  

• Maintaining a healthy weight through a balanced diet and regular exercise [23].  

• Engaging in regular physical activity for at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity aerobic exercise per week [34].  

• Participating in smoking cessation, managing high blood pressure, and working with healthcare providers to manage cholesterol levels through lifestyle changes or medication [23].  

Patient Education for Self-Management  

Patient education for self-management plays a vital role in preventing and managing heart disease. Healthcare professionals should begin by conducting a thorough assessment of each patient, considering their unique risk factors, medical history, and lifestyle choices related to heart disease and develop a personalized self-management plan that align with the patient's specific needs and objectives [35].  

Provide clear and concise information about heart disease, its risk factors, and prevention strategies, and address individual needs and concerns, with consideration of cultural background, lifestyle, and any underlying health conditions. Effective communication is paramount in this process. Health care professionals should employ strong communication skills to establish a meaningful connection and foster open and honest dialogue, active listening, and demonstration of empathy to gain insight into their preferences [36].  

To cater to diverse learning styles, it is essential to offer educational materials in various formats [37]. Tailor the educational approach to each patient's learning style, using plain language, visual aids, and active participation strategies. Involve the patient in setting realistic and achievable self-management goals [38]. These resources may encompass brochures, videos, or online materials. It is imperative that these materials are designed to be comprehensible and sensitive to cultural differences.  

Patients must be educated about modifiable risk factors that pertain to heart disease prevention [23]. This includes discussions on dietary choices, physical activity, smoking cessation, and responsible alcohol consumption [23]. Furthermore, healthcare professionals should articulate the significance of adhering to prescribed medications to manage cardiovascular conditions.   

Medical Management and Treatment  

In addition to lifestyle modifications, healthcare providers can prescribe medications to treat heart disease [23]. The common medications used to treat heart disease include antihypertensive medications to lower blood pressure, antihyperlipidemic medications to lower cholesterol levels, and antiplatelet medications to prevent blood clots [40]. Beta-blockers are used to slow the heart rate and lower blood pressure and angiotensin-converting enzyme (ACE) inhibitors are used to lower blood pressure and relax blood vessels. Angiotensin II receptor blockers (ARBs) are prescribed to lower blood pressure and relax blood vessels [41]. 

In some cases, invasive medical procedures may be required to treat heart disease. The common types of medical procedures used to treat heart disease include coronary angioplasty to open blocked or narrowed coronary arteries, and coronary artery bypass grafting (CABG) to create a new pathway for blood to flow around blocked or narrowed coronary arteries [39][42]. Other common procedures are heart valve surgery to repair or replace damaged heart valves, implantable cardioverter-defibrillators (ICD) to monitor the heart rhythm and deliver electrical shocks to correct abnormal heart rhythms, and implantable pacemakers to help control the heart rhythm [43]. 

Heart Health Resources 

Resources for heart disease prevention and management are essential for both healthcare professionals and patients. These resources encompass a wide range of tools, information, and support systems that play a crucial role in reducing the risk and managing heart disease. 

Educational Materials/Content 

Information is key to prevention and management. Patients and healthcare providers can access pamphlets, brochures, websites, and educational videos that explain the causes, risk factors, symptoms, and treatment options for heart disease [44]. These resources empower individuals to make informed decisions about their heart health. [44].  

Patients can benefit from resources that offer guidance on Heart-Healthy diets, including low-sodium meal plans, tips for reducing saturated fats, and strategies for incorporating more fruits and vegetables into their meals. 

Published Guidelines 

Medical organizations and government health agencies publish guidelines for heart disease prevention. These guidelines provide evidence-based recommendations for diet, exercise, smoking cessation, and medication management, with proper nutrition being a cornerstone of heart disease prevention and management [33].  

Support Groups 

Support groups provide a platform for individuals with heart disease to connect, share experiences, and receive emotional support [45]. These groups can be in-person or online and offer a sense of community for patients and their families [45].  

Technological Advancements 

Telehealth has become important in managing chronic conditions such as heart disease [46]. Patients can access virtual consultations with healthcare providers, receive remote monitoring, and access educational materials online. Smartphone apps and wearable devices can help individuals track their health metrics, such as blood pressure, heart rate, and physical activity [47]. Many of these tools provide real-time feedback and reminders to support heart-healthy habits.  

Nonprofit Organizations 

Nonprofit organizations dedicated to heart health advocacy, such as the American Heart Association, offer a wealth of resources. The American Heart Association (AHA) is a leading organization for heart disease research and education [48]. The National Heart, Lung, and Blood Institute (NHLBI) is a part of the National Institutes of Health (NIH) and offers information on heart disease prevention and management, as well as clinical trials and research studies [49]. 

Conclusion

Heart disease encompasses a spectrum of conditions with diverse underlying mechanisms and management strategies. Modifiable risk factors, including diet, exercise, smoking cessation, and stress management, play a crucial role in both prevention and management [23]. Resources for heart disease prevention and management empower individuals to take control of their heart health. These resources span from educational materials and support groups to telehealth platforms and smartphone apps, providing comprehensive guidance and support for both patients and healthcare professionals [44][45]. 

Introduction   

Research indicates that a heart-healthy diet is a powerful tool for the prevention and control of cardiovascular disease [1]. A heart-healthy dietary approach to wellness emphasizes the intake of the appropriate proportions of macronutrients, essential vitamins, minerals, and fiber while minimizing the consumption of saturated fats, trans fats, cholesterol, salt (sodium), and the reduction of processed foods, trans-fats, and added sugars [2] [3]. The cornerstone of the diet includes an abundance of fresh fruits and vegetables, whole grains, lean proteins, and healthy fats [2].  

For healthcare providers and patients, the goal of adopting a heart-healthy diet is multifaceted. The diet aims for a reduction in overall cardiometabolic risk, improving blood pressure, lowering cholesterol levels, reducing the risk of developing heart disease and stroke, and preserving the overall health of the circulatory system [3].  

Nurses play a pivotal role in patient education and promoting heart-healthy lifestyles by empowering patients with knowledge and skills related to nutrition and dietary choices. This course aims to equip nurses with comprehensive knowledge of heart-healthy eating principles, enabling them to guide and educate their patients.  

The adoption of healthy lifestyle choices, with nutrition being the most important behavioral factor, is estimated to reduce the risk of myocardial infarction (MI) by 81–94% [5][6][7]. In comparison, treatment with pharmacotherapies alone results in a 20–30% reduction [8]. 

Heart Disease: A Brief Overview 

Heart disease remains one of the leading causes of morbidity and mortality worldwide, with diet and nutrition playing a crucial role in both its development and prevention [4]. Cardiovascular diseases, also known as CVDs, are the primary cause of death worldwide, claiming an estimated 17.9 million lives per year [4].  

Cardiovascular disorders affect the heart and blood vessels, manifesting in coronary heart disease, cerebrovascular disease, rheumatic heart disease, and others. More than four out of five CVD fatalities stem from heart attacks and strokes, with one-third of these deaths occurring in individuals under the age of 70 [4].  

The term "heart disease" encompasses various conditions affecting the heart's structure and function, many of which are influenced by dietary habits [9]. Cardiovascular risk factors, including malnutrition, tobacco and alcohol use, stress, obesity, sedentary lifestyle, hypertension, diabetes, hyperlipidemia, and genetic predisposition, can increase an individual's likelihood of developing cardiovascular diseases [10] [12].  

The modifiable risk factors include sedentary lifestyle, smoking, high blood pressure, diabetes, hypercholesterolemia [12]. Almost three quarters of patients (73%) had at least three risk factors compared to 31% of healthy subjects. 

Family history of cardiovascular disease (CVD) is a significant independent risk factor for premature coronary heart disease (CHD). The risk of premature CHD increases in a linear fashion as the number of affected family members grows. [11]. Cardiovascular risk factors, including malnutrition, tobacco and alcohol use, stress, obesity, sedentary lifestyle, hypertension, diabetes, hyperlipidemia, and genetic predisposition, can increase an individual's likelihood of developing cardiovascular diseases [10].  

The five modifiable risk factors include sedentary lifestyle, smoking, high blood pressure, diabetes, and hypercholesterolemia [10]. A higher proportion of cardiovascular patients (73%) had at least three risk factors compared to healthy individuals, where less than one-third had three or more risk factors [10]. 

Types of Heart Disease / Statistics 

There are multiple types of heart disease, each with distinct mechanisms and implications for dietary management [13]. Coronary artery disease (CAD), heart failure, hypertensive heart disease, and arrhythmias represent a fraction of these conditions. The four main types of CVD include coronary heart disease, stroke, peripheral arterial disease, and aortic disease [15].  

Coronary artery disease (CAD) is the most common type of heart disease [14]. Cerebrovascular disease is the second leading cause of heart disease. Other forms of heart disease include congenital heart disease, heart valve disease, cardiomyopathy, pericardial disease, arrhythmia, and aortic dissection.  

Congenital heart disease (CHD) is the most common type of birth defect, affecting about 1 in 100 babies born in the United States [16]. CHDs can range from mild to severe and can affect the heart's structure, function, or both [16].  

Heart valve disease is a condition in which one or more of the heart valves are damaged or diseased, which causes blood to flow backward through the valves, damaging the heart and other organs [17]. Heart valve disease affects 2.5% of the U.S population and can be caused by several factors, including infection, injury, and aging [17].  

Heart failure is the heart's inability to pump blood, leading to symptoms such as fatigue, shortness of breath, swelling, chest pain, palpitations, weight gain, swelling in the ankles, legs, and abdomen, bloated or hard stomach, dry and hacking cough, and nausea [18] [19]. More than 6 million adults in the United States have heart failure [18].  

