Ohio APRN Renewal Bundle – Part 2

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Ethics for the Telehealth Nurse

With the increasing utilization of telehealth in the healthcare industry, it is vital that nurses become aware of the ethical principles involved in this hands-off, virtual approach to providing patient care. This course provides basic, ongoing, and applicable knowledge of nursing ethics to improve patient outcomes specifically for a telehealth nurse. All nurses are responsible for being familiar with the American Nurses Association’s (ANA) Code of Ethics for Nurses no matter the specialty they are in. The information offered in this course is being given as a guideline and does not replace the laws governing nursing practice. 

Introduction 

Although the utilization of telehealth has been incorporated into patient care for many decades, the impact of the COVID-19 pandemic has increased its prevalence in the industry; leaving many professionals with no choice but to adapt. With this recent change, most healthcare facilities were forced to create strategies that allowed them to not only prevent viral exposure but continue to provide quality patient care remotely. As a result, healthcare professionals faced many challenges, especially nurses (4). When considering that the nursing process has been taught, referenced, and utilized as one of the overarching ethical guidelines for hands-on nursing care for hundreds of years, it is evident that nurses have overcome many obstacles in a short period of time.  

It is vital for the telehealth nurse to continue to assess and interact with patient populations through this newer method of care while strictly following the ANA Code of Ethics for Nurses.  

Nursing Practice for the Telehealth Nurse 

The practice of telehealth allows a trained nurse the ability to communicate with patients and their families, provide assessments in real-time, and implement appropriate interventions virtually.   

The first telehealth nursing practice standards were published in 1997 by the American Academy of Ambulatory Care Nursing (AAACN) in response to the increased growth in popularity and utility of the field (1). The standards are divided into the domains of either Clinical Practice or Professional Performance; each standard has a set of competencies that the professional nurse must meet when practicing.  

Although telehealth nursing does not require direct patient contact, a nurse should uphold the same standards and ensure that their quality of care and compliance with ethical nursing practices does not change (4). It is of the utmost importance that the care provided remains patient-centered and quality-focused, and that the telehealth nurse continues to utilize the nursing process in all patient interactions.  

Code of Ethics for Nurses 

The ANA Code of Ethics for Nurses with Interpretive Statements is the non-negotiable framework surrounding how those in the nursing profession should incorporate both ethical and moral practices into their patient care (2). This code of ethics consists of nine principles that should be strictly followed, these include (2): 

1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. 
2. The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population. 
3. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. 
4. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care. 
5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. 
6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. 
7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. 
8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. 
9. The profession of nursing, collectively through its professional organization, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy (2). 

It is of the utmost importance that nurses abide by these nine provisions of the Code of Ethics for Nurses; this is no different for the telehealth nurse (2). 

Caring for a patient virtually does not relinquish the telehealth nurse of their duty to be accountable, responsible, compassionate, and respectful.  

Privacy

Telehealth nurses most often are in the same area as other nurses when working and interacting with patients, so it is crucial that patient confidentiality is ensured. The Code of Ethics for Nurses indicates that privacy must be maintained, and the patient should feel comfortable in disclosing sensitive information, even through the utilization of telehealth methods (2).  

Because the patient does not have the privacy of an exam room, the nurse should communicate to the patient that measures are in place to provide protection and privacy of their information during the telehealth visit. If the patient verbalizes concern in confidentiality, the nurse must document the patient concerning the patient record (5). 

Trust

The telehealth nurse has an obligation to initiate and ensure there is trust with the patient, as it is one of the main components of the Code of Ethics for Nurses (1,2,4,5).  

As the telehealth nurse, your patient must feel like you are giving accurate information when you are assisting them in making the right decision(s) for their treatment plan. When the patient makes the call to obtain information regarding their care, they are entrusting the nurse to have necessary and applicable knowledge. It is important to note that any initial information provided to the patient prior to consulting with a physician must be supported by evidence-based practices (5).  

Communication and Documentation

Any patient calls or interactions during telehealth visits must be documented. The nurse must communicate with the patient regarding their health or treatment plan in a way that is digestible allows them the opportunity to verbalize any questions or concerns.  

In order to ensure effective communication during telehealth visits, there are a number of things a telehealth nurse can do, these include: 

• At the beginning of the visit, provide a call back number in case the call is disrupted (allow the patient or family member to repeat the number back to establish the number is correct). 

• Allow the patient or family member to verbalize feedback if the visit met expectations and was satisfactory. 

• Ensure that the patient can hear and understand you clearly.  

• If the visit is through a virtual conferencing platform, ensure that you are incorporating forms of non-verbal communication such as eye contact, body language, and appropriate facial expressions that would be used in an in-person visit.  

• If necessary, explain the process of the telehealth visit and how it may differ from in-person.  

• Remain confident, unbiased, and professional while upholding patient confidentiality (3).

Explain how a nurse conducting telehealth nursing interventions may have a stricter adherence to ethics than face-to-face encounters?

By what reasoning would the effect of software compliance and security standards jeporadize the ethical behavior of a telehealth nurse?

Nursing documentation via telehealth is no different than in-person clinical settings, and it must embody the nursing process, Code of Ethics for Nurses, and your facility’s documentation protocols (4).  

ANA Principles for the Telehealth Nurse 

In addition to the ANA Code of Ethics for Nurses and the AAACN Scope and Standards of Practice for Professional Telehealth Nursing, the ANA has 13 principles of connected health that the telehealth nurse must follow, these read (3): 

1. The use of connected health technologies does not alter the standards of professional practice when delivering healthcare, conducting research, or providing education. Developed by each profession, in this case nursing, these standards focus on the healthcare professional’s responsibility to provide lawful, evidenced-based and high-quality personalized care regardless of the method of delivery, grounded in the Nurses Code of Ethics. 
2. As connected health is a method of healthcare delivery, the healthcare provided is subject to the same healthcare laws and board oversight as the healthcare provided in-person. Healthcare professionals should understand, however, that due to the nature of connected health business models, certain interstate commerce, fraud and abuse another applicable state and federal laws not commonly encountered when delivering healthcare in-person may apply. 
3. Healthcare services delivered via connected health technologies should prioritize improving access to quality healthcare that is guided by best available evidence, accepted clinical standards, and best practices. These services must include deployment of appropriate technological modalities which meet the patient’s needs, are practical and easy to use, and align with specific patient location and care setting. 
4. Professional practice and healthcare delivery, regardless of venue and channel of delivery, mandates that healthcare professionals meet state specific regulatory and institutional requirements in accordance with scope of practice. Due to variations in practice rules and regulations across states and facilities, providers must practice respective of these variations whilst delivering care via connected health. 
5. Nursing and other healthcare professions are responsible for developing their own competencies to ensure the safe, effective and competent delivery of healthcare via connected health technologies using a patient-and family-centered team-based approach. 
6. Healthcare services delivered via connected health technologies should be congruent with in-person care and must adhere to the best available evidence that represents current and emerging interdisciplinary standards of care, while recognizing the limitations inherent in technology to ensure optimal patient-centered outcomes.  
7. When using connected health technologies, the integrity and therapeutic value of the patient-healthcare professional relationship should be established, maintained, and promoted via connected health. 
8. Safeguards must be taken with the transmission of electronic information and communication conducted using connected health technologies in all connected health practice settings. This practice upholds the highest level of ethical conduct in the secure management of patient health information, patient privacy and confidentiality and protection against unauthorized breach of information. This includes informing patients of the use of third-party technology providers, the risk of disruption in the integrity of those providers’ data management practices, and a commitment to protecting patients from such event. 
9. Documentation requirements for healthcare services delivered via the utilization of connected health technologies should be consistent with requirements applicable to all other patient encounters. 
10. Patients involved in a connected health encounter should be informed about the process, the inherent risks and benefits, and their rights and responsibilities, in compliance with applicable federal and state laws. Informed consent for connected health may not need to be independent from other informed consent for treatment although mechanisms for obtaining electronic consent should comply with applicable federal and state laws. 
11. The safety of patients and healthcare professionals must be ensured. Hardware and software compliance with safety and security standards, the appropriateness of a connected health approach to the situation and demonstrated patient and provider user competency are essential components of safe connected health practice. 
12. In order to inform connected health, and ensure the best outcomes, it is essential that the assessment, evaluation, and study of all aspects of connected health are ongoing and systematic. This research should include key stakeholders as primary informants and the resulting evidence utilized in the development and implementation of connected health guidelines and best practices. 
13. Policies governing the practices and reimbursement of healthcare should be continuously updated and modernized to allow for the integration, national adoption, and sustainability of connected health (3). 

Although the telehealth nurse solely relies on the utilization of technology in order to interact with patients, this does not allow for altering of professional standards; providing quality-focused and patient-centered care is always required. 

Additionally, it is unethical for the telehealth nurse to falsely indicate time spent in teaching and discharging. Time spent gathering discharge follow up and future appointments should not be counted as patient interaction, if conducted prior to making the call to complete the after-visit discharge summary. The nurse is responsible for knowing the laws in their state in accordance with their scope of practice for telehealth (2). 

Conclusion 

No matter their specialty, field, or scope of practice, all nurses are accountable for their actions. Although the healthcare setting may vary, a telehealth nurse must be knowledgeable of their facility’s expectations during patient interactions as well as how to effectively deliver quality care virtually.  

With the prevalence of the utilization of telehealth continuing to rise in the healthcare industry, it is vital for the telehealth nurse to ensure they are abiding by the ANA Code of Ethics for Nurses, consistently upholding professionalism, and overall, ensuring patient confidentiality. 

One Hour Sepsis Bundle

Introduction

It is nothing new to healthcare workers that sepsis is a big deal and often at the top of the provider's differential diagnosis when patients begin to decompensate, and the cause is not yet clear.  

The incidence of sepsis from 1979 – 2000 increased by 8.7%, from 82.7 to 240.4 per 100,000 patients (1). The incidence of sepsis is rising as a result of the aging population, progressive increase in antibiotic resistance, reliance on implanted devices, organ transplantation, and an increasing prevalence of patients with long-term immunosuppressive diseases who are at risk for severe infection and sepsis (1). 

To understand the importance of the sepsis bundle, you must understand why there is an emphasis on treating sepsis as a medical emergency, similar to a STEMI or a CVA. 

Sepsis is a life-threatening syndrome consisting of numerous signs, symptoms, hemodynamic, and laboratory findings, caused by an exaggerated and dysfunctional immune response to severe infection that leads to organ dysfunction (2). Septic shock is a more severe subset of sepsis that commonly presents with circulatory and/or metabolic dysfunction. Septic shock carries a 30-40% mortality risk (2). 

Diagnostic Approach to Sepsis 

Early phases of sepsis can be subtle even in the carefully monitored patient, but if the subtle signs are missed, and the clinical signs of septic shock become glaringly apparent, you and your clinical team have already acted much too late.  

Below is a table depicting the most common hemodynamic changes seen in sepsis (1).  

Defining Sepsis 

The updated guidelines on sepsis use the Sequential (Sepsis Related) Organ Failure Assessment Score (SOFA) to define sepsis. The SOFA score assesses the degree of organ dysfunction across numerous domains.  

A score of 2+ reflects an overall mortality of about 10% in the setting of suspected infection (1). The laboratory data included in the SOFA score focuses on coagulopathy, hepatic dysfunction, and/or renal dysfunction (1). Other laboratory data (such as WBC) can aid in the diagnosis of infection but are not used to define sepsis or septic shock. 

A bedside tool called qSOFA (Quick SOFA) was developed to quickly identify adult patients with suspected infection who are likely to have poor outcomes (1). 

 The presence of any 2 of the following is equal to a positive qSOFA:  

1. Respiratory rate >/= 22/min 
2. Glasgow Coma Score <15  
3. SBP </= 100 mmHg (1) 

***The qSOFA is best used to identify early organ dysfunction in adults on general medical/surgical floors, whereas the SOFA score is used more in the critical care setting (1). 

