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New Jersey Opioid Prescribing

Introduction   

For centuries, humans have been using, developing, and synthesizing opioid compounds for pain relief. Opioids are essential for treating patients who are experiencing severe and sometimes even moderate pain. Chronic pain can negatively affect our lives. In 2011, the cost of chronic pain ranged from $560 to $635 billion in direct medical expenses, lost productivity, and disability. An estimated one in five U.S. adults has chronic pain (1).

Pharmacology of Opioids: Drug Class, Indications for Use, Most Prescribed Opioids, and their Effects. 

Opioids usually bind to mu-opioid receptor sites, where they have agonist effects, providing pain relief, sedation, and sometimes feelings of euphoria. Opiates refer only to natural opioids derived from the poppy plant. The term "opioids" includes all-natural, semi-synthetic, and synthetic opioids.  

Opioids are classified into several categories based on their origin and chemical structure: 

1. Natural Opioids (Opiates): These come from the opium poppy plant. Examples include morphine and codeine. 
2. Semi-Synthetic Opioids: These are natural opioids that are chemically modified. Examples include drugs like oxycodone, hydrocodone, oxymorphone, and hydromorphone. 
3. Synthetic Opioids: These opioids are entirely synthesized in a laboratory and do not have a natural source. Examples include fentanyl, tramadol, and methadone (1, 2). 

Providers must always caution patients about the benefits and risks. The main advantage of opioid medication is that it will reduce pain and improve physical function.  

A provider may use a 3-item Pain, Enjoyment of Life, and General Activity (PEG) Assessment Scale: 

1. What number best describes your pain on average in the past week?  
2. What number best describes how, during the past week, pain has interfered with your enjoyment of life?  
3. What number best describes how, during the past week, pain has interfered with your general activity?  

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The desired goal is improvement overall with opioid treatment (3). Providers should also go over potential side effects and cautions. Side effects include sedation, dizziness, confusion, nausea, vomiting, constipation, itching, pupillary constriction (miosis), and respiratory depression.  

Providers must also discuss the importance of consistently taking medication as prescribed. Taking opioids in larger than prescribed dosage, or in addition to alcohol, other illicit substances, or other prescription drugs, can lead to severe respiratory depression and death. Missing dosages can lead to decreased pain control and possible opioid withdrawal symptoms. Individuals should not drive when taking opioids due to the sedating effects and decreased reaction times (4).  

There are now thousands of different Food and Drug Administration (FDA) approved opioids available for providers to prescribe. They can be administered via other routes and come in various potencies. The strength of morphine is the "gold standard" used when comparing opioids. A morphine milligram equivalent (MME) is the degree of µ-receptor agonist activity.  

The following is a sample of some of the most prescribed opioids and their MME (5): 

To utilize this information, multiply the dose for each opioid by the conversion factor to determine the quantity in MMEs. For example, tablets containing hydrocodone 5 mg and acetaminophen 325 mg taken four times a day would include a total of 20 mg of hydrocodone daily, equivalent to 20 MME (5).  

A Brief History 

While the current opioid epidemic has caused devastating effects in recent years, destruction from opioids has been going on for centuries. In the early 1800s, physicians and scientists became aware of the addictive qualities of opium. This finding encouraged research to develop safer ways to deliver opioids for pain relief and cough suppression, which led to the development of morphine.  

By the mid-1800s, with commercial production and the invention of the hypodermic needle, morphine became easier to administer. During the Civil War (1861 to 1865), injured soldiers were sometimes treated with morphine, and some developed lifelong addictions after the war.  

Without other options for pain relief, physicians kept giving patients morphine as treatment. Early indicators that morphine should be used cautiously were largely ignored. Between 1870 and 1880, the use of morphine tripled. Even with the problems associated with opioids, they continued to serve a vital part in the pain treatment of patients, and their use and development continued (6).  

Drug law enforcement started in 1914, but it wasn't until July 1, 1973, that the Drug Enforcement Administration (DEA) was established in the United States. The Diversion Control Division oversees pharmaceuticals. Within this Division are five levels of controlled substances, which classify illicit and medicinal drugs.  

In the U.S., opioid prescribing increased fourfold during 1999–2010. Along with the increase in opioid prescriptions during this time, how they were prescribed also changed; opioids were increasingly prescribed at higher dosages and for longer durations. The number of people who reported using OxyContin for non-medical purposes increased from 400,000 in 1999 to 1.9 million in 2002 and to 2.8 million in 2003. This was accompanied by a fourfold increase in overdose deaths involving prescription opioids (8).  

In 2020, approximately 1.4 million people were diagnosed with opioid use disorder (OUD), of those associated with opioid painkillers, as opposed to 438,000 who have heroin-related OUD (1, 4). Over 100,000 people died of a drug overdose, with 85% involved in an opioid (1, 4).  

Widespread efforts were made to combat this growing issue. The prescribing rate peaked and leveled off from 2010-2012 and has been declining since 2012. In 2021, an estimated 2.5 million adults had been diagnosed with OUD. However, the amount of MME of opioids prescribed per person is still around three times higher than in 1999 (5).  

Controlled Substance Classification 

Schedule I Controlled Substances  

No medical use, lack of accepted safety for use under medical supervision, and high abuse potential. 

Examples of Schedule I substances are methaqualone, heroin, lysergic acid diethylamide (LSD), mescaline, methylenedioxymethamphetamine (MDMA), and marijuana (cannabis). 

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Schedule II/IIN Controlled Substances (2/2N)  

High potential for abuse, which can lead to severe dependence. Refills are not allowed for these drugs. Schedule II drugs have the strictest regulations compared to other prescription drugs presently.  

Examples include hydromorphone, methadone, meperidine, oxycodone, and fentanyl. Other narcotics in this class include morphine, opium, codeine, and hydrocodone. 

Some examples of Schedule IIN stimulants include amphetamine, methamphetamine, and methylphenidate. 

Other substances include amobarbital, glutethimide, secobarbital, and pentobarbital. 

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Schedule III/IIIN Controlled Substances (3/3N) (7) 

There is less potential for abuse than substances in Schedules I or II, and abuse may lead to moderate or low physical dependence or high psychological dependence. Schedule III drugs are able to be prescribed verbally over the phone, with a paper prescription, or via electronic prescribing. Within a six-month timeframe from the original prescription date, Schedule III drugs have requirements such that the medication can only have five refills. 

Include drugs containing not more than 90 milligrams of codeine per dosage unit like Acetaminophen with Codeine and buprenorphine. 

Schedule IN non-narcotics include benzphetamine, phendimetrazine, ketamine, and anabolic steroids such as Depo®-Testosterone. 

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Schedule IV Controlled Substances 

Have a low potential for abuse relative to substances in Schedule III. Similar to Schedule III drugs, Schedule IV drugs are able to be prescribed verbally over the phone, with a paper prescription, or via electronic prescribing. Within a six-month timeframe from the original prescription date, Schedule IV drugs have refill requirements such that the medications can only have five refills. 

Examples include alprazolam, carisoprodol, clonazepam, clorazepate, diazepam, lorazepam, midazolam, temazepam, triazolam, and tramadol. 

Schedule V Controlled Substances  

It has a low potential for abuse relative to Schedule IV and primarily consists of medications that have small quantities of narcotics. 

Examples include cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams and ezogabine. Other Schedule V medication examples include ezogabine, pregabalin, and atropine/diphenoxylate. Partial prescription fills cannot occur more than six months after the prescription issue date. When a partial fill occurs, it is treated in the same manner and with the same regulations as a refill of the prescription.

Opioid-Seeking Behaviors 

Opioid use disorder (OUD) causes significant impairment and distress. Diagnosis is based on the following criteria: unsuccessful efforts to reduce or control use or use that leads to social problems and a failure to fulfill obligations at work, school, or home. The term Opioid use disorder is the preferred term; "opioid abuse or dependence" or "opioid addiction" have negative connotations and should be avoided. (9). Presently, it is estimated that OUD affects over 16 million people globally, with over 2 million in the United States experiencing this condition. 

OUD occurs after a person has developed tolerance and dependence, resulting in a physical challenge to stop opioid use and increases the risk of withdrawal. Tolerance happens over time when a person experiences a reduced response to medication, requiring a larger amount to experience the same effect. Opioid dependence occurs when the body adjusts to regular opioid use. Unpleasant physical symptoms of withdrawal occur when medication is stopped. Symptoms of withdrawal include anxiety, mood changes, insomnia, abdominal pain, vomiting, diarrhea, etc. (9).  

Patients who have OUD may or may not have practiced drug misuse. Drug misuse, the preferred term for "substance abuse," is the use of illegal drugs and the use of prescribed drugs other than as directed by a doctor, such as using more amounts, more often, or longer than recommended to or using someone else's prescription (9). 

Some indications that a patient may be starting to have unintended consequences with their opioid prescription may include the following symptoms: craving, wanting to take opioids in higher quantities or more frequently, difficulty controlling use, or work, social, or family issues.  

If providers suspect OUD, they should discuss their concerns with their patients nonjudgmentally and allow the patient to disclose related concerns or issues. Providers should assess the presence of OUD using the DSM-5 criteria.  

Per the DSM-5, OUD is defined as repeated opioid use within 12 months leading to problems or distress with 2 or more of the following occurring: 

• Prolonged opioid use despite worsening physical or psychological health 
• Prolonged opioid use despite social and interpersonal negative consequences 
• Decreased social or recreational activities 
• Existing or increased difficulty fulfilling professional duties at school or work 
• Excessive time is taken to obtain or recover from taking opioids 
• Increased opioid consumption is present 
• Opioid cravings occur 
• Difficulty decreasing the frequency of using opioids 
• Tolerance to opioids develops 
• Opioid use continues despite the dangers it poses to the user 
• Withdrawal occurs, or the user continues to take opioids to avoid withdrawal 

The presence of 6 or more of these diagnostic criteria indicates severe OUD.  