Cardiomyopathy represents a collection of diverse conditions of the heart which makes it weaker and less able to pump blood. Cardiomyopathy can be caused by several factors, including infection, toxins, and genetic disorders [20]. Due to the potential for underdiagnosis, estimates of cardiomyopathy prevalence can vary. It is estimated that up to 1 in 500 adults may be affected by this condition [21].  

Pericardial disease is a condition that affects the pericardium, the sac that surrounds the heart [22]. This can cause inflammation, infection, or scarring of the pericardium, which can interfere with the heart's ability to function. Pericardial disease can manifest as acute pericarditis, pericardial effusion, cardiac tamponade, or constrictive pericarditis [22].  

Arrhythmia is a cardiac disorder characterized by an abnormal heart rhythm, manifesting as tachycardia (excessively rapid heartbeat), bradycardia (abnormally slow heartbeat), or irregular heartbeat patterns [23]. These irregularities can induce symptoms such as palpitations, dizziness, and syncope (fainting episodes) and can arise from various etiologies, including underlying heart conditions, electrolyte imbalances, and adverse effects of certain medications [23]. One in 18 people, or 5 percent of the U.S. population has an arrhythmia with a-fib (atrial fibrillation) being the most common [24].  

Aortic dissection is a rare, life-threatening condition in which the inner layer of the body’s main artery (aorta), tears [25]. This can cause blood to leak between the layers of the aorta, which can weaken the artery and cause it to rupture. Aortic dissection can be caused by several factors, including high blood pressure, atherosclerosis, and connective tissue disorders [25].  

Aortic dissection affects about 30 in 1 million people each year and more than 13,000 die each year [26]. Aortic dissection is most common in those individuals over the age of 60 and if not treated, the tear can worsen, ripping the outer layer of the aorta and allowing blood to escape the artery [25] [26]. As many as 40 percent of individuals who suffer from an aortic dissection die, and the risk of death increases by 3-4 percent every hour the condition is left untreated [26]. 

Evidence on Diet and Heart Health / Diet Options 

When considering the diet options for heart health, the Mediterranean diet, DASH diet, and plant-based diets are among the most researched and recommended. These diets share common elements such as an emphasis on whole foods, minimal intake of red meat, and a high volume of fruits and vegetables. Extensive research has demonstrated that the DASH dietary pattern lowers the risk of cardiovascular disease [37]. Numerous prospective studies have demonstrated the consistent benefits of the Mediterranean diet on cardiovascular health [30]. 

There is substantial evidence that most vascular events may be prevented by avoiding smoking, participating in regular physical activity, maintaining normal body mass index, and eating a healthy diet [27].  

Observational studies have demonstrated that dietary patterns rich in fruits and vegetables, excluding white potatoes, are linked to a lower risk of CVD [28] [29]. Regular consumption of whole grain foods has been linked to a reduced risk of cardiovascular disease (CVD), coronary heart disease (CHD), stroke, metabolic syndrome, and various cardiometabolic risk factors, as evidenced by robust observational studies and clinical trials [28]. Numerous randomized controlled intervention studies have demonstrated that replacing refined grains with whole grains leads to significant improvements in cardiovascular risk factors [28] [31].  

Except for a small trial that demonstrated a reduction in arrhythmia recurrences among regular drinkers with atrial fibrillation upon alcohol abstinence, no other studies have reported favorable outcomes associated with alcohol consumption for cardiovascular health [32].  

Dietary fiber, abundant in plant-based foods like fruits, vegetables, whole grains, nuts, seeds, beans, and legumes, have shown an inverse association with a lower risk of metabolic syndrome and cardiometabolic risk factors [33].  

A systematic review and meta-analysis provided evidence that substituting saturated fat with unsaturated fat can improve cardiovascular outcomes and reduce the risk of CVD [34]. Plant-based diets rich in foods like whole grains, fruits, vegetables, and nuts, have been linked to a reduced risk of cardiovascular events and intermediate risk factors [36].  

Current evidence does not support the widespread use of high-dose vitamin and mineral supplements for the prevention of cardiovascular disease (CVD) [28]. 

Role of Sodium and Fats 

Sodium and fats hold significant impact over heart health. High sodium intake is associated with hypertension, a risk factor for heart disease, while certain types of saturated and trans fats, are linked to an increase in LDL cholesterol and the development of atherosclerosis [28]. A systematic review and meta-analysis revealed the detrimental effects of saturated fat on cardiovascular disease (CVD) outcomes and risk factors compared to unsaturated fat. [36] 

A strong body of evidence has documented the adverse effects of trans fatty acids on cardiometabolic risk factors [37]. Adhering to current recommendations to replace saturated fat from meat and dairy with nontropical plant oils also lowers dietary trans fatty acids [38]. 

Healthy Eating Tips and Strategies 

Incorporating a heart-healthy diet into a patient’s lifestyle requires practical tips and strategies. First, make gradual changes instead of overhauling the entire diet. Meal planning can help with healthier choices.  

Setting realistic goals and collaborating with the patients to set achievable dietary goals. Controlling portion size, using smaller plates and bowls, prioritizing low-calorie, nutrient-rich foods like fruits and vegetables and limit high-calorie, high-sodium foods like refined, processed, or fast foods [39].  

Paying attention to the amount of saturated and trans fats, cholesterol, and sodium. Suggest lean protein sources such as fish, poultry, beans, and lentils and limit the intake of unhealthy fats and instead opt for healthy fats like those found in olive oil, avocados, and nuts [39].  

Consume at least five servings of fruit and vegetables daily [41]. Choose whole grains over refined grains and limit the intake of added sugars [28]. To have more control over the ingredients, cook and consume meals at home and make gradual changes to diet habits and build on those habits over time. 

Patient Education 

Nurses are well positioned to provide patient education and counseling on heart-healthy eating. The core of patient education lies in translating knowledge into practice. Nurses must communicate with consideration of cultural, linguistic, and individual patient dietary preferences. Education should be patient-centered, with actionable steps that patients can integrate into their daily lives [40].  

Effective patient education strategies can include establishing a rapport, assessing the patient's knowledge, and understanding, tailoring the educational approach, using plain language, incorporating visual aids, encouraging active participation, providing written materials and ongoing support and follow-up, and addressing any barriers and concerns [42]. 

Resources 

A wealth of resources is available to support nurses in their role as patient educators, from professional organizations like the American Heart Association to local community programs and online platforms [43]. These resources offer educational materials, dietary guidelines, and support tools that nurses can utilize to enhance their teaching.  

A heart-healthy diet is one that is low in saturated and trans fats, cholesterol, and sodium. It is also high in fiber, fruits, vegetables, and whole grains [2][3]. Eating a heart-healthy diet can help to lower your blood pressure, cholesterol levels, and risk of heart disease [2]. 

The National Heart, Lung, and Blood Institute (NHLBI) has a website with information on heart-healthy eating, including recipes, meal plans, and tips for eating out. The American Heart Association (AHA) has a website with information on heart-healthy eating, including recipes, meal plans, and tips for shopping for heart-healthy foods.  

The Dietary Approaches to Stop Hypertension (DASH) diet is a heart-healthy eating plan that has been shown to lower blood pressure [45].  

The Mediterranean diet is a heart-healthy eating plan that has been shown to have several health benefits, including reducing the risk of heart disease, stroke, and type 2 diabetes [44]. You can find information about the Mediterranean diet on the Mayo Clinic website.  

In addition to these websites, there are many cookbooks and other resources available on heart-healthy eating. Patients can also talk to their doctor or a registered dietitian for personalized advice on how to eat a heart-healthy diet. 

Conclusion

In conclusion, adopting a heart-healthy diet is a crucial step towards maintaining cardiovascular well-being and overall health [30]. The nurse's role as a patient educator in promoting a heart-healthy diet is pivotal. By leveraging a position of trust and frequency of contact with patients, nurses can champion dietary choices that can reduce the risk and impact of heart disease.  

Research underscores the importance of a balanced intake of nutrients to support the cardiovascular system's health, emphasizing whole foods, lean proteins, healthy fats, and a reduction in sodium, saturated fats, and sugars [3]. 

Patients adopting a heart healthy diet require a multifaceted approach, combining knowledge with actionable steps that are practical and sustainable. The role of healthcare professional is instrumental in this dietary transition.  

A heart-healthy diet offers a multitude of benefits beyond reducing heart disease risk. It can improve blood pressure control, lower cholesterol levels, promote healthy weight management, and enhance overall energy levels [2][3]. A heart-healthy diet can contribute to a stronger immune system, reduced inflammation, and improved mental clarity [46]. 

Introduction   

All children should grow and thrive in a caring, nurturing environment that meets their physical, emotional, and social needs. However, many are not so fortunate. Nearly every two in three Americans (64%) have experienced adverse childhood events (ACEs) (1, 2, 4, 5).  

ACEs are highly associated with future chronic health conditions, mental illness, premature death, and more (1). In fact, the more ACEs an individual has had, the higher their risk for having poor health outcomes as adults (13).  

Fortunately, there are preventive and protective measures that can be taken with the appropriate resources (1). With better awareness of ACEs and the right support in place, healthcare professionals can help improve the quality of life for a myriad of children and the adults they grow up to be. 

Definition 

Adverse childhood events, or ACEs, can occur from birth until age 18, and are great determinants of future health (1). These are any potentially traumatic events that happened to a child. ACEs are strongly linked to mental and physical disease in adults, contributing to at least half of the leading causes of death in the United States (1).  

The ACE score is a 10-item survey to identify any negative occurrences a person had before their 18th birthday (3). The higher a person’s ACE score, the more risk they have for an unhealthy adulthood (1,2). 