The qSOFA tool can be used to quickly screen and identify patients who are at risk for deterioration. It is being used both on admission and as ongoing tool to track changes in patient condition. 

The chart below illustrates common laboratory findings seen in sepsis (1). 

A Word on Septic Shock 

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

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

Early Septic Shock 

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

Late Septic Shock 

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

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

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

The bundles consist of various components of sepsis care: 

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

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

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

One Hour Sepsis Bundle Components and Strategies to Expedite Care 

The most critical change in the Surviving Sepsis Campaign bundles is that the previous 3-hour and 6-hour bundles are now combined into a single "hour-1 bundle" with the intention of beginning resuscitation and management immediately upon presentation (3) (5).

While more than one hour may be needed for patient resuscitation to be completed, the initiation should begin immediately upon suspicion that the patient may be presenting with sepsis. 

Measure lactate level.

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

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

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

Obtain blood cultures prior to antibiotics.

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

Administration of broad-spectrum antibiotics.

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

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

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

Administer IV Fluid.

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

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

Apply vasopressors.

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

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

Code Sepsis 

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

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

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

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

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

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

Conclusion 

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

Renal Failure Stages, Treatment and Outcomes

Overview of Kidney Anatomy and Function 

We will begin with an overview of the kidneys. They are two bean-shaped organs, roughly the size of an adult fist, that lie in the retroperitoneal cavity. The right kidney is slightly lower than the left because of the liver placement. The adrenal glands sit right on top of each kidney. Blood carrying excess fluid and waste products enter the kidney through the renal artery.

Within the kidney are millions of nephrons containing glomeruli that filter the blood and send waste, toxins, and excess fluid through the ureters, bladder, and urethra for excretion, or through the renal vein for recirculation back into the body. 

Relatively speaking, the kidneys are rather small; however, they hold a major role within the human body. The primary function is to balance the chemicals in the body so that homeostasis is maintained. They do this by releasing hormones to help regulate blood pressure, controlling sodium and fluid levels, stimulating the production of red blood cells, creating vitamin D to help the body absorb calcium, and balancing fluid and electrolytes.

The filtered toxins and excess water, now urine, travel from the kidneys to the ureters, where they collect in the bladder and then empty out through the urethra when nerves in the bladder signal the brain that it is time for excretion.

The kidneys receive approximately 25% of the body's cardiac output and produce about 2 quarts of urine each day when working optimally (3). The body begins to lose kidney function when there are interruptions that limit the amount of blood flowing to the kidneys after exposure to nephrotoxic agents or trauma. 

Renal Failure Stages 

Kidney health is determined by testing blood and urine. Blood tests measure the glomerular filtration rate (GFR) in the blood, and urine tests calculate the albumin to creatinine ratio (ACR) in the urine. The presence of protein in the urine could mean that the kidneys are not filtering well.  

CKD is classified into five renal failure stages based on GFR. 

At Renal Failure Stage 5, the patient has developed end-stage renal disease, also called chronic kidney disease, and will require life-long renal replacement therapy (2). If CKD is detected in the earlier renal failure stages, treatments can slow the disease progression and keep the kidneys functioning longer.  

Early referral to a nephrologist at the onset of renal failure symptoms allows for treatments to begin sooner and allows the patient to prepare for the disease progression physically, mentally, and emotionally. Unfortunately, many patients delay medical attention when they are feeling poor, and the delayed treatment leads to an accumulation of toxins in the bloodstream, called uremia.

Uremia can cause confusion, loss of appetite, nausea, and diarrhea. Some patients get a 'uremic frost' on their skin, which is a crystallization of the uremic toxins. Patient awareness is less than 10% for those with Renal Failure Stages 1-3. Awareness is much higher among people with Renal Failure Stage 4, who are beginning to experience obvious symptoms (7).

When situations necessitate immediate action and adequate time is not available, individuals often begin dialysis without appropriate planning. "Approximately 50% of all dialysis initiations occur in a suboptimal manner, meaning that half of the patients starting dialysis do not have the opportunity to psychologically adjust to this treatment and its impact on their life (6)." These patients are at greater risk of developing stress, anxiety, and depression. 

Acute vs. Chronic Renal Failure 

Renal damage can be categorized as acute or chronic. In acute renal failure (ARF), damage to the kidneys happens suddenly, causing the kidneys to lose some or all function temporarily. Acute causes of renal failure include trauma, exposure to nephrotoxic substances, infection, and temporary interruption of blood flow to the kidneys. In Acute Renal Failure, the damage is sudden, but the expectation is that the kidneys will return to normal function once the cause is eliminated and the kidneys have healed.  

On the other hand, chronic renal failure (CRF) occurs slowly over time and is irreversible. Often, lifestyle choices can lead to CRF as uncontrolled diabetes and hypertension are the most prevalent causes. Hypertension is often referred to as the 'silent killer because many people that have it are asymptomatic; therefore, diagnosis and treatment are delayed.

Other causes include chronic use of certain drugs (nonsteroidal anti-inflammatory drugs (NSAIDs), heroin, and some antibiotics), chronic infections (i.e., urinary tract infections, glomerulonephritis), polycystic kidney disease, and kidney stones. Sometimes, an acute cause of renal failure can lead to permanent loss of kidney function. If the kidneys do not regain function after 90 days of acute renal failure, the patient is diagnosed with chronic renal failure. From 1999-2012, CKD was most prevalent in non-Hispanic, black individuals, followed closely by Mexican Americans (7). 

Types of Dialysis 

Dialysis is a form of renal replacement therapy. The two main types are hemodialysis and peritoneal dialysis. Both modalities utilize a semi-permeable membrane to eliminate waste, toxins, and excess fluid from the body. A semi-permeable membrane allows smaller molecules and fluid to pass through a porous surface; however, larger molecules are unable to pass through and are separated from the rest.

In dialysis, molecules such as urea, toxins, and some electrolytes that are too concentrated in the blood pass through the semi-permeable membrane, while blood cells are too large to fit through, allowing them to remain in the bloodstream. Healthy kidneys function 24 hours a day and seven days a week. Dialysis treatments can only replace a fraction of this, no matter how frequently they are ordered or how effective it is. 

Hemodialysis

Hemodialysis is the most prevalent type of treatment. It requires the use of a dialysis machine with a pump to mimic the heart's pumping of blood through the body. The pump turns at an average rate of 400 ml/min. Different types of surgically placed accesses are used to enter the intravascular space, connecting an artery to a vein.

There are three main types of accesses: an arteriovenous fistula (AVF), arteriovenous graft (AVG), and a central venous catheter (CVC). The fistula is the most preferred access because it uses the patient's own artery and vein, whereas a graft uses a synthetic material to connect the artery to the vein. These are permanent accesses.

The CVC is the least preferred access because of its higher rates of infection and clotting, and the tip of it sits in the right atrium of the heart. This is generally treated as a temporary access to be used while a patient is actively pursuing placement of a permanent access. However, for many patients, the CVC is the last resort option because they do not possess the vasculature needed to place a permanent access.  

AVFs and AVGs require two large-bore needles to be placed into the access, allowing entry into the patient's bloodstream. One needle pulls the patient's blood out of the body through the access and into a circuit on the machine that contains a dialyzer – often referred to as an artificial kidney. The inside of the dialyzer contains thousands of tiny hollow fibers that are semi-permeable.

The blood travels inside the fibers in one direction, while a solution called dialysate (made of ultrapure water made through reverse osmosis (RO), sodium bicarbonate, and acid bath containing electrolytes such as sodium, potassium, calcium, and magnesium), travels in the opposite direction outside of the hollow fibers.

This causes a pressure gradient that allows diffusion and osmosis to take place within the dialyzer, assisting the body to return to homeostasis by removing waste, toxins, and excess fluid. As the blood is filtered through the dialyzer, the waste product (effluent) travels down into a drain, while the second large-bore needle in the access returns the cleaned blood back into the body.  

Peritoneal Dialysis 

In peritoneal dialysis, the patient has a catheter surgically placed into the abdomen that allows fluid to flow in and out of the peritoneal cavity. The semi-permeable membrane is the peritoneal membrane, also called the peritoneum. In this modality, the dialysate, a solution with a high concentration of dextrose (which pulls the waste, toxins, and excess fluid through the semi-permeable membrane), is inserted into the peritoneal cavity.

After a prescribed amount of time (dwell), the fluid is drained out through the catheter. This is the effluent. The cycle (exchange) is repeated a prescribed number of times, depending on the patient's residual renal function and lab results, this often correlates with their renal failure stage. No intravascular access is needed; therefore, no needles are used. 

Treatment Goals 

No matter which modality is chosen, all dialysis treatments have the same goals: to replace lost kidney function and return the body to homeostasis. Because fluid balance is a crucial goal of dialysis, accurate patient weights are extremely important. Each patient is prescribed an estimated dry weight (EDW) by a nephrologist. This EDW is the weight the patient would be without excess fluid in their body.

The machines are programmed to remove an amount of fluid during the dialysis treatment that will get the patient to their EDW by the end of treatment. Failure to remove the right amount of fluid or removal of fluid at the wrong rate could lead to undesired effects such as hypervolemia, leading to shortness of breath, pneumonia, pitting edema, congestive heart failure, pulmonary edema, and hypertension; or hypovolemia, which leads to cardiac stunning, hypotension, nausea, vomiting, muscle cramps, and dizziness. Fluid imbalances and infection are the primary reasons ESRD patients are hospitalized. 

Another goal of dialysis is the removal of waste and balancing of electrolytes. This is referred to as clearance or adequacy, and it lets the provider know if their orders are sufficiently cleansing the patient's blood. Some factors that can affect clearance are: 

• The size of the semi-permeable membrane 
• The amount of time and frequency of the dialysis treatments 
• The exposure time to the semi-permeable membrane 
• The proper functioning of the access 
• The concentration of the dialysate 
• The efficacy of anticoagulant or thrombolytic used (because clotted blood leads to decreased surface area available for filtering) 

Generally, the more concentrated the dialysate, the better the clearance. However, there are consequences in using a dialysate that is highly concentrated, such as damaging the peritoneal membrane in a high dextrose concentration or exposing the patient's blood to a hypertonic solution, which can lead to crenation of the red blood cells in hemodialysis. 

Medications can be given during dialysis treatments to mimic the kidney's functions related to hormone stimulation and to protect against infection. 

• Erythropoietin stimulating agents (ESAs) and iron are given to stimulate the production of healthy red blood cells. 
• Vitamin D is given to help the body absorb calcium. 
• Protein supplements can be given to boost the body's albumin to aid the body in shifting fluid to the intravascular space for removal. 
• Heparin is given to prevent coagulation and clotting. 
• Thrombolytics can be given to break up clots in a catheter. 
• IV antibiotics can be given to fight infections.  
• Vaccinations are given to protect against Hepatitis B, influenza, pneumonia, and now Covid-19.  
• Binders are often ordered for patients to take when eating to help limit their phosphorus absorption, which leads to better calcium absorption.

Dialysis Settings  

Both types of dialysis treatments can occur almost anywhere. Hemodialysis is generally performed in hospitals, outpatient clinics, or at a patient's home. Electricity is required to operate the dialysis and RO machines and there needs to be a water source to make the RO water. Depending on the machine that is used, the patient may also travel with their supplies and conduct their treatments wherever they go.

Peritoneal dialysis can be performed in the same places; however, electricity is not needed as there is a manual version of the procedure that only requires gravity. No matter the type of dialysis that is chosen or the setting that is chosen to complete it, infection control is of the utmost importance. Supplies are sterile when packaged and must remain clean when opened so as not to introduce microbes into the bloodstream or peritoneum. Aseptic technique must be utilized to minimize the risk of infection and/or cross-contamination.  

