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Illinois Implicit Bias

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. 

Illinois Sexual Harassment Training for Nurses

In this Illinois sexual harassment training for nurses, we will discuss sexual harassment in the nursing profession.  This course will cover topics required by the Illinois Department of Financial and Professional Regulation (IDFPR) and the Illinois Board of Nursing.

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.

Illinois Alzheimer’s and Dementia Training

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.   

Quality Improvement for Nurses

Introduction   

Welcome to the world of Quality Improvement (QI) in healthcare, a dedicated field committed to continually enhancing patient care and outcomes. Quality Improvement involves a systematic approach to identify, analyze, and address areas for improvement within healthcare processes, ultimately resulting in improved patient safety, satisfaction, and overall healthcare excellence (13). In this course, we will embark on a journey to explore the fundamental principles and practical applications of QI, explicitly tailored for nurses who aspire to make a positive impact in their healthcare settings.

As a nurse, you know the significance of providing high-quality patient care. However, you may wonder how you can actively contribute to improving the systems and processes in your workplace.

Imagine this scenario: You observe a recurring issue with medication administration, where doses are occasionally missed due to workflow inefficiencies. Through this course, you will acquire the knowledge and skills to apply QI methodologies like Plan-Do-Study-Act (PDSA) cycles to investigate such issues, implement changes, and monitor the impact of your interventions. By understanding QI principles and tools, you will be better equipped to collaborate with your colleagues, drive meaningful improvements, and ensure that your patients receive the best care possible.

What is Quality Improvement?

Quality Improvement (QI) in healthcare represents an ongoing, systematic effort to elevate the quality of patient care and healthcare services that involves identifying areas needing improvement, implementing changes, and evaluating the effects of those changes to ensure better patient outcomes (12).

Let’s envision a scenario where a hospital's surgical department grapples with a higher-than-average rate of post-operative infections. Through a QI initiative, the healthcare team can meticulously scrutinize the surgical processes, pinpoint potential sources of infection, and introduce evidence-based practices such as enhanced sterilization techniques or more rigorous antibiotic prophylaxis protocols. Over time, they can gauge the effectiveness of these changes by monitoring infection rates for a reduction.

Commonly used QI methodologies in healthcare include the DMAIC (Define, Measure, Analyze, Improve, Control) process and the Plan-Do-Study-Act (PDSA) cycle. These approaches provide structured frameworks for healthcare professionals to tackle issues systematically and iteratively. For example, imagine a bustling primary care clinic with extended patient wait times.

Here, the PDSA cycle can come into play using the systematic iterative steps below:

1. The team defines the problem (lengthy wait times)
2. The team proceeds to test a change (for example, adjusting appointment scheduling)
3. The team then scrutinizes the results and acts accordingly to refine the process.

History and Background of Quality Improvement 

The history and background of Quality Improvement (QI) in healthcare have a rich and evolving timeline, dating back to the early 20th Century, with significant developments occurring over the years. One pivotal moment in this journey was the introduction of statistical quality control by Dr. Walter A. Shewhart in the 1920s (24). Dr. Shewhart's pioneering work laid the foundation for using statistical methods to monitor and enhance processes, a concept that would become integral to QI initiatives (24). 

In the mid-20th Century, the contributions of Dr. W. Edwards Deming further propelled QI principles forward (7). Dr. Deming emphasized the significance of continuous improvement, active employee engagement, and process variability reduction. His ideas found fertile ground in post-World War II Japan, playing a crucial role in the nation's economic recovery and the emergence of renowned companies like Toyota, famous for its Toyota Production System (TPS), incorporating QI concepts (7). 

Until today, QI has become indispensable to healthcare systems worldwide (16). To illustrate, envision a scenario where a hospital grapples with a high readmission rate among heart failure patients. By scrutinizing historical data and implementing evidence-based protocols for post-discharge care, hospitals can effectively lower readmissions, enhance patient outcomes, and potentially evade financial penalties under value-based reimbursement models (16). 

Models 

At the heart of ongoing transformations in healthcare lies various Quality Improvement (QI) models. These models provide structured frameworks for identifying and addressing areas of improvement within healthcare systems (14). These models offer healthcare professionals a systematic approach to instigate meaningful process changes, ultimately resulting in elevated care quality. See some models below. 

Model for Improvement 

The Model for Improvement is a widely recognized and highly effective framework for Quality Improvement (QI) in healthcare. This is because it empowers healthcare professionals to systematically test and fine-tune their ideas for process improvement, ensuring that changes are grounded in evidence and proven effective (17).  

The Model for Improvement offers a structured and systematic approach to identifying, testing, and implementing changes to enhance healthcare processes and ultimately elevate patient outcomes.  

Developed by Associates in Process Improvement (API), this model revolves around the iterative "Plan-Do-Study-Act" (PDSA) cycle, which forms the foundational structure of QI initiatives (17). The Plan-Do-Study-Act (PDSA) cycle is a systematic approach that guides healthcare teams through quality improvement, and it comprises the four key phases below, each contributing to developing and implementing meaningful changes in healthcare practices (12). 

• Plan: In this initial phase, healthcare teams define the specific problem they aim to address, set clear and measurable goals, and craft a comprehensive plan for implementing the proposed change. For instance, if a hospital seeks to reduce patient wait times in the emergency department, the plan may involve adjustments to triage protocols or streamlining documentation processes. 
• Do: Once the plan is established, the proposed change is implemented, typically on a small scale or within a controlled or pilot environment. This enables healthcare professionals to assess the feasibility and potential impact of the change without making widespread adjustments. 
• Study: The study phase involves rigorous data collection and analysis to evaluate the effects of the change. In our example, the hospital would measure the impact of the new triage protocols on wait times, closely examining whether they have decreased as expected. 
• Act: Based on the findings from the study phase, the healthcare team makes informed decisions about the change. They may adopt the change if it has successfully reduced wait times, adapt it further for enhanced effectiveness, or, if necessary, abandon it.

The PDSA cycle's iterative nature means adjustments can be made, and the cycle repeats until the desired improvement is achieved (12).

Lean Model 

The Lean model, initially conceived in the manufacturing sector, has found considerable success and applicability in healthcare as a potent tool for process enhancement and waste reduction (22). At its core, Lean thinking revolves around the principles of efficiency and value optimization because it focuses on refining processes to eliminate wasteful elements while simultaneously delivering care of the highest quality (22).  

Healthcare organizations have adopted Lean methodologies to tackle many challenges, from reducing patient wait times to improving inventory management and elevating overall patient satisfaction (22). For instance, when a hospital is challenged with prolonged wait times in its outpatient clinic, it can apply Lean principles to systematically analyze the patient flow, pinpoint bottlenecks, and streamline processes.  

This might involve reconfiguring furniture to enhance flow, adjusting appointment scheduling, or implementing standardized work procedures. The ultimate objective is to cultivate a patient-centric, efficient environment that ensures timely access to care while meticulously conserving time and resources. 

Another integral aspect of Lean thinking is the unwavering commitment to continuous improvement and the pursuit of perfection through the systematic identification and eradication of various forms of waste (19). The forms of waste are often categorized into seven types: overproduction, waiting, unnecessary transportation, overprocessing, excess inventory, motion, and defects (19). By keenly identifying and addressing these forms of waste, healthcare organizations not only enhance the utilization of resources but also curtail costs and elevate the overall quality of care delivery. 

Six Sigma model  

The Six Sigma model is a robust and widely adopted healthcare method for improving processes and reducing mistakes (9). It was first used in manufacturing but is now used in healthcare to make processes more consistent and improved by finding and fixing mistakes and inefficiencies (9).  

An example is when a hospital is concerned about the accuracy of medication dosing for pediatric patients, a Six Sigma team might include: indicating the problem, gathering data on mistakes regarding dosing, and finding out why the mistakes happened. The strategy may encompass the implementation of standardized dosing protocols, refining staff training programs, and closely monitoring the medication administration process to ensure that mistakes are eliminated. 

Six Sigma uses a framework called DMAIC (Define, Measure, Analyze, Improve, Control) to make improvements. This framework utilizes data-driven tools to discern problems, quantify their origins, develop practical solutions, and institute control mechanisms to sustain improvements (11). Through this systematic journey, healthcare organizations position themselves to deliver care of elevated quality, curtail costs, and bolster patient safety.  

TeamSTEPPS model 

TeamSTEPPS, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety, is a teamwork and communication model designed explicitly for healthcare settings (4). Developed by the U.S. Department of Defense and the Agency for Healthcare Research and Quality (AHRQ), TeamSTEPPS focuses on improving patient safety by enhancing team collaboration, communication, and decision-making among healthcare professionals (4). 

One key element of TeamSTEPPS is using structured communication techniques to prevent errors and misunderstandings. For instance, during patient handoffs from one healthcare provider to another, TeamSTEPPS emphasizes using a structured tool like SBAR (Situation, Background, Assessment, Recommendation) to convey critical information succinctly and accurately. This ensures that essential patient details are noticed, reducing the risk of adverse events (18). 

In a surgical team scenario, TeamSTEPPS principles can be applied to improve teamwork and communication among surgeons, nurses, and anesthesiologists. The model encourages briefings before procedures to set clear objectives, huddles during surgery to address emerging issues, and debriefings afterward to reflect on the process and identify areas for improvement. By fostering a culture of open communication and mutual respect, TeamSTEPPS contributes to safer, more efficient healthcare delivery (4). 

IOM Six Domains of Patient Care 

The Institute of Medicine (IOM), now known as the National Academy of Medicine, introduced the Six Domains of Quality in Healthcare as a framework to assess and improve the quality of patient care (14). These domains, introduced in 2001, encompass various aspects of care delivery and patient experience, helping healthcare organizations and providers identify areas for improvement (14). The domains serve as pillars for assessing the different dimensions of care delivery, ensuring that healthcare organizations and providers address the holistic needs of patients (14).  

Definitions  

The Six Domains of Patient Care are essential for providing high-quality healthcare. See definitions of each of the IOM's six domains of patient care below. 

• Safe: Safety is the foundational domain, emphasizing the importance of reducing the risk of patient harm. This includes preventing medical errors, preventing infections, and ensuring the safe administration of medications. Healthcare organizations implement safety protocols and engage in continuous monitoring to minimize risks (14). 
• Effective: Effective care ensures that patients receive evidence-based treatments and interventions that result in the desired outcomes. It involves using the best available scientific knowledge to make informed decisions about patient care avoiding unnecessary or ineffective treatments (14). 
• Patient-Centered: Patient-centered care focuses on individualizing healthcare to meet each patient's unique needs and preferences. It involves respecting patients' values and preferences, engaging them in shared decision-making, and delivering care with empathy and compassion (14). 
• Timely: Timely care emphasizes reducing delays in healthcare delivery. It includes providing care promptly and avoiding unnecessary waiting times for appointments, tests, and treatments. Timely care is especially critical in emergencies (14). 
• Efficient: Efficiency in healthcare means maximizing resource utilization and minimizing waste while providing high-quality care. This domain emphasizes streamlining processes, reducing unnecessary costs, and optimizing healthcare resources (14). 
• Equitable: Equitable care underscores the importance of providing healthcare that is fair and just, regardless of a patient's background, socioeconomic status, or other factors. It aims to eliminate healthcare access and outcomes disparities among different patient populations (14). 

Measures 

Measures in the context of the Institute of Medicine (IOM) six domains of patient care refer to the metrics and indicators used to assess and evaluate the quality of care provided in each domain. According to (14), the measures below are essential for monitoring and improving healthcare services. See details below. 

• The "Safe" domain measures focus on tracking and reducing adverse events and medical errors. Key indicators include rates of medication errors, hospital-acquired infections, falls, and complications from procedures. Safety measures also assess the implementation of safety protocols, such as hand hygiene compliance and patient identification bracelets. 
• Measures in the "Effective" domain assess how evidence-based practices and treatments are utilized. These measures include adherence to clinical guidelines, appropriate use of medications, and the success rates of medical interventions. Additionally, outcomes such as patient recovery, remission, or improvement are indicators of the effectiveness of care. 
• The "Patient-Centered" domain focuses on assessing the patient’s experience and satisfaction with care. Patient surveys and feedback are standard measures, evaluating aspects like communication with healthcare providers, involvement in decision-making, and overall satisfaction with the care received. Healthcare organizations also measure shared decision-making and respect for patient preferences. 
• Measures related to the "Timely" domain evaluate the efficiency of healthcare delivery. Key metrics include waiting times for appointments, diagnostic tests, and procedures. Additionally, measures track the timely delivery of urgent care and the avoidance of unnecessary delays in treatment. 
• Efficiency measures aim to quantify resource utilization and the reduction of waste in healthcare. Metrics may include the cost of care per patient, length of hospital stays, and resource allocation efficiency. Improvement in resource utilization and cost-effectiveness are vital indicators of efficiency. 
• Measures within the "Equitable" domain assess disparities in healthcare access and outcomes among different patient populations. Healthcare utilization and outcomes data are stratified by demographics, socioeconomic status, race, and ethnicity to identify and address inequities. Key indicators include access to preventive care, healthcare utilization rates, and health outcomes across various demographic groups. 

Nursing Quality Indicators 

According to (5), nursing quality indicators are essential metrics used to evaluate and improve the quality of nursing care in healthcare settings. These indicators provide valuable insights into nursing practice and patient outcomes, helping healthcare organizations and nursing staff deliver safe, effective, patient-centered care. Let's delve into some key nursing quality indicators and their significance below. 

Patient Falls 

Patient falls are a critical quality indicator in nursing care since they can result in severe injuries and complications for patients (5). As a result, healthcare organizations measure and monitor the rate of patient falls to identify trends and implement preventive measures.  

For example, when a hospital notices an increase in the rate of falls among elderly patients in a particular unit, they may introduce interventions such as nonslip flooring, improved lighting, and patient education as fall prevention strategies to reduce the incidence of falls. 

Medication Administration Errors 

Ensuring accurate medication administration is crucial in nursing practice because medication errors can lead to adverse events, including patient harm or death (5). Nursing quality indicators related to medication administration errors include the rate of medication errors and adherence to medication reconciliation processes (5). For instance, nurses are encouraged to verify patient allergies and cross-check medication orders to prevent errors. If there is an increase in medication errors in a healthcare facility, it may prompt a review of medication administration protocols and additional staff training.

Pressure Ulcers (Bedsores) 

Pressure ulcers are a quality indicator of patient skin integrity since they develop when patients remain immobile for extended periods (5). As a result, healthcare organizations measure the incidence and prevalence of pressure ulcers as an indicator of the quality of nursing care (5).  

Patient Satisfaction 

Patient satisfaction is a patient-centered nursing quality indicator since it reflects the overall patient experience and perception of care (5). Surveys and feedback mechanisms are used to measure patient satisfaction. For example, a scenario might involve patients receiving post-discharge surveys that assess various aspects of their hospital experience, including nurse responsiveness, communication, and pain management. Healthcare organizations can use this feedback to identify areas for improvement and enhance patient-centered care. 

In summary, nursing quality indicators encompass a range of metrics that evaluate nursing care quality, patient safety, and patient experiences. By monitoring and responding to these indicators, healthcare organizations and nursing staff can continuously improve their quality of care, leading to better outcomes and increased patient satisfaction (5). 

Data Collection 

Quality improvement data collection is a critical component of healthcare quality initiatives, providing the necessary information to assess the current state of care, identify areas for improvement, and monitor progress over time (2). Accurate and meaningful data collection enables healthcare organizations to make informed decisions, implement evidence-based interventions, and ultimately enhance patient outcomes. Let's explore the methods of data collection below. 

• Clinical Outcome Collection: Clinical outcome data collection is essential for assessing the effectiveness of healthcare interventions (2). For example, consider a scenario where a hospital is implementing a quality improvement project to reduce surgical site infections (SSIs) following orthopedic surgeries. Data collection would involve tracking the number of SSIs occurring over a specific period and collecting information on patient characteristics, surgical techniques, and post-operative care protocols. By analyzing this data, the healthcare team can identify trends, risk factors, and areas for improvement, ultimately leading to targeted interventions to reduce SSIs. 
• Patient Satisfaction Survey Data Collection: Patient satisfaction surveys are valuable tools for collecting data on patient experience (2). A primary care clinic that aims to improve patient satisfaction may administer surveys to patients after each visit, asking about aspects of care such as communication with healthcare providers, wait times, and overall experience. The collected data can reveal areas of strength and areas requiring improvement. For instance, if survey results consistently indicate longer-than-desired wait times, the clinic can adjust scheduling practices or implement strategies to reduce wait times and enhance patient satisfaction. 
• Process Measures Data Collection: Process measure data collection focuses on evaluating the efficiency and effectiveness of healthcare processes (2). For instance, in a medication reconciliation scenario, a healthcare organization might collect data on the accuracy and completeness of medication lists during care transitions. By tracking the frequency of medication reconciliation discrepancies, they can identify process inefficiencies and implement standardized protocols for reconciliation, leading to safer care transitions and reduced medication errors. 
• Adverse Event Reporting Data Collection: Adverse event reporting is a crucial mechanism for collecting data on incidents that result in patient harm or near misses (2). For example, consider a scenario where a nurse administers the wrong medication dose to a patient but catches the error before any harm occurs. Reporting this near-miss event allows the healthcare organization to investigate the root causes, implement preventive measures, and share lessons learned with the care team to prevent similar incidents in the future. 