Providers can use validated screening tools such as: 

• Urine and oral fluid toxicology testing 
• Drug Abuse Screening Test (DAST) 
• Tobacco, Alcohol and/or other Substance use Tools (TAPS) 
• A three-question version of the Alcohol Use Disorders Identification Test (AUDIT-C) 

The following patients are at higher risk for OUD or overdose: 

• Depression or other mental health conditions 
• History of a substance use disorder 
• Loss of economic stability 
• Social distress, such as relationship issues or housing concerns 
• History of overdose 
• Taking 50 or greater MME/day or taking other central nervous system depressants with opioids

CDC Guidelines 

In 2022, the CDC updated the 2016 guidelines to help prescribers navigate prescribing opioids amid an epidemic.  

These guidelines are directed toward prescribing medications to adults to be taken in the outpatient setting, for example, primary care clinics, surgery centers, urgent cares, and dental offices. These do not apply to providers caring for individuals with sickle-cell disease, cancer, those receiving inpatient care, or end-of-life or palliative care. They are also intended to serve as a guideline, and each treatment plan should be specific to the unique patient and circumstances (1).  

Some of the Goals of the guidelines are to:  

• Improve communication between providers and patients about treatment options and discuss the benefits and risks before initiating opioid therapy. 
• Improve the effectiveness and safety of treatment to improve quality of life.  

• Reduce risks associated with opioid treatment, including opioid use disorder (OUD), overdose, and death. 

Recommendation #1 - Determining when it is appropriate to initiate opioids for pain (1). 

An essential part of the prescribing process is determining the anticipated pain severity and duration based on the patient's diagnosis. Pain severity can be classified into three categories when measured using the standard 1-10 numeric scale. Pain scores 1-4 are considered mild, 5-6 are moderate, and 7-10 severe. Opioids are typically used for moderate to severe pain.  

The patient's diagnosis will allow the provider to determine if pain initially falls into one of the following three categories of anticipated duration: acute, subacute, and chronic. Acute pain is expected to last for one month or less. Acute pain often is caused by injury, trauma, or medical treatments such as surgery. Unresolved acute pain may develop into subacute pain if not resolved in 1 month. If pain exceeds three months, it is classified as chronic. Pain persisting longer than three months is chronic. It can result from underlying medical conditions, injury, medical treatment, inflammation, or unknown cause. 

The CDC guidelines state that non-pharmacologic and non-invasive methods are the preferred first-line method of analgesia, such as heat/cold therapy, physical therapy, massage, rest, or exercises, etc. Despite evidence supporting their use, these therapies are only sometimes covered by insurance, and access and cost can be barriers, particularly for uninsured persons who have limited resources, no reliable transportation or live in rural areas where treatments are not available. 

When this is insufficient, non-opioid medications, such as Gabapentin, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAID), should be considered next. Selective antidepressants and anticonvulsant medications may also be effective. Some examples of when these drugs may be appropriate include neuropathic pain, lower back pain, musculoskeletal injuries (including minor pain related to fractures, sprains, strains, tendonitis, and bursitis), dental pain, postoperative pain, and kidney stone pain.  

Providers, however, must also consider the risks and benefits of long-term NSAID use because it may also negatively affect a patient's gastrointestinal and cardiovascular system. Depending on the diagnosis, a patient may also require an invasive or surgical intervention to treat the underlying cause to alleviate pain.  

If the patient has pain that does not sufficiently improve with these initial therapy regimens, at that point, opioids will be the next option to be considered. 

It does not mean that patients should be required to sequentially "fail" nonpharmacologic and non-opioid pharmacologic therapy or use any specific treatment before proceeding to opioid therapy. Example: A patient for whom NSAIDs are contraindicated has recently sustained a rotator cuff injury and is experiencing moderate pain to the point at which it is disturbing their sleep, and it will be several weeks before they can have surgery. 

Recommendation #2 - Discuss with the patient realistic treatment goals for pain and overall function (1). 

Ideally, goals include improving quality of life and function, including social, emotional, and physical dimensions. The provider should help guide these patients to realistic expectations based on their diagnosis. This may mean that the patient may anticipate reduced pain levels but not complete elimination of pain.  

The provider should discuss the expected or typical timeframe where they may need medications. If medications are anticipated for acute or subacute pain, a discussion about the expected timeframe for pain should be highlighted in the debate. The patient may then understand better if their recovery is progressing. For chronic conditions, the conversation will focus on or may emphasize the overall risks of beginning long-term medication therapy.  

They may also advise patients, particularly those with irreversible impairment injuries, that they may experience reduced pain but will not regain function. An exit strategy will be discussed if opioid therapy is unsuccessful or the risk vs. benefit ratio is no longer balanced. 

The second section of recommendations covers the selection of opioids and dosages. 

Recommendation #3 - Prescribe immediate-release (I.R.) opioids instead of extended-release and long-acting (ER/LA) opioids when starting opioid therapy (1). 

Immediate-release opioids have faster-acting medication with a shorter duration of pain-relieving action. ER/LA opioids should only be used in patients who have received specific dosages of immediate-release opioids daily for at least one week. Providers should reserve ER/LA opioids for severe, continuous pain, for example, individuals with cancer. ER/LA opioids should not be for PRN use.  

The reason for this recommendation is to reduce the risk of overdose. A patient who does not feel adequate relief or relief fast enough from the ER/LA dose may be more inclined to take additional amounts sooner than recommended, leading to a potential overdose. 

Recommendation #4 - Prescribe the lowest effective dose (1) 

Dosing strategies include prescribing low doses and increasing doses in small increments. Prescribe the lowest dose for opioid patients. Carefully consider risk vs. benefits when increasing amounts for individuals with subacute and chronic pain who have developed tolerance. Providers should continue to optimize non-opioid therapies while continuing opioid therapy. It may include recommendations for taking non-opioid medications in addition to opioids and non-pharmacologic methods. 

Providers should use caution and increase the dosage by the smallest practical amount, especially before increasing the total opioid dosage to 50 or greater morphine milligram equivalent (MME) daily. Increases beyond 50 MME/day are less likely to provide additional pain relief benefits. The greater the dosage increases, the tendency for risk also increases. Some states require providers to implement clinical protocols at specific dosage levels. 

Recommendation #5 - Tapering opioids includes weighing the benefits and risks when changing the opioid dosage (1). 

Providers should consider tapering to a reduced dosage or tapering and discontinuing therapy and discuss these approaches before initiating changes when: 

• The patient requests dosage reduction or discontinuation, 
• Pain improves and might indicate the resolution of an underlying cause, 
• Therapy has not reduced pain or improved function, 
• Treated with opioids for a long time (e.g., years), and the benefit-risk balance is not clear. 
• Receiving higher opioid dosages without evidence of improvement. 
• Side effects that diminish quality of life or cause impairment. 
• Opioid misuse  
• The patient experiences an overdose or severe event. 
• Receiving medications or having a health condition may increase the risk of an adverse event. 

Opioid therapy should not be discontinued abruptly unless there is a threat of a severe event, and providers should not rapidly reduce opioid dosages from higher dosages.  

Patient agreement and interest in tapering will likely be a key component of successful tapers. Integrating behavioral and non-opioid treatment and interventions for comorbid mental health conditions before/during a taper can help manage pain, strengthen the therapeutic relationship between the provider and patient, and improve the likelihood of positive tapering outcomes.  

When dosages are reduced or discontinued, a taper slow enough to reduce symptoms and withdrawal should be used. Patients should receive education on possible withdrawal symptoms and when to contact the provider. 

For those taking opioids for a shorter duration, a 10% decrease of the original dose per week or slower until close to 30% of the initial amount is reached, followed by a weekly reduction of roughly 10% of the remaining dose) is less likely to trigger withdrawal. Tapers of 10% per month or less are better tolerated than rapidly tapering off when patients have been taking opioids for a longer duration (e.g., for a year or longer).  

Significant opioid withdrawal symptoms can indicate the need to slow the taper rate further. Short-term medications might also help manage withdrawal symptoms. Providers should follow up frequently (at least monthly) with patients engaging in opioid tapering. 

Close monitoring is required for patients who cannot taper and that continue on high-doses or otherwise high-risk opioid regimens and should work with patients to mitigate overdose risk. Some patients with unanticipated challenges to tapering may need to be evaluated for OUD. 

The third section focuses on the duration of opioid therapy and routine patient follow-up. 

Recommendation #6 - Prescribing no greater quantity than needed for the expected duration of severe pain requiring opioids (1) 

A few days or less is often the length that opioids are used for common causes of nonsurgical acute pain. Many states have passed legislation that limits initial opioid prescriptions for acute pain to less than seven days. Many insurers and pharmacies have enacted similar policies. Providers should generally avoid prescribing additional opioids to patients if pain continues longer than expected. 

Providers should prescribe and advise opioid use only as needed rather than on a scheduled basis (e.g., one tablet every 4 hours). Limiting the duration of therapy can decrease the need to taper. However, tapering may need to be considered if patients take these medications around the clock for more than a few days.  

Longer durations of therapy may be needed when the injury is expected to result in prolonged severe pain (e.g., greater than seven days for severe traumatic injuries). Patients should be evaluated at least every two weeks if they are receiving opioids for acute pain. Suppose opioids are continued for a month or longer. In that case, providers should address potentially reversible causes of chronic pain so that the length of therapy does not continue to extend. 

Recommendation #7 - Evaluate the benefits and harms of opioid therapy regularly (1) 

The benefits and risks for Evaluating benefits and risks within 1-4 weeks of starting long-term opioid therapy for subacute and chronic pain should be evaluated within 1-4 weeks of initiating therapy and after dosage increases.  