Incenter Hemodialysis 

The most common setting for dialysis in the U.S. is the outpatient hemodialysis clinic. There are thousands of them in the United States. Direct patient care is provided by patient care technicians (PCTs) and licensed practical nurses (LPNs) who operate under the license of a registered nurse. The clinics are typically run by a nurse manager or facility administrator and a medical director.  

Other staff present in the clinic could include: 

• Other attending physicians 
• Nurse practitioners 
• Physician assistants 
• Social workers 
• Dietitians 
• Biomedical staff 
• Administrative personnel 

These facilities vary in size, depending on how many stations they are licensed to have and operate. Each patient station has a specialized reclining chair or bed and a dialysis machine where the treatments are performed. The average hemodialysis treatment duration is between 3 ½ to 4 ½ hours, with constant monitoring by the direct patient care staff. Patients enter the facility, are weighed in and assessed by an RN, and then proceed to their station for their dialysis treatment and medications. Once the treatment is completed, the patient is again assessed by the RN, weighed out, and discharged back home.  

Most patients have treatments ordered three times per week on either a Monday, Wednesday, Friday or Tuesday, Thursday, Saturday schedule, but some patients can be ordered more frequent treatments because of fluid balance issues. The number and frequency of treatments can depend on the patients’ renal failure stage. A clinic typically runs two shifts of patients and then closes for the day. Some clinics offer a third shift or a nocturnal shift in which patients dialyze overnight. 

Many patients prefer to dialyze in this setting because of opportunities for socialization and a feeling of security in having a health care provider run the treatment. This modality has the strictest dietary and fluid limitations for the patients because it is only a three times-per-week treatment. Also, there is less schedule flexibility because of the daily operating schedule of the facility and the staff's availability. 

Home Hemodialysis 

Hemodialysis can also be performed at home, even while the patient sleeps. The patient and care partner are trained to cannulate (insert needles) and facilitate the treatments. In the U.S., patients usually use either a NxStage machine or a Fresenius 2008K at home machine (often referred to as a Baby K because it is slightly smaller than the larger K machines utilized in the outpatient clinics and hospitals).

Both machines have the same function and operate the same way. The patients receive a recliner for their home just like the incenter patients use. There are weekly or biweekly shipments of supplies, depending on how much storage space the patient has available. The supplies can be delivered virtually anywhere, which allows the patients to be able to travel easily without skipping their dialysis treatments. 

Transplant 

13.5% of dialysis patients in the U.S. (about 100,000 people) are currently listed as actively awaiting a kidney transplant (1). A kidney transplant is a surgical procedure in which the ESRD patient, with Renal Failure Stage 5, receives a kidney from either a living or deceased donor. This allows the patient to almost return to the life they lived prior to their renal failure. Unless there is a compelling reason to remove the old, nonfunctioning kidney, it is left in the patient, and the new kidney is placed in the abdomen. A kidney from a living donor usually works better and lasts longer than a cadaver kidney. 

There is an extensive workup required by the transplant center that the candidate must undergo to be listed on the transplant list, including a complete medical and psychosocial assessment. This is to mitigate the risk that the transplant will be unsuccessful and ensure that the kidney will be given to a person who is likely to take care of themselves after the transplant surgery.

Any abnormalities should be treated prior to the transplant; risks to the transplant's success should be addressed, such as weight loss or smoking cessation. Often, a patient must start or continue dialysis while awaiting a kidney transplant. Labs are collected and evaluated monthly, either by the dialysis clinic or transplant center, to maintain the patient on the list. The patient must be free of cancer and other serious illnesses that could jeopardize the kidney. The transplant center also assesses the transplant candidate's compliance with their treatment prescription. A pattern of noncompliance prior to receiving a transplant could be a risk factor for an unsuccessful transplant.  

A patient's financial situation is assessed as it could become an obstacle for some. Beginning in 1972, Medicare began providing coverage for ESRD patients who have sufficient work history and contributions to the Medicare fund. These recipients can claim Medicare benefits regardless of age. Medicare covers about 80% of the cost of the transplant and related expenses, however, after a kidney transplant, the number of years of coverage is limited, and the patient may no longer be eligible to receive these benefits as long as the new kidney is working until they meet the suitable age for Medicare benefits without ESRD (1). 

While on the active transplant list, the patient is responsible for making sure that they can be reached anytime and anywhere by the transplant center. They also must ensure that they can arrive at the transplant center in minimal time if called with a kidney match. 

Palliative Care 

A diagnosis of Renal Failure Stage 5 does not mean end-of-life unless the patient decides that it is. For the patients who decide that they do not want to begin or continue dialysis treatments or a transplant, palliative care keeps them comfortable during the end-of-life process. The patient experiences a smoother transition when treatment goals, substitute decision-makers, and power of attorney have been decided in advance.

Patients that do choose to have dialysis treatments can also benefit from palliative care treatments that are received concurrently with their dialysis treatments. Many patients experience multiple symptoms during and after dialysis, which include fatigue, pruritus, diarrhea, and restless leg syndrome. Palliative care can help with the management of these symptoms.

Pros and Cons of Treatment Modalities 

Every patient diagnosed with chronic kidney disease must choose which treatment option(s) works best for them. Open and honest communication between the patient, family, caregivers, and the interdisciplinary team must take place to ensure that the patient is being treated in accordance with their wishes.

Patients must be seen monthly, if not more frequently, by their nephrologist to ensure that they are enrolled in the safest and effective modality to help them reach their optimal health. Each patient is unique, and their needs can vary depending on their health, preferences, and lifestyle. Each treatment option discussed has its pros and cons, which must be weighed when trying to decide which to choose. 

As written above, the most prevalent option in the U.S. is the outpatient hemodialysis clinic. Many patients choose this option because they feel safer with the presence of direct patient care staff that provide and oversee their treatments. They also enjoy the social connections that are made in the clinic with other patients and staff. Cons of this modality include:  

• Having to travel back and forth to the clinic at least three days per week 
• Being at the mercy of the dialysis clinic's schedule, which can be inflexible due to the number of patients admitted, clinic's operating schedule, and staff scheduling 
• Being vulnerable to the staff's level of competency and professionalism 
• An increased risk of infection due to the invasive nature of the procedure, exposure to microbes, and proximity to other patients 
• Cardiac complications due to the increased workload on the heart.  

The most preferred hemodialysis access is the AV fistula, followed by the AV graft, so a fear of needles would be another consideration of this modality, no matter the setting. 

Performing hemodialysis treatments at home is another option that is growing in popularity. There are three ways in which a patient can perform hemodialysis at home. Conventional "home hemo" is performed 3-4 days per week for 3-4 hours each time, just as with incenter. Short daily home hemo is completed 5-7 days per week for about 2 hours each time. Nocturnal home hemo treatments are done slowly (6-8 hours) while the patient sleeps. Treatments are either prescribed 6 nights per week or every other day. (1) 

Any dialysis treatment to be done at home requires an assessment of the home by a dialysis nurse. The nurse assesses if the patient will be able to aseptically perform their treatments in their home environment. A clean space in the home must be devoted to the patient's dialysis treatments.

If pets or plants are present, they must be kept out of the room to prevent infection risks. The patient and/or care partner is trained by the nurse to maintain aseptic technique when handling their supplies, equipment and initiating and terminating their treatment. They are also taught how to properly disinfect their equipment and household items utilized in the treatment.  

The positive benefits associated with home hemo are being able to perform dialysis treatments in the comfort of the patient's own home; flexible scheduling, fewer trips to the dialysis clinic, and in the case of the conventional and nocturnal options, slightly more liberal diet and fluid allowance since treatments are performed more frequently.

Patients are shown to thrive more when dialyzing at home. Generally, the more dialysis a patient receives, the more waste removal and balancing of electrolytes occurs; thus, these patients usually feel better and have a better quality of life. Patients tend to sleep better, with decreased restless leg syndrome and neuropathy. And they have more energy day to day. Less medication is required to control blood pressure, anemia, and phosphorus levels. Morbidity and mortality rates are also decreased (1). 

The cons of home hemodialysis treatments include: 

• The physical space that the machine and supplies take up in the patient's home 
• The absence of trained staff to perform the treatments 
• Shifting the responsibility solely to the patient or care partner 
• There could be fear of putting in one's own needles. 
• In the case of nocturnal hemodialysis, having a care partner is nonnegotiable for safety reasons. 

The training time to safely perform treatments at home requires a commitment of weeks to months, depending on the progress of the patient and/or care partner. They will not be released home until the training nurse is confident that the treatments can be performed safely at home. This may mean a leave of absence from work or school to meet the training time requirements. 

Peritoneal dialysis is the treatment that most nephrologists and nurses would choose if they were diagnosed with renal failure. It is considered to be gentler on the body than hemodialysis. Because it is performed every day, patients report feeling better and having a more liberal diet and fluid restrictions. There are no needles used in PD, and patients feel more comfortable dialyzing in their home environment, at whatever time they choose. Cons include: 

• Having to dialyze daily 
• Potential complications such as peritonitis 
• Drain pain (pain in the abdomen when fluid is being emptied by the catheter pulling the fluid out) 
• Intolerance of fluid in the belly during the dwell period 
• Dialyzing in the home environment requires ample storage space for the supplies that are needed. Delivery of supplies can be more frequent if the patient has limited storage space. 

The benefit of a kidney transplant is that the patient no longer has to undergo dialysis treatment, and so their lives can almost return to life as it was prior to their kidney failure. It is important to remember that a kidney transplant is not a cure. If the same circumstances exist that caused renal failure in the first place, the transplanted kidney may not last long. While eating and drinking can return to normal, it is advised that the patient follow a heart-healthy diet (1). Even if the patient does everything perfectly, there is always a chance that the new kidney will fail eventually, and the patient may find themselves having to decide which treatment option is best for them again. It is the hope that the kidney will last for years; however, many patients require more than one transplant in their lifetime. Kidney transplant recipients must take anti-rejection medications so that their body's immune system does not attack the new kidney. These medications can be expensive, have side effects, and can leave the patient susceptible to illness. In any surgery, there are inherent risks, and the kidney transplant surgery is no different.

Future State of Patients with ESRD 

1 in 3 adults is at risk for kidney disease (1). Currently, there is a huge urgency to increase transplants and make home therapies the prevalent modality for ESRD patients. There will not be enough chairs available in clinics to treat the potential pipeline of dialysis patients incenter. 

In 2019, President Trump addressed this issue and set 3 goals in an executive order:  

1. Prioritize a reduction of new ESRD cases by 25% in 10 years. 
2. Increase home therapy and/or transplant utilization to 80% by 2025. 
3. Double kidneys available for transplant by 2030.  

In the meantime, there is ongoing research to strengthen the fight against kidney disease. Through the National Kidney Foundation, there are grants and clinical trials underway to find a cure or better treatment options for the CKD population. Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines were established about 20 years ago to improve the diagnosis and treatment of kidney disease, and that has had profound effects in the lives of thousands of patients.  

Conclusion 

In conclusion, there is a lot to know about renal failure and the renal failure stages. This course provided an overview of chronic renal failure stages, causes, treatments, and outcomes. Though a lot has been learned through research and advocacy efforts, there is much more to be learned about how to slow this disease's prevalence and progression. 

Managing Conflict in a Nurse Leader Role

Introduction

Every organization will experience some degree of conflict at one time or another; healthcare is no exception. Uniquely, conflict can create serious issues regarding care delivery, patient safety, and patient outcomes. Other end results include cost impacts related to staff turnover in an already understaffed industry, regulatory fines, and even law suits due to errors; more serious results include psychological impacts on staff members. Characteristics, leadership styles, and the ability to handle conflict are vital to those fulfilling a nurse leader role. This educational course will help you to identify conflict, the components of conflict, reasons for conflict in healthcare as well as management strategies. Conflict management is not just the responsibility of one in a nurse leader role, but that of all team members, especially the registered nurse. "Conflict management helps foster stronger relationships horizontally between employees and vertically between employees and management by increasing awareness and understanding of different points of view and educating staff about how to avoid conflict in the first place" (1). 