Types of Data 

Data types play a crucial role in understanding the current state of care, identifying areas for improvement, and implementing evidence-based interventions (2). Let’s explore the different types of data used in quality improvement below. 

• Quantitative Data: Quantitative data involves numerical measurements and is particularly useful for assessing the frequency and extent of specific events or outcomes (2). For instance, in a hospital's quality improvement project focused on reducing hospital-acquired infections, the team collects quantitative data on the number of infections over time, allowing them to track trends and measure the impact of interventions, such as hand hygiene protocols or disinfection practices. 
• Qualitative Data: Qualitative data provides insights into the "why" and "how" behind healthcare processes and patient experiences (2). This data type is collected through interviews, focus groups, and open-ended surveys. For example, in a primary care setting aiming to improve patient satisfaction, qualitative data may be collected through patient interviews to gather in-depth information about their perceptions of care. Qualitative data can uncover nuances and provide valuable context to complement quantitative findings (2). 
• Patient-Reported Data: Patient-reported data includes information directly provided by patients about their health, symptoms, experiences, and preferences. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are standard data collection tools. In a scenario involving chronic disease management, patients with diabetes may be asked to complete a PROM assessing their quality of life and symptom management. This data helps healthcare providers tailor care plans to individual patient needs and preferences (2). 
• Process Data: Process data track the steps and activities involved in healthcare delivery to help assess the efficiency and effectiveness of care processes. For example, in a surgical quality improvement initiative, process data may include the time from patient admission to surgery, surgical team checklist completion, and adherence to anesthesia protocols. By collecting and analyzing process data, healthcare organizations can identify bottlenecks and areas for improvement in care delivery processes. 

In summary, quality improvement data collection relies on various data types, including quantitative, qualitative, patient-reported, and processed data. Each data type contributes to a comprehensive understanding of healthcare quality and supports evidence-based decision-making to enhance patient care and outcomes. 

Identification Stage  

The identification stage for quality improvement data collection is a critical initial phase where healthcare organizations and teams define what data to collect, why it is relevant, and how it aligns with their quality improvement goals (23). This stage is essential for ensuring meaningful data collection efforts will lead to actionable insights. Let's explore the identification stage in more detail. 

• Defining Objectives and Goals: During this stage, healthcare organizations must clearly define the objectives and goals of their quality improvement initiative (23). For instance, a hospital aiming to reduce readmission rates for heart failure patients may set a specific goal of reducing readmissions by 20% within the following year.  
• Selecting Relevant Metrics: Identifying the right metrics and data points is crucial, and organizations should choose metrics that directly relate to their quality improvement goals (23). Continuing with the example of reducing heart failure readmissions, relevant metrics might include the number of heart failure patients readmitted within 30 days, the reasons for readmission, and patient characteristics. By selecting these metrics, the organization ensures that data collection efforts are aligned with their specific improvement goal. 

• Determining Data Sources: Healthcare organizations must identify where the necessary data will be sourced (23). This may involve looking at electronic health records, claims data, patient surveys, or other sources. For instance, to collect data on heart failure readmissions, the hospital may extract relevant information from electronic health records, including admission and discharge dates, diagnosis codes, and patient demographics. 
• Creating Data Collection Protocols: Establishing clear data collection protocols is essential for consistency and reliability (23). Healthcare teams should define how data will be collected, who will be responsible for data collection, and the frequency of data collection. For example, in a hospital project aiming to improve hand hygiene compliance, data collection protocols might specify that trained observers will monitor hand hygiene practices at random intervals and record their findings on standardized forms. 

By carefully navigating the identification stage, healthcare organizations ensure that their quality improvement data collection efforts are purposeful and aligned with their goals. This sets the stage for collecting meaningful data to drive evidence-based decisions and interventions to enhance healthcare quality. 

Gathering Stage  

The gathering stage of quality improvement data collection is crucial for healthcare organizations to collect the identified data based on their quality improvement objectives and goals (23). This stage involves systematically collecting data from various sources and often requires careful planning and coordination to ensure data accuracy and completeness. Let's delve into the gathering stage in detail below. 

• Data Collection Methods: To gather data, healthcare organizations must determine the most suitable methods for collecting the identified data, which may involve a combination of electronic health records, patient surveys, direct observations, and administrative databases (23). For example, in a quality improvement project aimed at reducing hospital readmissions, data may be collected by reviewing electronic health records to track patient outcomes, conducting patient surveys to gather feedback on discharge instructions, and analyzing administrative data to identify trends in readmission rates. 
• Ensuring Data Accuracy and Consistency: Data accuracy is critical in the gathering stage, and organizations must implement procedures to collect data consistently and without errors (23). For instance, if a healthcare facility is collecting data on medication administration, nurses may use standardized protocols to accurately record medication administration times and doses. Regular training and quality checks may also be implemented to maintain data accuracy. 
• Timely Data Collection: Timeliness is another important aspect of the gathering stage, and data should be collected promptly to ensure it is current and relevant for analysis and decision-making (23). In a scenario involving tracking patient outcomes, healthcare teams may set specific intervals for data collection, such as collecting post-surgical complication data daily or weekly, depending on the project's requirements. 
• Data Security and Privacy: Protecting patient data is a paramount concern in healthcare. As a result, healthcare organizations must adhere to strict privacy and security protocols during the gathering stage to ensure that patient information is handled confidentially and complies with applicable laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) (23). For example, when collecting patient-reported data, organizations may anonymize responses to protect patient identities and comply with privacy regulations. 

By effectively managing the gathering stage, healthcare organizations can ensure that they collect accurate, timely, and secure data that will serve as the foundation for subsequent analysis and quality improvement efforts. 

Analysis stage  

The analysis stage for quality improvement data collection is a critical phase where collected data is processed, examined, and transformed into actionable insights. This stage involves various analytical techniques and tools to identify patterns, trends, and areas for improvement (2). Let's explore the analysis stage in detail below. 

• Descriptive Analysis: Descriptive analysis is the initial step in data analysis, focusing on summarizing and presenting data meaningfully (2). For example, in a quality improvement project aimed at reducing patient wait times in an emergency department, an analysis may involve calculating and displaying key statistics, such as average wait times, 95th percentile wait times, and the distribution of wait times (2). These descriptive statistics provide an overview of the current situation and help identify areas that need attention. 
• Root Cause Analysis (RCA): Root cause analysis is a critical aspect of the analysis stage, as it helps pinpoint the underlying causes of issues or problems (2). In our scenario, if the analysis reveals prolonged wait times in the emergency department, RCA may involve a thorough investigation into the factors contributing to the delays. Potential root causes include staffing shortages, inefficient triage processes, or bottlenecks in diagnostic testing. Identifying these root causes is essential for developing effective interventions. 
• Statistical Analysis: Statistical analysis plays a vital role in quality improvement by examining the relationships between variables and testing hypotheses (2). In reducing hospital readmissions, statistical analysis may be used to identify factors associated with readmission risk. For example, healthcare teams can use logistic regression to analyze patient data to determine which variables, such as comorbidities or medication adherence, are statistically significant predictors of readmission risk. This information can guide the development of targeted interventions for at-risk patients. 
• Benchmarking: Benchmarking involves comparing an organization's performance data with industry standards or best practices to identify performance gaps (2). When a hospital is looking to improve patient satisfaction, benchmarking may involve comparing its patient satisfaction scores to those of similar hospitals or national averages. Identifying areas where the hospital falls behind benchmarks can inform strategies for improvement, such as implementing best practices from higher-performing institutions. 

The analysis stage is critical for transforming raw data into actionable insights and understanding healthcare quality factors (2). Through descriptive analysis, root cause analysis, statistical techniques, and benchmarking, healthcare organizations can gain valuable insights that drive evidence-based decisions and interventions to improve care quality (6). 

Benchmarking 

The benchmarking stage in quality improvement data collection is a crucial phase where healthcare organizations compare their performance against established benchmarks or best practices (1). This gives healthcare organizations a clear understanding of their position relative to recognized standards and allows them to effectively identify areas for improvement, prioritize, and focus their improvement efforts (5). Let's delve into the benchmarking stage in detail below. 

• Defining Benchmarks: In the benchmarking stage, healthcare organizations must define the benchmarks or standards against which they will measure their performance. These benchmarks can be internal (comparing current performance to historical data) or external (comparing to industry standards, best practices, or similar organizations) (1). For example, a primary care clinic seeking to improve appointment scheduling efficiency may choose to benchmark its appointment wait times against industry benchmarks for acceptable wait times. 
• Collecting Comparative Data: Gathering data that allows for a meaningful comparison is critical in benchmarking, so healthcare organizations must collect data from relevant sources to measure their performance against the chosen benchmarks (1). Continuing with the appointment scheduling example, the clinic may collect data on the time it takes to schedule an appointment, the number of scheduling errors, and patient feedback. This data is then compared to industry benchmarks or best practices. 
• Identifying Performance Gaps: The benchmarking process reveals gaps or disparities between an organization's performance and the benchmarks to highlight improvement areas (1). For instance, if the clinic discovers that its appointment wait times are significantly longer than industry benchmarks, this identifies a performance gap that needs to be addressed to enhance patient access and satisfaction. 
• Developing Improvement Strategies: Healthcare organizations can develop targeted improvement strategies once performance gaps are identified. These strategies are based on evidence from the benchmarking process and aim to align performance with or exceed established benchmarks (1). In our scenario, the clinic may implement strategies such as optimizing appointment scheduling processes, enhancing staff training, or using technology to improve scheduling efficiency. 

Change Models in Healthcare 

Change models are essential frameworks used in healthcare, including nursing, to guide and manage the effective implementation of quality improvement initiatives (15). These models offer structured approaches to initiate, plan, execute, and sustain changes in healthcare practice (15). Let’s discuss some prominent change models used in nursing quality improvement below. 

• Kotter's 8-Step Change Model: Developed by Dr. John Kotter, this model emphasizes the importance of creating a sense of urgency, building a guiding coalition, and sustaining the change (15). For instance, in a nursing scenario focused on reducing hospital-acquired infections, the 8-step model would involve creating urgency by highlighting the impact of infections on patient safety, assembling a coalition of nurses and infection control specialists, and sustaining change by monitoring infection rates over time and continually reinforcing hygiene protocols. 
• Lewin's Change Management Model: Lewin's model consists of three stages: unfreezing, changing, and refreezing (15). Let's consider implementing a new electronic health record (EHR) system in nursing. Nurses first "unfreeze" by acknowledging the need for a new system and undergoing training. Then, they "change" by adopting the EHR and adjusting workflows. Finally, they "refreeze" by becoming proficient and maintaining the new system's use as a standard practice. 
• PDSA Cycle (Plan-Do-Study-Act): This model emphasizes iterative cycles of planning, implementing, observing, and adjusting (15). For instance, if a nursing unit aims to improve patient handoffs, they might "plan" by identifying handoff best practices, "do" by implementing changes, "study" by assessing the impact on patient outcomes, and "act" by making further refinements based on their findings. This continuous cycle allows for gradual, data-driven improvements. 
• ADKAR Model: The ADKAR model focuses on individual change management, and this could apply to a scenario where nurses are adopting new pain management protocols (15). Nurses would first need awareness of the change (A), followed by desire (D) to participate, knowledge (K) of how to implement the new protocols, ability (A) to do so, and reinforcement (R) to sustain the change over time. 

In summary, change models provide structured approaches to drive quality improvement initiatives in nursing, and by applying these models, nurses and healthcare organizations can systematically plan, implement, and evaluate changes to enhance patient care, safety, and outcomes (15).

Implementing Change 

Implementing changes for quality improvement in nursing is a multifaceted process that requires careful planning, effective communication, and the engagement of healthcare professionals at all levels. According to (15), successful implementation ensures that desired changes are integrated into daily nursing practice, improving patient outcomes. Let’s explore key strategies and considerations for implementing changes in nursing quality improvement below. 

• Engage Interdisciplinary Teams: According to (15), collaborative engagement is crucial when implementing changes in nursing practice, and healthcare organizations should assemble interdisciplinary teams that include nurses, physicians, administrators, and other stakeholders. For example, in a scenario involving the adoption of a new pain management protocol, nurses can collaborate with physicians to ensure the consistent application of evidence-based pain management practices. This team approach facilitates a shared understanding of the change and fosters buy-in from all parties. 
• Effective Communication: Clear and consistent communication is essential during the implementation phase, so nurses should communicate the rationale behind the change, its expected benefits, and the specific steps involved (15). For example, suppose a hospital is transitioning to a new electronic health record system. In that case, nurses can attend training sessions to understand its features and communicate effectively with patients about how it will enhance their care. This ensures that all stakeholders are informed and can adapt to the change seamlessly. 
• Training and Education: Providing adequate training and education is critical to equip nursing staff with the knowledge and skills to implement the change effectively (15). In the case of introducing a new wound care protocol, nurses would require training on the updated practices, wound assessment techniques, and the use of new wound care products. In addition to initial training, ongoing education would ensure that nursing staff stay current with best practices to provide quality care confidently. 
• Continuous Monitoring and Feedback: According to (15), implementing change is an ongoing process that requires constant monitoring and feedback since feedback mechanisms allow for adjustments and refinements to the change process. As a result, nursing quality improvement initiatives benefit from the regular collection and analysis of data to assess the impact of the change. For example, suppose a hospital introduces a sepsis screening tool. In that case, nurses can track the number of patients screened, identify missed cases, and evaluate whether early interventions have reduced sepsis-related mortality rates. By engaging interdisciplinary teams, fostering effective communication, providing training and education, and implementing continuous monitoring and feedback mechanisms, nurses can successfully implement changes that improve the quality of patient care and enhance overall healthcare outcomes (8). 

Evaluating Change 

Evaluating change for quality improvement in nursing is a critical phase that involves assessing the impact and effectiveness of implemented changes on patient care outcomes, safety, and the overall quality of healthcare services. According to (15), rigorous evaluation ensures that improvements are sustained, and necessary adjustments are made. Let’s explore key strategies and considerations for evaluating changes in nursing quality improvement below. 

• Establishing Clear Evaluation Metrics: To evaluate change effectively, it is essential to define clear and measurable evaluation metrics, and according to (15), these metrics should align with the specific objectives of the change initiative. For example, suppose a nursing unit has introduced a new hand hygiene protocol to reduce hospital-acquired infections. In that case, evaluation metrics may include the number of infections before and after the change, adherence to hand hygiene guidelines, and patient satisfaction scores related to cleanliness and infection prevention. 
• Data Collection and Analysis: Data collection is a fundamental component of the evaluation process, and nursing teams should collect relevant data using standardized methods and tools (15). In our scenario, data on infection rates can be collected regularly, and statistical analysis can be performed to determine whether the change has had a statistically significant impact. Nurses can then use run charts or control charts to visualize trends in infection rates over time, allowing for early detection of any potential issues. 
• Patient and Staff Feedback: Patient and nursing staff feedback is invaluable in evaluating change since patients' perspectives on the quality of care and their experiences following the change can provide insights into the initiative's effectiveness (15). Additionally, nursing staff can provide feedback on the practicality and feasibility of the new practices. For instance, nursing staff may suggest further improvements in infection control procedures. 
• Sustainability and Continuous Improvement: Evaluating change is not solely about assessing immediate outcomes but also ensuring sustainability and continuous improvement. According to (15), nursing teams should determine whether the positive effects of the change are maintained over time and whether there is room for further refinement. For example, when a nursing unit has reduced infection rates, regular audits and monitoring should continue to ensure sustained compliance with hygiene protocols. 

• Enhancing Medication Safety: Medication errors can have severe consequences for patients (6). A quality improvement project may target medication safety by introducing barcode scanning systems for medication administration, implementing double-check procedures for high-risk medications, and providing ongoing training to nursing staff. The project's effectiveness can be assessed by monitoring the number of medication errors reported and verifying that the new safety measures reduce the occurrence of such errors. For example, a nursing team could reduce the incidence of wrong-patient medication administration by implementing barcode scanning during medication administration. 

• Improving Nurse-to-Patient Ratios: Adequate nurse staffing levels are crucial for patient safety and quality of care (6). A quality improvement project may involve adjusting nurse-to-patient ratios based on patient acuity levels, introducing workload management tools, and conducting regular staffing needs assessments. In this case, the project's success can be measured by tracking patient outcomes, nurse workload, and patient satisfaction scores. For example, a nursing unit could reduce nurse burnout and improve patient care by optimizing staffing ratios during peak hours. 

• Enhancing Discharge Planning and Care Transitions: Effective care transitions from the hospital to home or other healthcare settings are essential to preventing readmissions and ensuring continuity of care (6). A quality improvement project may focus on improving the discharge planning process, including patient education, medication reconciliation, and post-discharge follow-up. Success can be assessed by monitoring readmission rates and patient-reported experiences. For example, a nursing team could work on reducing hospital readmissions by ensuring that patients receive thorough discharge instructions and have access to follow-up care. 