ACE was a term coined in a large-scale study published in 1998, describing them as childhood abuse and household dysfunction in seven specific areas (1, 2). In subsequent years, three more areas were added (3, 13). Altogether, the ten ACEs are comprised of the following examples of three broad categories:  

• Childhood abuse 

• • Psychological 

• • Physical 

• • Sexual 

• Household dysfunction 

• • Substance abuse 

• • Mental illness 

• • Parent treated violently. 

• • Family member incarcerated. 

• Neglect 

• • Emotional  

• • Physical  

Statistics and Demographics 

The initial adverse childhood experience (ACE) study, conducted in the late 1990s, included over 17,000 adult participants and revealed the following key demographic data (1, 2, 5):  

• Nearly 66% of women and 62% of men reported at least one ACE in their lives. 

• More than 1 in 6 people (17.3%) said they had experienced four or more types of ACEs.  

• Respondents’ races who reported ACEs were: 74.8% white, 11.2% Hispanic, 7.2% Asian/Pacific Islander, 4.5% black, and 2.3% other. 

• About 49% of those with college degrees experienced at least one ACE, compared to 44% without a high school diploma.  

• The age group who reported the highest incidence of ACEs was those from 35-49, where almost 70% had experienced at least one ACE. The lowest incidence was reported by those aged 65 and older, at 40%.  

• Of all women reporting ACEs, 25% said they endured sexual abuse, 30% witnessed substance abuse in the home, and 25% of the respondents’ parents got divorced.  

• Of all men reporting ACEs, 30% went through physical abuse, 24% saw substance abuse at home, and 22% of their parents were divorced.  

More recent data shows that at least 50% of the top causes of death in the US are associated with ACEs (6). As there is also a high association between ACES and depression, preventing these experiences could reduce adult depression by 44% (6).  

Causes and Risk Factors 

The causes of adverse childhood events are varied and multifaceted. They can stem from familial or communal challenges, often referred to as social determinants of health. Many of these determinants can cause ACEs, and may include (8):  

• Lack of access to healthcare or other resources 

• Financial difficulties 

• Homelessness or frequent moving 

• Discrimination 

• Any type of disrupted living situation  

As noted earlier, most of the American population has had some sort of adverse childhood experience. However, there are some factors that make it more likely for these to occur. Societal, communal, and familial cultures all play a role in adverse experiences.  

The following situations or conditions increase the likelihood of ACEs (7):   

Community Risk Factors: 

• High rates of poverty, crime, and violence 

• Limited educational, economic, and employment opportunities  

• Lack of community activities for youth 

• Unstable housing and frequent moves by community residents   

• Readily accessible alcohol and drugs 

• Frequent experiences of food insecurity  

Family and Individual Risk Factors:  

• Social or developmental disabilities or delays  

• Mental or chronic physical illnesses 

• A history of abuse experienced by caregivers themselves. 

• Youth dating or engaging in sexual activity early. 

• Single-parent families, particularly those with young caregivers 

• Low income and/or high economic stress 

• Low education levels 

• Children with few or no friends, or friends who partake in delinquent or aggressive behaviors 

• Caregivers with limited understanding of child development  

• Use of spanking or other corporal punishment as a form of discipline  

• Inconsistent discipline and/or little parental supervision 

• Families isolated from extended family, friends, and/or neighbors 

Cultural Considerations  

Though many people experience ACEs, some populations are affected disproportionately. This includes women and those in racial or ethnic minorities, who are at greater risk for experiencing 4 or more ACEs (6, 8). Specifically, African Americans, American Indians, and Alaska Natives (AI/AN) are far more likely to have multiple ACEs than any other race or ethnicity (9,10).  

The AI/AN community is a relatively young one, with poverty rates up to four times higher than the national average (10). Furthermore, the AI/AN group is often lumped together as “other” as a race category on surveys, making data harder to come by for this population (10).  

AI/AN children, when compared to the total US population, are more likely to have:  

• Parents who are divorced (33% versus 21%) 

• Lived with someone who abused a substance (24% versus 12%) 

• Witnessed domestic violence (15% versus 6%) 

• Lived with a parent who ultimately died (4% versus 2%) 

Lifespan Impact on the Individual 

While adverse childhood experiences affect most Americans, having been through four or more puts a person at significantly higher risk of health problems as an adult (1, 2, 9). In general, the more ACEs an individual has experienced, the more likely they will have poor outcomes later in life, with a specifically high correlation to diabetes, heart disease, obesity, depression, substance abuse, smoking, poor academic achievement, and early death (4).  

In fact, ACEs can reduce an individual’s life expectancy by as many as 20 years, compared to someone who has had zero ACEs (8).  

The original ACEs study was conducted to determine the link between childhood abuse and adult health risk factors (1). The conclusion was overwhelmingly that in the United States, the main causes of morbidity and mortality are related to many of the health behaviors exhibited by those who have experienced ACEs (1). More recent studies find that ACEs contribute significantly to substance abuse, violence, and self-harming behavior (11).  

At least 5 of the top 10 leading causes of death in the United States that are strongly related to ACEs include (9,11, 12):  

• Heart disease (#1 cause of death) 

• Stroke (#5) 

• Chronic lower respiratory diseases (#6)  

• Diabetes (#8) 

• Chronic liver disease and cirrhosis (#9) 

As far as mental health goes, the link with ACEs is clear: The higher one’s ACE score, the more likely they are to be depressed, experience impaired work performance, and have suicidal tendencies (13). Harmful behaviors associated with high ACE scores include smoking, drinking, and drug abuse, as these methods are often used to cope with past traumatic experiences (13).  

Societal Implications 

Adverse childhood events are preventable and have been shown to contribute to at least half of the leading causes of death in the United States (1, 9, 11). Thus, the impact of ACEs on public health is vast. Since the CDC considers ACEs a public health concern, it is of utmost importance to decrease their incidence (1). Through the reduction and prevention of ACEs, general public health would improve markedly, drastically cutting down on healthcare costs and resources (1, 5, 6, 9).  

The societal implications for reducing ACEs are manifold:  

• Dramatic reduction of preventable causes of death 

• Longer lifespans for the general population  

• Better mental health  

• More cost-effective physical and mental healthcare 

• Lower rates of disease and depression in the general population 

Ways to Mitigate ACEs 

Though ACEs are widely pervasive in American society, they need not be so. With proper resources and support systems, many -if not all- ACEs may be eradicated. The best way to mitigate ACEs would be to prevent them in the first place (4). This requires creating safe, stable, nurturing environments for children and their families (9). Furthermore, as ACEs can occur for a wide array of reasons, they need to be addressed at both the family and communal levels. 

With individuals, a first step would be prevention of ACEs in the home. This could involve a vast array of mental health, education, and social work services such as: home visits, parenting classes, therapy sessions, and more (8, 9). Different emotion management techniques and child development concepts could be taught to at-risk families, promoting bonding and trust between children and their caregivers.  

High-quality childcare and after-school programs with trusted adults can help mitigate ACEs as well (9). Screening for ACEs at regular intervals would also be helpful. This could include annual check-ups at the doctor’s office, visits with the school nurse or counselor, or a consultation with a home health provider. Medical management of physical and mental health conditions would be made available, including routine health screenings and necessary medications (4, 8, 9).  

At the community level, prevention could take the form of free education for family members, food and housing assistance, adequate access to healthcare services, and fostering safe neighborhoods (4, 9). Economic support for families could include family-friendly work policies, earned income tax credits, and so forth. Children could partake in community events like after-school clubs and sports, helping them build bonds with trusted and supportive adults.  

Three principles are the most helpful preventing long-term effects of ACEs, (4):  

• Reducing stress by ensuring basic needs are met, as well as tending to abusive situations, community crime, substance abuse, discrimination, and poverty. 

• Strengthening life skills can strengthen the resilience of children and their family members by practicing planning, focus, and self-control. 

• Building responsive relationships by having adults listen to their children and respond adequately to their needs, thereby fostering a safe, trusting relationship. 

Reporting ACEs 

Considering there are various types of ACEs, they can be difficult to identify and thus report. However, some are clear-cut. In situations where child abuse or neglect is occurring or suspected, a mandated reporter (e.g., nurse, teacher, counselor) would need to report it as soon as possible. If the child is in imminent danger, take them to a safe place and make a report.  

To report child abuse in the United States, call or text 1-800-4-A-CHILD (1-800-422-4453). The website is https://www.childhelphotline.org/.  

If there is suspicion that a child is being sexually exploited, the phone number to call is 1-800-THE-LOST (1-800-843-5678), and the website is https://report.cybertip.org/.  

To report human trafficking, call 1-888-373-7888, use TTY at 711, text BEFREE (233733), or visit the website at https://humantraffickinghotline.org/.  

For anyone experiencing feelings of self-harm or suicide, 988 is the national Suicide and Crisis Lifeline that can be called or texted. The website is https://988lifeline.org/.  

Support and Additional Resources 

While there is no single way to prevent ACEs from occurring, there is a plethora of resources available to help mitigate the effects and to educate others. Visting a healthcare provider can connect a patient to mental health professionals, support groups, or specialty services like social work and support groups (8).  

The Substance Abuse and Mental Health Services Administration (SAMHSA) has an abundance of resources on topics like trauma-informed care, early childhood mental health programs, Native Connections for the AI/AN population, school, and campus health, and much more. More information can be found at https://www.samhsa.gov/programs.  

Healthy Outcomes from Positive Experiences (HOPE) is a national resource center offering research, training, and technical assistance in order to better the lives of children and their families. Their website is https://positiveexperience.org/.  