The evaluation should include patient perspectives on progress and challenges in moving toward treatment goals, including sustained improvement in pain and function. The Three-item Pain, Enjoyment of Life, and General Activity (PEG) assessment scale could be utilized to help determine patient progress. 

Providers should also ask patients about common adverse effects, such as constipation and drowsiness, and assess for outcomes that might be early warning signs for more serious problems such as overdose or OUD.  

Patient re-evaluation should occur after therapy begins (about two weeks) when ER/LA opioids are prescribed if the total daily opioid dosage is greater than or equal to 50 MME/day or if there is a concurrent benzodiazepine prescription. These individuals are at a higher risk for overdose. Follow-up for individuals starting or increasing the dosage of methadone is recommended every 2-3 days for the first week. Providers should reassess all patients receiving long-term opioid therapy at least every three months. 

The last section of recommendations covers patients at risk for OUD and overdose.  

Recommendation #8 - Use strategies to mitigate risk by evaluating risk for opioid-related harms, discussing risk with patients, and incorporating risk reduction strategies into the treatment plan (1). 

The patient's habits (including alcohol and illicit drug use) and behavioral and mental health must be considered. Patients with a history of substance use disorders, depression, and/or mental health disorders have a higher risk of overdose and OUD. Even though the dangers of opioid therapy are higher with these patients, they may still require opioid treatment for pain management.  

Psychological distress can interfere with improvement of pain and/or function in patients experiencing chronic pain; using tools like the Generalized Anxiety Disorder (GAD)-7 and the Patient Health Questionnaire (PHQ-9 or PHQ-4) to assess for anxiety, post-traumatic stress disorder (PTSD), and depression might help providers improve overall pain treatment outcomes. They should also ensure that treatment for depression and other mental health conditions is effective, consulting with behavioral health specialists when needed. 

Additionally, providers should: 

• Educate on the risks for overdose when opioids are combined with other drugs or alcohol.  
• Use caution when prescribing opioids for people with sleep-disordered breathing due to their increased risk for respiratory depression. The provider may ascertain if a patient is compliant with prescribed CPAP.  
• Use caution and increased monitoring for patients with renal or hepatic insufficiency. 
• Use caution and increased monitoring for patients aged 65 years or older.  
• Offering naloxone when prescribing opioids, particularly to patients at increased risk for overdose. 

If patients experience a nonfatal opioid overdose, providers should evaluate for OUD. Providers should reduce opioid dosage and discontinue opioids when indicated and continue monitoring and support for patients prescribed or not prescribed opioids. 

Recommendation #9 - Reviewing Prescription Drug Monitoring Program (PDMP) data (1). 

Providers should review PDMP data specifically for prescription opioids, benzodiazepines, and other controlled medications patients have received from additional prescribers to determine all the opioids the patient could potentially receive.  

Patients with multiple prescriptions and from various providers are at an increased risk for overdose or OUD. PDMP data should be reviewed before initial drugs for subacute or chronic pain and at least every three months during long-term opioid therapy. 

Recommendation # 10 - Considering the benefits and risks of [urine] toxicology testing.  

Toxicology testing should be used to inform and improve patient care. Providers, practices, and health systems should minimize bias in testing and not test based on assumptions about different patients. 

Recommendation # 11 - Use caution when prescribing opioid pain medication and other medications concurrently (1). 

Benzodiazepines and opioids can cause CNS depression and potentiate opioid-induced decreases in respiratory drive. Because other CNS depressants can potentiate respiratory depression associated with opioids, benefits vs. risks should be considered. 

Recommendation # 12 - Offering or arranging treatment for OUD if needed (1). 

Includes referring a patient to a specific treatment center where behavior therapy and medications may be prescribed.

Prescription Drug Monitoring Programs (PDMP) and Electronic Prescribing 

PDMP is a database that keeps track of controlled substance prescriptions. They help improve opioid prescribing, inform clinical practice, and protect at-risk patients. A pharmacist must enter controlled substances into the state PDMP when dispensing them. When the pharmacist enters this data, it may occur at various intervals, from 1 month, daily, or even "real-time." However, a PDMP is only helpful if providers check the system before prescribing (10).  

Some states have implemented legislation that requires providers to check a state PDMP before prescribing certain controlled substances and in certain circumstances. Most current mandates require that all prescribers query PDMPs when prescribing any opioid.  

Some states require prescribers to query PDMPs every time a controlled substance is prescribed, while others require a query only for the initial prescription. Subsequent checks of PDMPs also vary from every time a drug is issued to specific intervals (e.g., every 90 days, twice a year, annually) should prescribing continue. Some mandates have categorical requirements, e.g., a query must be made if the prescription is over a three-day or seven-day supply or if a certain prescribed level of MME is exceeded.  

Other states' mandates are based on subjective criteria, e.g., a prescriber's judgment of possible inappropriate use or the prescriber's discretion regarding whether to query the PDMP. Finally, some states mandate that only prescribers in opioid treatment programs, workers' compensation programs, or pain clinics must query PDMPs (10, 11).  

In addition to PDMPs, there has been an increase in requirements for providers to utilize Electronic Prescribing for Controlled Substances (ECPS). Electronic prescribing programs for both providers and pharmacies must meet DEA requirements. The DEA's March 31, 2010, conditions were updated on July 27, 2023 (12).  

On January 1, 2023, CMS implemented additional requirements for controlled substances for recipients of Medicare Part D. There are over 51 million U.S. people enrolled in Medicare Part D (Center for Medicare Advocacy, 2023). In addition to state laws, these rules require that prescribers e-prescribe at least 70 percent of controlled substances for patients that have Medicare Part D. A waiver may be approved if the prescriber cannot conduct electronic prescribing due to circumstances beyond the provider's control (12).  

Starting June 27, 2023, the 'Consolidated Appropriations Act of 2023' requires new or renewing Drug Enforcement Administration (DEA) registrants, to have at least one of the following: 

• A total of eight hours of training from specific organizations on opioid or other substance use disorders. 
• Board certification in addiction medicine or addiction psychiatry from the American Board of Medical Specialties, American Board of Addiction Medicine, or the American Osteopathic Association. 
• Graduation within five years and status in good standing from medical, advanced practice nursing, or physician assistant school in the U.S. that included an opioid or other substance use disorder curriculum of at least eight hours (11,12).  

Providers must follow either state law or DEA/CMS regulations, whichever is more stringent. The following map indicates various rules in each state, which will continue to change when new legislation is enacted (11,12).  

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Opioid Storage and Disposal 

Prescription opioids need to be stored securely. It may include the necessity of keeping them in a locked area. This is especially true if children, teens, and other visitors in the house may be aware of their presence.  

Teens and young adults are the biggest misusers of prescription pain medication. In 2018, over 695,000 youths ages 12–17 and 1.9 million young adults ages 18–25 reported misusing prescription pain medication in the past year. Young people may misuse prescription opioids for many reasons, including curiosity, peer pressure, and wanting to fit in. Another reason teens and young adults may decide to take prescription opioids is because they can be easier to get than other drugs.  

Studies show that 53% percent of people over 12 who obtained prescription pain medication for non-medical use received them from a friend or relative (13).  

Patients should be advised on how to get rid of unused or expired medications. The best option is to immediately take them to a drug take-back site, location, or program. These sites or programs can be found online, or the pharmacist may have information.  

If it is not feasible for the patient to get rid of the drug using a take-back program, the patient should be advised to check if it is on the FDA flush list. If it is, the medication should be flushed down the toilet. Again, the list of drugs is available on the FDA website. If it is not on that list, it should be discarded in the trash at home.  

Patients should follow the following instructions: Mix medicines (liquid or pills; do not crush tablets or capsules) with an unappealing substance such as dirt, cat litter, or used coffee grounds. Next, place the mixture in a container such as a sealed plastic bag; then throw away the container in your trash at home. Last, the patient should remove or permanently cover all personal information on the prescription label of empty medicine bottles or packaging, then trash or recycle the open container (14).  

OUD Treatment 

Treatment for OUD is multi-faceted and typically includes both mental health components and FDA-approved OUD treatment medications. Mental health components may consist of counseling or a structured treatment program. Cognitive behavioral therapy (CBT) may also be beneficial.  

A potential barrier to OUD treatment, on the provider's and patient's behalf, is the perception that patients must engage in counseling to start or continue receiving OUD treatment medication. While the mental health components are essential, there may be barriers for patients to begin mental health treatment programs, which include expense, travel, and available openings within the programs.  

Medication therapy may be a helpful start for these patients (9). FDA-approved medications indicated for the treatment of OUD include methadone, buprenorphine, and naltrexone. Suboxone is a combination drug composed of buprenorphine and naltrexone.  

Medication has several advantages as part of the OUD treatment plan:  

• Help the individual to remain safe and comfortable during detox. 
• Reduce or eliminate cravings for opioids. 
• Minimize relapse since the individual is not experiencing uncomfortable withdrawal symptoms. 
• Allow the individual to focus on therapy without being distracted by withdrawal symptoms and cravings. 
• Increase safety in cases of overdose.  

Methadone 

Methadone is a fully agonistic opioid. It is a Schedule II controlled medication. It can be prescribed purely for the treatment of pain, as well as for OUD. Methadone treatment for OUD can only be provided through a Substance Abuse and Mental Health Services (SAMHSA)-certified opioid treatment program.  

Patients taking methadone to treat OUD must receive the medication under the supervision of a clinician. After consistent compliance, patients may take methadone at home between program visits. The length of methadone treatment should be a minimum of 12 months. Methadone doses are often adjusted and readjusted. Methadone is slowly excreted, and there is overdose potential if not taken as prescribed (9).  