The above examples illustrate the diverse range of quality improvement projects in nursing, each addressing specific challenges to enhance patient safety and care quality.

Conclusion

In conclusion, this course provides essential knowledge and skills valuable for nurses aiming to deliver high-quality, safe, patient-centered care. Quality improvement in nursing is not merely a theoretical concept but a practical approach that can be applied to various aspects of healthcare, and one critical aspect to remember is the importance of interdisciplinary collaboration. As frontline caregivers, nurses must collaborate with physicians, administrators, pharmacists, and other healthcare professionals to drive improvements in healthcare delivery.  

As nurses continue to play a pivotal role in healthcare delivery, the knowledge and skills gained from this course will empower them to lead and actively participate in quality improvement initiatives. By applying quality improvement principles, nurses can contribute to better patient experiences, patient outcomes, and overall healthcare quality. 

Final Reflection Questions 

1. What have you learned from this course? 
2. Why is interdisciplinary collaboration essential for nurses to effectively implement quality improvement initiatives in healthcare settings, and how can nurses foster collaboration among healthcare professionals? 
3. How does the concept of continuous learning and adaptation align with the dynamic nature of healthcare, and what strategies can nurses employ to stay current with evolving best practices and guidelines? 
4. In what ways does Quality Improvement benefit both healthcare providers and patients?  
5. What are the potential challenges in implementing QI initiatives in a healthcare organization? 
6. In what ways has QI in healthcare become intertwined with the broader goals of healthcare reform, such as improving patient outcomes and reducing healthcare costs? 
7. What role does leadership play in the effective implementation of QI models? 
8. How can leaders promote a culture of continuous improvement within healthcare organizations? 
9. How do QI models facilitate interdisciplinary collaboration among healthcare professionals to drive improvements in patient care? 
10. What challenges might healthcare organizations face when attempting to adopt and sustain QI models, and how can these challenges be overcome? 
11. How does the "testing and learning" concept in the PDSA cycle align with the principles of evidence-based practice in healthcare? 
12. In what ways do QI models promote patient-centered care and patient safety, and can you provide examples of tangible improvements in these areas achieved through QI initiatives? 
13. How can the Six Sigma model contribute to the reliability and consistency of healthcare processes? 
14. Safe: What steps can healthcare organizations take to minimize the risk of medical errors and adverse events? 
15. Practical: How do healthcare providers ensure that evidence-based treatments and interventions lead to positive patient outcomes? 
16. Patient-centered: Why is it important to involve patients in their care decisions, and how can healthcare professionals effectively engage patients in the decision-making process? 
17. Timely: What are some key factors contributing to delays in healthcare delivery, and how can these delays be reduced to improve timeliness? 
18. Efficient: How can healthcare processes and workflows be streamlined to enhance efficiency and reduce waste? 
19. Equitable: What are some barriers to achieving healthcare equity, and how can healthcare organizations address these disparities? 
20. How can nurses actively involve patients in data collection to enhance patient-centered care? 
21. What tools or technologies are available to streamline data collection processes in nursing practice? 
22. How can nurses effectively collaborate with interdisciplinary teams to gather comprehensive data for quality improvement initiatives? 
23. What strategies can nurses employ to maintain patient privacy and confidentiality while collecting sensitive healthcare data? 
24. What methods can nurse use to analyze and interpret the data they collect to identify areas for improvement? 
25. Why must nurses regularly review and assess the data they collect to drive continuous quality improvement in healthcare settings? 
26. Regarding patient falls, what strategies can healthcare organizations implement to reduce the incidence of patient falls, and how can nursing staff actively contribute to fall prevention efforts? 
27. How can nurses ensure the accurate and safe administration of medications, and what measures can be taken to minimize medication errors? 
28. What are the key nursing practices and interventions that can prevent the development of pressure ulcers in hospitalized patients, and how can nursing staff collaborate to achieve this goal? 
29. Why is patient satisfaction an important nursing quality indicator, and what actions can nurses take to enhance the overall patient experience? 
30. What impact do nurse-to-patient staffing ratios have on the quality of nursing care, and how can healthcare organizations ensure safe nurse staffing levels? 
31. How can nurses enhance patient education to promote better understanding and self-management of their health conditions? 
32. How can you ensure that the data collected is reliable and valid? 
33. What role does standardization play in data collection for quality improvement? 
34. How can you establish baseline data for comparison in your quality improvement project? 
35. What challenges or obstacles might you encounter when collecting data for quality improvement? 
36. How frequently should data be collected to monitor progress in a quality improvement project? 
37. How can you involve frontline staff in the data collection to ensure accuracy? 
38. What measures can be taken to protect patient privacy and confidentiality during data collection? 
39. How can you analyze the data collected to identify trends or patterns? 
40. What actions should be taken if the data collected indicates a problem or deviation from the desired outcome? 
41. What strategies can ensure that data collection remains an ongoing and sustainable practice in healthcare quality improvement efforts? 
42. What are the potential challenges or resistance nurses might encounter when implementing changes using these models? 
43. How can a guiding coalition or interdisciplinary team be effectively assembled to support nursing quality improvement efforts? 
44. What strategies can nurses employ to sustain changes and prevent reverting to previous practices once implemented? 
45. How can nursing leaders ensure that staff have the necessary knowledge and skills to embrace the changes outlined in these models? 
46. How can nurses use these change models to promote a culture of continuous improvement in healthcare settings? 
47. How can nurses ensure their implementation changes align with evidence-based best practices and clinical guidelines? 
48. What potential challenges or barriers might nurse teams encounter when trying to implement changes for quality improvement? 
49. What strategies can address resistance to change among nursing staff and promote their active participation in the implementation process? 
50. How can nursing leaders effectively communicate the expected outcomes and benefits of the change to gain support and commitment from their teams? 
51. What are the advantages of using data and performance metrics to monitor the progress and impact of change implementation in nursing practice? 
52. How can nursing staff ensure that changes are sustained and become integral to their daily practice rather than temporary modifications? 
53. Why is it crucial to consider the sustainability of change when evaluating its long-term impact on nursing quality improvement? 
54. What challenges or obstacles might nurse teams encounter when collecting and analyzing data for change evaluation, and how can these challenges be addressed? 
55. How can nursing leaders encourage a culture of continuous improvement among their teams as part of the change evaluation process? 
56. What strategies can be employed to ensure that the feedback and insights gathered during the evaluation phase are actively used to refine and optimize nursing practices? 
57. What are the potential consequences of not conducting thorough and systematic evaluations of changes in nursing practice for quality improvement? 
58. How can nursing staff and healthcare organizations ensure that the lessons learned from change evaluations are applied to future improvement initiatives to enhance patient care outcomes? 

Workplace Violence Against Nurses

Introduction   

The role of the registered nurse, while fundamentally dedicated to the care and wellbeing of patients, has long been fraught with challenges that extend beyond the complexities of medical care. One such pressing concern is workplace violence, an issue that nurses confront with alarming frequency. Recent statistics show that healthcare workers, particularly nurses, are at a higher risk for workplace violence compared to other professions.  

Given the vital role nurses play in patient care and the broader healthcare system, it is imperative to understand the scope, sources, and solutions to this pressing issue. This continuing education course is dedicated to arming nurses with the knowledge, tools, and strategies to recognize, respond to, and prevent incidents of workplace violence, thereby ensuring their safety and the uninterrupted provision of quality care. 

Workplace Violence  

Definitions 

The Occupational and Safety Health Administration (OSHA) (3) defines workplace violence (WPV for the purpose of this course) as any act or threat of physical violence, harassment, intimidation, or other threatening, disruptive behavior that occurs at the work site.  This can also include verbal, written, or acts of sabotage against an individual while they are at work. 

Workplace violence crosses all demographic barriers and is indiscriminate in who it can and does affect. Even seeing workplace violence influences morale, attendance, and the overall well-being of employees and their co-workers.  

Types of Violence  

Currently, there are four categories of workplace violence according to the American Nurses Association (5).  

1: Criminal Intent - normally involves theft from the business or employees. 

Example: Carol is working on documentation and notices a person lingering in the hallway. Carol doesn’t really think anything of it, assuming they are family members of one of the patients. Several minutes later, the person exits quickly from the supply room and down the stairs. Carol calls security to let them know, but they can’t locate the individual. After looking through the supply room, they find that several containers of wound dressing supplies are missing.  

2: Customer/client/patient - the individual becomes violent with employees while receiving services. 

Example: David was updating a family on their father’s critical condition. David could tell the family was upset, but the patient’s son seemed more frustrated than the others. During David’s explanation, the son grabbed David’s clipboard and yelled, “You’re not doing anything! You’re just letting him die!” The son then threw the clipboard at David’s head. David blocked the clipboard with his arm, receiving a rather deep cut as a result. Security became involved, and David had to go to the ER for treatment.  

3: Worker on worker - an employee bullies, attacks, or threatens another employee. 

Example: Emily was rounding when Dr. G. came onto the floor. This doctor was well known for being difficult to work with, and he always required the nurses to stand behind him in the room while he talked with his patients. Emily had one of Dr. G.’s patients today and was in the room, he asked her if the patient had ambulated. Emily told him they had not, but they planned to before and after lunch. The doctor made an audible sigh and while shaking his head at the patient said, “See…this is what I deal with every day. These nurses can’t get anything right. They’re all useless.” 

4: Personal relationship - involves a person who has an interpersonal relationship with the nurse, but no association with the nurse’s employer or the business. 

Example: Rebecca was walking to her car after work. Halfway to her car, she noticed an individual leaning against the trunk of her vehicle. Rebecca recognized this person as the someone her friend was currently dating. This person approached Rebecca aggressively and began yelling about gossiping and trying to break their relationship. Rebecca started back toward the building, hoping security was nearby, and was pursued by the female. Eventually, Rebecca made it to the building and got inside. Luckily, the door only opened with an employee badge, and Rebecca was safe. She went ahead to security.  

Currently, the customer/client type of workplace violence is the most prominent, especially in healthcare and toward nurses. The American Nurses Association (ANA) reports that OSHA does not require employers to implement workplace violence prevention programs, but it supplies voluntary guidelines and may cite employers for not supplying a workplace free from recognized serious hazards.  

Some states have legislated that employers develop a program while most states have advanced laws that amend existing statute for assaults of first responders by adding health care providers / nurses and/or increasing the penalty associated with such behavior. (3) 

It is worth noting that since there are, in most cases, no actual requirements for employers to provide safe work environments for nurses, preventing and dealing with WPV proves problematic. It falls on nurses to understand what constitutes WPV, how to manage it, how to cope with it, how to report it, and how to ensure action is taken and a resolution is reached when WPV occurs.  

Epidemiology 

Workplace violence can take many forms, and the possible varieties and scenarios are endless. Regardless of how it manifests, the effects of workplace violence are clear and widespread. It can affect productivity of employees, morale, attendance, turnover rates, quality of work, patient outcomes, and much more.  

Workplace violence can affect and involve workers, clients, customers, and visitors. WPV ranges from threats and verbal abuse to physical assaults and even homicide. In 2010, the Bureau of Labor Statistics (BLS) data reported healthcare and social aid workers were the victims of approximately 11,370 assaults by persons; a greater than 13% increase over the number of such assaults reported in 2009 (10). Almost 19% of these assaults occurred in nursing and residential care facilities alone. Unfortunately, many more incidents probably go unreported (5). 

Impact on Nurses Well-Being 

Workplace violence can take a heavy toll on nurses. These tolls can be emotional, mental, and physical as well as short-term or long-term. The seriousness of these injuries can vary widely ranging from minor upset to permanent injury and in worst cases, even death. (13) 

This harm doesn’t stop with the nurse. The effects of workplace violence may also include effects spanning the unit the nurse works on or even the entire facility. Low morale, reduced productivity, lack of trust in employers, and fear of going to work can be results of violent events occurring to even a single co-worker.  

Workplace violence can also have a financial effect on nurses and their employers related to lost time at work from injury or callouts, costs of care for treatment related to the incident (physical and/or psychological), or even legal fees. (13) 

Given that incidents of workplace violence are rapidly increasing, these impacts are expected to increase as well. It is easy to see how this harm is widespread and can potentially ripple outward into the nurse’s professional and personal life. The stress and harm do not stay at work, and can spread to the nurse’s family, social interactions, and more. 

Barriers to Reporting 

One way to combat workplace violence is knowledge of its existence, its nature, and its frequency. Unfortunately, there are many factors that either prevent or discourage nurses from coming forward with reports when they are the victims of WPV.  

A study presented in a Chinese nursing journal surveyed 325 nurses. Of these nurses, 266 were spread across 165 hospitals, and these hospitals were in 72 cities.   

A total of 172 nurses (64.7%) experienced violent incidents during the past year. Of these incidents, 45.5% were reported; and the reporting rate of physical assaults (69.0%) was higher than those of verbal abuse (36.9%), threatening behavior (51.7%), and sexual harassment (60.0%). Formal reporting accounted for 25.4% (15.4% in written form and 10.0% through a computer-assisted reporting system. 

 Almost half of the nurses (49.6%) said that the hospital had no reporting system, or they were uncertain about the reporting system. For reasons of not reporting, 51.9% of the nurses were unaware of how and what types of violence to report, and 50.6% of the nurses believed that the hospital paid greater attention to patients rather than staff. (7) 

Interestingly, almost fifty percent of the nurses surveyed had limited knowledge, if any, of a reporting system available to them, while fifty percent felt the hospital favored the patients over their own employees. Combined with an actual or perceived lack of supervisory support, this encourages an environment where nurses feel powerless to protect themselves or to take proper action when threatened or harmed. 

The Minnesota Nurses Association, in August of 2022, published a press release with the results of a nursing survey on the topic of workplace violence. In this survey, ninety-seven percent of the nurses surveyed observed WPV or harassment over the previous two years.  

The top reasons cited by nurses who did not report workplace violence were lack of time due to overwork and under-staffing, cited by fifty-eight percent of respondents, and lack of action by hospital management, cited by fifty-three percent of nurses in the survey. (4) 

It would appear from these studies that many nurses feel it is futile to report incidents of workplace violence they encounter, and even if they realized an incident was reportable, they may not be aware of a way to report it or have time to do it. This perceived powerlessness and sense of futility in the face of abuse and violence will only continue to worsen unless action is taken to remove barriers to reporting and for nurses to have access to aid and support for supervisory staff. 

Culture of Safety 

A commonly used phrase is “Culture of Safety”, but is there a standardized definition of what it is or could be? Many resources point to the safety of patients about medical errors, patient rights, and protecting the patient’s information, but few address the issue facing caregivers and especially nurses. However, there is no agreed-upon or standard definition of what exactly a “culture of safety” is or what it should look like.  

The American Nurses Association approaches the concept by saying, “Establishing a culture of safety in health care is essential to the security and well-being of your patients, staff, and organization. Effective nurse leaders embrace safety protocols that ensure their organization delivers a secure, protective environment that prioritizes patients and caregivers.” (12)  

Currently, there is only a single federal legislation in place about the issue. 

The only federal regulation currently in place is the General Duty Clause of the Occupational Safety and Health Act of 1970. This clause requires employers to supply a work environment free from recognized hazards that are causing or likely to cause death or serious physical harm. However, the general duty clause offers no specific recommendations about management of workplace violence.  

The Occupational Safety and Health Administration (OSHA) issued guidelines for workplace violence prevention for health care and social service workers. First issued in 1996 and later updated, the guidelines are only advisory. (1) 

It is paramount that nurses and other direct care providers accept the responsibility of creating policies and procedures within their organizations to define and enforce a work environment where violence is not tolerated and dealt with accordingly. 

There is currently a small body of research and work of the effects workplace violence has on nurses as human beings. Most of the evidence focuses on how workplace violence increases the risk nurses present to patients in the form of medical errors, staffing issues due to missed work, poor documentation, etc. 

The main body of evidence discussing how workplace violence affects nurses is noted in research around nurse burnout. A 2020 study published by the National Health Institute (10) states, “Workplace aggression is a source of extreme socio-emotional stress, which may lead to the experience of psychological strain.  

A large body of research shows that exposure to workplace aggression and violence may severely impair healthcare workers’ mental health, including symptoms of post-traumatic stress disorder, depression, and burnout.” 

This study also shows an important association with workplace aggression and violence targeting nurses and drastically increased levels of emotional exhaustion, depersonalization, and deep feelings of poor personal accomplishment. Over time, these feelings lead to complete burnout, and even worse, possibly psychological and/or physical conditions in the nurse affected.   

Even with this preliminary information and research, we still have a long way to go to show the full and far-reaching effects of workplace violence on nurses. Again, by being proactive and acting now, we as nurses can foster this research and bring to light the issues so they can be addressed. 

ANA Zero Tolerance Policy 

In 2019 the American Nurses Association (ANA) (2) release a brief titled “Reporting Incidents of Workplace Violence”. In it, they discussed several issues surrounding workplace violence, barriers to its reporting, and made recommendations to healthcare organizations on strategies relating to the issues of workplace violence.  

They also set forth a “Zero Tolerance Policy on Workplace Violence”, which provided some definitions and several recommendations on how to deal with WPV. 