The Centers for Disease Control and Prevention (CDC) offers ACE-specific information at this website: https://www.cdc.gov/violenceprevention/aces/resources.html.  

Conclusion

Adverse childhood events, or ACES, affect the majority of the American population. Strongly correlated with many leading causes of death, ACEs are preventable and warrant attention from healthcare providers and the general public alike. Fortunately, many resources exist at the individual, community, and national levels to provide care and prevention for these experiences.  

Though ACEs tend to lead to negative health outcomes, they need not condemn a person to lifelong problems. Through screening tools, community food and housing programs, mental health assistance, education, and adequate medical care, ACEs can be mitigated, well managed, and prevented.  

Despite the misfortune in a child’s life, there is still much hope available when they reach adulthood.  

Introduction

As nurses, we have been trained to perform ongoing assessments on patients with every encounter. Many patients have gone through traumatic events that often go undiscovered by the healthcare team.

A trauma informed care approach will help healthcare providers uncover past trauma. This will allow them to tailor a plan of care that helps alleviate patient suffering by decreasing overall stress and anxiety. When the healthcare team is aware of past trauma, they can avoid conversations and situations that could potentially re-traumatize the patient.

Trauma Informed Care 

Trauma is a human experience that can affect people from all different backgrounds and walks of life. There is no race, gender, sexual orientation, or social class that is immune to the far-reaching clutches of trauma. A traumatic event is an event that is marked by sexual violence, severe injury and/or death. These events can be first-hand accounts where the people themselves were the victims of the event.  

They can also be indirectly experienced by witnessing the event take place on another person. The event can also produce vicarious trauma when it happens to a close friend or loved one. No matter how traumatic an event was experienced, it can have severe and long-lasting effects (1). 

Despite the rising accounts of traumatic events, trauma informed care is an underused skill in the healthcare field. Those who support and use trauma informed care understand that there is a large population of people seeking healthcare services who have had past traumatic experiences. They are also aware that just by seeking out care, they have the potential of being re-traumatized.  

Empowering the patient to have control over their care through collaboration will help decrease the chances of re-traumatization.  

There are six principles of trauma informed care: 

1. Safety 
2. Trustworthiness and transparency 
3. Peer support 
4. Collaboration and mutual support 
5. Cultural and historical sensitivity  
6. Empowerment of voice and choice 

Trauma informed care runs parallel to ethics in the healthcare setting. It endeavors to ease the patient’s suffering by preventing re-traumatization and empowering the patient. (3)

Principles of Trauma Informed Care 

It is meaningful to explore each of the six principles of trauma informed care 

Safety 

In trauma informed care, safety pertains to both the psychological and physical safety of the patient and their family throughout their encounter with the healthcare organization. The goal is to prevent any form of re-traumatization. This is accomplished by creating safe spaces, access to services, and engagement between the patient and the healthcare team.  

One of the greatest aspects of safety in trauma informed care is environmental. This demands that the healthcare teams create an environment that is both welcoming and accommodating to all patients regardless of their diverse backgrounds. We must understand that patients who have undergone traumatic events can be hypersensitive to their environmental safety.  

The trauma informed care plan must be individually tailored and include communication initiatives that promote the patient’s self-identity and how they would like to be addressed (1).

Trustworthiness and Transparency 

Nursing has long been recognized as the nation’s most trusted profession. This has been accomplished through the intentional focus of patient advocacy. Nation-wide policies and safety goals have promoted diversity, equity, and inclusion. Initiatives to make sure that the patient understands and agrees with their plan of care, such as using their preferred language in plain and clear terms, is an example of how nurses build that trust.  

Using the concept of patient-centered care helps demonstrate transparency, which is a way nurses further build trust. True transparency can be accomplished through encouraging patients to be involved in their care. Asking patients if it is acceptable that we document their experiences and even share our notes or computer screens to demonstrate our desire to be transparent.  

Educating patients using the teach-back method also indicates our transparency as our knowledge becomes theirs (1).

Peer Support 

Contrary to popular beliefs, the goal of peer support in trauma informed care is not fixing the individual. Rather, the goal is to assist the individual to empower themselves by connecting them with supportive groups of peers that have similar experiences, culture, beliefs, and religion. Empowerment of the patient should be the goal of peer support. Traumatic stress is often accompanied by a re-traumatization cycle that can be interrupted and ultimately stopped through individual empowerment of the patient.  

These peer support groups often contain members who themselves have survived traumatic events. To have the best probability of success, the patient should leave behind former friends who enable the re-traumatization cycle and gravitate to the peer support group members. This can leave the patient with further feelings of loss and grief. This has to be considered when developing the plan of care for the patient (1). 

Identifying Past Trauma 

Trauma informed care does not mean that the care is tailored to a patient’s specific trauma. Nor does it mean that the team endeavors to heal or even address past trauma. Rather, in simple terms, trauma informed care recognizes that the patient has been through a traumatic ordeal and that the plan of care must take that trauma into account in order to properly care for the patient.  

The patient’s reaction and compliance may be affected by their past trauma. Past trauma needs to be identified and acknowledged. Past trauma can affect all aspects of a patient’s life. Identifying and acknowledging the trauma and how the patients then needed coping mechanisms may now have become detrimental to their health is important for the overall well-being of the patient.  

Through the identification of past trauma, the team can take the opportunity to ensure that the patient does not feel responsible for the life-altering trauma and understands that the trauma was not their fault. Identifying the trauma can lead to the revelation that there is a connection between past trauma and the patient’s current coping and functioning; this can change their overall perspective, thus changing their lives (4). 

Collaboration and Mutual Support 

Collaboration and mutual support demand that the entire healthcare team see the patient as both an equal partner and the expert in their own personal experiences. The patient should be allowed to both identify and prioritize their goals, then the healthcare team can work with the patient to for the plan of care with these goals at the forefront.  

Collaboration takes more time than the traditional healthcare “do as I say” method. It helps in the trust-building process and when done properly, it helps the patient to succeed as the goals have come from them. This is something that can also interrupt the re-traumatization cycle. It also increases the probability that the patient will be compliant with the plan of care and any after-care appointments and follow-ups (1,4). 

Cultural and Historical Sensitivity 

The entirety of the patient’s identity is surrounded in cultural and historical sensitivity. Not only does this encompass aspects such as race, gender, age, etc. but it also includes life experiences and relationships right down to the base familial associations.  

It also includes beliefs, core values and experiences in open spaces. When seeking healthcare, no matter the reason, all of these aspects of the patient’s identity are brought to the facility and laid in front of the healthcare team (1).  

Empowerment of Voice and Choice 

As discussed earlier in the peer support principle, empowerment is paramount in trauma informed care. Empowerment of voice and choice is perhaps the chief cornerstone and is present in all the other principles of trauma informed care. Trauma informed care empowers patients by making them feel heard and that their voice is important for their overall well-being.  

Though the healthcare team may not always agree, trauma informed care also enforces the concept that the patient’s choices are to be respected. Through the trauma informed care journey, the patient develops their ability to navigate the healthcare setting and becomes familiar with the language of the medical community.  

This further empowers the patient as they can understand the plan of care and become an active participant in that plan, as they were involved in both the planning and implementation. Further, trauma informed care creates a safe and supportive environment where the patient is allowed to grow and mature in their knowledge and understanding of themselves and their health (1).

Effects of Traumatic Stress 

Traumatic stress has shown to increase chronic illness, mental health issues and early death. When left alone, traumatic stress can morph into enduring stress. Some forms of enduring stress include: 

• Chronic stress – this happens when trauma is continuous over a long period of time. 

• Toxic stress – this is found in children who experience long-standing and/or frequent trauma such as emotional and physical abuse, neglect, and exposure to violence.  

Traumatic stress can have altering effects on multiple brain processes. This includes the neurologic, immunologic, endocrinologic, metabolic, inflammatory, and autonomic processes. Depending on which phase of brain development the patient is in when the trauma occurs, it determines the long-lasting effects.  

Repeated trauma can cause a hormonal cascade which can result in the allostatic load phenomenon. This phenomenon distorts the normal stress mediating processes.  

Traumatic stress often leads to self-destructive behavior. Drug and alcohol use/addiction, violence and risky behavior often follows those who have had traumatic stress events. There is a fear among traumatic stress victims that they may be judged for their choices and lifestyle (1). 

Adverse Childhood Experiences 

Nearly 40% of people have been exposed to adverse childhood experiences. Of course, adverse childhood experiences harm the overall health and well-being of the child; they also have a potential great impact on the physical and mental health of the person as they transition into adulthood.  

Adverse childhood experiences and childhood trauma have shown to leave the patient with an increased risk for developing leading causes of death and disability. These conditions include heart disease, stroke, cancer, and depression with suicidal ideation. Also, childhood trauma can lead to symptoms of chronic headache and pain as an adult (2). 

As most childhood trauma is perpetrated by someone known and close to the child such as a parent, relative or close family friend, the child is often left with an altered expectation of interpersonal relationships. This may lead to severe insecurity and distrust where negative personal perception especially in relation to others may develop.  

People who develop physical symptoms of past childhood trauma are often unable to adjust and move on post-trauma. On the other hand, those who are able to form positive relationships tend to have fewer physical symptoms and are more liable to have adjusted to childhood trauma. Childhood trauma can have long-reaching effects on the ability of the adult to form positive relationships and have normal responses to stressful situations (2). 

Trauma Informed Approach 

The trauma informed approach was born out of the research on adverse childhood experiences. The research showed that the more adverse childhood experiences that took place in the patient’s life, the more it affected their mental and physical health; even leading to early death.  