Buprenorphine 

Buprenorphine is a partial agonist opioid. Buprenorphine can be prescribed by any provider with a current, standard DEA registration as a Schedule III Controlled Substance. Like opioids, it produces effects such as euphoria or respiratory depression. With buprenorphine, however, these effects are weaker than those of full opioids such as heroin and methadone. It also has unique pharmacological properties that help lower the potential for misuse and diminish the effects of physical dependency opioids, such as withdrawal symptoms and cravings (9). 

Subutex was a brand-name version of buprenorphine, discontinued in 2011 after new formulations that were less likely to be abused were developed.  

Naltrexone 

Naltrexone is an opioid antagonist. It is not addictive and does not cause withdrawal symptoms. It blocks the euphoric and sedative effects of opioids by binding and blocking opioid receptors and reduces and suppresses opioid cravings.  

There is no abuse and diversion potential. Naltrexone can be prescribed in any setting. It can be taken as a pill or once monthly extended-release intramuscular injection (9).  

It was estimated 2021 that of the 2.5 million people with OUD, only 36% received any treatment, and only 22% received medications. A part of the July 27, 2023, Consolidated Appropriations Act amended the Controlled Substances Act to eliminate the requirement that providers obtain a specific waiver (a DATA waiver) to prescribe buprenorphine (including Suboxone) to treat opioid use disorder, known as the X-waiver.  

Additionally, there are no longer any caps on the number of patients a practitioner can treat. This, however, does not change the requirements for methadone treatment (15).  

Nursing Considerations 

What Is the Nurses' Role in Opioid Patient Education and Opioid Medication Management? 

Nurses remain the most trusted profession for a reason, and APRNs are often pillars of patient care in several health care settings. Patients turn to nurses for guidance, education, and support.  

While there are no specific guidelines for the nurses' role in opioid education and management, here are some suggestions to provide quality care for patients currently taking opioid medications. 

• Take a detailed health history. Often times, pain, and mental health, can be dismissed and overlooked in health care settings. If a patient is complaining of symptoms that could be related to pain, inquire more about that complaint. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms.  

If you feel like a patient's complaint is not being taken seriously by other health care professionals, advocate for that patient to the best of your abilities. A detailed pain assessment and history can provide context for opioid pain management and a patient's plan of care. When taking a health history, ask about any prior surgeries, major life stressors in the past year, or any prior opioid usage.  

• Review medication history at every encounter. Often times, in busy clinical settings, reviewing health records can be overwhelming. Millions of people take pain medications, including opioids, for various reasons. Ask patients how they are feeling on the medication, if their symptoms are improving, if there are any changes to medication history, if they use any other substances other than prescribed medications, such as alcohol, tobacco, or other drug use.  

Remember, prescription medications are not the only medications people take. Confirm medication route, dosage, frequency, and all the details to make sure you and the patient are on the same page and to avoid medication errors and complications.  

• Be willing to answer questions about pain, mental health, and opioid medication options. Society stigmatizes open discussions of prescription medication and pain. Sometimes, people are afraid of asking for pain medication for perception of being a "drug seeking" patient without having their pain concerns addressed. Other times, there are patients who might have OUD and continuously ask for an increased number of opioid medications.  

Be willing to be honest with yourself about your comfort level discussing topics and providing education on opioid medications, drug interactions, and pain management.  

• Communicate the care plan to other staff involved for continuity of care. For several patients, especially for patients with chronic pain or who use opioids long-term, care often involves a team of mental health professionals, physical therapists, nurses, specialists, pharmacies, and more. Ensure that patients' records are up to date for ease in record sharing and continuity of care and to reduce the incidence of opioid medication errors. 
• Stay up to date on continuing education related to opioid medications, pain management, and prescribing regulations. Evidence-based information and scope of practice is always evolving and changing. You can then present your new learnings and findings to other health care professionals and educate your patients with the latest information.  

You can learn more about the latest research on pain management medications, non-pharmacological pain management options, and opioids by following updates from evidence-based organizations, such as the Centers for Disease Control and Prevention (CDC) or your local health department.  

How can nurses identify if someone is in pain?  

Unfortunately, it is not possible to look at someone with the naked eye and determine if they are in pain. Sometimes, a patient in pain will be very obvious with visible lacerations and need pain management options, such as opioids. Other times, pain management is often done as a result by taking a complete health history, listening to patient's concerns, completing a pain assessment, and offering testing to determine the cause of pain. 

How can nurses identify if someone has OUD? 

Unfortunately, it is not possible to look at someone with the naked eye and determine if they have OUD. Sometimes, a patient in pain will be very obvious with visible withdrawal symptoms, such as asking for more opioid medications or discussing symptoms of OUD. Often times, OUD is diagnosed and recognized as a result by taking a complete health history, listening to patient's concerns, and offering testing to determine the cause of pain. Remember, anyone can have OUD, and no two OUD patients appear the same.  

What should patients know about opioid medication?  

Patients should know that anyone has the possibility of experiencing side effects on opioid medications, just like any other medication. Patients should be aware that if they notice any changes in their breathing, changes in their heart rate, or feel like something is a concern, they should seek medical care.  

Because of the social stigma associated with opioids and pain management, people are hesitant to seek medical care because of fear, shame, and embarrassment. However, as more research and social movements discuss opioid use, there is more space and awareness for opioid education and opioid overdose prevention.  

Nurses should also teach patients to advocate for their own health in order to avoid possible opioid complications or not have their pain be poorly managed.  

Here are important tips for patient education in the inpatient or outpatient setting:  

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors) 
• Tell the health care provider of any existing lifestyle concerns, such as alcohol use, other drug use, sleeping habits, diet, menstrual cycle changes (need to identify lifestyle factors that can influence opioid use and pain management) 
• Tell the health care provider of any prior experiences with opioid medication (if applicable) and any medication reactions or side-effects you remember (need to identify risk factors, address pain management appropriately, identify any allergies, and avoid possible opioid overdose symptoms) 
• Tell the health care provider if you have any changes in your breathing, bodily functions, or heart rate (potential opioid overdose symptoms) 
• Tell the nurse of health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life 
• Keep track of your pain, overall health, medication use, and health concerns via an app, diary, or journal (self-monitoring for any changes) 
• Tell the health care provider right away if you are having thoughts of hurting yourself or others (possible increased risk of suicidality and public safety concerns) 
• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options or surgeries 
• Tell the health care provider if you notice any changes while taking medications or on other treatments to manage your pain (potential worsening or improving health situation) 

Research Findings 

What Research on Opioid Medication Exists Presently? 

There is extensive publicly available literature on opioids medications via the National Institutes of Health and other evidence-based journals.  

What are some ways for people who take opioids to become a part of research? 

If a patient is interested in participating in clinical trial research, they can seek more information on clinical trials from local universities and health care organizations. 

New Jersey Safe Prescribing for Opioids for APRNs 

APRNs in New Jersey can obtain prescriptive authority for controlled substances from the New Jersey Division of Consumer Affairs' Drug Control Unit. APRNs need to obtain federal Drug Enforcement Agency (DEA) controlled substance registration and then apply for a New Jersey Controlled Drug Substance (CDS) registration (16, 17).  

N.J. Admin. Code § 13:37-7.9 provides an overview for the prescriptive practice of APRNs (18). Questions regarding the scope of practice for APRNs and controlled substances can be addressed to the New Jersey Division of Consumer Affairs directly (17).  

Conclusion 

Even providers who do not prescribe opioids should be familiar with the effects of opioids and OUD due to its high prevalence in the United States. Understanding the types of pain, how pain occurs, and how it impacts a person's quality of life is especially important. There is still an associated stigma among patients who use Opioids to treat chronic pain conditions. It is essential to recognize that there are times when opioid use is appropriate, as long as the provider practices the recommended guidelines and sound clinical judgment.  

Case Study #1:  

Patient Name: John Henderson 

Gender: Male 

Age: 60 

Height: 6' 1" 

Weight: 190 lbs. 

John arrives at the primary care office after work for a routine office visit. He is employed as a grocery store manager. He reports he does not use tobacco and has never used tobacco. He reports that he drinks alcohol a few times a week and reports no illicit drug use. He has hypertension and high cholesterol and takes Losartan 50mg daily and Atorvastatin 20 mg daily. He reports that he does not have a blood pressure monitor, but sometimes checks his blood pressure after work at the grocery store pharmacy.  

This patient presents to a primary care office with pain and stiffness in the right shoulder joint, which has progressively worsened for six months following rotator cuff surgery. He states his pain is unchanged, and he has a limited range of motion in the right shoulder that is getting worse. Now, for the past few weeks, the pain has started to interfere with his ability to do his job. He said he went to physical therapy for a few weeks after his surgery, but admitted he did not often complete the home exercise program regimen. An MRI was obtained and showed he had adhesive capsulitis. 

When you assessed his right shoulder compared to the left shoulder, there was a noticeable difference between the two. John was also visibly in pain after the right shoulder assessment.

After assessing John's shoulder and completing a few pain assessments, John asked about opioids. John is interested in learning more, but he states he "doesn't wany any crazy side effects because of my work and family life." He states that he also doesn't want "to end up a junkie on drugs" and wants to know if he can drink alcohol still and take his other medications while on opioids. John also wants to know if he will have to take opioids forever like the other medications he's taking.

Given the patient's diagnosis, non-opioid therapy options include nonsteroidal anti-inflammatory drugs, intraarticular glucocorticoid injections, steroid injections into the shoulder joint, range of motion exercises, physical therapy, and consulting with an orthopedic specialist who may recommend a joint manipulation under anesthesia. Each of these should be considered before opioid therapy.  

Case Study #2:  

Patient Name: Pilar Aguilar 

Age: 40 

Height: 5' 1" 

Weight: 135 lbs. 

She reports that she does not smoke, drink alcohol, or take illicit substances. She reports experiencing a hip injury following a car accident three years ago and developed chronic post-traumatic arthritis in the hip. After a total hip arthroplasty, she was diagnosed with heterotopic ossification (HO).  