The introduction to the “Culture of Safety” part of this brief is as follows:  

By prioritizing, developing, and sustaining an organizational culture focused on safety, we can drive the future of healthcare to a place where patients and those who care for them are free from harm. It is not only one of many priorities but is the overriding ethical imperatives for all leaders. (9) 

The ANA also suggested a three-level prevention strategy, each with a part for the employer and the employee. Essentially, the role of the employer is gathering data, providing a “safe” work environment, non-punitive reporting, and development of programs to provide a safe work environment for nurses. The employee’s role is to take part in the implementation and evaluation of said programs.  

Unfortunately, these are only suggestions and employers do not have to implement any programs or services to protect employees against workplace violence. Also, healthcare employers do not have to report any incidents to JCAHO who consider events of workplace violence to be “sentinel events”.  

In the end, it falls on the nurses and employees directly affected by WPV to assume the charge against workplace violence, hold employers accountable, communicate with local and state legislators, and effect change to protect themselves. 

Strategies to Prevent Workplace Violence 

To end nurse abuse for good, Boston-Leary says it takes every nurse speaking up and reporting abuse within an organizational culture that has an established process for allowing nurses to report abuse without fear of recrimination and then follows up with a resolution. (8) 

There are some suggested actions to help prevent and combat workplace violence in your practice setting. These actions include: 

Know the definition of abuse.  

The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty.” 

Agreeing on this definition is an important first step to achieving widespread acknowledgement of the distinct types of nurse abuse, particularly non-physical abuse, Boston-Leary explains. (8) 

Report Abuse 

Ask about how your workplace manages abuse reporting, whether it is in your current workplace or when you are applying for a position, Boston-Leary suggests. “Ask about how reporting abuse happens during any shift because there should be a reporting mechanism in place for everyone, even if it’s on a weekend or evening shift with no manager easily accessible to report to.” 
 
If (when) you do experience abuse, it’s essential that you speak up immediately and note any witnesses who could corroborate your description of the incident, she says. 
 
Even after you experience abuse and even if you didn’t report it, it’s important to share your past abuse with others to empower them to report abuse they experience. (8) 

Change Your Culture 

Join or meet a committee to build or strengthen zero-tolerance abuse policies. Based on ANA’s Zero Tolerance Policy on Workplace Violence, Boston-Leary suggests these crucial elements of a zero-tolerance abuse program: 

Stop violence before it starts through education to find risks and reduce vulnerabilities for workplace violence. 

Create an effective response to violence immediately after it occurs, including emergency care. 

Establish long-term responses that reduce the long-term negative effects of workplace abuse. (8)  

Communicate with your Legislator! 

Congress was considering legislation to #End Nurse Abuse by passing The Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R 1195). If approved, this law would have required health care and social service industry employers to develop and implement a comprehensive workplace violence prevention plan that protects nurses and other healthcare professionals from on-the-job abuse. 
 
Boston-Leary believes legislators are very attuned to the trusted voice of nurses to share about what is happening in health care today (8). 

Nurse-led Strategies 

You can join these committees or work with your employer to create them. Collaborating with your supervisory staff and HR, you can create workflows, policies, reporting methods, and provide education on prevention of workplace violence and make a difference in your overall work environment.   

Regarding Your Legislators 

As mentioned before, 2021 Congress was considering federal legislation to end nurse abuse by passing The Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R. 1195). The bill was passed by the House on April 16, 2021, but was never passed by the Senate.  

You can find your local and state legislator contact information very easily on the internet. A simple search for “how to find state legislator contact information” is a wonderful place to start. As a voting citizen, you have every right to contact them, and demand laws be created to protect you while you work.  

Below are some links to help you find elected officials: 

• https://www.usa.gov/elected-officials 
• https://www.usa.gov/state-governor 
• https://www.senate.gov/senators/senators-contact.htm 
• https://www.house.gov/representatives/find-your-representative 

Advocate for your own safety the same way you would for your patients!  

As nurses we aren’t afraid of stepping up to bat for our patients when they need something, but we are notorious for taking a hit and letting it slide, sometimes even to our own detriment.  

We owe it to ourselves to offer that same level of advocacy to ourselves and our co-workers.  

Resources 

The Joint Commission supplies resources available to report and learn about how to report workplace violence. The links included are for federal, state, professional, and other resources. The direct link to this page is: 

The Joint Commission: Workplace Violence Prevention Resources 

Local law enforcement  

As a private citizen, you are protected by laws about assault, battery, and other attacks on your person. You are within your rights to call the police on events of workplace violence, especially if your life or health are threatened, or you are physically attacked. It is likely your employer will not support you in this situation due to legal implications. It is best to ask your HR department and supervisory staff how these situations should be managed if they occur. 

Legal Counsel 

Consult with a lawyer about your legal rights in situations on workplace violence and how to best manage them. Be sure to bring scenarios, information on how your employer suggests dealing with these situations, and examples of violence you have seen or have experienced.  

Educate and Train Yourself 

Learn as much as you can about recognizing and managing workplace violence. Your employer may supply these courses, and if they don’t, it may be prudent to request them. Also, you can seek outside education and training on these topics including self-defense classes and crisis management courses. 

Practice Self-Awareness 

We all have inherent beliefs, perspectives, and feelings that can prevent us from acting in certain situations. Knowing yourself and understanding possible nuances within yourself that could be a detriment to you appropriately handling a situation of workplace violence could mean the difference between prevention and becoming a victim.   

Conclusion

Being an agent of change can be intimidating, terrifying, and even force us to deal with feelings and beliefs we didn’t even realize were in our way. Incidents of WPV have been rising sharply over the past several years, and there is no sign of slowing. It’s up to us as front-line workers, nurses, and co-workers to take responsibility for our own safety and work environment.  

Through cooperation and consistency, we can create and bring solutions to the workplace and hopefully one day, aid in the creation of laws that make our jobs safer for us to supply the care and support our patients need. We owe it to ourselves to take the necessary steps to show our employers it’s time to address this issue. “Be the change you wish to see in the world.” ~Mahatma Gandhi – 

Telemetry Basics - Rhythm Recognition

Introduction   

To truly understand telemetry, nurses must have knowledge about the anatomy of the heart and how electricity passes through it, how the electrocardiograph (EKG) works to receive and record the electrical activity, and how this information is transmitted via telemetry to the appropriate receiving device.

Defined as the transmission of instrumental readings by various methods such as radio waves or wires, telemetry gathers and transmits EKG readings to a central or remote monitor for interpretation and storage (71). The ability to read EKG rhythms from a variety of monitors consists of more than looking at a rhythm strip and identifying the rhythm. It consists of knowing the anatomy of the heart, how electricity travels through it and translates into the EKG we know, and what changes can happen based on injury, electrolytes, or other causes.

Heart Anatomy 101

As we know, the heart consists of four chambers, two atria—right atria (RA) and left atria (LA)—and two ventricles—right ventricle (RV) and left ventricle (LV)—working in a cycle to ensure adequate blood flow occurs. The heart receives blood from the inferior and superior vena cava (IVC and SVC) and enters the RA, moves to the RV, passes through the pulmonary artery (PA) and lungs, returns to the LA, enters the LV, and exits the heart through the aorta.

Heart cells, known as myocytes, are negatively charged, or “polarized” at rest. When these muscle cells contract, they become “depolarized” or positively charged. But how do the myocytes know when to contract? Less than 1% of the cells in the heart have a special role and name. These are known as the pacemaker cells and their role is to ensure that the heart beats. This is done through the action potential that is spontaneously created by the pacemaker cells. Some of these pacemaker cells have different speeds in depolarization, meaning that the fastest pacemaker cells are the ones controlling the speed. This will make more sense later when discussing specific cardiac rhythms (69).

Starting in the right atria, the sinoatrial node (SA node) is the primary group of pacemaker cells that determines the heart rhythm. The SA node, as well as the other pacemaker cells within the heart, progress through a rapid depolarization and repolarization process (2).

Pacemaker cells do not have a true resting potential, this means they are always in an “unstable” state to create spontaneous action potential. The action potential is the brief reversal of polarity in the cell; polarity consists of potassium (K⁺) in the cell with a negative charge, while sodium (Na⁺) and calcium (Ca⁺⁺) are outside of the cell with a positive charge (2).

Starting at the beginning of the cardiac cycle the pacemaker cells always have a membrane potential or voltage—the voltage of the cellular membrane as a result of permeability and concentrations of ions inside and outside the cell—of -60 microvolts (mV). From -60mV to -50mV the channels within the cells open, leading to a slow influx of Na⁺ inside the cell and a slow depolarization of the cell. Once the membrane voltage has reached the minimum threshold of -50mV the Ca⁺⁺ channels open, causing Ca⁺⁺ to move into the cell. This is known as the rising depolarization phase. The membrane voltage reaches the peak and the next thing that happens is the falling repolarization phase. This is where the K⁺ channels open to return the cell to a repolarized state (2).

(20)

Once these steps have occurred, the energy is transferred to surrounding cells, and the cardiac cycle continues. However, the action potential in the other myocytes is slightly different. Myocytes have a resting potential, which is different from the pacemaker cells. The resting potential is around -90mV and these cells only start the depolarization process when stimulated by an external force. During the end of the pacemaker cell’s action potential phase, additional Ca⁺⁺ is passed into the neighboring myocytes through gap junctions. The introduction of Ca⁺⁺ into the cell causes a sharp rise in the membrane voltage that approaches the threshold which is -70mVs. Once that threshold has been reached, the NA⁺ fast channels open and a rapid depolarization occurs since Na⁺ is brought into the cell. The Ca⁺⁺ slow channels open at -40mVs, further causing depolarization with Ca⁺⁺ entering the cell (2).

At the peak of cellular depolarization, the Na+ channels close, leading to a slight repolarization through some K⁺ entering the cell. This is minor as the Ca⁺⁺ channel is still open and continues to move K⁺ out of the cell. A plateau is created because of this and allows for the cell to go through two important phases. The first phase starts when the membrane voltage increases from the resting potential and continues until the plateau phase ends. This is known as the absolute refractory period and is where the myocytes relax before they can respond to additional stimuli. It prevents summation and tetanus which could lead to the heart not beating. The second phase is where additional Ca⁺⁺ is pulled out of the sarcoplasmic reticulum (SR) to further push K⁺ out of the cell (2).

The phase ends when the Ca⁺⁺ channel closes, extra Ca⁺⁺ is sent back to the SR, and K⁺ is allowed back into the cell. The sodium/potassium pump allows Na⁺ to exit the cell, returning the cell to its resting potential. This rapid process occurs in every myocyte for the life of the cell. Pacemaker cells are the only cells that can generate a heartbeat. Impulses from the nervous system can increase or decrease the heart rate, but they are influencing the pacemaker cell to generate more beats, not creating them (2).

It is important to note that there are several sets of pacemaker cells within the heart. The SA node starts the process, but there are a few others spaced out along the electricity’s path to ensure that the atria and ventricles of the heart have time to fill and properly contract. The second set of pacemaker cells is the atrioventricular node (AV node) where a slight delay of 0.01-0.05 meters per second (m/s) happens to make sure that the ventricles fill up adequately. The bundle of His takes the electric impulse to the left and right bundle branches and from there, the Purkinje Fibers are triggered. These fibers have a speed of 2-4 m/s to provide enough force to eject the blood from the ventricles (69).

Correlating all of this back to telemetry, scientific development within the medical profession has allowed us to visualize this electrical activity and translate it into an effective method of diagnosing cardiac conditions such as abnormal heart rates or cell death.

Types of Telemetry

EKG

There are many ways to view cardiac rhythms now, however, the oldest method is the EKG. During the late 1700s, the Italian physician Luigi Galvani was experimenting with electricity and animal tissue. His experiments spanned at least three decades and inspired other physicians during and after his time. Using legs removed from the bodies of frogs, Galvani theorized that “animal electric fluid” enabled the muscles within the legs to move when touched by metals; according to him, this was “natural” fluid and not created as static electricity or friction is. He went on to theorize that the brain is an essential part of creating the “electric fluid” with nerves as the conductors (6).

Jumping forward to 1842, Doctor Carlo Matteucci made a significant contribution to EKGs. During his time researching electrical detection in animals, he discovered the electrical currents within the heart that accompany each heartbeat. Thirty-five years after Matteucci, Augustus Waller was able to use a capillary electrometer and electrodes to perform the first human EKG. These electrodes were placed on the chest and back of the participant and were vital in demonstrating there was electrical activity that preceded the contraction of the ventricles. William Bayliss and Edward Starling improved upon Waller’s research by using improved capillary electrometers to demonstrate triphasic cardiac electrical activity (1).

The Dutch physician most noted for creating the EKG known today was Doctor Willem Einthoven. He was inspired by Waller and those before him to improve the capillary electrometer, successfully identifying five deflections that were initially named ABCDE. Having to factor for inertia, Einthoven implemented mathematic correlation, resulting in the traditional EKG rhythm strips we use today with the letters PQRST depicted in the image below. Einthoven is also responsible for coining the word electrocardiogram or electrokardiogram in Dutch. This is where providers get the “k” in EKG from (1).

While Waller’s EKG utilized ten electrodes, Einthoven was able to condense that number to three, eliminating the right leg and the mouth electrodes. These three leads created Einthoven’s triangle; an important concept still used today and that will be discussed later. All of Einthoven's work resulted in him being awarded the Nobel Prize in Physiology and Medicine in 1924 (1).

Bedside Monitor

Emergency departments (ED), intensive care units (ICU), and other specialized areas that require continuous monitoring of a patient’s EKG and vital signs utilize various bedside monitors to ensure they are receiving accurate, real-time information on the patient. Cords are used to connect the patient to the monitor. The electrodes to display and document cardiac rhythm and heart rate are applied to patients in the standard 5 lead placement displayed in the below image. The vitals displayed on the monitor can also be displayed outside the room on a screen with multiple patients. Nurses, paramedics, or trained telemetry monitor technicians can watch many of these monitors at a time.

(14)

The placement of the five leads consists of the following:

• RA: 2^nd intercostal space, anterior axillary on the right – some providers may put this lead higher on the chest or on the right arm
• LA: 2^nd intercostal space, anterior axillary on the left – some providers may put this lead higher on the chest or on the left arm
• RL: 8^th intercostal space, anterior axillary on the right – some providers may put this lead lower on the abdomen
• LL: 8^th intercostal space, anterior axillary on the left – some providers may put this lead lower on the abdomen
• V: 4^th intercostal space, right margin of the sternum

Note: Always follow the manufacturer’s instructions for specific lead placement.

Helpful Tip: Many healthcare providers quickly remember lead placement based on color is smoke (black) over fire (red) and snow (white) over grass (green). This leaves brown (chocolate) in the middle.

These bedside monitors can monitor pulse oximetry, respiratory rate, temperature, capnography, blood pressure, and arterial pressure. Some devices may have other unique monitoring features. These monitors may be portable or have a way to transfer the cords to a transport monitor. They come with alarms that can be adjusted based on the patient’s unique vital signs or hospital policy.

First responders have similar devices they use when transporting patients with the added benefit of having a defibrillator and a real-time feedback device built in (91).

Remote Monitoring

Remote cardiac monitoring is similar to bedside monitoring; however, the EKG rhythm, heart rate, and pulse oximetry are not displayed at the bedside. Instead, they are displayed in a different location, sometimes a monitor room, where a trained professional is watching many patients. When they recognize an abnormal rhythm, they will contact the appropriate staff to assess the patient. They may call for the leads to be removed, a change in rhythm, or a low battery.

The EKG leads are placed the same way as the bedside monitor leads are placed (always be sure to consult the manufacturer’s instructions). The information is transmitted wirelessly via wireless medical telemetry service (WMTS) from the “tele box,” but the leads must be wired to the box. WMTS does not use Wi-Fi and protects transmissions from Wi-Fi interference (48).

Mobile Cardiac Monitor and Event Monitor

A mobile cardiac or event monitor is a device attached to the skin that can perform continuous or event-specific monitoring. This device is attached to the patient’s chest near the heart and records when activated. This device is smaller than other portable cardiac monitoring devices like the Holter Monitor which will be discussed later. Information can be transmitted to the monitoring center to be reviewed by trained staff and/or artificial intelligence. Abnormalities like tachycardia, bradycardia, atrial fibrillation, or cardiac pauses are reported to a physician. The patient may or may not know about the rhythm abnormalities occurring as some patients are asymptomatic (18).

Event monitoring consists of the following methods (23):

• Patch monitor: depending on the manufacturer, the device is stuck to the chest and left on for a designated period of time.
• Loop memory monitor: the sensors always stay on the patient and the patient activates the devices to begin recording when symptoms occur in addition to a few minutes before the event starts and after it ends. There is an implanted option as well.
• Symptom event monitor: Patients place the monitor on them and activate it like a patch monitor, but only when symptoms start.

Insertable Monitor

Insertable or implantable cardiac monitors are just like mobile and event monitors, but they are surgically inserted into the patient. They perform the same actions, but there is an added benefit to these devices. If the patient has worn an external device in the past and has known cardiac arrhythmias, they may have an implanted cardioverter-defibrillator (ICD) inserted to detect and treat the abnormal rhythm. These devices are connected to the heart via wires (they may be placed in the right atria, the right ventricle, or both) and are operated by batteries that do need to be changed per manufacture direction. Patients and providers should be aware of magnets, or electrical signals from other devices that can interfere with the insertable device (61).