Conflict 

Conflict is defined as an internal discord resulting from differences in ideas, values, or feelings between two or more parties. Evoking feelings of hostility, anxiety, and stress can be extremely disruptive to a unit or department's functioning. Another definition includes a disagreement through which the parties involved perceive a threat to their needs, interests, or concerns. Workplace conflicts in the healthcare environment tend to be far more complicated because they often involve ongoing, complex relationships that are based on emotion (1). 

Stages

Conflict has different stages, and for those fulfilling a nurse leader role, it is useful to become aware of these so you can develop stage-appropriate interventions. The stages of conflict include: 

• Latent: At this point, the participants are not even aware of the conflict. Differences exist; perhaps, something has happened. 
• Perceived: The participants have become aware of the conflict. 
• Felt: The stress and anxiety of the conflict are being felt. 
• Manifest: The conflict is open and observable. 
• Aftermath: The result of the conflict, which can be either negative or positive (2).  

The earlier the conflict is identified, the less time it may remain open. Preserving the safe and efficient functionality of the unit or department is one reason why early management is important.

Types

Healthcare and nursing present a unique environment, which can lead to different types of conflict. We all bring our values, ideas, thoughts, and education to this work environment.  The types of conflict most identified within the healthcare environment includes a nurse-to-nurse, nurse-to-outside departments, physician-to-nurse, and generational differences. Let’s break these down.  

Nurse-to-Nurse Conflict (Horizontal)

Nurses often work closely with other teams where there are different values, opinions, and ages; the environment can be emotionally charged. Oftentimes, conflict resolution skills are not taught in school. The conflict can be staff nurse-to-staff nurse or staff nurse-to-nurse leader. 

 Nurse-to-Outside Department (Interdisciplinary)

The nurse is often the leader of the interdisciplinary team. Again, this is an area where there is little if any conflict training. Each department tends to be loyal and supportive of their department when there is conflict. This type of conflict often is between the physician and nurse.   

Generational Differences

Unprecedented, the nursing workforce currently spans five different generations, each with different characteristics and work ethics. The different generations are described as follows: 

• Silent Generation: Born between 1922 – 1946. They are known as traditionalists.  Characteristics include respect for authority, hardworking, and sacrifice for work. This generation values loyalty and may delay retirement (3). 
• Baby Boomers: Born between 1947 – 1964. Characteristics include a belief that workers need to pay their dues. Oftentimes, the generation includes workaholics with traditional learning styles; rewards are expected for hard work (3). 
• Generation X: Born between 1965 – 1977. Characteristics include independence, self-reliance, and skepticism of authority. This generation tends to work better with flexibility (3). 
• Millennials (or Generation Y): Born between 1978 – 1991. Characteristics include team-oriented, technological, entrepreneurial, and the need for quick feedback. This generation wants to be coached and mentored (3).  
• Generation Z born after 1991. Although there is a lot we do not know yet about this generation, some of their characteristics include tech-savviness, being a self-starter, and pragmatic (3).  

Most of you are familiar with the phrase, "nurses eat their young." This is not a new concept, and despite the valiant efforts of organizations, this type of conflict has persisted. Usually, horizontal, nurse-to-nurse bullying with the older generations makes the new generations feel unwelcome, incapable, and unwilling to help when asked (4). However, it is important to note that the opposite is also a workplace issue. Younger, newer nurses are perceived as faster, able to utilize technology at lightning speed, and can cope better with variable shifts than older nurses. This gives the newer nurse a perceived power gradient over the older nurse and can be used as a form of bullying (4). 

Leadership 

Qualities 

Leadership requires many qualities; this should begin with relational intelligence.  Relational intelligence revolves around the idea of how you positively navigate through relationships with others. For one fulfilling a nurse leader role, this skill is absolutely necessary for your team’s success (5). Although nurse leaders are looked to when there is conflict, it is not solely their responsibility to resolve it, but that of all team members (5).  

Other qualities needed include integrity, critical thinking, communication, dedication, self-awareness, and professionalism. There is not an adequate or inadequate strategy to deal with conflict. However, early detection of conflict and adoption of the most effective conflict resolution behavior is essential in organizations as soon as possible (6). How these qualities are learned is an important issue. Many nurse leaders have little training to prepare them for the responsibility of conflict resolution. However, unresolved or unmanaged conflict may end with work disruption, poor work performance, tardiness, absenteeism, low staff morale, low staff productivity, increased psychological distress, and burnout (6). It can affect the productivity of the organization. 

Another important quality to develop at all levels of nursing especially for those in a nurse leader role is communication skills; including both how the message is sent, and how the message is received. Listening skills is a vital aspect of nursing and oftentimes, we are moving at a fast pace and already thinking about an answer before the person finishes speaking; with that being said, misunderstandings are easy to cause but not always so easy to fix.  

For nurse leaders, it is important to recognize and engage in managing conflict. Many times, there are barriers, including time constraints, fear of retaliation, and fear of exclusion. Of course, no one wants conflict, and sometimes this results in an attempt to soothe and prematurely place a solution. Those in the nurse leader role must learn how to positively engage in conflict resolution and stay engaged to promote collaboration and effective care. Being successful includes dialogue, coaching, the identification of the potential conflict, education, and training. 

Styles 

Leadership styles are the set of management thoughts and behaviors related to your personality, communication preferences, strengths, weaknesses, and values (7). Styles can develop over time or be influenced by the organization. The most common styles leadership styles are (7):  

• Democratic: The democratic style is team-oriented and involves openness in conversations and management. Although the leader has the final say, the opinions of others are valued; this style tends to be successful. 
• Autocratic: The autocratic style is the opposite of the democratic style; where the leader has their way and does not consider or consult team members. This style does not tend to be successful.   
• Transformational: The transformational style has defined goals, a clear direction, and looks at the big picture. Those in the leadership role share their vision with staff and thinks outside the traditional path; this style tends to be successful. 
• Coaching: The coaching style is similar to the transformational style and involves mentoring to bring the team closer. Having the nurse leader walk the direct care nurse through a variety of conversations to resolve a dispute or disagreement provides the opportunity for alternative solutions to be considered; this also tends to be a successful style.  
• Lassiez-Faire: The lassiez-faire style is casual and laid back; meaning there is little leadership. In fact, authority is turned over to the staff. Generally, this style does not want to deal with conflict and is not successful.  
• Situational: The situational style is used when instant change is needed for safety or regulatory reasons. Often the style is used to respond to an event and is not always accepted by staff. 

While developing a style, it is important to allow for the expression of multiple viewpoints and how to build better relationships (8). The absentee leader does little to communicate, mentor, and plan. The incompetent leader has little involvement in planning and faces serious moral issues. If the environment is not maintained and cohesive, job satisfaction and performance can be impacted negatively.   

Regulatory Issues and Conflict 

In 2008, The Joint Commission released a sentinel event alert addressing disruptive behaviors and provided recommendations as to how organizations should address their relational issues and conflicts. The defined behaviors recognized more of the physician-to-nurse issues, but placed all disruptive behavior on its radar. Identified behaviors included: verbal outbursts, physical threats, uncooperative attitudes, and cooperation refusal (i.e. not taking pages or answering calls). Other behaviors include condescending language and refusing to complete tasks (9). Disruptive behaviors often go unreported, and therefore unaddressed for several reasons. Whether that is fear of retaliation and the stigma associated with "blowing the whistle" on a colleague, or a general reluctance to confront an intimidator, it all contributes to underreporting of intimidating and/or disruptive behavior (9). Part of the sentinel event has given guidance on what defines behaviors and required resolutions. Organizations are required within this mandate to develop a specific ‘Code of Conduct’ that outlines acceptable and disruptive behaviors as well as the processes managing these behaviors. Additionally, organizations are to develop policies and procedures that clearly state zero tolerance and provide training and education; this includes physicians.    

Regarding nurse-to-nurse (horizontal) disruptive behavior, the American Nurses Association (ANA) Code of Ethics for Nurses includes interpretive statements outlining that nurses are required to "create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect," (10). Similarly, nurses must be afforded the same level of respect and dignity as others; thus, the nursing profession should no longer tolerate violence of any kind from any source. As someone who is fulfilling a nurse leader role, it is essential that you refer to the ANA Code of Ethics for Nurses when managing conflict within the workplace.  

Nurse Leader Role: Conflict Strategy 

As one involved in a nurse leader role, in order to effectively eliminate or manage conflict, it cannot be ignored. Engagement must be an ongoing process. To be successful, one must learn to not only engage in conflict, but remain engaged to promote collaboration and effective care coordination (11). The earlier conflict is identified, the better, as dysfunctional patterns can take place and can potentially define the culture of the department.   

Common Strategies (11):

• Safe Space: It is important that staff feel they are meeting in a safe space, and that there is privacy and support. 
• Coaching: Coaching can be in either group or individual settings. Coaching sessions are confidential (unless otherwise agreed upon), must follow a consistent format, and include a written summary of the session. 
• Facilitation: There is usually a defined agenda. You will need someone neutral who can see past the fireworks or walls of silence and assist the group with arriving at the core problems or issues. 
• Dialogue: The importance is to have a discussion that addresses the issue and clears the air; avoid saying “always” and “never.” Nursing leaders and direct care nurses need to engage in dialogues that address conflict and conflict management behavior as a first step in creating a healthy work environment (1).  
• Collaborative: Collaborative works with the group problem solving together.  
• Storytelling: Storytelling works with traditional stories that are told to help move from personal experiences to broader, helping to negotiate group conflict.  
• Mediation: Can be formal or informal. 
• Education and training: Nurses need to be educated on conflict and conflict management strategies that address and effectively resolve conflict. Learning conflict management strategies empowers nurses to resolve conflict early and influence the work environment in which they deliver patient care. "The training should not be limited to the handling of interpersonal conflicts; it should include all types of conflict commonly encountered in the healthcare setting. Additionally, individuals who have a propensity for managing conflict well should be identified and developed” (1). Education and training should also include communication skills.  

"Leaders can change the climate in the workplace and promote better collaboration among workers by interrupting a group's dysfunctional behavior patterns," (12). Adding the skills of self-awareness and emotional skills helps to bring a team together. Relational ethics emphasizes the importance of mutually respectful relationships. People work to improve their awareness of how their choices and actions help shape their conversations and social interactions. The relational approach addresses conflict as it unfolds – just as a relationship evolves and unfolds over time. It incorporates the essential qualities that form the core of human relationships. It is hard to imagine an approach to conflict that excludes consideration of integrity, respect, identity, compassion, humility, shame, trust, fear, hope, pride, acceptance. Love, joy, and other human dynamics are at the heart of most conflicts (12). 

Emotional and social intelligence are defined as "skills that enable an individual to understand the impact of emotions on behavior and thinking, to regulate emotions and behavior, to understand the importance of emotions in others, and to understand social interactions and engage in adaptive ways with others in social situations," (12).  

An Example of Failed Conflict Management from a Nurse Leader Role 

This story is based on a true example experienced by the author; names and locations have been changed. 

Looking back to the 1980s, the nursing profession was struggling with shortages and how to produce more nurses quickly. During this time, the entry-level for nursing was either a three-year hospital diploma program or a BSN. Many times, nurses were made managers without experience. In a small California Neonatal Intensive Care Unit (NICU) in the mid-1980s, this unit called ‘neonatal’ was staffed by only nurses. The original manager was a diploma graduate who had newborn experience for many years, but not in the NICU specialty; however, she was beloved. Over the next two years, there were four different managers who did not work out. To be honest, the staff did not want it to work out but were weary and wanted some leadership.  The next nurse manager, Mary, was a BSN graduate with little NICU experience and no management experience; she immediately made several changes that completely divided the staff. During this time, one staff nurse, Jane, was undergoing some extreme personal issues.  She and Jane absolutely did not get along. Jane had been a nurse in this unit for over ten years and was an excellent clinician, but she had become a nightmare to work with. She was mean to her colleagues and had become a bully. Additionally, she would never help others, except for the few in her circle.  