Trauma informed approach begins at the organizational level, where the culture must adapt to prevent re-traumatization. There are a few aspects that need to be incorporated into the organization’s training to accomplish the changes needed.  

The organization must put on trauma glasses and view the healthcare team through the trauma lens. There is a direct correlation between trauma and mental health; this needs to be acknowledged, accepted, and viewed as part of the care plan. 

In order for the trauma informed approach to be effective, the organization must realize that trauma expands beyond Post Traumatic Stress Disorder (PTSD). Rather, trauma incorporates a multitude of differing issues that can include mental, emotional, physical, and other multiple trauma sources.  

The healthcare professional who is assessing the patient should be trained in recognizing the signs of trauma and, if disclosed, be able to respond appropriately in the moment. Training needs to be done with all front-line staff who the patient may confide in. 

The healthcare team should be aware of resources that are available in the community and be able to refer the patient to those organizations. Being as trauma specific as possible so that the patient can connect in a meaningful way with this new support system. The organization should partner with these support groups to ensure easy transitioning from the institution to the community. 

The team should also prioritize the principles of trauma informed care. For instance, to promote trustworthiness and transparency, the team could limit the number of healthcare providers who will ask the patient to repeat the story of their traumatic experience. Turning to more collaborative communication and relationships between the team and the patient; allowing the patient to be actively involved in their plan of care also promotes the trauma informed care principles. 

Promoting safety within the organization for both the patient and the healthcare team also helps to change the culture to one of a trauma informed approach. Trauma survivors could be approached and asked to help design, implement, and evaluate the trauma informed approach to be used. What better way to get to know your community resources than to actively partner with them to help meet the needs of the organization’s patients. 

It needs to be recognized that not all patients who show similar symptoms to those of past trauma have gone through a traumatic event. There is no cookie-cutter plan of care, and all patients must be properly assessed to determine what their plan of care will be (6).

Impact of Trauma Informed Care 

The impact of trauma-informed care on the patient and on the healthcare system as a whole cannot be overstated. By understanding that a great deal of the patients who seek out healthcare services have undergone a traumatic event and tailoring the assessment with that in mind, an organization can minimize the occurrence of re-traumatization.  

When we understand how trauma has affected our patients’ lives, how they perceive the healthcare system and what their previous experiences within that system have been like, steps can be taken to ensure better outcomes within this population (1).

Nursing Implications 

In order for trauma informed care to be properly accepted and put into use in the healthcare setting, the culture must be transformed to be a trauma-informed culture. Nursing is with the patient around the clock and nurses have the ability to touch patient’s lives in the most impactful way.  

Here are a few considerations that pertain to the healthcare team but when used by nurses have the ability to transform the patient’s environment into a true trauma informed care setting. 

Introductions 

Even if the nurse believes that the patient knows who they are, it is important for the nurse to reintroduce themselves with every interaction. The patient generally has many different members of the healthcare team entering their space throughout their stay. Team members tend to meld into one anonymous face to the patient; the nurse by introducing and reintroducing themselves and their role to the patient will not only foster an understanding of who does what, but they will empower the patient to be engaged and involved in their plan of care. 

Body Language 

Body language is important when caring for any patient. When caring for a patient who has experienced trauma, this becomes even more impactful. Open body language sets the stage for trust.  

Trauma survivors may often feel a sense of being trapped or confined which may lead to an overall sense of powerlessness. Unintentional threatening body language magnifies these feelings and could bring on a re-traumatization episode. By contrast, non-threatening body language decreases the trauma center and leaves the patient calm and non-triggered.  

Trauma informed care body language includes being at the patient’s level; commit to sit or raising the bed so that both patient and nurse are at the same level. Knowing the environment and deescalating trauma by the nurse positioning themselves properly in relation to the patient and the door; allowing for both to access so that the patient does not feel confined. 

Anticipatory Guidance 

Past trauma may have been unpredictable or an outright surprise. Verbally telling a patient what will be expected during their stay will reassure them even if the coming procedure or test may cause pain. Sharing who will be part of their care during their stay will also set them at ease. Knowing and understanding the expectation further empowers the patient to be involved in their plan of care.  

The expectation, when known, decreases those feelings of surprise which could bring them back to that time of trauma.

Permission 

Touch can have an incredible impact on the patient who has experienced past trauma. Unwanted or inappropriate touch quite likely may have been a part of their traumatic experience. It can activate those traumatic memories and activate the re-traumatization cycle. Touch is also inevitable when it comes to the nurse/patient relationship.  

What the nurse can control is when the touch occurs. Touch should always be preceded by the nurse explaining what they are going to do and asking for the patient’s permission to touch them. Asking permission puts the ball in the patient’s court and empowers them as they are now given a choice and are in control of their body and space.  

Permission to touch the patient should never be assumed; permission should be asked every time the nurse needs to touch the patient. 

Protect 

In many cases, patients who have experienced trauma experienced it at the hand of someone that they know. Many times, the patient will not be alone in their room; family and friends are often present. Patient advocacy has always been the primary role of the nurse.  

As part of being an advocate for the patient, the nurse should protect the privacy and safety of the patient. Asking those present in the room to leave prior to discussing the patient’s plan of care is a way to protect both privacy and safety. The patient may not feel safe asking visitors to leave their room especially if they may have been involved in the prior traumatic episode.  

By asking visitors to leave, the nurse gives control back to the patient. In private, the nurse can ask who the patient is comfortable with remaining in the room. Once again, the patient is empowered. 

Clear and Consistent 

Realistic expectations are understood when given in clear and consistent language. This will also foster trust especially if the entire healthcare team is on the same page and vocalizing the same message, consistency. Using language that the patient understands is also paramount. Avoiding medical terminology and acronyms also builds trust as the patient knows that the nurse has made it their priority that the patient understands their plan of care. 

Universal Precaution 

Finally, trauma informed care needs to be a universal precaution regardless of if the patient’s past trauma history is known or not. By treating all patients as if they had experienced past trauma, those who have will be more apt to share the experience.  

Also, nurses will be less likely to start the re-traumatization cycle by inadvertently triggering an episode. It will help treat the patient without relying on the patient to disclose something that they may not yet feel comfortable sharing. (3)

Resources 

It is not easy to become a center where trauma informed care is practiced, it does not happen overnight. Trauma informed care is an intentional shift in culture at the facility and/or system level. Trauma informed training should be implemented, and the staff need to understand the “why” behind the training in order to buy-in.  

Trauma informed care not only helps the patient to be empowered and prevent re-traumatization, but staff that have undergone past traumatic experiences can also be helped once a facility adopts this culture. This culture should be at the forefront of both staff and leadership minds. Staff meetings, unit huddles and any other opportunity where leadership actively communicates with staff should incorporate the messaging of trauma informed care.  

Facilities should actively be hiring a trauma informed workforce. People from wide varieties of racial and cultural backgrounds should be on the interview panel. Questions pertaining to trauma informed care can and should be asked to pick up on skills and traits that will promote this culture. 

A few environmental factors to create the trauma informed culture include keeping doors and common areas well-lit, keeping noise levels low and having warm, cozy colors as decoration in common areas.

Below are some websites that can be visited in order to help kickstart the culture of trauma informed care: 

• https://TraumaInformedCare.chcs.org 

• https://www.creatingpresence.net/ 

• https://www.chcs.org/resource/key-ingredients-for-successful-trauma-informed-care-implementation/ 

• https://store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884 

(5) 

Conclusion

Though not a new concept, trauma informed care is essential to help patients who have had traumatic experiences navigate through the healthcare system. Trauma informed care empowers patients to take control of their care in collaboration with the healthcare team. Ultimately, the goal of trauma informed care is to prevent re-traumatization of the patient at the hands of the healthcare team.

The trauma background of any given patient is unknown when they arrive at the facility. It is the responsibility of the nurse to use trauma informed care to both assess the patient and create trust so that they will disclose the trauma. Once known, the team will be able to work together with the patient to prevent further trauma and have positive outcomes.

Introduction   

Lewy body dementia is one of the more common causes of dementia. Currently it is the second most common dementia disorder following Alzheimer’s disease [2]. This condition is shown to affect more than 1.4 million people in the United States [1] [2]. Of dementia cases in older adults, Lewy body dementia is said to make up 5% of people with dementia [2]. Lewy body dementia is a disorder that progresses over time [1]. The progression of the disease differs between individuals and the severity of the symptoms [1].  

On average an individual lives between five to eight years after diagnosis [1]. Currently there is not a cure for this disease [1]. This course will examine the causes of this disease, signs and symptoms patients might experience, diagnostic tests, types of management, and educational resources for family members. This course is designed to inform nurses about this common disease and to use this information in their daily practice to care for their patients.  

Definition

Lewy body is an umbrella term that includes two separate diagnoses: Dementia with Lewy bodies and Parkinson’s disease dementia [5]. As these diseases progress, they develop together and are seen as one entity, not two separate conditions [4]. Lewy body dementia is a condition that involves neurocognitive disorders that include hallucinations, memory loss, behavior changes, and parkinsonism features [2]. This disease can also affect intellectual abilities and cause individuals to act out dreams during REM (rapid eye movement) sleep [2]. REM sleep behavior disorder sometimes may be experienced before any other symptoms are exhibited [2].   

Lewy body dementia is known for a buildup of deposits of alpha- synuclein proteins called Lewy bodies [1]. Diagnosing this condition can be difficult because many neurological disorders have similar symptoms. Lewy body dementia and Parkinson disease dementia are very similar. For a diagnosis of Lewy body dementia, there must be a cognitive impairment with motor symptoms occuring in less than 12 months [3].  Parkinson’s disease dementia affects an individual’s movements; cognitive symptoms appear later (greater than one year) [5].  