Healthcare providers can “interrogate” ICDs or pacemakers with a device created by the monitor’s manufacturer. When interrogated, the device’s information is transmitted to a monitor center who calls the provider to give them a verbal report of what the device has recorded; a paper copy is often faxed to the provider as well. Some newer interrogation devices may display the information of the device on the screen.

Holter Monitor

As mentioned with mobile cardiac monitors, the Holter monitor is another wearable device that can be used to monitor and diagnose cardiac arrhythmias outside of the hospital setting. This device consists of five electrodes and a monitor that the patient can wear or carry on them. It is similar to the remote telemetry devices used in the inpatient hospital setting as shown in the next image. Patients wear this device for a short time, and information is not transmitted to a monitor technician. Instead, information collected is sent to a monitoring center where it is interpreted and sent to the physician (58).

As covered in this section, there are many options for cardiac telemetry monitoring, and providers may encounter many types of them. It is important to know these devices and how they operate.

Lead Placement

Now that we have discussed the types of telemetry monitoring devices that are available, it is time to discuss how to properly place the EKG leads on a 12 lead, 15 lead, right-sided EKG, and where to place the V₄R lead.

12 Lead EKG

For the 12 lead EKG, providers should start with the four limb leads (14):

• RA: On the upper or lower right arm
• LA: On the upper or lower left arm
• RL: on the upper or lower right leg
• LL: on the upper or lower left leg

From there, the six pericardial leads are placed strategically around the chest to create a partial circle around the heart (14):

• V1: 4^th intercostal space, right margin of the sternum (this is lead V on the 5 lead EKG)
• V2: 4^th intercostal space, left margin of the sternum
• V3: sits midway between leads V2 and V4 on the left
• V4: 5^th intercostal space, mid-clavicular line on the left
• V5: 5^th intercostal space, anterior axillary line on the left (aligned horizontally with V4, between V4 and V6) on the left
• V6: 5^th intercostal space, mid-axillary line on the left (aligned horizontally with V4)

15 Lead EKG

The 15 lead EKG uses the same leads as the 12 lead EKG, but it adds V7, V8, and V9, known as the posterior leads, to encompass the posterior angles of the heart (14):

• V7: left posterior axillary line (aligned horizontally with V6, across from V5)
• V8: tip of the left scapula (aligned horizontally with V6, across from V4)
• V9: left of the spinal column (aligned horizontally with V6, across from V3)

Right Sided EKG

The right-sided EKG is important to rule out the diagnosis of a right-sided myocardial infarction (MI) or ischemia in or out while treating a patient. Lead placement is the same for the four limb leads, but the 6 precordial leads are flipped (14):

• V1: 4^th intercostal space, left margin of the sternum
• V2: 4^th intercostal space, right margin of the sternum (this is lead V on the 5 lead EKG)
• V3: sits midway between leads V2 and V4
• V4: 5^th intercostal space, mid-clavicular line on the right
• V5: 5^th intercostal space, anterior axillary line on the right (aligned horizontally with V4, between V4 and V6)
• V6: 5^th intercostal space, mid-axillary line on the right (aligned horizontally with V4)

V4R Lead Placement

A full right-sided EKG is not always needed. Lead V4 on the right side of the heart is the most important lead when it comes to determining an MI on the right side of the heart (14):

• V1, V2, V3, V5, V6: same placement as the 12 and 15 lead EKGs.
  • V4 is removed and placed on the right side of the chest
• V₄R: 5^th intercostal space, mid-clavicular line on the right (Where it is located on a complete right sided EKG)
  • The “R” stands for right to ensure that those reading the EKG are aware that lead is on the right while the rest are located on the left side of the chest.

Limb Leads

Now that lead placement has been covered, we can now discuss how lead placement shows different parts of the heart.

Leads I, II, III, AVR, AVL, and AVF are considered limb leads when reading the EKG. It is important to note that the right leg lead is the grounding electrode and does not affect the EKG (83). Leads I, II, and III leads form a triangle over the chest known as Einthoven’s Triangle as reflected in the below image. Lead I always has negative polarity while lead III always has positive polarity. Lead II’s polarity depends on what side of the triangle is being discussed. If we are looking at lead I on the EKG, then lead II is positive, but if we are looking at lead III, then lead II is negative (82).

The importance of what leads are negative and positive comes from how electricity travels through the heart. It starts on the right side and moves to the left, so it would make sense for lead I to have negative polarity while leads II and III are positively charged (82). This is also why the height of a PQRST complex changes based on what lead is being looked at on an EKG as reflected below.

Augmented or unipolar leads AVR, AVL, and AVF have the heart as the negative electrode and the limb leads are the positive electrodes. AVR goes from the heart to the right arm lead, AVL goes from the heart to the left arm lead, and AVF goes from the heart to the left leg lead. Just as discussed with leads I, II, and III, the path of the electricity in the heart determines how the PQRST complex appears on the rhythm strip (82). Lead II is the preferred strip to read by providers due to the best view of the rhythm due to the way electricity travels through the heart and how lead II follows that path by starting at the right shoulder and going to the left leg.

The chest leads, V1 – V9, create a circle around the heart on a horizontal plane. These leads are unipolar as well, with the heart being the negative electrode. Multiple views of the heart are captured because of the many leads placed along the patient’s body. This can give providers valuable knowledge on what areas of the heart may be affected. The next image gives a visual depiction of how the leads display their view of the heart.

Reading EKGs: EKG Components

To be able to interpret EKGs successfully, nurses must first have knowledge about the EKG components displayed on the EKG strips and how each part correlates to a part of a single heartbeat.

P wave

The P wave is the first deflection from the isoelectric line or baseline. Correlating this to the heart, this is where the atria depolarize or contract. The contraction of the right atria starts at the beginning of the P wave while the contraction of the left atria begins in the middle and end of it. Normal P waves are apparent between 120 and 200 milliseconds (msec) before the upward deflection of the QRS complex (44)

PR Interval

The next part of the PQRST complex is the PR interval. The interval symbolized the time between the depolarization of the atria and the depolarization of the ventricle. The normal speed is 120 to 200 msec (44).

PR Segment

Next is the PR segment. This is similar to the PR interval but starts at the end of the P wave and ends at the start of the Q wave. This line is important because if there is a deviation from the isoelectric line, it could indicate a cardiac rhythm abnormality like Wolff-Parkinson-White syndrome which will be discussed later. The EKG may have a “slurred” upstroke from the P to R points on the EKG, making the Q wave appear to be on the isoelectric line. This is because the ventricles were stimulated or excited early, leading to a shortened PR interval. The “slurred” area is known as a delta wave (13).

QRS Complex

The QRS complex is where the ventricles depolarize and contract. The first downward deflection of the beat is the Q wave that lasts for < 0.05 seconds. It is present in all leads save for V1 and V3 due to the angle of the vector. The R wave is the upward deflection of the complex. R waves do not have a set height, but severely elevated R waves can be an indicator of ventricular hypertrophy. The second downward deflection is the S wave. Overall, the QRS complex is 0.07 to 0.10 seconds long and variations to this time can be an indicator of abnormal heart rhythms (17).

ST Segment

The ST segment starts when the S wave ends by returning to the isoelectric line and ends when the T wave begins. This period represented the completion of ventricular depolarization (17). The ST segment lasts 0.08 seconds to 0.12 seconds (51).

T Wave

The final wave in the standard EKG components is the T wave. This wave symbolizes the ventricles repolarizing. Inverted T waves can be an indication of past or current infections. A peaked T wave—as opposed to the normal curved T wave—can be caused by hypocalcemia, hyperkalemia, and left ventricular hypertrophy (17). The T wave runs from 0.01 seconds to 0.25 seconds (51).

The image below depicts the components of an EKG with labels to assist with understanding how the waves appear.

(4)

Reading EKGs: EKG Paper

The EKG paper has sets of squares, 25 little squares within one larger square. The smaller squares symbolize 0.04 seconds making the larger square 0.20 seconds. A single small square is 1mm while the large square is 5mm, this is because the larger square is five small squares tall.

(15)

Some EKG strips are presented in a six second format. To determine if the strip is a six-second, you must count the larger boxes. 30 larger boxes are required for the strip to be six seconds. Some may even have second markers that symbolize one second of time passed.

The 12 lead EKG can be more challenging to read and is often used to make an overall observation about the patient’s heart rate and rhythm. It can provide more information to providers than a single lead strip can. 

As discussed previously, the leads are placed along the path of the heart, and providers can determine what part of the heart may be affected by knowing what leads are placed where.

(51)

Now that we have discussed leads, lead placement, the PQRST complex, and EKG paper, it is time to cover different cardiac rhythms that you may encounter.

Rhythm Recognition

Normal Sinus (41):

• Rate: 60-100 beats per minute (bpm)
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic (curves above and then dips below the isoelectric line) in V1
  • Duration:
    • Less than 0.12 seconds
  • Rhythm Strip:

(29)

Sinus Bradycardia (87):

• Rate: less than 60bpm
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:
    

(87)

• Signs and Symptoms:
  • None – depending on the patient
  • Cyanosis
  • Peripheral edema
  • Shortness of breath
  • Dizziness
  • Fatigue
  • Syncope or near syncope
  • Lightheadedness
• Causes (not limited to):
  • Normal physiology in an athlete
  • Medications like beta-blockers
  • Ischemia
  • Heart diseases
  • Sick sinus syndrome
  • Hypothermia
  • Hypothyroidism
  • Neuro-mediated bradycardia as caused by a vasovagal reaction
  • Pericarditis
  • Hypoxia

• Electrolyte imbalances

• Treatment:
  • None if asymptomatic, admission for observation may be indicated
  • Medications:
    • Atropine 0.5mg every 3 to 5 minutes for a maximum dose of 3mg
    • Antidotes or reversal agents
  • Transcutaneous cardiac pacing or pacemaker
  • Return patient to a normothermic state if hypothermic

Sinus Tachycardia (55):

• Rate: greater than 100bpm but less than 150bpm
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:

(42)

• Signs and Symptoms:
  • Shortness of breath
  • Chest pain
  • Dizziness
  • Syncope or near syncope
  • Lightheadedness
  • Palpitations
• Causes:
  • Infection or sepsis
  • Medications
  • Withdrawal
  • Electrolyte imbalances
  • Blood loss or anemia
  • Dehydration
  • Hypoglycemia
  • Pulmonary embolism
  • Trauma
  • Cardiac tamponade
  • Myocarditis
  • Pregnancy
• Treatment:
  • Medications
    • Antibiotics
    • Antidotes or reversal agents
    • Insulin
    • Electrolyte replacement
    • Fluids
    • Heparin or other anticoagulant medications
  • Blood replacement
  • Surgery

1st Degree AV Block (68):

• Rate: 60-100 beats per minute (bpm)
• Conduction:
  • PR interval greater than 0.20 seconds
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • A QRS complex always follows the P wave
• Duration:
  • Less than 0.12 seconds
• Rhythm Strip:

(32)

• Signs and Symptoms:
  • None
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
• Causes:
  • Increased vagal tones in young patients
  • Fibrotic changes in the elderly
  • Cardiac disease
  • Inflammation
  • Medications
  • Electrolyte abnormalities
• Treatment:
  • None if asymptomatic
  • Medications
    • Antibiotics
    • Antidotes or reversal agents
    • Electrolyte replacement

2nd Degree Type I AV Block (Mobitz Type 1 or Wenckebach) (60):

• Rate: varies
• Conduction:
  • PR interval increases with each beat, eventually “dropping off” and another P wave appears
  • “Longer, longer, drop, that’s a Wenckebach.”
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:

(27)

• Signs and Symptoms:
  • None
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
• Causes:
  • Increased vagal tones
  • Cardiomyopathy
  • Myocardial infarction
  • Cardiac surgery
  • Electrolyte abnormalities
  • Medications
• Treatment:
  • None if asymptomatic
  • Medications
    • Atropine if bradycardic
    • Antidotes or reversal agents
    • Electrolyte replacement

2nd Degree Type II AV Block (Mobitz II) (60):

• Rate: varies
• Conduction:
  • PR interval varies
  • QRS width 60-100ms when present
    • QRS does not follow all P waves
  • P wave morphology:
    • The maximum height of the P wave is:
      • Lead II and III: 2.5 mm
    • The P wave is:
      • Positive or above the isoelectric line in II and AVF
      • Biphasic in V1
    • Rhythm Strip:

(40)

• Signs and Symptoms:
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
  • Cardiac arrest
• Causes:
  • Structural heart disease
  • Amyloidosis
  • lymphoma
  • Cardiac tumors
  • Transcatheter placement of valves
  • Myocardial infarction
  • Genetics
• Treatment:
  • None if asymptomatic
  • Medications
    • Atropine does not work on these patients
    • Antidotes or reversal agents
  • Transcutaneous cardiac pacing or pacemaker since this rhythm can progress to a complete heart block or cardiac arrest

3rd Degree AV Block (78):

• Rate: varies, but usually bradycardic
• Conduction:
  • PR interval varies
  • QRS width 60-100ms when present
  • P wave and QRS complex do not communicate (called AV disassociation)
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:

(33)

• Signs and Symptoms:
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
  • Hemodynamic instability
  • Cardiac murmurs
  • Cardiac arrest
• Causes:
  • Cardiac surgery
  • Cardiac disease
  • Medications
  • Electrolyte imbalances
  • Lyme disease
  • Transcatheter aortic valve replacement
  • Myocardial infarction
  • Systemic lupus erythematosus
  • Sarcoidosis
• Treatment:
  • Medications
    • Atropine usually does not work, but can be administered
    • Epinephrine
    • Dopamine
    • Antidotes or reversal agents
    • Electrolyte replacement
  • Transcutaneous cardiac pacing or pacemaker

Premature Ventricular Contraction (PVC) (88):

• Rate: varies, underlying rhythm is usually normal sinus
  • The impulse to beat comes from the ventricles, not from the SA node
• Conduction:
  • PR interval varies, but in a regular PQRST complex PR interval is 120-200ms
  • PR interval after a PVC is longer due to the PVC and the retrograde concealed conduction goes back into the AV node junction.
  • PVC QRS width is at least 120ms but usually 160-200ms
  • Regular QRS width is 60-100ms
  • PR interval after a PVC is longer due to the PVC and the retrograde concealed conduction goes back into the AV node junction.
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:
    • Monomorphic: All PVCs are shaped the same

(38)

• Biomorphic: PVCs are shaped differently

(64)

• Bigeminy: Every PVC is separated by one sinus beat.

(35)

• Trigeminy: Every PVC is separated by two sinus beats.

(9)

• Ventricular Couplet: Two PVC beats in a row.

(9)

• Ventricular Triplet: Three PVC beats in a row.