For the past year, she has been taking 20 mg of oxycodone twice daily to manage chronic hip pain after unsuccessful non-opioid therapies. She has three children with no known pregnancy or postpartum complications. She previously worked part-time as an administrative assistant but has been off work since a car accident three years ago. She has PTSD related to this car accident. She has been prescribed Xanax 0.5mg up to three times daily for anxiety. 

The patient was present at an urgent care clinic today, complaining of a severe migraine, which started yesterday. She stated she needed to take more of her oxycodone to deal with the pain and because she could not sleep last night. She is concerned because she is running out of pills. She said her primary care doctor's office was closed, so she came to the urgent care. The following strategies would be an appropriate course of action for this patient:

Here are some things to consider for Case Study #2: 

• Discuss concerns with the patient. This includes taking the opioid more often than prescribed, potential problems with respiratory depression, and overdose.  
• Recommend trying eletriptan or dihydroergotamine nasal spray first rather than additional opioids. 
• Review the PDMP to see the prescription history for this patient. Attempt to contact the primary care provider to develop a plan of care. 
• Consider conducting toxicology testing 
• Consider offering naloxone  
• Use the DSM-5 criteria to assess the presence (and severity) of OUD or arrange an assessment with a substance use disorder specialist. Offer treatment for OUD if it is confirmed. 

Case Study #3 

Sabrina is a 16-year-old Black high school student working as a waitress at a local restaurant. She arrives at the local pediatric emergency room after her shift with her mom because she thinks she is experiencing a sickle cell crisis.  

Sabrina reports that she has these crises every few months, and this is probably the third time she's been in this much pain. She reports being at this ER last year for something similar. Her mother is there completing paperwork and would like Sabrina to get some pain medication as well.  

Sabrina agrees to provide bloodwork, complete imaging, and be admitted. She said that no health care provider talked to her about how painful sickle cell crises can be, and she doesn't routinely take pain medication because she "doesn't want to be addicted." Sabrina and her mom heard about pain management options for these extremely painful episodes from social media and the Internet and would like Sabrina to get her pain controlled. Sabrina said that she had some opioid last time she was in the ER, but she doesn't remember the name. Her mom doesn't remember the name either, but she remembers it was in an IV.

Sabrina has been in the pediatric ER for over a day receiving IV hydromorphone. She reports some relief, but Sabrina and her mom are concerned. Sabrina wants to live her life like a normal teenager without being in the hospital every few months for pain.  

Her mom asks if there is a way to have pain medication at home. Both Sabrina and her mom would like to know if there is anything that can be done to help with the pain outside of medications as well. Sabrina doesn't want to use pain medications daily but wants to have them at home just in case she can't get to the hospital.  

New Jersey Implicit and Explicit Bias

Introduction   

In OB-GYN care, biases—both implicit and explicit—can affect pain management during labor, the interpretation of patient concerns, and treatment decisions based on factors such as race, ethnicity, weight, age, or sexual orientation [1]. These biases contribute to disparities in care and can result in negative health outcomes [1]. Implicit bias stems from unconscious stereotypes, while explicit bias involves expressed discriminatory attitudes [2]. 

The presence of both explicit and implicit biases among maternity care providers plays a significant role in creating disparities in person-centered maternity care (PCMC) [3]. These biases can influence providers' perceptions and behaviors, leading to unequal treatment of pregnant persons during childbirth. Individuals of lower socioeconomic status (SES) often experience less dignified, less responsive care compared to those of higher SES, perpetuating healthcare inequalities [4]. Understanding the impact of these biases is crucial for addressing disparities in PCMC and ensuring that all pregnant persons receive respectful, responsive care regardless of their socioeconomic background. Implicit bias often leads to associating high socioeconomic status (SES) with positive patient traits and low SES with negative ones, contributing to inequities in the quality of care provided [5].  

PCMC, defined as respectful and responsive care that honors the preferences, needs, and values of pregnant person during childbirth, has gained prominence in global health discussions [6]. Despite this focus, PCMC remains suboptimal, with significant disparities based on SES. Pregnant persons of lower SES tend to experience poorer PCMC, characterized by less dignified treatment, ineffective communication, and diminished respect for autonomy, compared to pregnant person of higher SES [7]. Disrespectful and non-responsive care, common in facility-based childbirth, deters pregnant persons from seeking institutional care, which can affect maternal and neonatal health outcomes.  

Positive PCMC experiences lead to improved outcomes, including increased patient engagement, trust, satisfaction, and stronger psychosocial health [8]. Studies have demonstrated that essential components of PCMC, including birth companionship and respectful communication, are associated with favorable clinical outcomes like shorter labor duration and lower rates of cesarean deliveries [9]. Disrespectful treatment and assumptions about the cognitive abilities or cooperation of low SES pregnant person perpetuate negative healthcare experiences and reinforce community mistrust of facility-based childbirth services [3].  

Both explicit and implicit biases shape these care disparities. Explicit bias reflects conscious negative attitudes or beliefs toward certain groups [2]. Implicit bias influences behavior through quick, automatic associations triggered by characteristics like appearance or SES [2].  

While much of the research on healthcare provider bias has focused on racial disparities, SES bias is relevant in contexts where racial distinctions are less pronounced. In the United States, many perceive low-SES patients as less intelligent, compliant, or engaged in their health, leading to poorer care, shorter consultations, and fewer diagnostic tests [4][10]. Patients report feeling the impact of SES bias through perceived discrimination and lower quality interactions with healthcare professionals, contributing to mistrust and poorer health outcomes over time [1][4].  

These outcomes emphasize the need to address both forms of bias through targeted interventions aimed at improving PCMC is those with a lower SES. Improving provider awareness and enhancing communication, respect, and responsiveness in care delivery are critical steps in reducing disparities and improving health outcomes for all pregnant persons [11]. 

Bias and Stereotyping in Healthcare 

Unscientific beliefs that attribute racial health disparities to biological or genetic differences, rather than to racism, remain pervasive in medical education and practice [12]. These misconceptions, often left unchallenged at the institutional level, infiltrates treatment decisions involving race, and this harms outcomes. For instance, medical students and residents who held explicit stereotypes about Black individuals being of biological difference made less accurate pain management decisions for Black patients [13].  

Within the field of obstetrics and gynecology there are significant and perpetuating such stereotypes. The unethical experiments conducted by early gynecologists like J. Marion Sims and François Marie Prevost on enslaved women, including Anarcha, Lucy, and Betsy, while resulting in advances such as vesicovaginal fistula repair and cesarean delivery, contributed to harmful racial stereotypes [14]. These experiments fostered the false belief that Black pregnant persons have a higher tolerance for pain, a stereotype that persists today and may explain why Black pregnant persons may receive epidural analgesia at a reduced rate during labor or postpartum opioids, even when pain levels are comparable [14]. 

This belief continues to influence modern obstetric tools and decision-making processes. The Vaginal Birth After Cesarean (VBAC) success calculator is a tool to estimate the likelihood of a successful vaginal delivery after a previous cesarean section [15]. The calculator incorporates several factors, including maternal age, body mass index (BMI), prior vaginal delivery, and notably, race or ethnicity. As a result, well-meaning clinicians practicing evidence-based medicine may provide differing counseling to White and Black patients. For instance, the calculator might predict a 66.1% chance of successful VBAC for a White woman but only 49.9% for a Black woman with identical clinical characteristics [12]. This race-based counseling can lead to different decisions—where a White woman may pursue a trial of labor, a Black woman may opt for cesarean delivery, thus contributing to unnecessary maternal morbidity and exacerbating racial disparities in healthcare. 

Transformations in Care Delivery 

The use of standardized protocols can enhance outcomes and address disparities [16]. In California, hospitals implemented a hemorrhage quality improvement collaborative that reduced Black–White disparities in severe maternal morbidity [17]. A labor induction protocol reduced racial disparities in cesarean deliveries and neonatal morbidity [28]. However, standardized protocols may also contribute to disparities. A California hospital implemented a prenatal substance use reporting protocol to child protective services, causing reports of Black mothers to occur five times more often than reports of White mothers during the study period [12]. This outcome resulted from the policy. Standardized quality improvement protocols can worsen disparities across care settings because health systems serving vulnerable populations lack sufficient resources to implement these initiatives [29]. 

It is important to invest in initiatives aimed at reducing Black–White maternal health disparities and to pilot test them before wide-scale implementation to prevent exacerbating inequalities. The American College of Obstetricians and Gynecologists' support of the Black Maternal Health Momnibus Act of 2021 shows how medical professionals can direct resources to underfunded healthcare systems that serve Black women, ensuring they have the necessary tools to implement and monitor quality improvements [18]. 

Furthermore, patients of all backgrounds should receive care based on clinical guidelines supported by reliable data. Such care can reduce or even eliminate racial disparities in certain health outcomes, as seen in ovarian cancer survival rates [19]. The Research Working Group of the Black Mamas Matter Alliance developed a research framework to ensure that Black pregnant persons participate in research teams and studies [20]. 

Framework for Addressing Implicit and Explicit Bias in Maternity Care 

Curriculum Design with Antiracism and Social Justice Foundations 

Develop an educational framework rooted in antiracism and social justice theories. This equips learners to recognize and challenge practices within the field of care. 

Bias Awareness and Management Training 

Incorporate training on recognizing and managing bias throughout the curriculum. This training should focus on both implicit and explicit biases, helping healthcare providers understand their impact on patient care and outcomes. 

Removal of Stereotypical Patient Descriptions 

Eliminate stereotypical patient descriptions from all syllabi, case studies, and examination materials. This prevents the reinforcement of harmful biases in the learning environment and promotes equitable care for all patients. 