Lewy body dementia is known to affect older adults generally between the ages of 50 and 85 [2]. This disease is said to be underdiagnosed due to a large number of diagnoses occuring post-death during autopsies [4]. Several medications used to treat neurocognitive and behavioral symptoms in other conditions can worsen the symptoms of Lewy body dementia [4]. Therefore, an accurate diagnosis can impact an individual’s quality of life.  

Epidemiology 

Lewy body dementia affects a significant number of individuals in the United States. This condition is found more often in men than women [4]. Age is thought to be the greatest risk factor for an individual developing this disease [4]. An individual who has a family history of Lewy body dementia and Parkinson’s disease is at a higher risk for developing this condition [3].

Lewy Body dementia is more widespread in European, Asian, and African ethnic groups [3].  In individuals with Parkinson’s disease, the incidence of Parkinson’s disease dementia is said to be around 25-30% [4]. The incidence of individuals with Parkinson disease developing this type of dementia after having Parkinson’s for more than 20 years increases to around 83% [4].  

Pathophysiology 

There is a buildup of alpha- synuclein proteins that causes neurons to die in Lewy body dementia [2] [5].  As mentioned above in this course, this buildup of proteins is called Lewy bodies. The death of neurons that produce dopamine result in problems with movement, cognitive impairment, a decline in cognition, and sleep disturbances [4].  In Lewy body dementia there is a deficiency of acetylcholine [3]. There is also a decrease in acetylcholine with Alzheimer’s disease, but the deficiency is greater with Lewy body dementia [3]. The decrease in neurons that produce acetylcholine causes memory loss and learning impairment [4].  

The mutation of synuclein alpha and synuclein beta genes can cause dementia with Lewy bodies [2]. Mutations in apolipoprotein E and GBA genes are potential risk factors for developing the disease [2]. There have been cases where a buildup of alpha-synuclein was found during an autopsy, but the individual did not show any clinical signs of Lewy Body dementia when alive [4]. The function of these proteins in this condition is still undetermined [5]. 

Etiology 

The exact cause of Lewy body dementia is still unknown. While research is ongoing and new developments are occuring, the specific cause has not been determined. The accumulation of Lewy bodies cause cell death which causes symptoms, however, the reason for the buildup of Lewy bodies is still under research [5]. As mentioned earlier, there are specific gene mutations that have been shown to increase the likelihood of producing altered alpha- synuclein proteins, in turn causing them to clump together (forming the Lewy bodies) [2].  

The mutation of the GBA gene interferes with the function of lysosomes, which can affect the breakdown of the alpha- synuclein proteins, causing the proteins to accumulate [2]. The e4 allele type of the APOE gene has been shown to increase the risk of developing Lewy body dementia [2]. These clumps of Lewy bodies form inside and outside of neurons in different areas of the brain, where they can alter the function of the cell and can cause the cell to die [2].

The neurons that develop the neurotransmitter dopamine are especially impacted by these clumps of Lewy bodies, which was addressed earlier in this course [2]. Further research is required to find out why these Lewy bodies develop in certain individuals. Currently, age, genetics, and environmental factors are some of the greatest risk factors [3]. 

 ​

Clinical Signs and Symptoms 

Lewy body dementia is a progressive disorder - the signs and symptoms worsen over time. The symptoms that are more common are sleep changes, impaired behavior, movement, and cognition [5]. Research shows that the location of Lewy body accumulation impacts the clinical signs and symptoms the individual experiences [3]. If Lewy bodies develop in the brainstem and cerebral cortex first, the condition is called dementia with Lewy bodies, and the onset of the dementia is early [3]. If Lewy bodies accumulate in the brain stem and then develop into the cerebral cortex as time passes, the onset of dementia appears later, and this condition is called Parkinson’s disease dementia [3].  

Rapid Eye Movement Sleep Behavior Disorder 

Rapid eye movement (REM) sleep behavior disorder is sometimes the first clinical sign of dementia with Lewy bodies [2]. Individuals with this disorder move and talk while dreaming in their sleep [2]. The movements can be violent and cause the individual to fall out of bed [5]. Individuals may kick, punch, and scream in REM sleep (the second half of their sleep) [4]. REM sleep behavior disorder is seen in 76% of patients with dementia with Lewy bodies [4].   

This disorder can cause fractures and contusions in some individuals resulting from falling out of bed [4]. This can not only affect the individual, but also the sleep partner of the patient [4]. In some cases, separate sleeping arrangements are needed for the safety of the individual and their sleeping partner. A questionnaire by the patient and sleep partner is part of the diagnosis of REM sleep behavior disorder [14]. If the individual does sleep next to someone, this questionnaire can be helpful as most of the time the patient cannot recall the events while asleep [14]. Video polysomnography is required for a complete diagnosis of this disorder [14]. These events while asleep must be repeated to meet the diagnostic criteria [14]. 

Other Sleep Disorders 

Other disorders of sleep include sleepiness in the daytime, restless leg syndrome, confusion when awakened, and obstructive sleep apnea [4]. 

Visual Hallucinations 

Visual hallucinations are present in about 80% of individuals with Lewy body dementia [1]. Visual hallucinations are a core clinical symptom of dementia with Lewy bodies [4]. They are more common in women than in men [4]. Individuals are aware of these hallucinations and can tell others what they experienced [4]. Visual hallucinations are vivid to individuals and have been said to range from people walking around the house to seeing people that have died sitting next to them [6]. During the beginning stages of the disease, the hallucinations do not seem to affect the patient as much as when the disease progresses [6]. Patients are said to be afraid of these hallucinations in the later stages of the disease [6]. Nonvisual hallucinations are less common, however can occur in some patients [1]. These hallucinations include smelling or hearing something that is not in their surroundings [1]. 

Fluctuation in Cognition 

Fluctuation in cognition is also a clinical sign that is associated with dementia with Lewy bodies [4]. This symptom includes changes in attention, concentration, and alertness [5]. These changes are random and can differ day-to-day [1]. Symptoms can include delirium, and mimic symptoms that are caused by metabolic diseases, which can further the difficulty with identifying the correct diagnosis [4]. To diagnose dementia with Lewy bodies, one of the episodes must be confirmed [4]. These fluctuations can be present in other forms of dementia in their later stages but when present in earlier stages, they point to dementia with Lewy bodies [4].  

Memory loss that impacts activities of daily living can be found in later stages of Lewy body dementia [1]. Memory loss early on is more often a characteristic sign of Alzheimer’s dementia [1]. Confusion about the individual’s whereabouts, and inability to multitask can also occur in dementia with Lewy bodies [4]. 

Problems with Movement 

Problems with movement are signs of Lewy body dementia. Bradykinesia (slow movements) and rigidity occur in about 85% of individuals with dementia with Lewy bodies [4]. Tremor at rest is less common in individuals with this condition [4]. Loss of coordination and difficultly swallowing can occur [1]. Problems with movement greatly increase the risk of falls for these individuals [4]. This can place strain on the individual’s caregivers [4]. 

Autonomic Dysfunction 

Autonomic dysfunction can be present in dementia with Lewy bodies and Parkinson’s disease dementia. This symptom is seen in about 90% of patients with Lewy body dementia [4]. The symptoms that result from autonomic dysfunction can be constipation, urinary incontinence, orthostatic hypotension, erectile dysfunction, and dizziness [1] [4]. Orthostatic hypotension appears as early as five years prior to the diagnosis of Lewy body dementia [4]. Syncope and falls are usually the result of orthostatic hypotension [4]. Constipation can also occur earlier in the disease process [4]. 

Diagnostic Tests and Evaluations  

Throughout this course, it has been mentioned that Lewy body dementia is significantly underdiagnosed. Individuals are usually diagnosed as the disease progresses due to the symptoms that overlap with other forms of dementia and other neurological and psychiatric disorders [3]. An autopsy of the brain after death is one of the only ways to have a conclusive diagnosis of Lewy body dementia [16]. There are certain diagnostic criteria and diagnostic tests that are used to diagnose an individual with Lewy body dementia. 

Diagnosis by Symptoms 

Lewy body dementia is probable when an individual experiences dementia and two main features of the disease. Lewy body dementia is a potential diagnosis if the individual experiences progressive dementia and one main feature of the disease [3]. As discussed in the clinical signs and symptoms section of this course, key features of Lewy body dementia are cognitive fluctuations, dementia that progresses, problems with movement (signs of parkinsonism), REM sleep behavior disorder, and visual hallucinations [3] [16].  

Timing of symptoms is relevant for distinguishing between the two forms of Lewy body dementia [3]. Currently healthcare providers use the time span of one year to distinguish the two forms [3]. If dementia occurs within one year of the appearance of movement problems, then a diagnosis of dementia with Lewy bodies is used [3]. If an individual is diagnosed with Parkinson’s disease and starts experiencing symptoms of dementia more than one year after their Parkinson’s diagnosis, then Parkinson’s disease dementia is used [3]. Some indicative biomarkers in addition to clinical symptoms are used in diagnosis [4]. Some of these biomarkers can be found in cerebral spinal fluid (CSF) and are still under research [4].  

Cognitive Tests 

Cognitive testing can be used to show the cognitive impairment of patients with Lewy body dementia [3]. The Mini-Mental State Examination can be used as an initial screening test [4]. This exam tests cognitive function by focusing on concentration, orientation, and memory [15]. This test can be limited since symptoms of these patients can fluctuate day to day [3]. Another cognitive function test is the Montreal Cognitive Assessment (MoCA) [15]. Providers do not usually diagnose based on a single test; instead, they use the results to look for other signs and symptoms of Lewy body dementia [4]. 