(9)

• Signs and Symptoms:
  • None
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Palpitations
  • Lightheadedness
  • Abnormal neck pulsation
  • Hemodynamic instability with frequent PVCs
  • Cardiac arrest
• Causes:
  • Hypoxia
  • Illicit drug use
    • Amphetamines
    • Alcohol
    • Cocaine
  • Electrolyte imbalances
  • Myocarditis
  • Mitral valve prolapse
  • Hypercarbia
  • Cardiomyopathies
  • Myocardial infarction
  • Medications
• Treatment:
  • None if asymptomatic
  • Medications
    • Beta-blockers
    • Calcium channel blockers
    • Amiodarone is for those with preexisting coronary artery diseases, but used with caution and close observation and monitoring
    • Antidotes or reversal agents
    • Electrolyte replacement
  • Cardiac ablation
  • Defibrillation if cardiac arrest occurs

Premature Atrial Contractions (PAC) (54):

• Rate: varies, underlying rhythm is usually normal sinus
• Conduction:
  • PR interval varies, but in a regular PQRST complex PR interval is 120-200ms
  • PAC
  • Regular QRS width is 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave:
    • Can be inverted
    • May be hidden in the T wave creating a hump or peaked T wave
  • These rhythms can come in the same variations as PVCs:
    • Bigeminy
    • Trigeminy
    • Couplet
    • Triplet
  • Rhythm Strip:

(37)

• Signs and Symptoms:
  • None
  • Palpitations
  • Shortness of breath
  • Anxiety
  • Signs and symptoms of heart failure
  • Early or additional heart sounds
  • Pauses in rhythm
• Causes:
  • Coronary artery disease
  • Left ventricular hypertrophy
  • Septal defects
  • Congenital heart deformities
  • Medications
    • Beta-blockers
    • Chemotherapeutic agents
  • Congestive heart failure
  • Diabetes mellitus
  • Hypertension
  • Chronic obstructive pulmonary disorder
  • Anxiety
• Treatment:
  • None if asymptomatic
  • Avoiding triggers
  • Medications
    • Beta-adrenergic blockers
    • Antiarrhythmic agents are used with caution and close observation and monitoring
    • Antidotes or reversal agents
    • Cardiac ablation

Ventricular Tachycardia (V Tach) (45):

• Rate: greater than 100bpm
• Conduction:
  • PR interval none
  • QRS width greater than 140ms
• P wave morphology:
  • Not present
• Non-sustained V-Tach: three or more ventricular beats over a maximum of 30 seconds.
• Sustained V-Tach: a run of V Tach for more than 30 seconds or less is treated by cardioversion
• Monomorphic V-Tach: all ventricular beats look the same
• Polymorphic V-Tach: the ventricular beats look different.
• Biphasic V Teach: where the QRS complexes alternate with each beat.
  • Digoxin intoxication
  • Long QT syndrome
• Rhythm Strip:
  • Monomorphic V-Tach

(11)

• Signs and Symptoms:
  • Palpitations
  • Shortness of breath
  • Chest pain
  • Syncope or near syncope
  • Signs of heart failure
  • Hemodynamic instability
  • ICD shocks if the patient has one
  • Cardiac arrest
    • Also known as pulseless V-Tach
  • Causes:
    • Ischemic heart disease
    • Acute coronary artery disease
    • Myocardial scar-related reentry
    • Congenital heart deformities
    • Cardiomyopathy
    • Illicit drugs
      • Cocaine
      • Digitalis toxicity
      • Methamphetamine
    • Medications
      • Beta-blockers
      • Chemotherapeutic agents
    • Electrolyte imbalances
    • Sepsis
    • Metabolic acidosis
    • Inherited cardiac channelopathies
  • Treatment:
    • Cardiopulmonary resuscitation (CPR) and defibrillation if no pulse present
    • Cardioversion if hemodynamically unstable and has a pulse
    • Treatment for myocardial infarction
    • Medications
      • Amiodarone, procainamide, sotalol
      • Antidotes or reversal agents
    • ICD
    • Cardiac ablation

Torsades de Pointes (V Fib) (25):

• Rate: none
• Conduction:
  • Polymorphic V-Tach with a prolonged QR interval
• P wave morphology:
  • Not present
• Rhythm Strip:

(12)

• Signs and Symptoms:
  • None
  • Syncope or near syncope
  • Dizziness
  • Lightheadedness
  • Hypotension
  • Rapid pulse
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Medications
      • Zofran causes a long QT interval (19)
    • Congenital prolonged QT:
      • Jervell and Lange-Nielsen
      • Romano-Ward syndrome
    • Bradycardia
    • Diuretic use
    • Female gender
    • Age
  • Treatment:
    • Electrolyte replacement
    • CPR and defibrillation
    • Medications
      • Epinephrine
      • Atropine
    • Cardioversion
    • Treatment of the underlying cause

Supraventricular Tachycardia (SVT) (72):

• Rate: Greater than 160bpm
• Conduction:
  • PR interval not present
  • QRS width less than 120 milliseconds = narrow complex, regular SVT
  • QRS width greater than 120 milliseconds = wide complex, regular SVT
• P wave morphology:
  • Not present
• Rhythm Strip:
  • Narrow complex, regular SVT

(30)

• Wide complex, regular SVT

(79)

• Signs and Symptoms:
  • None
  • Hypotension
  • Shortness of breath
  • Lightheadedness
  • Signs and symptoms of heart failure
  • Shock
• Causes:
  • Narrow complex, regular SVT - Orthodromic reentry phenomenon (56):
    • Accessory pathway that connects the atria and ventricles without passing through the AV node
    • A pulse goes through the AV node, down into the ventricles via the Bundle of His, up through the accessory pathway, and back into the AV node
  • Wide complex, regular SVT - Atrioventricular reentry phenomenon (57):
    • Signals from the SA node travel through the accessory pathway down the ventricles via the Bundle of His and up to the AV node, creating a backward cycle.
    • This is slower than the orthodromic SVT because it is traveling against the regular path of conduction, leaving to a wide QRS complex
  • Medications
  • Caffeine
  • Smoking
  • Stress
  • Alcohol
• Treatment:
  • None if asymptomatic
  • Vagal maneuvers
    • Bearing down
    • Blowing into a straw
  • Medications
    • Adenosine: 1^st dose 6mg, 2^nd dose 12mg
      • Ensure rapid saline flush after pushing medication as it has an extremely short half-life
    • Cardizem
    • Antidotes or reversal agents
  • Cardioversion
  • Cardiac ablation

 Ventricular Fibrillation (V-Fib) (3):

• Rate: none
• Conduction:
  • PR interval not present
  • QRS width not present
• P wave morphology:
  • Not present
• Rhythm Strip:

(39)

• Signs and Symptoms:
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Myocardial infarction
    • Congenital heart defects
    • Sudden blow to the chest right over the heart
    • Medications
    • Anemia
    • Cardiomyopathy
    • Electrocution
    • Thoracic trauma
    • Heart surgery
  • Treatment:
    • CPR and defibrillation
    • Medications
      • Epinephrine
      • Atropine
      • Electrolytes
    • Surgery
    • Coronary perfusion
    • Treatment of the underlying cause

Asystole (59):

• Rate: none
• Conduction:
  • PR interval not present
  • QRS width not present
• P wave morphology:
  • May or may not be present
• Rhythm Strip:

(21)

• Signs and Symptoms:
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Myocardial infarction
    • Congenital heart defects
    • Medications or illicit drugs
    • Blood loss
    • Cardiomyopathy
    • Electrocution
    • Trauma
  • Treatment:
    • CPR
      • Since there is no electrical activity with this rhythm, defibrillation cannot be used
    • Medications
      • Epinephrine
      • Atropine
      • Electrolytes
    • Surgery
    • Coronary perfusion
    • Treatment of the underlying cause

Pulseless Electrical Activity (PEA) (22):

• Rate: varies
  • There is no pulse with this rhythm despite the fact that it may appear as an organized rhythm
• Conduction:
  • PR interval none
  • QRS width greater than 110ms
• P wave morphology:
  • Not present
• The P wave is:
  • Not present
• Rhythm Strip:

(22)

• Signs and Symptoms:
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Myocardial infarction
    • Congenital heart defects
    • Medications or illicit drugs
    • Blood loss
    • Cardiomyopathy
    • Electrocution
    • Trauma
    • Hypothermia
    • Pneumothorax or hemothorax
  •  Treatment:
    • CPR
      • Since there is no electrical activity with this rhythm, defibrillation cannot be used
    • Medications
      • Epinephrine
      • Atropine
      • Electrolytes
    • Surgery
    • Coronary perfusion
    • Treatment of the underlying cause

Atrial Flutter (73):

• Rate: varies
  • Depends on how many QRS complexes there are
    • Atrial rate 250-350 bpm
    • Ventricular rate 75-150bpm
  • P waves can come in blocks
    • 2 P waves per 1 QRS (2:1)
    • 3 P waves per 1 QRS (3:1)
    • 4 P waves per 1 QRS (4:1)
    • Intervals of P waves per 1 QRS (2:1 then 3: 1 then 2:1 then 4:1)
  • Conduction:
    • PR interval varies
    • QRS width 60-100ms
  • P wave morphology:
    • The maximum height of the P wave is:
      • Lead II and III: 2.5 mm
      • Sawtooth pattern
    • Rhythm Strip:

(31)

• Signs and Symptoms:
  • None
  • Palpitations
  • Fatigue
  • Syncope or near syncope
  • Shortness of breath
  • Regular or irregularly regular pulse
• Causes:
  • COPD
  • Heart failure
  • Atrial size abnormalities
  • Hypertension
  • Diabetes mellitus
  • Age
  • Male gender
• Treatment:
  • None if asymptomatic
  • Medications
    • Amiodarone
    • Cardizem
    • Metoprolol
    • Anticoagulation to prevent stroke
  • Catheter ablation
  • Treatment of the underlying cause

Atrial Fibrillation (AFib) (89):

• Rate: varies
  • Atrial rate 400-600 bpm
  • Ventricular rate 75-175 bpm
    • Anything over 100 is considered A Fib with rapid ventricular response (RVR)
  • Conduction:
    • PR interval varies
    • QRS width 60-100ms
  • P wave morphology:
    • The maximum height of the P wave is:
      • Lead II and III: 2.5 mm
    • Rhythm Strip:
      • A Fib

(28)

• A Fib RVR

(34)

• Signs and Symptoms:
  • None
  • Palpitations
  • Fatigue
  • Syncope or near syncope
  • Shortness of breath
  • Regular or irregular pulse
    • Patients can go in and out of A Fib or it can be permanent,
    • They can go in and out of RVR
  • Causes:
    • Heart disease
    • Genetics
    • Pulmonary embolism or other hemodynamic stressors
    • Obstructive sleep apnea
    • Heart failure
    • Pericarditis
    • Myocarditis
    • Myocardial infarction
    • Hypertension
    • Diabetes mellitus
    • Age
  • Treatment:
    • None if asymptomatic
    • Medications
      • Cardizem
      • Metoprolol
      • Amiodarone
      • Anticoagulation to prevent stroke
    • Catheter ablation
    • Treatment of the underlying cause

Idioventricular Rhythms (47):

• Rate: varies
  • Idioventricular rate 35-40bpm
  • Accelerated rate 60-120bpm
• Conduction:
  • PR interval not present
  • QRS width greater than 120ms but can be greater than 160ms
    • The normal conduction system does not transmit the signal to beat, the vertical signal is transmitted from cell to cell
  • P wave morphology:
    • Not present
  • Rhythm Strip:
    • Idioventricular rate

(36)

• Signs and Symptoms:
  • None
  • Palpitations
  • Fatigue
  • Lightheadedness
  • Syncope or near syncope
  • Cardiac arrest
• Causes:
  • Electrolyte imbalances
  • Reperfusion of cardiac cells after a myocardial infarction
  • Medications
    • Digoxin
    • Beta-adrenoreceptor agonists
  • Illicit drug use like cocaine
  • Cardiomyopathies
  • Congenital cardiac defects
  • Athletes
• Treatment:
  • None if asymptomatic
  • Medications
    • Atropine
    • Amiodarone or lidocaine
    • Reversal agents
  • Rarely cardiac pacing
  • Treatment of the underlying cause

Junctional Rhythms (52):

• Rate: varies
  • Junctional bradycardia less than 40bpm
  • Junctional escape rhythm 40-60bpm
  • Accelerated junctional rhythm 60-100bpm
  • Junctional tachycardia greater than 100bpm
• Conduction:
  • PR interval not present
  • QRS width 60-100ms
• P wave morphology:
  • Not present
• Rhythm Strip:
  • Accelerated Junctional Rhythm
    • Rhythms look the same but have more beats depending on the type of rhythm

(52)

• Signs and Symptoms:
  • None
  • Shortness of breath
  • Palpitations, intermittent or continuous
  • Fatigue
  • Lightheadedness
  • Syncope or near syncope
• Causes:
  • Electrolyte imbalances
    • Can be caused by anorexia nervosa
  • Thoracic trauma
  • Myocarditis
  • Reperfusion of cardiac cells after a myocardial infarction
  • Medications
    • Adenosine
    • Clonidine
    • Antiarrhythmics
    • Lithium
    • Digoxin
  • Sleep apnea
  • Hypoxia
  • Coronary artery disease
  • Congenital cardiac defects and repairs of these defects
• Treatment:
  • None if asymptomatic
  • Medications
    • Atropine
    • Reversal agents
  • Transcutaneous pacing
  • Permanent pacemaker
  • Treatment of the underlying cause

Bundle Branch Blocks (BBB) (43, 53, 70):

• Rate: varies
• Conduction:
  • Right BBB (RBBB):
    • QRS interval greater than 120ms
    • Septal depolarization that leads to a:
      • Small R wave being present in V1
      • Q wave in V6
    • The left ventricle’s contraction leads to and:
      • • S wave in V1
        • R wave in V6
    • The right ventricle’s contraction leads to an:
      • R wave in V1
      • Deep S wave in V6
    • Left BBB (LBBB):
      • QRS interval greater than 120ms
      • T wave inversion is due to abnormal repolarization
      • From first principles:
      • Septal depolarization that leads to a:
        • Q wave in V1
        • R wave in V6

• • • The right ventricle’s contraction leads to an:
      • R wave in V1
      • S wave in V6
    • The left ventricle’s contraction leads to and:
      • S wave in V1
      • R wave in V6
  • P wave morphology:
    • The maximum height of the P wave is:
      • Lead II and III: 2.5 mm
    • Rhythm Strip:
      • RBBB

(71)

• • • • LBBB

(71)

• Signs and Symptoms:
  • None
  • Lightheadedness
  • Syncope or near syncope
• Causes:
  • RBBB:
    • Myocardial infarction
    • Congenital cardiac defects
    • Pulmonary embolism
    • Myocarditis
    • Pulmonary hypertension
  • LBBB:
    • Myocardial infarction
    • Hypertension
    • Cardiomyopathy
    • Myocarditis
  • Treatment:
  • None if asymptomatic
  • Treatment of the underlying cause

Identifying Ischemia and Infarction

Known as coronary artery disease (CAD), acute myocardial ischemia is the decrease of blood flow to the heart by atherosclerosis or plaque. The atherosclerosis starts as a plaque streak within the large arteries and continues to build up. After the plaque has grown to a significant size, occlusion begins and blood flow to areas below the growing occlusion suffers a decrease in blood flow. This is what is known as ischemia (81).

When resting, patients may not experience any signs or symptoms. Upon exertion, however, patients may experience stable angina—chest pain, discomfort, pressure, etc.—as activity requires increased blood flow and the arteries constrict to pump blood through the body faster. This pain is relieved at rest and can be further treated by nitrates. The routine is what makes this stable angina (81).

Unstable angina begins once the artery has become occluded enough to create a significant obstruction of blood flow. Signs and symptoms can include chest pain or other discomfort that is challenging to relieve, even when at rest. Patients may be woken from sleep due to the pain and report that it takes longer for the pain to decrease or resolve completely. These signs and symptoms symbolize that the plaque within the artery is unstable and could potentially rupture (90).

Infarction is when the blood flow is completely obstructed and the cells below the obstruction begin to die off. This often occurs when the plaque within the artery ruptures, leading to the body’s natural clotting processing in an attempt to repair the rupture, and a complete occlusion of the artery occurs (46).

Now that we have discussed ischemia and infarction, it is time to discuss how a myocardial infarction (MI) appears on an EKG and how to identify it. You may also hear them referred to as STEMIs or ST-elevation myocardial infarction.

The progression of PQRST complex changes during an MI can start with hyperacute T waves. The T wave will increase with amplitude and become wider, while some ST elevation may be noted. This elevation begins to occur as injury to the heart muscle begins. From there, the ST elevation increases and creates the image often associated with an MI. Pathological Q wave may develop as the MI progresses. As discussed earlier, the Q wave is the first downward deflection of the QRS complex and is normally 1mm or less in depth. Pathological Q waves are measured by greater than 1mm wide or greater than 25% of the R wave’s amplitude (84).

T wave inversion occurs when the cells have become necrotized and begin to form fibrosis. Once all necrotized cells have become fibrotic, the Q waves will remain, but the T waves will become upright again (84).

(84)

These changes should be present in at least 2 contiguous leads or leads that are side by side. To discuss this more, we will refer to the 12 lead EKG photo we used earlier. It is important to know that there will be leads with ST elevation and there will be leads with reciprocal ST depression based on the type of MI and how these leads are placed in relation to the area of the heart that is being affected.

(82)

With posterior MIs the elevation must be at least 0.5mm, there will be tall, broad R waves of at least 30ms long, and the T wave will be upright. When looking at an EKG for a posterior MI, the ST depression is what will be observed in leads V1, V2, and V3. If a posterior MI is suspected, look at the EKG from the back of the paper by flipping it over and holding it to light. This will display the ST depression as ST elevation, prompting you to consider a posterior EKG. It is advised that a posterior EKG with leads V7, V8, and V9 be done. A quick method to do this is by removing leads V4, V5, and V6; placing them in the posterior lead positions; and relabeling them on the EKG. (77).

Right ventricular MIs can occur, and it is important to assess and treat them appropriately. To assess for a right-sided MI, first look at the standard EKG. If ST elevation is noted in leads II and III, but the ST elevation is greater in lead III than lead II, consider right ventricular involvement. As discussed previously, one method is to do a right-sided EKG, with lead placement along the right side of the chest. The second, quicker way to do this is to take lead V4 and place it on the right side of the chest and mark it as V4R on the EKG (77).

Another rhythm that can be an indicator of an MI is a bundle branch block. New or suspected new BBBs are to be treated as a MI by providers. But what if you have a copy of an old EKG and the BBB isn’t new, can the patient still be having an MI? The answer is yes. However, it can be challenging to determine what is a change from the MI and what is from the BBB. The Sgarbossa criteria is useful in making these determinations and can also be used for patients who have a pacemaker (77)

Sgarbossa criteria (77):

• Concordant ST elevation that is greater than 1mm
• Concordant ST depression that is greater than 1mm
• Excess discordant ST elevation that is greater than 5mm in leads with negative QRS complexes – these are complexes below the isoelectric line

For reference, concordance means that the ST segment and QRS complex go in the same direction, either both deflecting upwards or downwards. Discordance is what should be seen in a BBB or paced rhythm. This is where the ST segment and the QRS complex go in different directions. Smith et al. created a modification to the Sgarbossa criteria to include a greater than 1mm ST elevation to an S-wave amplitude ratio of greater than 0.25mm (7).