Critical Analysis of Epidemiology and Evidence-Based Medicine 

Encourage critical review of epidemiology and evidence-based medicine to identify and address assumptions rooted in discriminatory practices or structural racism. This ensures that medical knowledge does not unintentionally perpetuate stereotypes and biases. 

Competency-Based Education and Holistic Evaluations 

Adopt competency-based medical education and holistic evaluation methods to reduce bias in the assessment of learners. This approach emphasizes skills and knowledge over factors that bias may influence, promoting fairness in evaluation and advancement. 

Strategies for Addressing Implicit Bias in Healthcare 

To address health inequities, many U.S. states have considered or enacted laws requiring implicit bias training (IBT) for healthcare providers. California's "Dignity in Pregnancy and Childbirth Act" mandates that hospitals and birth centers offer IBT to perinatal clinicians to improve outcomes for Black pregnant persons and birthing people [21]. Gathering insights from IBT stakeholders is essential for shaping policy, developing curricula, and guiding implementation efforts. 

Education on implicit bias and strategies for managing its impact should be a core component of broader health system efforts to standardize knowledge on recognizing and addressing bias. Research conducted by the Center for Health Workforce Studies at the University of Washington School of Medicine evaluated the effectiveness of a brief online course on implicit bias in clinical and educational settings. The study found that the course increased bias awareness among a national sample of academic clinicians, regardless of their personal characteristics, practice setting, or the level of their implicit racial and gender-based biases [22].  

Public policy plays a key role in addressing bias in medical care and promoting racial diversity in the perinatal workforce. The federal government also plays a crucial role in addressing discrimination in healthcare. The Office of Civil Rights conducts Title VI investigations into allegations of discrimination within organizations receiving funding [23]. Legal and healthcare experts have suggested reforms to Title VI to extend these investigations to include all physician-provided services. This helps increase trust among patients, promotes diligence among physicians, and works to reduce disparities in treatment. 

Beyond raising awareness, clinicians can take concrete steps to manage the impact of implicit bias in patient care. Act by engaging in role modeling; participate in training to address and interrupt microaggressions and behaviors; and undergo training to eliminate descriptions in notes and communications. Teaching faculty at academic medical centers can contribute by developing inclusive curricular materials that feature diverse imagery and examples, and by consistently using inclusive language in all forms of communication. 

At the organizational level, the foundation of bias-management efforts should be a comprehensive, ongoing diversity, equity, and inclusion (DEI) education program [24]. This program should focus on interactive, skill-building education that addresses implicit bias recognition and management and should involve all employees and trainees across the healthcare system. Organizations should also collect data to track equity and monitor progress and adopt best practices for increasing workforce diversity and integrate antibias education and practices into their professionalism policies. Policies for hiring, performance review, and promotion should also give weight to candidates’ DEI contributions.  

Reporting systems can further institutional efforts to manage bias. Incident-response teams can review incidents, gather information, and either refer the matter to a department, such as human resources, or conduct further investigation. Transparency is key to the process, and reporting on bias incidents, detailing affected groups, locations, and common themes. The four high-priority areas for intervention: bias in pain management, responses to microaggressions and implicit bias, biased behaviors from patients toward medical staff, and opportunities for enhancing institutional inclusivity [25]. By implementing similar strategies, both individuals and organizations can take meaningful steps toward reducing bias and promoting equity in healthcare settings.  

Implicit Bias Training (IBT) is a vital tool for reducing disparities in healthcare and improving patient outcomes in maternity care [26]. Effective IBT helps healthcare providers recognize and address their unconscious biases, leading to more equitable and compassionate care. The following domains outline key areas for enhancing IBT, offering practical strategies for its expansion, effectiveness, implementation, cultural integration within healthcare facilities, and fostering provider engagement. 

Implicit Bias Training Domains 

Domain 1: Scope and Requirements of Implicit Bias Training (IBT) 

Instructive Summary: To improve IBT, expand the scope to include non-perinatal and outpatient healthcare providers. Set clear guidelines on training frequency and duration, and establish accountability measures, such as penalties and standards linked to bias performance. 

Domain 2: Effectiveness and Structure of IBT 

Instructive Summary: For IBT to be effective, it must address systemic biases and provide practical strategies for clinicians. Use real patient stories and case studies to foster reflection and offer actionable insights for managing bias in clinical situations. 

Domain 3: Implementing IBT in Healthcare Settings 

Instructive Summary: Ensure successful IBT implementation by selecting credible trainers, including community members where possible, and creating safe, nonjudgmental training environments. Provide protected time, continuing education credits, and use data to assess the training's impact on clinical outcomes. 

Domain 4: Healthcare Facility Culture and IBT 

Instructive Summary: Leadership must demonstrate commitment to reducing bias, fostering trust, and encouraging open dialogue among staff. Implement accountability measures, such as tracking IBT participation and monitoring care quality, to ensure progress in addressing bias. 

Domain 5: Provider Engagement and IBT 

Instructive Summary: Providers must approach IBT with an open mind and work to recognize their own biases. Focus on engagement to prevent reactions, while understanding that even changes in behavior can improve outcomes. 

Conclusion

Biases contribute to disparities in healthcare [27]. Biases include attitudes and assumptions individuals recognize and report, leading to actions based on race, gender, and sexual orientation. Other biases involve attitudes related to characteristics like race, ethnicity, age, and gender, influencing judgments and behaviors without awareness. These biases operate within systems like racism and sexism, affecting patient care, medical training, workforce diversity, and career advancement [25]. Addressing both types of bias is important for achieving equity and improving outcomes. 

In OB-GYN care, biases around factors like race, socioeconomic status (SES), weight, and sexual orientation impact pain management, interpretation of patient concerns, and treatment decisions. Individuals from lower SES backgrounds often receive less care, reinforcing inequalities [1]. Providers may associate high SES with certain traits and low SES with others, affecting the quality of care they provide [4]. This occurs in maternity care, where biases can lead to issues in treatment, communication, and autonomy for patients from lower SES backgrounds, affecting health outcomes [4]. Interventions that address these biases, empower patients, and hold providers accountable are important for improving maternal care and reducing disparities in outcomes. 

Organ and Tissue Donation

Introduction   

Doctor Joseph Edward Murray performed the first successful human kidney transplant on December 23, 1954, in Boston, Massachusetts [1]. This groundbreaking procedure took place between identical twins, and it enabled the recipient twin to live an additional eight years. Over the years, transplant milestones have included the first simultaneous kidney/pancreas transplant in 1966, the first liver transplant in 1967, and the first heart and lung transplants in 1981 [2].  

According to the United Network for Organ Sharing (UNOS), the U.S. achieved over 42,800 transplants in 2022 alone, marking 1 million total transplants as of September 2022 [3]. There are over 103,924 individuals waiting for transplants, with kidneys being the most needed organ [4]. Each day, 20 people die waiting for a transplant with a single donor having the capacity to save up to eight lives and affect over 50 more by donating organs and tissues [4].  

In the United States various regulations and guidelines govern organ donation. The National Organ Transplant Act (NOTA) of 1984 established the Organ Procurement and Transplantation Network (OPTN), managed by UNOS under federal contract [5]. This organization oversees organ allocation policies, data collection, and educates both the public and healthcare professionals.  

The Centers for Medicare and Medicaid Services (CMS) ensure hospital compliance with U.S. donation programs, while The Joint Commission requires hospitals to maintain agreements with organ procurement organizations and follow specific donation procedures [6].  

UNOS also coordinates the matching of donors with recipients, prioritizing based on medical urgency, tissue compatibility, waiting times, and geographical factors, with special consideration for pediatric patients and previous living donors who are experiencing organ failure [7]. 

Becoming a Donor 

Organ transplantation is a critical medical procedure that transfers a healthy organ from one individual to another and can occur either during the donor's lifetime or after their death. The collections of organs from deceased donors occurs after the declaration of brain-death—a permanent cessation of all brain activity—or following cardiac death, when heart and respiratory functions stop due to severe cardiac issues [9].  

In 2019, the American Academy of Neurology (AAN) supported this by affirming that brain death constitutes the irreversible loss of all functions of the entire brain and is equivalent to circulatory death [10]. 

Individuals interested in becoming organ donors can register through online platforms, local Department of Motor Vehicles (DMV) offices, or via voter registration cards, as state regulations allow. This registration serves as legal consent for organ donation, followed by a medical evaluation to ensure the suitability of the donor’s organs for transplantation.  

Donatable organs and tissues include the heart, heart valves, kidneys, liver, lungs, pancreas, intestines, corneas, skin, veins, bone, and bone marrow. Living donors can donate kidneys, parts of their liver, lungs, intestines, or bone marrow [4]. According to the Health Resources & Services Administration (HRSA), kidneys are the most transplanted organ [4]. 

Determination of Brain Death/Death by Neurologic Criteria  

The process to determine Brain Death or Death by Neurologic Criteria (BD/DNC) requires a thorough clinical examination that verifies the absence of neurological function, evidenced by coma, brainstem areflexia, and apnea. The specific clinical indicators include: (1) no arousal or awareness in response to strong external stimuli such as visual, auditory, or tactile pain; (2) pupils that are midsize or dilated and do not respond to light; (3) no corneal, oculocephalic, or oculovestibular reflexes; (4) lack of facial movement in reaction to painful stimuli; (5) no gag reflex upon stimulation of the back of the throat; (6) absence of a cough reflex when performing deep tracheal suctioning; (7) absence of brain-mediated motor responses to painful stimulation of the limbs; and (8) no spontaneous breathing when apnea testing results in a pH below 7.30 and a Paco2 of 60 mm Hg or more [11].  

Healthcare professionals and nurses give special considerations to certain groups including children, individuals undergoing extracorporeal membrane oxygenation, patients experiencing therapeutic hypothermia, and factors related to religious, societal, and cultural norms [11]. 