Imaging Tests 

There are certain imaging tests that can help with diagnosis and distinguishing between other dementia disorders. A single-photon emission computerized tomography (SPECT) scan can help support a diagnosis [16]. This is a nuclear scan that can sense radioactivity [16]. If the SPECT scan shows a reduced dopamine transporter uptake in the basal ganglia, this can be a sign of Lewy body dementia [16]. This will separate the diagnosis between Lewy body dementia and Alzheimer’s disease [4]. Performing this scan alone will not lead to a possible diagnosis of Lewy body dementia; however, in combination with other diagnostic tests, the scan can lead to a more certain diagnosis [4]. Results from these scans can appear normal initially, and the scan may need to be repeated [4].  

An iodine- MIBG myocardial scintigraphy can be performed to support Lewy body dementia [16]. This would show decreased communication of cardiac nerves [16]. The results may be skewed by heart disease or certain drugs [4]. A CT or MRI may be used but these imaging tests can present mixed results [4]. With Alzheimer’s disease, significant atrophy is seen in the medial temporal lobes [4]. There is normally minimal atrophy in Lewy body dementia [4].  

As mentioned earlier in the course, video polysomnography is needed for the diagnosis of REM sleep behavior disorder [14]. This sleep study without the loss of muscle tone can also point towards a diagnosis of Lewy body dementia as REM sleep behavior disorder has now moved to a key feature of this disease [14]. 

Case Studies 

Case Study #1 

A 74-year-old male presents to his primary care provider after his wife reports abnormal behavior over the past several months. His wife reports the patient kicks and screams during sleep. The patient reports seeing little people walking around the living room during the day. The wife states the patient some days will fall asleep throughout the day while completing activities.  The patient states difficulty walking and muscle stiffness.  

The wife states last week the patient was supposed to go to the local grocery store to buy milk. After two hours passed, the wife called her husband as she was worried about him. He states he got lost finding the grocery store and did not know where he was. The wife said she had to drive to find her husband and bring him home. The patient also reports dizziness when standing. After the nurse obtained an orthostatic blood pressure, the patient was positive for orthostatic hypotension. 

• Which form of dementia is the patient most likely experiencing? 
• What type of symptoms is the patient experiencing that would point to that diagnosis? 
• What diagnostic tests or evaluations should the patient undergo? 
• What types of supportive treatment should the healthcare provider include in the treatment plan for this patient? 

Case Study #2 

A 70-year-old female presents to the emergency department via EMS after falling at home. The patient’s daughter called 911 after finding her on the floor when going to visit her. Upon arrival at the emergency department the patient is oriented to self. The patient does not know where she is or what happened to precipitate the fall. The patient has a past medical history of hypertension, diabetes type II, and Parkinson’s disease.  

The patient was diagnosed with Parkinson’s disease two years prior. The daughter states the patient has been forgetful lately and not acting like herself. The daughter reports that her mom’s behavior is different from day-to-day. An MRI and the National Institutes of Health Stroke Scale (NIHSS) are used to rule out a cerebrovascular accident. A complete blood count (CBC), a complete metabolic count (CMP), and urinalysis are obtained. The patient suffered a contusion to her right cheek and a right radius fracture. The patient states that she sees figures dancing in the room and smells popcorn. The patient appears to be frightened by the hallucinations. The patient’s daughter states for the last six months the patient has had difficulty swallowing and a reduced appetite.  

• Which form of dementia is the patient most likely experiencing? 
• What would the MRI of the patient most likely show? 
• What clinical signs of dementia is the patient exhibiting? 

Management 

Currently there is not a cure for Lewy body dementia, only supportive treatment. The management of this disease involves a multifaceted approach, including therapies, pharmacological treatments, and family support. 

Therapies 

Specific therapies can help with symptom management and help improve the individual’s quality of life. Occupational therapy can help improve a patient’s ability to complete activities of daily living. Speech therapy can help with swallowing coordination and improve the clarity and volume of speech [5]. Physical therapy can aid patients with problems with movement [5]. Mental health counseling can help individuals and their families with managing behaviors and their emotions [5]. 

Medications 

Pharmacotherapy can help with supportive treatment but can also worsen symptoms if certain medications are taken. Below are some examples of medications that are used by patients with Lewy body dementia. 

• Cholinesterase Inhibitors are used to help cholinergic activity to improve cognitive function [6].  

• Rivastigmine was one of the first of these drugs to be tested [6]. Patients were noted to have improved on their cognitive exams [6]. It is also shown to reduce hallucinations and lessen anxiety [6]. This class of drugs has been said to improve the quality of life for some patients [4].   

• Donepezil and Galantamine are also used to reduce dementia symptoms of hallucinations [6]. These drugs were initially targeted for patients with Alzheimer dementia, however, they are effective for individuals with Lewy body dementia as well [3]. A study was done stating even if there is not a sign of cognitive improvement, this should not be the criteria to stop the medication as this medication has been proven to protect the individual from further impairment of cognition [4]. 

• Atypical Antipsychotics are prescribed to patients that are not seeing a reduction of symptoms while on cholinesterase inhibitors [3]. These types of drugs are seen as controversial due to the many adverse effects that have been seen in patients [4]. Drugs such as haloperidol and olanzapine should be avoided in patients with Lewy body dementia as they can cause neuroleptic malignant syndrome (a life-threatening condition) [5]. Quetiapine, clozapine, pimavanserin, and aripiprazole are atypical antipsychotic drugs that can be used to improve agitation and help prevent cognitive fluctuations [5]. 

• Carbidopa-Levodopa can be used in patients to manage problems with movement [3]. This medication can cause side effects and can result in hallucinations, delusions, and increase confusion [3]. Providers should begin with low doses of this medication [3]. 

• Clonazepam is a benzodiazepine that can lessen the REM sleep behavior disorder that patients with dementia with Lewy bodies can experience [5]. Between 33-65% of patients with REM sleep behavior disorder can experience an injury while sleeping [5]. This medication has been proven to decrease injuries that occur during sleep [5]. Clonazepam can adversely affect individuals with gait disorders or sleep apnea [5]. 

• Melatonin is a hormone that can be used for patients that are affected by REM sleep behavior disorder (5). Studies have shown that the use of melatonin lessened the frequency and the severity of symptoms associated with REM sleep behavior disorder [5]. Melatonin can have side effects such as headaches in the morning, sleepiness during the day, and hallucinations [5]. 

• Memantine is used to treat dementia symptoms [5]. This medication is an NMDA receptor antagonist that stops effects of glutamate in the brain [5]. Memantine has been shown to improve symptoms of patients early in the disease [5]. 

Nursing Care 

As mentioned before, there is not a cure for Lewy body dementia. Caring for patients with Lewy body dementia includes supportive treatment. Nurses can play a significant role in caring for these patients and providing the family with support. Home health nurses can help with frequent assessment of the patient and their environment [3]. Environmental changes may be needed to protect the patient from falls and other accidents. Home health nurses can assess the type of assistance the patient would benefit from.  

Nurses can aid the family by providing education to assist in how to care for the patient. Family members and caregivers must be aware of the changes in behavior, fluctuations in cognition, and hallucinations that the individual might experience [3]. Nurses must also provide education to the caregiver of the patient on the side effects of certain medications, as they can affect an individual with this disease [7]. 

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Family Support 

Lewy body dementia is growing in recognition; however, many people might not be aware of this condition and the disease process. Family members need support from health care professionals to better care for their loved ones. Support can come in the form of education and preparing the family for the symptoms the individual may experience. The cognitive function of patients with this disease can be very limited [3]. Family members must be educated on monitoring the individual closely to promote safety [3]. These individuals are at a high risk for falling and developing aspiration pneumonia (due to swallowing difficulties) [3]. Family members should be educated in preparing for an emergency.  

Individuals with Lewy body dementia may need care and the family needs to know how to inform health care providers of their specific needs. It is important to educate family members that their roles in their past relationship with the patient will likely change due to the disease process. To prevent caregiver burnout, family members must be aware of their limitations and know when they need help [7]. Modifying the patient’s home may be needed for patient safety [3]. Each patient may have specific needs and family members should know what modifications may be necessary [3].  

Prognosis 

The prognosis of Lewy body dementia can be viewed as poor. As mentioned briefly earlier in this course, this disease is progressive and after diagnosis, the life expectancy is five to eight years [3]. The range of expectancy has also been attributed to delay in diagnosis, which can further delay supportive treatment to improve quality of life for the individual [3]. Patients can die from complications from the disease. Complications can include cardiac complications, falls, adverse effects from medications, pneumonia, and suicide [3].  

Compared to Alzheimer’s dementia, the risk of hospitalization or death due to respiratory infections is higher in patients with Lewy body dementia [8]. The median age at death is said to be similar between patients with Alzheimer’s dementia and Lewy body dementia [8]. The life expectancy from diagnosis to death is shorter in patients with Lewy body dementia [8]. The patient’s environment has been shown to play a role in the increased risk of mortality [8]. Patients in nursing homes have been shown to have a higher risk of mortality [8]. Caregivers can decrease the risk of complications by educating themselves on this disease and keeping their loved ones safe. 

Resources for Family Support  

Lewy body dementia is a diagnosis that can affect all aspects of an individual’s life and their family members lives. As nurses we must provide support for family members so they can better care for their loved ones and improve their quality of life. As recognition of this condition grows, family support resources are increasing. The Lewy Body Dementia Association is a nonprofit organization that raises awareness and provides support for families with individuals that suffer from Lewy body dementia [10]. Support groups can be found on their website to help families across the country in their local area [10].  