Human Resources offered no help.  

The morale was dismal, and staff began to leave. During this time, to the horror of the staff, Jane committed suicide. The note she left cited personal issues, but also included the horrible work relationship she had with Mary as part of her reason. Staff felt responsible and guilty; they completely divided, making work a nightmare. Few resources were given to help with the situation, and many staff members left within the year; perhaps, an experienced manager may have been able to diffuse the situation differently.  

This is an extreme example but one that illustrates what can happen without leadership at both the unit and senior management level. In situations of conflict, the most powerful weapon we have is control over our own behavior.  If there is a single contributory factor that reduces and eliminates negative conflict, it is trust. Our ability to trust each other greatly impacts our working lives, family interactions, and achievement of personal and organizational goals. To create trust, it is necessary to avoid aggressive behaviors and at the same time develop supportive behaviors where people are respected for what they are or what they believe in and are treated equally without bias or prejudice. If a conflict develops at any level, it should be resolved with mutual benefit in mind (12).   

Conclusion 

Those with a nurse leader role have large responsibilities. They need to understand the definitions of conflict and how to manage it as soon as possible. They need to acknowledge the responsibilities of conflict resolution. Part of this responsibility is understanding the type of conflict, leadership qualities and styles, regulatory issues, and the ramifications of poor management. These ramifications can result in serious medical errors, patient safety concerns, poor patient outcomes, and psychological manifestations for staff.  

Not every nurse is a leader, but part of their role should understand conflict and conflict management. "Nursing professionals must use constructive conflict management approaches rather than destructive conflict management approaches when dealing with conflict situations. It is necessary to avoid aggressive behaviors and at the same time develop supportive behaviors where people are respected for what they are or what they believe in and are treated equally without bias or prejudice," (14). 

Nursing Interventions for Acute Pain Management

Introduction to Nursing Interventions for Acute Pain Management 

Pain is one of the most common reasons why people seek care in a hospital, and it is one of the most distressing symptoms of hospitalized patients. It is also directly linked to a patient’s satisfaction with their care: people are more likely to report being unhappy with their care if they had unrelieved pain during their stay.  

Most importantly, it is our job as nurses and healthcare providers to relieve the pain and suffering of the people in our care. There are legitimate concerns about the overuse and addictive nature of opioid pain relievers, and thankfully there are many alternative options. These non-opioid nursing interventions for acute pain management include non-opioid pain relievers, complementary techniques, and non-medication strategies. Nurses must regularly assess pain and collaborate with both the patient and provider to ensure that timely access to adequate pain relief is a priority of their care.  

This course will discuss the pathophysiology of acute pain, the classification of different types of pain, strategies for a comprehensive pain assessment, guidelines for treatment, and the different types of nursing interventions for acute pain management. 

Prevalence of Acute Pain  

Acute pain is a major problem for hospitalized patients and has been identified as a priority in the provision of quality and effective care. In addition, pain management has been identified by the Quality and Safety Education for Nurses (QSEN) project for nurses as a core competency under Patient-Centered Care (1). This is important because if not properly treated, pain can cause anxiety, depression, reduced healing, fatigue, non-compliance with treatment, and longer hospital stays (2). Pain is also costly in other ways: causing decreased productivity, income, and quality of life.  

Despite knowing the potential consequences of poor pain relief and having multiple modalities available as nursing interventions for acute pain, many patients are still inadequately managed for pain during hospitalization. A 2016 study of hospitalized patients in the UK found that between 38-84% of patients experienced pain, while 9-36% of patients experienced severe pain (3). In their R3 report published in 2017, the Joint Commission also acknowledges that under-treatment of pain still occurs in the hospital setting (4). This is because many barriers still exist that prevent patients from being treated appropriately for their pain. These potential barriers include (5): 

• Lack of knowledge or skills about nursing interventions for acute pain management 
• Heavy nursing workload or lack of time 
• Provider concerns about causing tolerance or addiction 
• Patient fears of side effects or addiction 
• Insufficient provider orders or time to premedicate patients before painful procedures 
• Providers focus on treating pathophysiology, rather than managing pain or other symptoms 

While all healthcare providers should aim to reduce a patient's pain, nurses are in the unique position to make a difference with individual patients, as well as system-wide pain management protocols.

Pathophysiology of Pain  

There is no set definition of pain, but it is commonly defined as an unpleasant experience, usually related to underlying tissue damage or injury. Pain is a subjective experience and one that very much depends on the person experiencing it. What one person experiences as pain, another person may as a minor discomfort, and another may consider intolerable. It is a complex sensation, the experience of which involves the interaction of three different systems:  

Sensory/Discriminative System 

The actual sensation of and reaction to pain through sensory and afferent nerves, spinal cord, and brain stem. This system causes the body to try and remove itself from the source of the pain. 

Motivational/Affective System 

A person's learned approach/avoidance behavior concerning pain, which occurs through the interaction of the brain stem, the reticular formation, and the limbic system. 

Cognitive/Evaluative System 

A person's learned behavior towards the pain experience, including appropriate (and inappropriate) pain behaviors. This learned behavior can block or increase a person's perception of their pain (6).

Anatomy and Physiology of Pain 

The nervous system is the primary body system responsible for the experience and interpretation of pain. The four main steps involved in this process are transduction, transmission, perception, and modulation. 

Step 1: Transduction 

The process of transduction begins with the afferent pathway, which is responsible for the actual detection of pain. Nociceptors are pain receptors found at the end of small afferent neurons that detect noxious stimuli, which include changes in temperature, pressure, and other mechanical or chemical stimuli. These nociceptors are found deep in the skin, muscles, tendons, and subcutaneous tissue and produce a large variety of different – and not all unpleasant – sensations. These can range from a cool breeze to a pleasant massage to cutting, crushing, and burning sensations. 

When these receptors are activated, they cause the release of chemical mediators, such as prostaglandins, substance P, serotonin, histamine, bradykinin, and potassium. Among other functions, these mediators generate an action potential by exchanging sodium and potassium at the cell membrane and activating and sensitizing the nociceptors to further stimulation by the stimuli.  

Step 2: Transmission 

The sensation travels along A- and C-nerve fibers to the dorsal horn of the spinal cord. A-nerve fibers are lightly myelinated (insulated in a protein and fatty acid substance known as myelin, which allows nerve impulses to travel faster), while C-nerve fibers are unmyelinated. The thicker the nerve fiber (and myelin coating), the quicker that nerve impulses will travel. The table below shows the different types of these fibers and the sensations they detect. Nerve impulses travel the fastest along the A-alpha and A-beta fibers and slowest along the A-delta and C-nerve fibers.

Once these nerve signals reach the spinal cord, excitatory neurotransmitters cross the synaptic cleft with the nociceptive dorsal horn neurons (NDHN). The neurotransmitters involved in this process include: 

• Substance P 
• Nitric oxide 
• Bradykinin 
• Glutamate 
• Adenosine triphosphate 

From here, the nerve impulse travels up the spinal cord to the thalamus, where they are sent to different areas in the brain for processing.  

Step 3: Perception  

Pain perception translates all this nerve activity into a conscious and actual experience for the patient. This is facilitated by several different areas of the brain and central nervous system. 

Reticular Formation Tracts 

Reticular formation tracts are responsible for the recognition of and response to pain. For example, if you step on a tack, the reticular formation track recognizes the painful stimulation and causes you to move your foot quickly. This area is also responsible for the alert and attentive feeling that comes with pain. 

Limbic System 

The limbic system also plays a key role in the unpleasant emotional and behavioral response to pain and actions taken to reduce it. 

Thalamus 

The thalamus acts as a switchboard of sorts, helping to direct the pain signal to the different locations in the brain. Some parts of the thalamus also direct the motor, behavioral, and emotional responses that come with the presence of painful stimuli.  

Somatosensory Cortex 

The somatosensory cortex comprises two distinct regions in the parietal lobe of the brain that are responsible for receiving and processing sensory information from all over the body. This region receives information about painful stimuli and identifies the location, intensity, and type of pain. It also connects the current pain sensation with previous experiences with pain. 

Step 4: Modulation 

Modulation is the final step in the pain pathway. This process is the changing of pain impulse transmission in the spinal cord and is due to the descending modulatory pain pathways (DMPP). Endogenous hormones and substances are found within this pathway and help to either block pain signal transmission or increase it. Inhibitory neurotransmitters help to block the transmission of pain nerve impulses to relieve pain and include: 

• Acetylcholine 
• Oxytocin 
• Serotonin 
• Gamma-aminobutyric acid (GABA) 
• Norepinephrine (noradrenalin) 
• Neurotensin 
• Endogenous opioids, such as enkephalins and endorphins 

Excitatory neurotransmitters increase the transmission of pain to the brain and are usually responsible for the increased mental alertness and cognition associated with a painful event.  

The Gate Control Theory is one of the most familiar theories of pain modulation. Under this theory, there are a series of gates found throughout the spinal cord. When these gates are open, pain messages are able to get through to the central nervous system, making the pain feel worse. Factors like stress, tension, anxiety, boredom, and lack of physical activity can all help to open those gates and worsen pain sensations.  

On the other hand, when those gates are closed, fewer pain messages get through to the central nervous system, reducing the pain experience. Factors that help to close the gates include feeling relaxed, regular exercise, distraction, certain medications, and other types of stimulation (such as massage, heat, ice, or acupuncture). This theory is often used to explain why non-medication nursing interventions for acute pain can be so effective.

Classification of Pain  

Pain can be classified based on its duration, location, quality, and intensity. Understanding these different types of pain can help the medical and nursing team plan appropriate nursing interventions for acute pain management. The figure below shows the organization and classification of these different types of pain.  

Duration of Pain 

One of the most common and important distinctions of pain is its duration. There are two classifications of pain based on duration: acute and chronic.  

Acute 

Acute pain is short-term pain that lasts less than six months. It is usually associated with a specific insult or injury, such as a broken leg, a ruptured appendix, or even childbirth. In most cases, once the cause is addressed and treated, the pain subsides. Acute pain is often described as sharp, stabbing, or burning. There are many effective nursing interventions for acute pain. 

Chronic 

Chronic pain, however, is far more complex. Chronic pain is pain that has lasted longer than 6 months and is not usually associated with a specific cause or injury. Headaches, fibromyalgia, and arthritis are all examples of this type of pain. Chronic pain can be described as sharp or intense, but it can also be described as dull, aching, or burning. In addition, chronic pain often has a psychological or emotional component, causing anxiety, insomnia, depression, and a decrease in a person's ability to perform everyday tasks. This type of pain is much more difficult to treat and can severely interfere with a patient's quality of life. 

Location 

Pain can also be classified based upon the location where the pain is occurring. Both acute and chronic pain can be classified by any of these categories.  

Visceral Pain 

Visceral pain arises from the internal organs in the abdomen and pelvis, such as the intestines, female reproductive organs, kidneys, and liver. This type of pain is often described as diffuse, and it is often difficult to isolate where it is actually coming from. One reason for this is the phenomenon of referred pain, where the pain is actually experienced in a location different from the actual injury. Think about having left arm and shoulder pain during a heart attack.  

While the internal organs are mostly immune from injuries like lacerations or burning (short of a catastrophic injury), they are more likely to cause pain by inflammation, ischemia (death of tissue), and stretch (like overdistended intestines). Visceral pain is often described as pressure, dull, throbbing, or aching.  