The Nurse's Role in Organ and Tissue Donation 

Nurses are a foundational component of the organ and tissue donation process. Their roles extend beyond clinical duties to encompass emotional support, educational advocacy, and participation in multidisciplinary teams [12]. Their involvement is critical at every stage, ensuring that they oversee both the technical and human aspects of the donation process with care and expertise.  

A significant part of a nurse's role involves ensuring that the family is well-informed about the brain death diagnosis, what it means, and the processes involved in organ donation [14]. This role is crucial as it often helps families understand and accept their loved one's condition, facilitating their decision about organ donation.  

Nurses are vital in guiding patients and their families through this complex journey by providing detailed education on what to expect before, during, and after the surgery [14]. They explain the surgical procedures, potential risks, and complications, and address any concerns the patient or their family might have, including dispelling myths about the extensive recovery process.  

Nurses also advocate for better educational programs to inform both the healthcare team and the public about the importance of organ donation. They work towards enhancing the understanding of organ donation's impact, thereby increasing participation in donation programs. This advocacy is crucial for shifting public perceptions and improving the rates of organ donations [13].  

Nurses are key connectors between hospitals, organ procurement organizations, physicians, and families of potential donors. Their attitudes and knowledge impact the success of the donation process [13][15]. Along with other healthcare providers, Nurses help identify patients who are brain dead or nearing brain death due to severe medical conditions and in order of frequency: cardiopulmonary arrest, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage [16].  

Nurses are responsible for informing the Organ Procurement Organization (OPO) about all potential donors, and it is the OPO's duty to assess whether these individuals qualify as potential donors [17]. Organ Procurement Organizations (OPOs) are vital not-for-profit entities in the U.S., tasked with the recovery of organs from deceased donors for transplantation. The U.S. has 56 federally mandated OPOs, each responsible for a specific donation service area [23].  

Their main functions include assessing donor potential, gathering and providing accurate clinical information, and adhering to national policies for organ offerings [23]. While OPOs manage the initial stages of organ procurement and work with the families of potential donors to facilitate the donation process, transplant hospitals are responsible for reviewing and accepting organ offers [17][23]. OPOs play a crucial role in the authorization, testing, recovery, and delivery of donor organs to transplant hospitals, ensuring that each step of the process supports the life-saving mission of organ transplantation. 

The presumption is that a registered donor has consented to organ donation, and this decision is often final and not reversible by the family. If the donor has not registered, the nurse must facilitate obtaining consent from an authorized party according to the Uniform Anatomical Gift Act, which governs organ and tissue donation in the U.S. [18].  

In an ideal setting, organ recipients benefit from the care of a dedicated transplant nurse, supported by a multidisciplinary team. Transplant nurses assist the patient and their family throughout the transplant process—before, during, and after surgery—managing critical tasks such as fluid and blood replacement and monitoring for potential complications. The process from obtaining consent to organ recovery takes 48 to 72 hours [17]. During this period, the nurse and coordinator collaborate to manage the donor and provide ongoing support to the family, ensuring successful organ recovery and helping to save the lives of recipients.  

However, the organ donation journey can be challenging. Recipients may experience desperation while waiting for a suitable organ match or face difficulties during their recovery post-transplantation.  

Ethical Considerations  

Ethical considerations are paramount in the transplant process, often leading care teams to seek third-party ethical consultations. The American Nurses Association’s Code of Ethics offers guidance to nurses, including those involved in transplantation [19].  

Key among these is ensuring that the perception of hastening of a donor's death for organ procurement does not exist, and that decisions of the individual's donor status are independent decisions and with prioritization of the patient's wishes. Another important consideration is ensuring that transplant patients, both donors and recipients, have adequate support systems in place after discharge. This support is often critical for their long-term care and is something confirmed during the pre-screening process.  

The motivations behind an individual's decision to donate organs are complex and require private discussions during pre-screening. Reasons including expected rewards, feelings of obligation, or the fear of losing a loved one can influence a decision to donate. By advocating for their patients, nurses play a crucial role in preserving patient autonomy and respecting their decisions about life and the meaningful impact of their potential organ donation. 

Medical Management of Potential Donors Before Brain Death 

Patients with devastating brain injuries (DBI) require aggressive resuscitation and full support to achieve physiological stability, which is crucial both for their immediate health and their potential as organ donors [20]. This includes maintaining hemodynamic stability, ensuring end-organ perfusion, and achieving euvolemia. Hormone Replacement Therapy HRT plays a significant role in managing patients with DBI before brain death, promoting hemodynamic stability, enhancing organ recovery rates, and improving graft function and survival [17][21][22].  

HRT involving thyroid hormones, corticosteroids, insulin, and vasopressin is a key part of this management strategy, though the effects of early HRT still require further study [21][22]. However, the routine use of corticosteroids in patients with severe TBI is controversial due to associations with poorer outcomes [1]. 

In managing potential donors who have not entered the donation process, it is vital to continue aggressive care unless there are directives from a Legally Authorized Representative (LAR) or explicit advanced directives restricting treatment [17]. This approach helps optimize perfusion, stabilize physiological parameters, and sets the necessary conditions for a formal brain death examination. 

Integrating donor-specific management strategies, such as invasive monitoring or renal replacement therapy, must align with the overall goals of care, respecting the patient’s health status and the expectations of families or LARs. This comprehensive approach emphasizes the complexity of managing potential donors and the necessity for tailored medical interventions that respect the patient’s medical needs and their potential to contribute to life-saving organ donations. 

Conclusion

Dr. Joseph Edward Murray pioneered the first successful human kidney transplant in 1954, marking the beginning of a series of advancements in organ transplantation [1]. With decades of considerable progress, including the introduction of multi-organ transplants and increases in transplant numbers, with over 42,800 transplants recorded in 2022 alone in the U.S. [3]. Today, the demand for organs outweighs supply, as evidenced by over 103,924 individuals waiting for transplants, highlighting the critical need for more donors [4].  

The governance of organ donation process is a stringent and regulated process, with the National Organ Transplant Act (NOTA) and organizations like the United Network for Organ Sharing (UNOS) playing key roles in managing and overseeing organ allocation and transplantation guidelines [5][7].  

Nurses are instrumental throughout the organ donation process, bridging the gap between potential donors, healthcare facilities, and organ procurement organizations. Their roles encompass clinical duties, educational advocacy, and providing emotional support to donors' families, which is crucial in navigating the complex process of organ donation.  

Nurses ensure thorough communication and understanding between all parties involved, including educating families about brain death and the significance of organ donation. Nurses are also pivotal in managing the medical care of potential donors to maintain organ viability, further underscoring their essential role in the success of transplant outcomes and rate of organ donations.  

Conclusion

BODY TEXT

Flap Surgery: The Basics

Introduction

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

Flap Surgery: What is it?

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

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

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

Types of Flap Surgeries 

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

• Blood supply  

• Type/composition of tissue  

• Distance of the healthy site from the recipient tissue  

• Locations of donor and recipient tissue 

• Movement 

Figure 1: Classification of Flaps 

Classification by Blood Supply 

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

• Random Flaps 

• Not based on a specific vessel 

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

• Axial Flaps 

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

• Named according to the pathway 

Classification by Tissue Type 

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

Common flaps: (5) 

• Skin Flap: Skin and superficial fascia 

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

• Fascial Flap: Deep fascia only 

• Muscle Flap: Muscle only 

• Myo-cutaneous Flap: Muscle and skin 

• Osteomyocutaneous Flap: Muscle, bone, and skin 

• Bone Flaps: Bone (vascularized) 

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

Fascio-cutaneous Flap  

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

Muscle Flap 

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

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

Musculocutaneous Flap 

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

Bone Flap 

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

Classification by Location and Movement 

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

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

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

Figure 2: Example of Flap Type 

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

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

Indications for Surgery 

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

General Indications: 

• Protection of the greater vessels 

• Correction of congenital defect 

• Abdominal wall reconstruction 

• Deep, gaping wounds 

• Reconstruction after tumor excision 

• Trauma 

• Debridement procedure to remove infected or necrotic tissue 

• Venous ulcers (non-healing) 

• Pressure ulcers (non-healing) 

• Breast reconstruction 

• Rhinoplasty 

• Scar Revision 

• Skin Cancer 

• Burns 

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

Risks versus Benefits 

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

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

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

Preparing for Surgery 

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

Addressing Comorbidities and Other Conditions 

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

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

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

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

Preoperative considerations should include: (9) 

• Patient age  

• Diabetes status 

• Smoking history 

• Atherosclerosis 

• Peripheral vascular disease 

• Steroid use 

• Previous surgeries 

• The extent and location of the defect 

Providing Preoperative Instructions 

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

Preoperative education list: 

• Assess the patient’s level of understanding. 

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

• Review specific pathology and anticipated surgical procedure.  

• Verify that consent has been obtained / signed. 

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

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

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

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

• Discuss postoperative pain management plan and options.   

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

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

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

• Offer pastoral spiritual care or counseling. 

Post-Operative Considerations 

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

Assessment 

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

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

Assess circulation of the flap: 

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

• Warmth 

• Dry/Intact? Leaking Fluids? 

• Changes in size 

• Edema 

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

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

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

• Color and thickness: (7) 

• Sanguineous: fresh bleeding  

• Serous: clear, thin, watery plasma 

• Serosanguinous: serous drainage with small amounts of blood noted 

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

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

• Color duplex ultrasound 

• Near-infrared spectroscopy 

• LASER Doppler flowmetry 

• Implantable Doppler (useful for buried flaps) 

Assess circulation distal to the flap: 

• Capillary refill 

• Color  

• Temperature 

• Pulses  

• Edema 

Drains 

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

Patients may have the following drains after flap surgery: 

• Jackson Pratt (JP) drains 

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

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

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

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

• Penrose drains: 

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

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

Positioning 

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

Negative Pressure Wound Therapy 

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

NPWT is also known as a wound vac. NPWT uses sub-atmospheric pressure to help reduce inflammatory exudate and promote granulation tissue in an effort to enhance wound healing (4). The idea of applying negative pressure therapy is that once the pressure is lower around the wound, the gentle vacuum suction can lift fluid and debris away and give the wound a fighting chance to heal naturally. NPWT systems consist of a sterile foam sponge applied to the wound bed, a semi-occlusive adhesive cover, a fluid collection system or cannister, and the suction pump (1). The foam sponge is applied to the wound and covered. A fenestrated tube is embedded in the foam, the wound is sealed with adhesive tape to make it airtight, and the machine delivers continuous or intermittent suction, ranging from 50 to 125 mmHg (1). 