The Lewy Body Dementia Association was started by caregivers of individuals with this condition. They also focus on education and research into the disease. This association is a resource for family members [10]. 

Another resource for family members is The Lewy Body Dementia Resource Center. This is a nonprofit charitable organization that gives assistance and support to those who care for someone with Lewy body dementia [9]. This organization was founded by caregivers of individuals with Lewy body dementia. They have a support phone line that is available seven days a week to answer questions [9]. They also promote research and early diagnosis of this disease [9]. 

Research Programs 

Lewy body dementia is the second most common form of dementia in the United States [4]. This illness is thought to be underdiagnosed and commonly mistaken for other neurological disorders [3]. Research on Lewy body dementia can decrease the time it takes to diagnose a patient, and can help with management of the condition.  

The National Institute of Neurological Disorders and Stroke provides support for a variety of research endeavors for Lewy body dementia [11]. In 2021 The National Institute of Health spent $93 million dollars on Lewy Body dementia research [11]. One program is the Biomarkers for Lew body dementias program. This program aims to increase clinical data collection from patients with this condition, find biomarkers to expand further research, and allow access to the science community to help with further studies [11]. Another program is the Parkinson’s Disease Biomarkers Program. This program’s purpose is to collectively research with healthcare professionals, patients and family members, and technology professionals to increase biomarker research [11]. 

Biomarker research has been increasing in Lewy body dementia. A biomarker is a feature that can specifically indicate a certain disease [12]. For quite some time there were not any identified biomarkers for Lewy body dementia. There are certain biomarkers that aid in distinguishing Alzheimer’s disease from Lewy Body dementia [13]. These biomarkers can be assessed through imaging or in cerebral spinal fluid [13]. Currently these biomarkers are only helpful if another disease is doubtful [13].  

New biomarkers are needed to separate Alzheimer’s dementia from Lewy Body dementia and other neurological disorders [13]. Biomarkers that can help with early diagnosis would be beneficial for early treatment [13]. 

Conclusion  

Lewy Body dementia affects 1.4 million Americans [2]. The disease is underdiagnosed and often diagnosed incorrectly. Incorrect diagnoses can lead to worsening of symptoms and the administration of drugs that can lead to adverse effects.  

Educating healthcare providers and the community about Lewy body dementia can improve quality of life for individuals with the disease. As nurses, we must be informed about this disease to better educate our patients and their caregivers, and to know how to advocate for our patients.  

Introduction   

A lupus diagnosis and the complications that arise can be devastating for patients. Nurses are often looked to for support and answers, so it is important to educate ourselves on these serious conditions. Lupus nephritis (LN) is considered one of the most severe organ manifestations of the autoimmune disease systemic lupus erythematosus (SLE). Essential knowledge on lupus nephritis includes the defining features, epidemiology, pathophysiology of normal kidney function and lupus nephritis, clinical presentation, and treatments.

Lupus Nephritis 

Lupus nephritis (LN) is an organ manifestation of the autoimmune disease systemic lupus erythematosus (SLE). The cause of lupus erythematosus is not known. Researchers suggest a genetic predisposition, but a genetic link has not been identified (2). This is a difficult reality, as patients and healthcare providers usually hope for a why. We will discuss the definition, prevalence, pathophysiology, manifestations, clinical diagnosis guidelines, and treatment regimens for LN.  

Definition 

Lupus nephritis (LN) is considered a condition and a manifestation. LN is one of the most severe organ manifestations of the autoimmune disease systemic lupus erythematosus (SLE). LN is a form of glomerulonephritis, which is inflammation of the glomeruli (the tiny filters within the kidneys). This inflammation causes significant imbalances within the body due to impaired kidney function.

Overview of Systemic Lupus Erythematosus (SLE) 

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by a loss of immune tolerance of endogenous nuclear material, which leads to systemic autoimmunity that may cause damage to various tissues and organs (1). Essentially, the damage to DNA structures causes the body’s immune system to be incidentally programmed to attack its own tissue. There are two types of lupus: systemic lupus erythematosus and “discoid” lupus erythematosus. SLE is systemic, meaning it can affect almost any organ system or tissue and presents in different manifestations impacting the skin, joints, kidneys, and brain (2). “Discoid” lupus erythematosus only affects the skin tissue. Our focus will be on systemic lupus erythematosus (SLE) as we gain a deeper understanding of lupus nephritis.  

The causes of SLE are unknown but many attribute it to genetic, environmental, and hormonal factors. SLE is hard to diagnose because the symptoms are often mistaken for those of other conditions. There is no cure for SLE, but symptoms can be managed. SLE presentation and prognosis are highly variable, with symptoms ranging from minimal to life-threatening. Patients with lupus may experience periods of exacerbation of symptoms, sometimes called 'flares', as well as periods of remission. SLE is associated with substantial morbidity and mortality, particularly caused by renal and cardiovascular disease and infections. LN is considered one of the most severe manifestations of SLE.  

SLE can be compared to a guard dog intended to protect your home. The guard dog (immune system) protects you from unwanted intruders (infection), but also bites friends, family, and the mailman (your own organ tissue)!

Epidemiology and Statistical Evidence of Lupus Nephritis 

Systemic lupus erythematosus has an estimated prevalence of about 10–150 per 100,000 persons (2). However, a large number of people could be undiagnosed due to being asymptomatic or the symptoms mistaken for other diseases. An average of 40% of SLE patients develop lupus nephritis (LN). Those diagnosed with SLE at a younger age are at a higher risk of developing LN and other complications (1). 

SLE in general is more prevalent in women, especially women of reproductive age, than in men; the ratio is 9:1 (1). Therefore, 90% of SLE cases are women. However, men who have been diagnosed with SLE more commonly develop LN than women with SLE. Numerous studies have also found that the prevalence of LN in patients with SLE is higher in African American, Hispanic, and Asian populations (1). The impact of SLE disproportionately affects children and adults living in poorer geographic areas (8).  

Within 10 years of the initial SLE diagnosis, 5–20% of patients with LN develop end-stage kidney disease and the multiple comorbidities associated with immunosuppressive treatment (1). Mortality in LN is quite variable ranging in between 15% and 25% (6). It is important to remember that the treatments are also very risky because it is difficult to balance the risks and benefits of suppressing the immune system. LN is a topic of significant research, so nurses can have a meaningful impact in raising awareness and encouraging hope for more advanced treatment development.

Normal Kidney Function 

The kidneys have several life-sustaining functions. The kidney serves to maintain fluid and chemical homeostasis and to contribute to hemodynamic stability (3). The renal tubules of the kidneys have unique and vital roles. Daily urine output is about 1–2 L, and over 98% of the glomerular filtrate is reabsorbed by the renal tubules (3).  

There is a delicate balance and interdependency between the kidneys and other organs. For example, the kidneys produce hormones that help regulate blood pressure and control calcium metabolism, the kidneys also release a hormone that stimulates red blood cell production. A simple and fun mnemonic formula to help you remember the vital functions: A WET BED. 

A WET BED: Functions of the Kidneys 

A - controlling ACID-base balance 

W - controlling WATER balance 

E - maintaining ELECTROLYTE balance 

T - removing TOXINS and waste products from the body 

B - controlling BLOOD PRESSURE 

E - producing the hormone ERYTHROPOIETIN 

D - activating vitamin D 

Controlling acid-base balance 

• Our bodies always have a state of delicate equilibrium among the acids and bases, which has a parameter known as pH.  

• The kidneys excrete or retain acids and bases when there is an excess or lack of them.  

• The normal pH of the blood is 7.35 to 7.45. 

Controlling water balance 

The kidneys regulate the volume of urine produced and adapt to one’s hydration level to maintain water balance.  

Maintaining electrolyte balance 

The kidneys filter specific electrolytes from the blood, return them back into circulation, and excrete excess electrolytes into the urine. Kidneys maintain electrolyte balances like sodium and phosphate. 

Removing toxins and waste products from the body 

The kidneys remove water-soluble waste products and toxins and excrete them in urine.  

Controlling blood pressure 

The kidneys produce an enzyme called renin, which converts the angiotensinogen produced in the liver into angiotensin I, that is later converted in the lungs into angiotensin II. Angiotensin II constricts the blood vessels and increases blood pressure. Another way the kidneys help reduce elevated blood pressure is they produce more urine to reduce the volume of liquid circulating in the body to compensate. 

Producing the hormone erythropoietin 

The kidneys produce a hormone called erythropoietin, which aids in the creation of more red blood cells (erythrocytes), which are vital for the transport of oxygen throughout all the tissues and organs. 

Activating vitamin D 

The kidneys transform calcifediol into calcitriol, the active form of vitamin D.

Anatomy and Physiology of the Kidneys 

It is important to review the anatomy and physiology of the kidneys. The urinary system as a whole is composed of two kidneys, a pair of ureters, a bladder, and a urethra. The kidneys are located at the back of the abdominal wall and at the beginning of the urinary system. The size of each kidney is dependent on age, sex, and height, but the average length is approximately 10–12 cm, and the right kidney may be slightly smaller than the left kidney (3). The kidneys are made up of nephrons, which are microscopic structures composed of a renal corpuscle and a renal tubule.  

The average human kidney is composed of approximately one million individual functioning nephrons, each containing a single glomerulus or filtering unit (3). The function of filtration is accomplished by three major components of nephron activity: (1) glomerular filtration, (2) tubular reabsorption, and (3) tubular secretion. These components respond to factors including renal blood flow, neuroendocrine effects, and the fluid and nutrient supply to the body. 

Vascular Structure of the Kidneys