Somatic Pain 

Somatic pain, on the other hand, is pain that is experienced in the skin, muscles, bones, and joints. While visceral pain is diffuse, somatic pain is usually well-localized and easy to determine where it is coming from. It is usually described as sharp, stabbing, aching, or burning. Somatic pain can result from an injury, such as a papercut, or an illness, such as arthritis or bone cancer.  

Somatic pain can be further categorized as deep or superficial, depending on where the injury occurs. 

Deep Pain 

Deep somatic pain comes from structures deep within the body. Think of bones, muscles, tendons, and joints. 

Superficial Pain 

Superficial somatic pain comes from structures closer to the surface of the body, like the skin and mucus membranes.

Pathophysiology 

The last main way to classify pain is based upon its cause or pathophysiology. There are three types of pain in this category: nociceptic, neuropathic, and psychogenic.  

Nociceptic Pain 

Nociceptic pain comes from an injury to the body tissues and is the type of pain that most people are familiar with. It can be acute, chronic, visceral, or deep pain. It covers many kinds of injuries or illnesses, from the simple paper cut or stubbing a toe to arthritis or cancer pain.  

Nociceptic pain is usually responsive to changes in the environment: shifting position, applying ice or a heat pack, or elevating the injured site.  

Neuropathic Pain 

Neuropathic pain arises from damage to the neurons in the peripheral or central nervous system itself. Familiar with the tingling associated with hitting your funny bone? That's neuropathy: you've hit and temporarily injured the large nerve that runs through the elbow. Other common causes of neuropathies include multiple sclerosis, diabetic neuropathy, and even phantom limb pain.  

Unfortunately, neuropathic pain doesn't respond well to changes in the environment and is more likely to develop into chronic pain. Damaged neurons or nervous tissue don't heal quickly or easily. 

Psychogenic Pain 

Psychogenic pain is pain for which no underlying cause can be found and is attributed to psychological factors. It is no longer an official diagnosis and the term is not frequently used anymore, simply because we have a greater understanding of neuropathic and chronic pain disorders. The correct term is Persistent Somatoform Pain Disorder (PSPD), which is defined by the ICD-10 as:  

The predominant complaint is of persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences. The result is usually a marked increase in support and attention, either personal or medical. Pain presumed to be of psychogenic origin occurring during the course of depressive disorders or schizophrenia should not be included here (8). 

However, the ICD-10 is being phased out and replaced by the ICD-11 in early 2022, which no longer acknowledges Persistent Somatoform Pain Disorder. Instead, this type of pain is referred to as Bodily Distress Disorder, and defined as: 

Bodily distress disorder is characterized by the presence of bodily symptoms that are distressing to the individual and excessive attention directed toward the symptoms, which may be manifest by repeated contact with health care providers. If another health condition is causing or contributing to the symptoms, the degree of attention is clearly excessive in relation to its nature and progression. Excessive attention is not alleviated by appropriate clinical examination and investigations and appropriate reassurance. Bodily symptoms are persistent, being present on most days for at least several months. Typically, bodily distress disorder involves multiple bodily symptoms that may vary over time. Occasionally there is a single symptom—usually pain or fatigue—that is associated with the other features of the disorder. The symptoms and associated distress and preoccupation have at least some impact on the individual's functioning (e.g. strain in relationships, less effective academic or occupational functioning, abandonment of specific leisure activities). (9) 

Despite this changing definition, we do know that depression, anxiety, and other psychological problems can interact with pain, particularly chronic pain. Depression (anxiety, etc.) can worsen pain, and ongoing pain can significantly worsen associated psychological symptoms. As nurses, we should be mindful of and sensitive to these types of issues. 

Performing a Pain Assessment 

One of the most important nursing interventions for acute pain management is regular assessment of the patient's pain and the effectiveness of their pain management plan.  

There are two main components of a pain assessment: health history/interview and a physical exam.  

Health History and Interview 

Assuming that you are working with an established patient, you don't need to complete a full history or patient interview, but you should touch upon the relevant clinical factors about their pain. If this is a new admission or a new patient, you will need to perform the comprehensive initial history and assessment first.  

The PQRSTU mnemonic can help you remember all the different points you should hit during the interview to assess the characteristics of their pain. The table below shows the important questions that you should ask about a patient's pain.

Pain Scales 

Pain scales are useful tools that the nurse can use to assess and rate a patient's pain. There are several different scales that can be used in different clinical situations, and it is up to the nurse's judgment to determine which is the most appropriate one to use.  

Number Rating Scale 

This is the most common pain scale, and the one that most people are familiar with. It is appropriate for adults (or older children) who are alert, oriented, and responsive. Ask the patient to rate their pain on a scale from one to ten, with one being no pain and ten being the worst pain they've ever had. 

Wong-Baker FACES 

This pain scale is very commonly used for children aged three and older. The scale uses six pictures of faces varying from a face without pain to a face with a lot of pain. To use it, the child is asked to pick which face represents how they are feeling.  

FLACC 

The FLACC scale is used for young children from ages 0-2 years of age. It stands for Face, Legs, Activity, Cry, and Consolability. The nurse assesses each of these characteristics and assigns a score from zero to two. These scores are added together for a total score between zero and ten. The higher the number, the higher the patient's pain is assumed to be. (10) 

CRIES 

The CRIES scale is also used for young infants who are greater than or equal to 38 weeks of gestational age. This scale is similar to the FLACC scale in that the nurse evaluates the infant based on five characteristics, assigning a score of zero to ten. The scores are totaled, where a score greater than 6 indicates the need for analgesia. The characteristics used by this scale are the presence of high-pitched cry, the requirement of oxygen to maintain oxygen saturation above 95%, increased blood pressure and pulse, facial expression, and sleeplessness. (11) 

CPOT 

The CPOT (Critical Care Pain Observation Tool) was developed to be used in critically ill patients who may not be able to verbalize their own pain. It is similar to the CRIES and FLACC scales: four different criteria are assessed on a scale from zero to two, with a maximum score (indicating the most pain) of eight. The domains used in this scale include facial expression, body movements, muscle tension, and compliance with mechanical ventilation (in intubated patients) or vocalization (in non-intubated patients) (12). 

Please note that this is not a comprehensive list of all available pain scales. You should defer to your institutional policies when appropriate. 

The patient should be assessed frequently, especially if they are having pain or receiving pain medication. The nurse should also ask about the presence of associated signs and symptoms: insomnia, nausea, vomiting, shortness of breath, itching, etc. Make sure to evaluate the effectiveness of the nursing interventions for acute pain by reassessing the pain level after administering analgesia or other non-pharmacological interventions.  

The nurse must always remember that pain is what the patient says it is, regardless of their body language. If the patient states that their pain is a level 7, but is laughing and hanging out with family members, the nurse must document and act as if the pain level is a 7.

Physical Exam 

The physical exam should also be abbreviated and limited to what is actually relevant to the patient's pain, if appropriate. Make sure to get a set of vital signs and then examine the area that is causing pain.  

• Look for redness/swelling/warmth of the skin. 
• If the pain is related to a recent surgical procedure, check out the surgical wound and surrounding tissue.  
• Palpate gently, if safe and appropriate, to determine where the pain might be coming from. 
• If the pain is in a joint or muscle, perform gentle range of motion exercises to see what movements trigger the pain. 

If the pain is new, make sure to notify the provider in case it signals a change in status.

Non-Pharmacological Nursing Interventions for Acute Pain 

For patients with mild pain, non-pharmacological nursing interventions for acute pain can sometimes be very effective. They can also work well in conjunction with pain medications and other nursing interventions for acute pain.  

Acupressure 

Acupressure is a traditional Chinese modality that has been used for generations. By applying pressure to certain points on the body, the belief is that you can help to restore the flow of energy and balance throughout the body. Though acupressure is mostly considered safe, there are some points that should not be stimulated in pregnant women as they might stimulate labor. Press firmly and use an up-and-down or circular movement for several minutes. Make sure to stop or ease up pressure if the motion causes worsening pain or discomfort.  

Acupuncture 

Acupuncture is also a traditional Chinese modality that has recently gained popularity in the United States and other Western countries. It is believed that the insertion of small needles into the skin at specific points helps to stimulate endorphin release and trigger other pain-relieving changes in the brain. The needles are left in place for 10 to 30 minutes at a time so the patient can rest. The needles are then removed, and the treatment is repeated several times. Acupuncture is quite safe but should only be performed by a licensed practitioner. Research about effectiveness is mixed, but it may be worth a try for patients with complicated or chronic pain.  

Aromatherapy 

The use of essential oils is an ancient therapeutic modality that dates back hundreds of years and has gained popularity in recent years. It involves the absorption of essential oils through the skin or olfactory system to reduce pain, nausea, muscle tension, anxiety, and depression. Studies on the effectiveness of aromatherapy vary. One review of nine randomized controlled trials was split nearly 50/50: Five studies found that aromatherapy could be effective for postoperative pain, and four found no statistical difference associated with aromatherapy use (13).  

Distraction 

Distraction is quite an effective and simple nursing intervention for acute pain. Remember the gate theory of pain? Distraction is one of those factors that can help to close the pain gates, which reduces the experience of pain. In fact, the presence of strong sensory input can help a person be unaware of their pain.  

Music 

Music therapy works similarly to distraction. It gives the person something else to focus on apart from their discomfort. When using this nursing intervention for acute pain, the nurse must remember to let the patient select the type of music that they prefer to listen to.  

Heat 

The application of a heating pad or hot water bottle may stimulate the closure of the pain gates, reducing pain and discomfort. It may also stimulate the release of endorphins, which also reduce pain. The patient should be reminded to not lie directly on the heat source due to the risk of burns. If the nurse applies the heating pad, the site should be reassessed frequently to reduce the possibility of injury. 

Cold

Applying a cold or ice pack works similarly. Cold can relieve inflammation and pain, and promotes healing. It works best over inflamed joints. Like applying heat, the nurse must carefully and frequently assess the patient's skin to ensure that injury does not occur and remove the ice if the patient feels numbness, aching, or burning. Ice can be particularly effective before a needle puncture or injection. 

Guided Imagery 

This nursing intervention for acute pain involves the nurse sitting close to the patient and helping them to create a calming and relaxing image in their mind. The nurse speaks quietly, helping the patient to concentrate on the image and relax.  

Massage 

Massage is a great technique to soothe tense muscles and promote relaxation and sleep. This touch stimulation may trigger the release of endorphins or help to close the pain gates responsible for pain transmission.  

Biofeedback 

Biofeedback is a type of behavioral therapy that is taught to the patient over several weeks. It allows the patient to visualize physiological responses and eventually learn to control them. This technique is particularly beneficial for people with headaches or muscle tension.  

Transcutaneous Electrical Nerve Stimulation (TENS) 

This technique uses a special device that produces a mild electrical current through the skin via external electrodes. The machine produces a buzzing or tingling sensation, the intensity of which can be controlled by the patient in response to the pain they are feeling. This treatment does require a physician's order, and the nurse should help the patient with hair removal if needed before applying the electrodes.

Analgesics as Nursing Interventions for Acute Pain 

For patients with pain that does not respond to non-pharmacological measures, analgesics may be more effective. There are three types of pain medication: 

1. Non-steroidal anti-inflammatory drugs (NSAIDs) and non-opioids 
2. Opioids or narcotics 
3. Adjuvants 

Non-Opioid Analgesics 

Non-opioid analgesics can be used to treat mild to moderate pain and are often combined with opioid pain relievers to enhance their effectiveness. The two main types of drugs in this category are cyclooxygenase inhibitors and acetaminophen.  

Cyclooxygenase Inhibitors 

Cyclooxygenase inhibitors are mostly made up of nonsteroidal anti-inflammatory drugs and aspirin. Cyclooxygenase, or COX, is an enzyme in the pathway to synthesize prostaglandin, a key inflammatory hormone-like substance, from arachidonic acid. When produced, prostaglandins have several different effects on their target organs and are known to contribute to nociceptic pain.  