Another method that has been created, but not validated is the Barcelona criteria. This criterion has greater than 1mm ST deviation concordance or discordance with QRS polarity in any EKG lead. Discordant ST deviation is greater than 1mm in any lead where the R or S points of the QRS complex are less than 6mm (7).

There is an EKG rhythm that can indicate a future MI which is known as Wellens syndrome. This EKG has a deeply inverted or biphasic T wave in leads V2 and V3. The patient is often pain-free when the rhythm is present, ischemic chest pain can obscure the rhythm by creating a false normal appearance of the T waves in the affected leads. Their cardiac enzymes may not even be elevated. Any patient presenting with chest pain should have serial EKGs done for this reason, since they may be pain-free at a later time. These EKG changes symbolize the critical stenosis of the proximal left anterior descending artery (LAD). This is the artery that provides the left ventricle with blood (65).

Cardiac Assessment:

A traditional cardiac assessment focuses on more than just the heart; it encompasses aspects of both the neurological and respiratory systems. However, we will begin our focus with the heart.

Pain may not be a word patients use to describe what they are feeling. As mentioned, they may vocalize discomfort, pressure, cramping, burning, or tightness. Women may have jaw or arm pain as opposed to the traditional chest pain that men may experience. Ask them to rate their pain on a scale of one to ten, looking for changes in the value. An EKG based on pain, discomfort, pressure, cramping, or tightness should be completed within the time frame set by hospital policy.

The PQRST pneumonic can assist providers in remembering the specific information they need to collect (90).

P: What provokes, precipitates, or palliates/alleviates the pain or discomfort the patient is feeling? Does it get worse or better when you do certain things, i.e., walk or rest?

Q: What is the quality of pain or discomfort you are feeling?

R: Does this pain or discomfort radiate anywhere else in your body? Jaw, arm, back?

S: Are there associated symptoms with the pain or discomfort? Shortness of breath, dizziness, heartburn?

T: What time elements are involved? When did it start? Did it stop and come back? Are you currently feeling it now? Was it gradual or did it occur suddenly? Did it wake you up?

Patients should be asked about palpitations or any experienced abnormal heart rhythms detected on monitoring devices. Many individuals have smartwatches that can detect heart rates and some rhythms. If the patient is wearing one, determine if the device has recorded anything.

Edema in the legs can be a sign of acute heart failure while pain in the calf can indicate a blood clot that could have traveled from another part of the body (85). In A Fib, the blood can clot in the ventricles due to poor circulation of blood. It will pool until it clots or is ejected from the heart. Once expelled, the clot will travel until it can no longer pass through the veins (63).  Ensure a thorough assessment of the patient’s distal pulses is done as well to determine circulation. The further pulse locations can be an indicator of poor circulation (85).

Moving on to the respiratory system, we will reflect on the many arrhythmias that have shortness of breath as a sign or symptom. Providers should assess lung sounds to determine if there is any fluid buildup, a sign of acute heart failure. Determine if the shortness of breath is all the time, upon exertion, or at rest. Also, it is important to ask if the patient has been woken from sleep due to a shortness of breath. Sometimes arrhythmias occur at unexpected moments, even in the middle of the night (85).

Syncope was another common sign or symptom of cardiac arrhythmias due to decreased perfusion to the brain. Providers should determine if the patient currently feels lightheaded or dizzy, if they felt that way in the past, or if they have fainted. They should ask when this feeling happens—at rest, while moving, or both—and if they get any warning signs or auras beforehand. Always ensure you ask the patient to describe what happened so it can be added to the assessment (85).

A full medical history should be obtained, with a special focus on any past cardiac medical history the patient or their family has. Providers may consider asking the following questions:

• Have you been diagnosed with coronary artery disease, high blood pressure, peripheral vascular disease, valve problems, heart failure, high cholesterol, or other heart conditions?
• Have you had a heart attack or stroke in the past?
• Have you had any surgical procedures to help with your heart function? This may include things like ablation or stent placement.

Asking about medications can assist providers in determining any missed diagnoses with the patient while asking about social history can provide information about smoking, illicit drug use, alcohol consumption, and exercise habits (85).

Conclusion

Thanks to advancements within the medical profession, cardiac telemetry can be greatly beneficial to patients in and outside of the hospital setting. From devices you can carry, to devices implanted inside someone, patient outcomes have improved for identifying, treating, and managing cardiac arrhythmias that had once been deemed unmanageable. With proper knowledge of EKG rhythms, nurses can confidently provide the proper care for their patients by being an advocate for those they care for.

Heart Failure Updates

Introduction   

In 1997, Heart Failure (HF) was designated an epidemic due to the significant increase in hospitalizations. (2) This increase in hospitalizations appears to be due to accurate management of HF patients who re-hospitalize for stabilization and medication management rather than a new diagnosis or end-stage disease.

HF occurs when the heart is too weak to pump blood to the body and lungs. The blood then backs up into the heart, lungs, and lower extremities, causing less blood supply to the body. HF can also be so severe that it can cause death in patients. (1)

It is crucial for nurses to understand the pathophysiology of HF, risk factors, and what education and treatment a nurse can incorporate in the plan of care, which will slow the progression of disease and maintain quality of life.

Statistical Evidence/Epidemiology

Epidemiologists study a disease's incidence, mortality, and prevalence to predict health care costs, how many people have a disease, how it affects society, and when the numbers of a disease change.

According to the CDC, there are approximately 6.2 million patients with heart failure in the United States. The diagnosis was noted on 13.8% of death certificates in 2018. (2) $30.7 billion was spent on HF in 2012, including health care costs, days away from work, and medications that treat HF.

Although HF is higher in the elderly population, the more significant number of patients ages 35 and above who die with HF are concentrated in the southeast, southwest, Indiana, Wisconsin, and Illinois, with some counties in Utah, Oregon, Montana, South Dakota, and Nebraska.

Readmission rates declined when the Hospital Readmission Reduction Program (HRRP) began in 2012 to reduce costs and deliver care more safely.

Hospitals are penalized by the Centers for Medicare and Medicaid to lower readmission rates to less than 30 days for some diagnoses, and HF was among them. Hospitals began to look closer at the readmission rates, which helped them to focus on improved management. (2) . Using the information below, nurses can better assess the patient and add more information to their care plan.

The classifications of HF as defined by the New York Heart Association are:

• No symptoms with regular physical activity.
• Some mild symptoms with physical activity but not at rest
• Comfortable at rest but with moderate symptoms with some minor physical activity.
• Severe shortness of breath with rest. (2)

Providers typically use echocardiograms to measure heart failure using the ejection fraction (EF) percentage. Ejection fraction demonstrates the blood pumping rate from the left ventricle to the body.

An EF of below 30% indicates severe disease, while an EF at or above 50% indicates milder or no condition. Left ventricular failure with an EF of 50% or above is considered HF with preserved EF. An EF of 30% or below is considered HF with reduced EF. There is now a new category called HF with mid-range, which shows an EF of 40%-50%.

Approximately 15% of the HF population shows mid-range EF.

Incidence - is the number of new disease cases in certain patients. In HF, this number also helps scientists understand how the prevalence of the disease results from a lifestyle change. These studies aid in determining the burden of HF on society, which in turn helps to make changes in public policy and, eventually, how HF patients are treated. "For HF, incidence as a measure of new cases is particularly helpful to assess how the occurrences of HF might have changed over time as a result of changes in risk factors." (2)

Prevalence - measures the commonality of a disease, in this case HF, in the at-risk population at or over a given time. It also measures how often an HF patient will be encountered. (6)

Mortality - CHF is one of the top causes of death. Mortality rates are high, and the data shows that 50% of HF patients die at or within five years of diagnosis. (2) More recent studies show mortality rates in HF are increasing, which may be due in part to an aging population.

Etiology and Pathophysiology  

Heart failure is often caused by an injury to the heart's muscle, such as Myocardial Infarction (MI), valvular regurgitation, stenosis of the heart's valves, and arrhythmia. (4) It is essential that the provider determines the cause to treat these patients appropriately. 

The most common cause of HF is cardiovascular disease. When fatty deposits or plaque buildup in the vessels supplying the heart, the arteries become narrowed and decrease blood flow to the heart muscle. This can cause ischemia (lack of oxygen) to the area of the heart's power involved, causing an MI. This, in turn, causes damage to the heart's muscle, reducing its ability to pump normally. 

There are two main types of HF:

• Left ventricular HF or systolic (LHF)
• Right ventricular HF or diastolic (RHF) 

LHF occurs when the damage to the left ventricle occurs, and RHF occurs when the damage is to the right ventricle. 

The following Table taken from the National Institutes of Health shows comorbidities for Systolic and Diastolic HF: 

Systolic (LHF) 

• Coronary Heart disease 
• Arterial Hypertension 
• Valvular Heart Disease 
• Arrhythmias 
• Inflammatory disease 
• Idiopathic cardiomyopathy 
• Toxic Cardiomyopathy (alcohol)
  

Diastolic (RHF) 

• Diabetes Mellitus 
• Arterial Hypertension 
• Valvular Heart Disease (pressure load) 
• Hypertrophic Cardiomyopathy 
• Restrictive Cardiomyopathy 
• Constrictive Pericarditis 
• Amyloidosis (storage disease) 

HF causes volume overload in the ventricles of the heart. This is due to enlargement and stiffness of the ventricles, so they cannot pump enough blood to the lungs and the body. (1,4) The nurse can utilize this information to care for the patient and implement essential treatments. 

Genetics also play a role in HF but are varied and complex. Studies have found more than 100 genes that may contribute to cardiomyopathy. Depending on where the failure occurs, more genetic testing is recommended in some instances: Left, Right, or Biventricular determines what signs and symptoms may be present in a patient.  

In a patient with an MI or volume/pressure overload, the whole heart will change in structure and function. There will be hypertrophy of the Left ventricle and the dilatation of the chambers, which will cause further deterioration in cardiac function. (4) 

Certain medications may also lead to HF in some patients. These are the diabetic medications Actos and Avandia. NSAIDS (non-steroidal inflammatory drugs) and certain medicines that treat hypertension, cancer, blood dyscrasias, mental health, lung urinary issues, and infections. (1) 

Aging also contributes as the heart's ability to work decreases over time. Too much alcohol and smoking are also important considerations. Heart failure may also cause complications such as kidney damage and failure, more heart problems, and liver disease caused by the backup of fluid that the liver cannot handle. 

The photo below shows the difference between a normal heart and an enlarged one (12). 

Preventable and non-preventable risk factors for heart disease are:  

• Poor diet  
• Smoking 
• Lack of exercise 
• Alcoholism 
• Obesity 
• Genetics/Race-non preventable         

It is also known that Hispanic women are at higher risk for diabetes, which can lead to heart disease if their diabetes is not managed well. Also, African American men are at higher risk for heart disease, possibly leading to HF. 

Interestingly, some studies have shown that the incidence of hospitalizations has declined. This may be due to early diagnosis, better use of medications and newer devices, earlier and ongoing patient education of risk factors, and stellar outpatient and preventive care of those patients living with HF or at risk in the community (2). 

Diagnostic and Screening Tools for Heart Failure (HF) 

Essential diagnostic screening tools are heart rate, cholesterol testing, blood pressure, and weight. Blood pressure measurement is one of the most critical tests since it can have no symptoms.  

If high, it significantly increases the risk of cardiac disease. Fortunately, diet exercise can control blood pressure to lose weight if needed, and medications.  

According to the American Heart Association, the standard for blood pressure is 120/80 or below and should be measured starting at age 20. (5) Next is the fasting cholesterol profile. Again, starting at age 20, a fasting lipid profile should be done. (5) This will give the provider and patient a baseline to follow and assist nurses in developing and implementing care plans. 

The following chart describes lab values for cholesterol. As you can see, the values in red are at the highest risk for cardiovascular disease, which could lead to HF. 

(13)

Body habitus is another crucial factor in predicting CAD. Body mass index (BMI), Waist measurements, and body structure can help predict how at risk a patient is for many diseases, including CAD, diabetes, atrial fibrillation, HF, and stroke. (7) 

The typical Western diet is full of fats and sugars. In the US, many processed foods containing high salt, fat, and sugar are used. 

These foods are unhealthy for the body and cause obesity and poor health. The Mediterranean diet, in turn, is full of fresh fruits and vegetables, lean meat, and a few processed foods. This is the most recommended diet for all populations. 

High blood glucose is another indicator of poor health. Insulin resistance is the precursor to diabetes. A patient has insulin resistance when the body's muscles and tissues cannot respond to insulin, so glucose increases in the blood. (5)  

Causes of insulin resistance are thought to be obesity with a large waist measurement. Blood glucose is usually tested with routine blood work. This gives the provider knowledge if a patient is at risk for diabetes and, therefore, heart disease. (5) Smoking and lack of physical activity can cause poor health, which may lead to cardiovascular disease. 

Echocardiogram, Holter monitoring, stress tests, and nuclear stress tests are routinely used when a patient presents with symptoms of or has known cardiovascular disease. These tests provide a look at heart function and are used to determine disease progression or maintenance. 

Medication Management 

Treating HF with medications can reduce disease progression, and relieve symptoms of dyspnea, fatigue, and edema.  Several classes of drugs can be used to treat HF.  Each one may be used to treat a different symptom. 

The classes are as follows:

Angiotensin-Converting Enzyme (ACE) Inhibitors 

These medications open blood vessels decreasing blood pressure and lowering the heart’s work to keep HF from worsening. (6) 

Some common ACE inhibitors are: 

• Captopril 
• Enalapril 
• Lisinopril 
• Ramipril  

Angiotensin-Receptor Blockers (Arbs)

• Losartan
• Valsartan
  

Angiotensin-Receptor Neprilysin Inhibitors (Arnis) 

Entresto is a drug combination in the class of Angiotensin-receptor neprilysin inhibitors (ARNIs). ARNIs limit the enzyme neprilysin from breaking down natural substances in the body.  By limiting this enzyme, the arteries can open to increase blood flow.  This drug also limits the retention of sodium. (7) 

Beta Blockers  

Beta-blockers work to slow down the heart rate and increase blood flow by widening blood vessels. This also lowers blood pressure. (9) 

Common Beta Blockers are: 

• Atenolol 
• Bisoprolol 
• Carvedilol 
• Labetalol 
• Metoprolol succinate 
• Metoprolol tartrate 
• Nadolol 
• Propranolol 

Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors 

Jardiance and Farxiga are Sodium-glucose cotransporter-2 (SGLT2) inhibitors that were designed to treat diabetes, but they have been found to be cardio-protective. (7) 

Diuretics 

Diuretics allow the body to release extra fluid and sodium through the kidneys.  They cause increased urination so should be taken earlier in the day. 

Most common diuretics are: 

• Lasix 
• Bumex 
• Torsemide 
• Diuril 
• Hydrochlorothiazide (HCTZ) 
• Metolazone 

Other medications can be prescribed depending on the patient's needs, such as anticoagulants to keep the blood thin, statins to lower cholesterol, and Digoxin to control heart rate and increase pumping strength. Calcium channel blockers allow the heart muscle to relax, thereby reducing blood pressure and circulation within the heart. Potassium may be used with certain diuretics that cause potassium to leave the body.  

It is needed to keep the heart's rhythm in control. Oxygen may also increase its amount in the blood, assisting with dyspnea and activity tolerance. (7) It is the nurse's responsibility to evaluate these medications and interventions for plan updates. 

Other Interventions 

Several types of surgery can be utilized for the most severe cases of HF. Bypass surgery has been used for many years. This procedure bypasses blocked coronary arteries, allowing for better blood flow to the heart muscle.  

Replacing damaged or stenosed heart valves will assist blood flow within the heart chambers. In some patients, biventricular pacing with a pacemaker allows both sides of the heart to work in sync. (10) An ICD, or implantable defibrillator, can shock the heart from a life-threatening rhythm back to normal.  

The ventricular assist device or VAD can assist the ventricles to pump blood out to the body. (10) This device can be used either waiting for a transplant or permanently.  

Heart Transplants can be used as the last intervention, with a success rate of 88% after one year and 75% after five. If a patient has sleep apnea, it can be linked to heart failure. In this case, an evaluation and treatment will be performed. (10)

Current areas of research in HF are producing more effective drug therapy, genetic testing, non-surgical devices, transplants, and mechanical support. (8) 

The research is now studying drugs that improve physical symptoms when added to the standard drug treatment and care. These drugs have shown improvement in reducing hospitalizations. 

The newer diabetic medications Jardiance, Invokana, and Farxiga are being studied on HF patients without diabetes to learn if they will improve function and risk reduction of MI, stroke, or cardiovascular death. (8) 

Non-invasive imaging such as MRI, ultrasound, nuclear testing, and radiology are being researched in the hope that advancing these technologies will "provide additional information about coronary arteries and heart tissue, coronary strain, the function and structure of the heart." (8)  

Genetic testing is under investigation to help determine if there is an inherited disease, especially in specific cardiomyopathies. These cardiomyopathies present differently and may be treated with differing modalities. 