Figure 3. Negative Pressure Wound Therapy Visual 

Home Care and Patient Education 

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

• Wound Assessment  

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

• Signs of Infection 

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

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

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

• Dressing changes, wound cleansing, and hand hygiene 

• Methods to prevent skin breakdown 

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

• Common areas: Sacrum, heels, elbows. 

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

• Importance of turning, mobility, and ambulation 

• Pain management 

• Medications 

• Heat/cold therapy applications and precautions 

• Negative Pressure Wound Therapy devices (wound vac) 

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

• Drain maintenance 

• Showering restrictions 

• Reduction of stress and tension at wound site 

• Avoid constipation, strenuous movements, and lifting 

• Restrictions vary for location of flaps and per surgeon instructions 

• Follow-up appointments 

Flap Dehiscence or Loss 

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

Prevention Strategies 

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

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

Management and Treatment 

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

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

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

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

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

Recovery 

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

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

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

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

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

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

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

Examples of Patient Outcomes following flap surgery: (3) 

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

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

• Management of pain 

• Prevention of further damage or skin breakdown 

Conclusion

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

Diabetic Ketoacidosis Management

Introduction   

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

Definition

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

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

Epidemiology

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

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

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

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

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

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

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

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

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

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

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

Pathophysiology

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

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

Clinical Signs and Symptoms

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

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

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

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

Teens/Young Adults

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

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

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

Young Children

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

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

Infants/Toddlers

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

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

Etiology

Etiology: Causes of Diabetic Ketoacidosis

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

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

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

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

Etiology: Precipitating Factors

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

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

Etiology: Diabetic Ketoacidosis and Corticosteroid Use

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

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

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

Treatment

Emergency Treatment

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

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

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

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

Initial/Emergency treatment of DKA includes (20):

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

Laboratory Findings

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

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

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

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

Fluid Resuscitation Guidelines

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

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

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

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

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

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

Insulin Therapy and Acute Diabetic Ketoacidosis

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

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

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

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

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

Laboratory Tests Guidelines Therapy Goals

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

Electrolyte Imbalance (Hyperkalemia-> Hypokalemia)

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

Treatment-Related Complications

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

Cerebral Edema

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

Initial symptoms of cerebral edema may include the following:

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

Symptoms that may indicate worsening of cerebral edema. 

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

Confirmation Testing: 

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

Treatment for DKA Related Cerebral Edema

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

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

Nursing Care and Management

Nursing Care: Patient Placement

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

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

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

Nursing Care: Acute Phase

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

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

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

Patient Education

Diabetes Self-Management Education and Support (DSMES)

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

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

Additional Resources

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

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

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

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

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

Patient Education and Follow-up Care (DSMES)

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

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

Medicare and Medicaid

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

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

Qualifying Labs for DSMES

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

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

DSME Contents Overview

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

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

Safety Considerations (Sick Day Management)

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

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

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

Patient Education: Sick Day Management

Home treatment/ self-care (30)

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

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

Sick Day Management Guidelines

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

Seek emergency care for the following signs/ symptoms:

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

Research Findings

Research: Diabetes Distress and Burnout

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

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

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

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

Reserach: Diabulimia

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

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

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

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

Research: Insulin Affordability

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

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

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

Research: Insulin Delivery Systems

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

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

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

Examples of insulin delivery devices:

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

Case Studies

Case Study #1

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

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

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

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

Case Study #2

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

Patient past medical history includes old CVA, T2DM.

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

Case Study #3

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

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

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

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

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

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

Conclusion

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

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

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

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

Heart Disease Prevention & Management

Introduction   

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

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

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

Types of Heart Disease  

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

Congenital heart disease (CHD) 

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

Heart Valve Disease 

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

Heart Failure 

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

Cardiomyopathy 

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

Pericardial Disease 

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

Arrhythmia 

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

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

Aortic Dissection 

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

Epidemiology/Statistical Evidence  

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

Epidemiology: Modifiable and Non-Modifiable Risk Factors 

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

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

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

Statistics on Ethnic/Racial Minorities 

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

Epidemiology: Genetic and Environmental Factors 

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

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

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

Prevention Strategies 

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

Key prevention strategies include: 

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

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

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

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

Patient Education for Self-Management  

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

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

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

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

Medical Management and Treatment  

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

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

Heart Health Resources 

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

Educational Materials/Content 

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

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

Published Guidelines 

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

Support Groups 

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

Technological Advancements 

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

Nonprofit Organizations 

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

Conclusion

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

Nutrition for a Healthy Heart

Introduction   

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

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

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

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

Heart Disease: A Brief Overview 

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

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

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

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

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

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

Types of Heart Disease / Statistics 

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

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

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

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

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

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

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

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

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

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

Evidence on Diet and Heart Health / Diet Options 

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

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

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

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

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

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

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

Role of Sodium and Fats 

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

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

Healthy Eating Tips and Strategies 

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

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

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

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

Patient Education 

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

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

Resources 

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

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

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

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

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

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

Conclusion

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

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

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

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

Adverse Childhood Experiences

Introduction   

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

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

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

Definition 

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

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

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

• Childhood abuse 

• • Psychological 

• • Physical 

• • Sexual 

• Household dysfunction 

• • Substance abuse 

• • Mental illness 

• • Parent treated violently. 

• • Family member incarcerated. 

• Neglect 

• • Emotional  

• • Physical  

Statistics and Demographics 

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

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

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

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

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

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

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

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

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

Causes and Risk Factors 

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

• Lack of access to healthcare or other resources 

• Financial difficulties 

• Homelessness or frequent moving 

• Discrimination 

• Any type of disrupted living situation  

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

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

Community Risk Factors: 

• High rates of poverty, crime, and violence 

• Limited educational, economic, and employment opportunities  

• Lack of community activities for youth 

• Unstable housing and frequent moves by community residents   

• Readily accessible alcohol and drugs 

• Frequent experiences of food insecurity  

Family and Individual Risk Factors:  

• Social or developmental disabilities or delays  

• Mental or chronic physical illnesses 

• A history of abuse experienced by caregivers themselves. 

• Youth dating or engaging in sexual activity early. 

• Single-parent families, particularly those with young caregivers 

• Low income and/or high economic stress 

• Low education levels 

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

• Caregivers with limited understanding of child development  

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

• Inconsistent discipline and/or little parental supervision 

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

Cultural Considerations  

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

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

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

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

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

• Witnessed domestic violence (15% versus 6%) 

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

Lifespan Impact on the Individual 

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

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

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

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

• Heart disease (#1 cause of death) 

• Stroke (#5) 

• Chronic lower respiratory diseases (#6)  

• Diabetes (#8) 

• Chronic liver disease and cirrhosis (#9) 

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

Societal Implications 

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

The societal implications for reducing ACEs are manifold:  

• Dramatic reduction of preventable causes of death 

• Longer lifespans for the general population  

• Better mental health  

• More cost-effective physical and mental healthcare 

• Lower rates of disease and depression in the general population 

Ways to Mitigate ACEs 

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

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

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

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

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

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

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

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

Reporting ACEs 

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

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

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

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

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

Support and Additional Resources 

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

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

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

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

Conclusion

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

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

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

Conclusion

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

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

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

Trauma Informed Care in Nursing

Introduction

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

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

Trauma Informed Care 

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

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

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

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

There are six principles of trauma informed care: 

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

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

Principles of Trauma Informed Care 

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

Safety 

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

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

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

Trustworthiness and Transparency 

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

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

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

Peer Support 

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

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

Identifying Past Trauma 

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

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

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

Collaboration and Mutual Support 

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

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

Cultural and Historical Sensitivity 

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

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

Empowerment of Voice and Choice 

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

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

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

Effects of Traumatic Stress 

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

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

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

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

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

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

Adverse Childhood Experiences 

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

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

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

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

Trauma Informed Approach 

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

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

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

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

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

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

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

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

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

Impact of Trauma Informed Care 

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

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

Nursing Implications 

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

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

Introductions 

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

Body Language 

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

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

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

Anticipatory Guidance 

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

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

Permission 

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

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

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

Protect 

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

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

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

Clear and Consistent 

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

Universal Precaution 

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

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

Resources 

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

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

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

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

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

• https://TraumaInformedCare.chcs.org 

• https://www.creatingpresence.net/ 

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

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

(5) 

Conclusion

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

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

Conclusion

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

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

Nursing Care in Lewy Body Dementia 

Introduction   

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

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

Definition

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

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

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

Epidemiology 

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

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

Pathophysiology 

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

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

Etiology 

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

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

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

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Clinical Signs and Symptoms 

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

Rapid Eye Movement Sleep Behavior Disorder 

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

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

Other Sleep Disorders 

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

Visual Hallucinations 

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

Fluctuation in Cognition 

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

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

Problems with Movement 

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

Autonomic Dysfunction 

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

Diagnostic Tests and Evaluations  

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

Diagnosis by Symptoms 

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

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

Cognitive Tests 

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

Imaging Tests 

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

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

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

Case Studies 

Case Study #1 

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

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

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

Case Study #2 

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

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

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

Management 

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

Therapies 

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

Medications 

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

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