There are two types of COX enzymes: COX-1 and COX-2. COX-1 is found primarily on the gastric mucosa, kidneys, and blood vessels. Inhibition of this enzyme is believed to contribute to renal toxicity and gastrointestinal effects. COX-2 enzymes are activated by the processes causing pain, fever, and inflammation.  

Selective COX-2 inhibitors were introduced as an alternative to non-selective COX-1/COX-2 inhibitors with the goal of reducing the gastric side effects linked to COX-1 inhibition. However, the drugs were quickly linked with some potentially serious cardiovascular safety concerns, including myocardial infarction, cerebrovascular accident, and other thromboembolic diseases (14). Most of these medications were removed from the market, and the FDA recommended limiting the use of celecoxib (Celebrex), the remaining selective COX-2 inhibitor. 

Salicylates, like aspirin, are non-selective COX inhibitors, and they also inhibit platelet aggregation, block pain impulses, and may act on the hypothalamus to reduce fever and pain. The table below shows selected medications belonging to the COX inhibitor class of drugs.

Acetaminophen 

Acetaminophen is thought to inhibit prostaglandin synthesis in the central nervous system. It also reduces fever and inflammation, though less effectively than the COX inhibitors. It is used to treat mild to moderate pain and can also be used as a fever reducer. Dosing in children depends on their age and weight, but in adults, the dose is typically 650mg q4 hours or 1,000mg q6 hours, with the maximum daily dose to not exceed 4g per day. Patients with a history of liver failure should not exceed 2g per day. 

Acetaminophen is metabolized in the liver, but larger doses can cause the accumulation of a hepatotoxic metabolite that can build up and cause liver damage. Hepatotoxicity is the primary adverse effect of acetaminophen, and the nurse should carefully counsel patients to be aware of hidden sources of the drug in cold medicine and other combination products. 

Acetaminophen overdose is a medical emergency and is often fatal secondary to hepatotoxicity. There are four phases of acetaminophen overdose: 

Phase 1 – Occurs within the first 2 to 24 hours after ingestion. 

The patient experiences symptoms such as nausea, vomiting, sweating, abdominal pain, and diarrhea. 

Phase 2 – Occurs 24 to 72 hours after ingestion. 

The patient may be feeling better, though right upper abdominal pain often persists. Serum liver enzymes, bilirubin, and prothrombin time begin to rise. 

Phase 3 – Occurs 72 to 96 hours after ingestion. 

Symptoms begin to reappear, including nausea/vomiting, jaundice, confusion, and coma. Even more dramatic rises in liver enzymes and other markers will be present.  

Phase 4 – Occurs 6 to 7 days after ingestion. 

Liver enzymes begin to trend back towards normal and hepatic damage may begin to resolve. However, depending on the amount of acetaminophen ingested, the treatment, and the extent of liver damage that occurs, full hepatic failure and death is possible.

The treatment for acetaminophen overdose includes gastric lavage, administration of activated charcoal, and acetylcysteine every 4 hours (started within the first 8 hours after ingestion) for 18 doses. Acetylcysteine interferes with the formation of hepatotoxic metabolites. In addition to administering medication and providing supportive care, the nurse will need to follow plasma acetaminophen levels.  

Opioid Pain Management  

Opioid pain relievers are a nursing intervention for acute pain that is usually reserved for cases of severe pain, such as cancer or post-surgical pain, or moderate pain that is not well-controlled with other types of drugs. This class of medication acts directly on receptors in the central nervous system in a few different ways: they block transmission of nociception from the peripheral nerves to the spinal cord, change the activity of the limbic system in the brain, and modulate the descending inhibitory pathways in the spinal column to prevent transmission of pain signals.  

There are three types of opioid receptors: mu, kappa, and delta, and drugs are classified based on their response at these receptors.  

• Pure Agonists bind directly to mu receptors to relieve pain 
• Partial Agonists work similarly to pure agonists but don't produce the same full response as pure agonists. As the dosage gets higher, the analgesic effect will not increase, but the potential for side effects does.  
• Mixed Agonists-Antagonists act as an agonist to produce analgesia at the kappa receptors but as an antagonist at the mu receptors.  
• Antagonists bind to receptors and competitively block other opioids from binding there.  

Morphine sulfate is the prototype opioid prescribed for pain and the drug against which the other opioids are compared. It is the drug of choice for cancer patients and is often used for other types of moderate to severe pain. In addition to producing analgesia, morphine has several other clinically useful effects, including reduction of the emotional response to pain, suppression of the cough reflex, reduction of cardiac workload, and reduction of anxiety. Because of this, morphine is an effective nursing intervention for acute pain management. 

In addition to morphine, there are many other options for opioid pain relievers. The table below shows some common drugs in this class of medication.

Opioid medications do carry the risk of some serious side effects, which the nurse must monitor for. Side effects include: 

• Constipation 
• Itching 
• Respiratory depression 
• Vertigo/lightheadedness 
• Confusion 
• Nausea/vomiting 
• Hypotension 

Due to their similar nature, many of the opioids produce similar effects in varying degrees. However, opioid antagonists are the exception and cause very different side effects, which can include: 

• Nausea/vomiting 
• Hypertension 
• Dizziness 
• Abdominal pain 
• Insomnia 
• Weakness 
• Headache 
• Muscle pain 

There is also a risk of allergy, which can occur with any of the major opioid drugs, including morphine. The nurse must be especially careful of this risk and other adverse effects when administering opioids to an opioid-naïve patient.

Adjunct Analgesics 

Adjunct, or adjuvant drugs are the final type of medications that are used for analgesia. These drugs are often combined with analgesics to enhance pain relief. Sometimes, these drugs are used on their own to manage specific types of pain. There are many different types of adjuvants, depending on the patient's needs and clinical situation.  

Corticosteroids 

Corticosteroids are primarily used to manage acute and chronic cancer pain, pain due to spinal compression, and pain affecting the musculoskeletal system. Though the exact mechanism is unknown, corticosteroids are known to reduce swelling, inflammation, and edema. However, corticosteroids do cause some serious side effects, including hyperglycemia, increased susceptibility to infection, reduced immune system function, and suppression of adrenal function. Dexamethasone, prednisone, and methylprednisolone are the three most prescribed corticosteroids. Corticosteroid injections are one of the most common nursing interventions for acute pain management of arthritis and joint pain. 

Antidepressants 

A class of antidepressants, known as tricyclic antidepressants (TCAs) can be used with opioid or non-opioid pain relievers to help relieve pain. They are most effective for neuropathic pain and may work by increasing the levels of serotonin and norepinephrine in the synaptic cleft, preventing the transmission of pain signals. Doses for TCAs tend to be lower when used to treat pain than the dose used to manage depression. The most common side effects are weight gain, loss of sexual desire, dry mouth, orthostatic hypotension, and urinary retention. 

Antiepileptic Drugs 

Antiepileptic or antiseizure drugs affect the central nervous system in several different ways that can reduce neuropathic pain. They modulate amino acids and neurotransmitters in a way that reduces the transmission of pain signals between the periphery and central nervous system. These drugs tend to be used for chronic pain disorders, such as diabetic neuropathy and fibromyalgia. 

Antihistamines 

Some antihistamines, particularly hydroxyzine, have been found to have analgesic, anxiolytic, and sedative properties that can be useful in patients with acute or chronic pain. 

Local Anesthetics 

Local anesthetics are a great option for well-localized pain, usually in the skin or superficial structures. Topical EMLA creams work well to minimize the pain due to venipuncture, intravenous line insertion, or other simple procedures. Lidocaine or prilocaine can be injected into the tissue to help with pain associated with invasive procedures, while patches can be used to manage post-herpetic lesions and neuropathies. 

Alpha-2 Adrenergic Agonists 

Alpha-2 adrenergic agonists may decrease the release of peripheral norepinephrine and work on the central alpha-2 adrenergic receptors, both of which may help to reduce chronic headache and neuropathic pain. The drugs from this class that are most commonly prescribed for pain are clonidine (Catapres) and zanidine (Zanaflex). Side effects are mild, but may include dry mouth, orthostatic hypotension, and sedation.  

GABA Receptor Agonists 

More commonly known as muscle relaxants, GABA receptor agonists work best on neuropathic pain and muscle spasms. These drugs block the transmission of pain impulses and can decrease spasticity. 

It may take time and trial and error to find a regimen that works. The nurse's role in the assessment and evaluation of different nursing interventions for acute pain plays a crucial role in helping patients be as comfortable as possible. Most importantly, the nurse must advocate for patients who are struggling with pain management in the acute care setting.

Nursing Care of Patients Receiving Analgesia 

The nursing care plan is an invaluable tool when caring for a patient with acute pain. 

Assessment 

The nurse should start with an assessment, as described earlier in this module. For a new complaint of pain, the nurse should perform a more comprehensive assessment: determine if there are other symptoms, ask about the characteristics of their pain (PQRSTU questions), and perform a physical examination as needed.  

When caring for someone with known or expected pain, such as a post-surgical patient or after a broken ankle, the assessment could be more focused on the patient's current pain level. Even in these situations, you should continue to perform a complete assessment at least once per shift or according to your institutional policies.  

Make sure to report any new or unexpected complaints of pain or abnormal assessment findings to the provider and document them in the patient's chart.

Identifying Goals and Planning 

Based on the data identified during the assessment, the nurse will formulate goals and objectives to meet the patient's needs. The primary goal for someone with acute pain is relief from that pain, but there may be other goals that are also appropriate. They may include: 

• Improved physical mobility 
• Improved self-care 
• Decreased anxiety 
• Improved rest and sleep 
• Relief from analgesic side effects 

Creating a concept map can be a useful tool to help identify potential problem statements and the relationship between them, as pain is often interrelated with other health problems. 

Once goals are set, it is important to establish criteria against which the goals are measured. For example, you may identify that your patient will have a tolerable amount of pain upon discharge from the hospital. Your expected outcome may be that their pain level is consistently reported to be at a 4 or below.  

A comprehensive pain management plan must consider the entire interdisciplinary care team. Did the medical provider enter orders for pain management medications? Are they appropriate? (For example, a simple acetaminophen order after a surgical procedure may not be sufficient to deal with post-surgical pain). Is the physical therapist planning to start mobility exercises to get the patient back on their feet? Does the patient want to speak with a clergy member to help focus on spiritual health? Is a pain management specialist needed? Having the appropriate team members in place makes it more likely that the patient will achieve the planned outcomes. 

Implementation 

Depending on the extent of the patient's pain, you'll use your nursing judgment to select and implement nursing interventions for acute pain to address it. For mild pain, non-pharmacological measures may suffice; for severe pain, regular administration of opioid pain relievers (as ordered) may be the best course of action. For these patients, it is important to stick with the scheduled doses as closely as possible because the pain becomes much harder to treat once it becomes severe. 

Once you get their pain under control, it is important to begin teaching and involving the patient in their own care. Non-pharmacological comfort measures, wellness strategies, what to expect during the healing period are all important for the nurse to teach the patient. This information helps them become more capable of caring for themselves and promotes both physical and emotional healing. 

Evaluation 

Remember those expected outcome statements you created earlier in the planning stage? Well, now is when you'll put them to use by comparing those expected outcomes to the actual outcomes experienced by the patient. The best way to evaluate patient outcomes is to ask the patient themself. Key questions could include: 

• Are you still having pain? 
• What is your current pain level? 
• Have you experienced any side effects from your treatment? 
• How is your pain limiting your ability to function or perform your activities of daily living? 
• How is the treatment affecting your ability to perform activities of daily living? 
• Are you able to rest? 
• Are you able to eat comfortably? 
• And any other questions that could apply to the patient's specific problem statement.  

If the patient is unable to communicate, the family could also be a useful source of information. It is important for the nurse to explicitly ask these questions: some patients may not readily volunteer this information or be afraid to mention that they are still in pain or having side effects.  