One of the newest areas of HF management and treatment is remote monitoring. Nurses are at the forefront of home monitoring in many areas as they are the clinicians making home visits. 

New types of VADs are emerging as treatments for advanced illnesses. They are being manufactured to be more durable and portable. (8) 

Conclusion

As discussed in this course, Heart Failure affects over 6 million people in the US. Age, lifestyle, race, and genetics may predispose a patient to this disease.

HF burdens society and health care costs due to missed work, rehospitalizations, and poor outcomes. As a nurse, learning the mechanisms of HF is imperative. Understanding etiology, statistics, pharmaceuticals, and other interventions will assist nurses in administering the best care.

New research shows how emerging medications, improved implantable devices, and surgery can improve outcomes. However, patient education and prevention are vital to caring for HF patients.

Hypertension Updates

Introduction

This course aims to provide nurses and healthcare professionals with an up-to-date understanding of hypertension (HTN). The course covers epidemiological evidence, etiology, diagnostic tools, medication management, other interventions, and future research on HTN. 

Hypertension, or high blood pressure, is a chronic condition and a significant risk factor for heart disease, stroke, kidney failure, and other serious health problems. The American College of Cardiology defines hypertension as systolic blood pressure greater than 130 mmHg or diastolic blood pressure greater than 80 mmHg [1].

Statistical Evidence/Epidemiology 

According to the Centers for Disease Control and Prevention (CDC), hypertension afflicts 108 million Americans and contributes to almost 500,000 deaths per year in the United States [2]. The prevalence of hypertension varies by race and ethnicity, with non-Hispanic Black adults having the highest majority (57.1%), followed by Hispanic adults (43.7%) and non-Hispanic White adults (43.6%).  

Hypertension is also more common among older adults, with (74.5%) of adults aged 60 and over having high blood pressure [3]. Despite the high prevalence of hypertension, less than a quarter of all adults with hypertension in the United States have their blood pressure under control [2].  

This leaves millions at risk for serious health problems from uncontrolled hypertension, such as heart disease, stroke, kidney failure, and eye problems. In 2021, high blood pressure was a primary or contributing cause of death for more than 691,095 Americans [4]. 

[31] 

Etiology/Pathophysiology of Hypertension 

Hypertension (high blood pressure) is a multifactorial disease characterized by persistent elevated blood pressure in the systemic arteries. Understanding hypertension's etiology, pathophysiology, and sequela is crucial for effective management and treatment.  

There are two main types of hypertension: primary hypertension and secondary hypertension. Primary or essential hypertension (idiopathic hypertension), which accounts for about 80-95% of all cases, has no identifiable cause and results from complex interactions between genetic, environmental, and other unknown factors [5].  

The cause of secondary hypertension (15-30% of cases) is often an underlying medical condition, such as kidney disease, adrenal gland tumors, diabetes, or thyroid disease [6]. Family history plays a role, although science has identified no genetic factor as the "hypertension gene" [7].  

A key mechanism in hypertension is the imbalance between the forces that constrict and dilate blood vessels. This imbalance can be caused by several factors, including increased activity of the sympathetic nervous system, which leads to vasoconstriction, increased production of vasoconstrictor hormones, such as angiotensin II and aldosterone, a decreased output of vasodilator hormones, such as nitric oxide, and structural changes in the blood vessels, such as thickening of the vessel walls [8]. 

The most understood mechanism of hypertension involves increased peripheral vascular resistance due to constriction of small arterioles. The Renin-Angiotensin-Aldosterone System (RAAS) is a hormonal system that regulates blood pressure. Dysfunction of the RAAS can lead to fluid retention and vasoconstriction [9]. Endothelial dysfunction involves the inner lining of the blood vessels (endothelium) and the release of nitric oxide, which promotes blood vessel relaxation. The dysfunction of nitric oxide is a primary contributor to hypertension [10]. 

Secondary hypertension often involves: 

• The kidneys and volume overload. 
• Leading to elevated blood pressure. 
• Often affecting younger patients and those with resistant or refractory hypertension. 

The typical secondary causes of hypertension include: 

• Primary aldosteronism (PA). 
• Renovascular disease. 
• Chronic kidney disease (CKD). 
• Obstructive sleep apnea (OSA). 
• Drug-induced or alcohol-induced hypertension [11]. 

Overactivation within the sympathetic nervous system can result in increased heart rate (tachycardia) and vasoconstriction, both of which can cause a temporary elevation in blood pressure. Within the metabolic process, insulin resistance has been associated with endothelial dysfunction and hypertension [12]. 

Diagnostic and Screening Tools 

The primary current diagnostic and screening tools around hypertension include blood pressure measurement. Blood pressure consists of systolic blood pressure (SBP) and diastolic blood pressure (DBP).  

SBP is the pressure when the heart is beating, and DBP is the pressure when the heart is resting. A diagnosis of hypertension can be established when the Systolic Blood Pressure (SBP) is 130 mmHg or above or when the Diastolic Blood Pressure (DBP) is at least 80 mmHg [1].  

The American Heart Association (AHA) recommends that all adults have their blood pressure checked at least once a year. People with risk factors for hypertension, such as obesity, diabetes, and kidney disease, should have their blood pressure checked more often [13]. 

Secondary tools for evaluating hypertension include ambulatory blood pressure monitoring (ABPM). ABPM is a more accurate way to measure blood pressure, measuring blood pressure over 24 hours. ABPM is an integral part of hypertensive care [14].  

Urine tests can check for protein in the urine, a sign of kidney damage. Kidney damage is a risk factor for hypertension. Blood tests can be used to check for other medical conditions that can cause hypertension, such as diabetes and kidney disease, cholesterol levels, and other risk factors for heart disease.  

Hormonal Tests can measure hormones produced by the adrenal and thyroid glands, which can help diagnose secondary hypertension. Regardless of the diagnostic or screening tools, early diagnosis and management of hypertension save lives [15]. 

Imaging and Other Diagnostic Tests 

Ultrasound of the Kidneys: To rule out kidney abnormalities. 

Echocardiogram: To assess heart function and structure. Useful if hypertension has been longstanding. 

Eye Exam: A fundoscopic examination can reveal changes in the retinal blood vessels, indicative of chronic hypertension. 

Telemedicine: Remote monitoring can be helpful for ongoing assessment and titration of treatment. 

Healthcare Apps: Smartphone apps can log and track blood pressure readings over time. 

Medication Management 

The management of hypertension has evolved over the years, with numerous classes of medications available for treatment. The type of medication best suited for your patients will depend on their needs and health history.  

Treatment strategies often begin with monotherapy, a single drug, usually a diuretic, beta-blocker, ACE inhibitor, or Angiotensin II receptor blocker (ARBs) [16]. Combination therapy for patients with stage 2 hypertension or those not reaching the target BP with monotherapy, which may include two or more drug classes, is also used.[16].  

Step therapy involves starting with one drug and adding others to achieve the desired effect. A tailored approach is considered if comorbid conditions are present, such as diabetes or heart failure, which may influence drug choice. 

Several standard classes of antihypertensive medications are used to treat hypertension, including first-line thiazides such as hydrochlorothiazide, which help rid excess salt and water and lower blood pressure [17]. Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril and ramipril block the production of angiotensin II, a hormone that narrows blood vessels.  

Angiotensin II Receptor Blockers (ARBs) such as losartan and valsartan which inhibit the action of angiotensin II, leading to vasodilation [17]. Beta-blockers such as atenolol or metoprolol slow the heart rate and reduce the force of the heart's contractions, which can lower blood pressure [17].  

Calcium channel blockers such as amlodipine and diltiazem relax the muscles of the blood vessels by inhibiting the movement of calcium into vascular smooth muscle cells, thus lowering blood pressure [17]. Alpha-blockers such as doxazosin work by blocking alpha-adrenergic receptors, leading to vasodilation. Vasodilators such as hydralazine and minoxidil relax the muscles in blood vessel walls [17]. 

Central action agents such as clonidine, methyldopa, and moxonidine work on the central nervous system to lower blood pressure [17]. Moxonidine is a new-generation antihypertensive drug that works by activating imidazoline-I1 receptors in the brain, and it may be used when other antihypertensive drugs, such as thiazides, beta-blockers, ACE inhibitors, and calcium channel blockers, are not appropriate or have failed [18].  

Thiazide-like diuretics such as chlorthalidone and indapamide have found increased use for their more prolonged duration of action and better cardiovascular outcomes when compared to traditional thiazides [19]. New evidence-based medications are coming into play, such as angiotensin receptor-neprilysin inhibitors (ARNIs), and a clinical trial is underway to test the effectiveness of a new drug called finerenone in preventing heart failure and kidney disease in people with hypertension and diabetes [20] [21]. 

Due to their safety profiles, there are special considerations with hypertensive management, including methyldopa and labetalol for pregnancy [22].  

For older people, care is taken to avoid overtreatment, considering the risks of low blood pressure. For patients with chronic kidney disease (CKD), ACE inhibitors and ARBs are often favored due to their renal protective effects.  

Generics are preferred when appropriate to reduce patient costs [23]. Digital adherence tools, including smartphone apps and telemedicine platforms, monitor patient compliance and adjust treatment as necessary. 

[32] 

Other Interventions  

Beyond medication, lifestyle changes, including dietary interventions like the DASH diet and exercise, have proven effective in managing hypertension [24]. The DASH diet focuses on a high intake of fruits, vegetables, and low-fat dairy foods and is low in saturated and total fat.  

A reduction in dietary sodium has been shown to lower blood pressure, with a general recommendation to consume less than 2,300 mg per day, with an ideal limit of 1,500 mg for most adults [24]. Regular aerobic exercise such as walking, jogging, or swimming can lower blood pressure.  

Weight loss of even 5-10% can significantly impact reducing blood pressure [25]. Alcohol moderation and smoking cessation can also lead to blood pressure reduction. 

Behavioral therapies, including stress management techniques such as deep breathing, meditation, and relaxation exercises, can help reduce short-term spikes in blood pressure. There is some evidence that suggests that Cognitive CBT can be effective in managing hypertension [26].  

Biofeedback can help manage stress triggers and measure physiological functions like heart rate and blood pressure [26]. Although evidence is mixed, some studies suggest acupuncture can help lower blood pressure.  

Renal denervation is an invasive procedure using radiofrequency energy to destroy kidney nerves contributing to hypertension. Central sleep apnea therapy can treat central sleep apnea and lower blood pressure.  

Weight loss surgery can be an effective way to lower blood pressure in people who are obese or overweight. Several stress management techniques, such as yoga, meditation, and deep breathing, can be helpful. 

Self-monitoring and regular medical check-ups can ensure that the treatment plan is effective and can be adjusted as needed. Remote consultations can offer more frequent touchpoints for adjustments in treatment plans.  

Various mobile applications can help patients track blood pressure readings, medication schedules, and lifestyle changes. Community-based interventions to educate the public about hypertension risks, prevention, and management can be effective.  

On a policy level, changes and initiatives that reduce sodium in processed foods can have a broader societal impact [27]. 

Upcoming Research 

Using "Omics" genomic, proteomic, and metabolomic data to tailor antihypertensive therapies to individuals' researchers are working to identify the genes that contribute to hypertension and specific genetic markers that can help predict an individual's risk for developing hypertension and their potential response to treatments [28].  

This information could be used to create new genetic tests to identify people who are at risk of developing the condition. Personalized medicine seeks to create customized approaches to managing hypertension, which would involve tailoring treatment to the individual's needs and risk factors.  

Non-invasive treatments, such as devices worn on the body to deliver medication or stimulate the nerves, may also be effective. Researchers are developing a new type of blood pressure monitor that can be worn on the wrist and measure blood pressure throughout the day. 

A study is underway to investigate the use of artificial intelligence to develop personalized treatment plans for people with hypertension. With predictive analytics, AI models are trained to predict hypertension risk and disease progression using large-scale electronic health records [29]. 

In the area of new therapeutic targets, researchers are looking into novel ways to improve endothelial function and vascular health. Studies into how the gut microbiome may influence blood pressure regulation offer potential for new treatment modalities [30]. Research on how diet interacts with genes within the gut microbiome may affect blood pressure. 

Awareness and Patient Education 

What your patients should know: 

• Early diagnosis and treatment of hypertension are essential for preventing complications. 
• There are several different types of medications available to treat hypertension. 
• Lifestyle changes, such as eating a healthy diet, exercising regularly, and maintaining a healthy weight, can also help to lower blood pressure. 

Nurses and healthcare professionals should be aware of the following: 

• Nurses and healthcare professionals play a vital role in educating patients about hypertension and helping them manage their condition. 
• The latest epidemiological statistics on hypertension, including its prevalence, risk factors, and impact on public health. 
• The etiology and pathophysiology of hypertension, including the different types of hypertension and their underlying causes. 
• The diagnostic tools used to diagnose hypertension include blood pressure measurement, ambulatory blood pressure monitoring, urine tests, blood tests, and imaging tests. 
• The different types of medications available to treat hypertension, as well as their side effects and interactions. 

Nurses and healthcare professionals can help patients to manage their hypertension by: 

• Educating patients about hypertension and its risks. 
• Helping patients develop a treatment plan that includes lifestyle changes and medications. 
• Monitoring their blood pressure and adjusting their treatment plan as needed. 
• Providing support and encouragement. 

By working together, nurses and healthcare professionals can help patients manage their hypertension and reduce their risk of complications. 

Conclusion

Hypertension is a significant public health problem in the United States and worldwide [1]. It is a chronic condition that can lead to serious health problems like heart disease, stroke, kidney failure, and eye problems. However, despite its complexity, hypertension is manageable with lifestyle changes, medications, and the potential information from future genomic discoveries [25] [17]. 

GI Bleed: An Introduction

Introduction   

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

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

Epidemiology  

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

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

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

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

Etiology/ Pathophysiology

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

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

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

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

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

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

Upper GI Bleeding (UGIB) Etiology 

Underlying conditions that may be responsible for the UGIB include: 

• Peptic ulcer disease 

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

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

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

(1, 4, 5, 8. 9) 

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

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

Lower GI Bleeding (LGIB) Etiology

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

(1, 4, 5, 9)

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

Laboratory and Diagnostic Testing

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

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

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

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

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

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

Signs and Symptoms 

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

Mild vs. Severe Bleeding  

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

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

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

History and Physical Assessment

History

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

Assess for the following:

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

Physical Assessment

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

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

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

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

Treatment and Interventions

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

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

(8) 

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

Subjective Data (Client verbalizes)

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

Objective Data (Clinician notes during assessment)

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

Nursing Interventions

Ineffective Tissue Perfusion:

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

Acute Pain:

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

Risk for Decreased Cardiac Output

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

Risk for Deficient Fluid Volume:

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

Nursing Goals / Outcomes for GI Bleed:

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

Case Study

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

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

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

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

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

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

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

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

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

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

Conclusion

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

Constipation Management and Treatment

Introduction   

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

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

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

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

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

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

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

Epidemiology  

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

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

Etiology/Pathophysiology  

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

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

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

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

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

Signs and Symptoms  

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

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

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

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

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

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

Pharmacological/Non-Pharmacological Treatment 

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

Pharmacological 

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

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

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

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

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

Non-pharmacological 

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

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

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

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

Complications 

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

Hemorrhoids 

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

Anal Fissure 

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

Fecal Impaction 

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

Rectal Prolapse 

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

Nausea and Vomiting 

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

Bowel Obstruction 

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

Prevention  

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

Dietary Adjustments 

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

Hydration 

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

Exercise 

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

Lifestyle Awareness 

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

Patient Education 

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

Nursing Implications 

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

Holistic Assessment 

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

Effective Communication 

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

Collaboration with Multidisciplinary Teams 

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

Patient-Centered Care Plans 

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

Education and Empowerment 

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

Continuous Monitoring and Evaluation 

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

Compassionate Support 

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

Conclusion

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

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

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

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

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

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

Spinal Cord Injury: Bowel and Bladder Management

Introduction   

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

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

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

Spinal Cord Injuries: The Basics

Spinal Cord Function 

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

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

Spinal Cord Injury Definition 

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

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

Spinal Cord Injury Causes 

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

Trauma 

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

Medical Conditions 

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

Spinal Cord Injury Statistics 

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

Age/Gender 

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

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

Race/Ethnicity 

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

Mortality 

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

Financial Impact 

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

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

Spinal Cord Injuries: Types and Complications

Four Levels of the Spinal Cord 

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

Types of Spinal Cord Injuries 

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

Injury Level 

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

Impairment 

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

Spinal Cord Injury Complications 

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

Depression 

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

Pressure injuries 

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

Spasticity 

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

Autonomic dysreflexia 

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

Respiratory problems 

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

Sexual problems 

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

Changes in bowel and bladder function 

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

Bowel and Bladder Dysfunction in Spinal Cord Injuries 

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

Normal Bowel and Bladder Function 

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

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

Bowel Dysfunction with Spinal Cord Injuries 

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

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

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

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

Bladder Dysfunction with Spinal Cord Injuries 

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

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

The Nurse’s Role in Bowel and Bladder Management 

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

Nurse Assessments 

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

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

Questions the nurse can ask the patient: 

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