In addition to speaking with the patient (or family) directly, objective data can also provide useful information, particularly about potential side effects, such as oversedation or respiratory depression. The nurse should collect data, such as: 

• Vital signs 
• Level of consciousness  
• Sedation 
• Oxygen saturation 

If the data suggests that the patient's pain is under control and there are no bothersome side effects, then great! In this situation, you'll continue to care for the patient according to the care plan and periodically evaluate the patient to ensure continued success.  

If, however, the patient is still experiencing unacceptable amounts of pain or having side effects (whether they are dangerous or just uncomfortable), then the nurse will need to immediately make changes to the plan. This may include administering a second dose of medication, speaking to the provider about adding additional pain medication, adding in alternative methods of pain management, or discontinuing a medication that is causing side effects, and obtaining an order for a different option.  

The nurse must continue to check in with the patient and provide reassurance and education about pain management. For example, if the patient complains that intravenous pain medication is not working 5 minutes after administration, the nurse should reassure the patient that the medication will have peak effectiveness at about 15 to 30 minutes, and they'll check back then. 

Nursing Interventions for Acute Pain in Special Populations  

Pain management strategies may need to be adjusted when caring for certain populations. Three populations that will always need special consideration are infants and children, older adults, and people with a history of addiction. 

Infants and Children 

Healthcare providers used to believe that infants did not feel pain and would not provide pain medication for certain invasive procedures, such as circumcision (15). Thankfully, we now know that this is not correct, or ethical for that matter, and medicate infants appropriately for painful procedures.  

While the process is the same as with adult patients, assessment tools and treatments must be modified to work for the developmental ages of the young kids they are caring for. Pain scales like the FACES, FLACC, and other scales specifically designed for use in pediatric patients should be used when assessing for pain, and the nurse can also rely on input from the parents. As discussed earlier, these scales rely on the nurse's own observations of the child to determine pain level, rather than asking the child to describe their pain, which they may not be able to do.  

Older children and adolescents are more likely to be able to verbalize their pain, making it more appropriate for the nurse to ask these kids directly. 

When administering pain medication to children, especially infants or very young children, the nurse must be extremely careful when drawing up and administering intravenous medications. Some institutions may even require that a second nurse be present to review the order, medication label, prepared medication, and patient ID band before a narcotic is administered. Frequent assessments should be performed to reduce the risk of serious adverse reactions. 

Older Adults 

Age-related changes can influence not only a patient's experience of pain but also how they metabolize pain medication. Older adults are more likely to suffer from multiple health conditions, which can make the assessment process a bit more confusing. This would require the nurse to perform a more in-depth or comprehensive assessment to determine the source and type of pain that a patient is experiencing. In addition, the nurse must take a careful medication history, as they are at higher risk for side effects and drug interactions. Other factors that could increase a person's risk for adverse effects include (16, 17): 

• Slowing of gastrointestinal function that slows the absorption rate of medications 
• Decreased renal or hepatic function 
• Decreased muscle, fat, and bone mass, which can lead to a higher risk of overdose 
• Poor nutrition causing decreased albumin levels, which may be an issue with protein-bound drugs 
• Thinner skin, which can impact absorption of topical medications  

The nurse must be careful to take these factors into account when administering narcotics or other pain medications to an older adult, and monitor them closely for side effects, adverse reactions, or drug interactions.  

In addition, older adults may be more likely to suffer from cognitive impairments, like Alzheimer's disease or dementia, which could impact their ability to accurately communicate or report their pain. Again, the nurse must be aware of these limitations and use the appropriate tools when working with these patients. 

Safety is a major concern for this population as well, particularly when administering medications that can increase drowsiness, dizziness, or the risk for falling. The nurse must be careful to check on the patient frequently, provide assistance with ambulation and place the call bell or other needed items within easy reach of the patient.

People with a History of Addiction 

People with a history of addiction pose a unique challenge to the implementation of pain management strategies. Patients in recovery are often concerned about the risk of relapse, whether they were addicted to opioids, alcohol, or other substances. And patients who are actively using may be concerned about withdrawal while being in the hospital, or even whether their pain will be taken seriously given their history.  

Healthcare providers may also struggle with providing opioids for patients with a history of substance abuse: they may be worried about diversion or overtreatment of pain or be distrustful of a patient's report of pain (18). 

When treating opioid-dependent patients with narcotics for pain, they will likely need higher doses to achieve pain relief. The nurse must carefully monitor patients in this situation due to the risk of toxicity. The addition of adjuvants may also be particularly useful in this population. (18).  

Patients who refuse opioid treatment due to the risk of relapse should be respected; this may mean finding other viable alternatives, such as non-opioid adjuvants, local or regional medications (like an epidural or spinal block), and non-pharmacological methods of pain relief. 

Conclusion 

Acute pain is a public health emergency. If left untreated, pain can lead to depression, anxiety, reduced healing, non-compliance with medical treatment, longer hospital stays, poor quality of life, and even reduced patient satisfaction with the healthcare facility. However, treating pain is not simple. It is a complex phenomenon that is experienced differently by everyone and influenced by many different factors. The nurse plays a vital role in identifying patients with unrelieved pain and advocating for better pain management strategies. 

A-fib and Stroke Risk

Introduction 

In 2023, stroke was the third leading cause of death in the United States after heart disease and cancer (1). As the life expectancy of the average American is approximately 76 years (2), an increasing number of people will live with comorbid health conditions compared with prior generations. One risk factor for stroke, apart from high blood pressure, is atrial fibrillation (also known as AFib or AF), which causes approximately 15% of strokes (3). Furthermore, people living with AFib are up to five times more likely to have a stroke than those without this condition (4). Nurses are critical providers of education and information to patients about their risk of AFib and stroke. They can elucidate a deadly subject to help patients reduce their risk of morbidity and mortality.

Pathophysiology of A-Fib and Stroke 

Atrial fibrillation, the most common arrhythmia, is due to rapid or disordered electrical signals in the heart's upper chambers (the atria). These impaired signals cause the atria to contract too chaotically and quickly, termed fibrillation. AFib causes blood to pool in the atria and increases the risk of blood clots, stroke, and heart disease (15).

Since AFib can exist in asymptomatic patients, estimates of its prevalence vary between 3 to 6 million Americans, with 12 million patients affected by the year 2030 (15). Worldwide, that number is estimated at over 33 million, or approximately 0.5% of the planet’s population, though numbers are likely far higher due to the underdiagnosing of the condition (15). Within the United States, AFib is directly linked to nearly 160,000 deaths per year (15, 16). Part of the reason AFib is so deadly is that 1 in 7 strokes are caused by this condition (16). 

Strokes occur when blood vessels in the brain rupture (hemorrhagic) or are blocked by a clot (ischemic). These incidents reduce blood flow to the brain, affecting the transport of essential elements like oxygen and nutrients for cell survival. Ischemic strokes occur in approximately 87% of cases (5).

Strokes originating from cardiac factors like AFib are known as cardioembolic; AFib is one of the major causes of cardioembolic strokes (6). Approximately 20-25% of ischemic strokes are cardioembolic in nature, their incidence increasing with age (6,8). A cardioembolic stroke occurs when blood clots or emboli travel from the heart or aorta and lodge in the cerebral circulation, causing ischemia. The risks of both AFib and stroke grow with age, and when the two conditions occur together, the results of the stroke are usually more severe and deadly (7, 8, 15).

While AFib is the highest contributor to cardioembolic stroke, other causes include sick sinus syndrome, structural diseases (like patent foramen ovale), valvular heart disease (such as infective endocarditis and valvular calcifications), septal or ventricular aneurysms, heart failure with reduced ejection fraction (HFREF), and myocardial infarction (MI) (6).

The course of illness depends on the severity of the stroke, pre-existing conditions, age, and any other complications present. Stroke generally presents rapidly and is a medical emergency. Most hospitals require patient education regarding stroke signs, symptoms, and management, such as when to call for EMS promptly.

Risk Factors for A-Fib and Stroke  

In general, the risk factors of cardioembolic stroke overlap with the general risk factors for stroke and include hypertension, diabetes mellitus, hyperlipidemia, cardiac diseases, and lifestyle factors. When educating patients with AFib about their risk of developing a stroke, numerous risk factors may be considered for teaching opportunities.

The following chart shows modifiable versus non-modifiable risk factors for AFib that lead to stroke (9,10,11,15):

The clinical team must work with the patients and families to identify the specific risk factors for each patient to reduce the risk of stroke.  

CHADs and Stroke Risk Scoring in A-Fib

Cardiologists and other clinicians use a scoring system to evaluate the stroke risk for those with atrial fibrillation. The CHADS₂ score was first published in 2001 and stands for Congestive heart failure, Hypertension, Age ≥75 years, and Stroke [Double weight] (12). Its goal is to predict the risk of stroke in patients with nonrheumatic AFib, and the score assists practitioners in making anticoagulation decisions (12).

Patients with high scores (>2) are at significant risk for stroke: They have a 5.9% annual risk with a score of 3 and as high as an 18.2% yearly risk for those with a score of 6 (12). The CHADS₂ did not include some additional risk factors for stroke. It was revised to the CHA₂DS₂-VASc, which contains three more risk factors: vascular diseases (e.g., coronary artery disease and aortic atherosclerosis), age (65-74 years old), and female sex (12). See tables below (12).

CHADS2 Score: Stroke Risk Assessment in Atrial Fibrillation: (4) 

CHADS2 Score and Corresponding Annual Stroke Risk: (4) 

CHA2DS2-VASc Score and Risk Criteria: (4) 

The American Heart Association/ American College of Cardiology/ Heart Rhythm Society (AHA/ACC/HRS) considers recommending oral anticoagulants to patients who have a CHA₂DS₂-VASc score of 1; at a score of 2 or higher; the recommendation is certain (14).

Case Study 

John, a 76-year-old Caucasian male patient, presents to the ED with cellulitis, intermittent heart palpitations, and shortness of breath. He has a history of diabetes mellitus and peripheral arterial disease with right-toe amputation. John quit smoking two years ago after a 60-pack-year history. His vital signs upon presentation are Temp: 38.1°C, HR 130, BP 150/88, RR 16, SpO₂ 94% on room air. His ECG rhythm reads atrial fibrillation, and he states he had never been told he had this condition before.

He did not want to come to the hospital, but his wife Sally insisted since his cellulitis wounds started spreading and weeping. Sally states that John has seemed tired and irritable lately and has endorsed some new-onset lightheadedness and shortness of breath at rest. He is treated with broad-spectrum IV antibiotics and moderate-rate fluid replacement. Cardiology was called to evaluate the AFib.

Oral Anticoagulants in A-Fib and Stroke Reduction 

Patients with AFib-induced stroke will have an anticoagulation regimen prescribed, likely along with other treatments, whether newer or traditional; anticoagulants on the market can be confusing and difficult for patients to differentiate when evaluating risks and benefits.

There are many oral anticoagulants available now, each with its unique properties. If warfarin (Coumadin) is used, the INR goal is generally around 2.5. However, there are situations, especially in the over-75 age group, where a lower INR goal of 2.0 is acceptable (13). Warfarin has an onset of 36-48 hours and can last in the system for 2-5 days, delaying any surgical procedures. Other oral anticoagulants for atrial fibrillation include apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa), and rivaroxaban (Xarelto). Each has a unique drug profile, half-life, and reversal agent.

For those unable to take anticoagulants and at risk for atrial thrombus (which can form in the left atrial appendage due to reduced contractility during AFib), a device called the Watchman has been created. It is a tent-like device surgically placed in the left atrial appendage to seal it off. Since more than 90% of stroke-causing clots come from the left atrial appendage in nonvalvular AFib, the Watchman aims to significantly reduce the risk of clots at that site (13). The outpouching of the sac is seen protruding from the left atrium in the diagram below (13).

Other treatments for AFib include lifestyle changes, medicines, surgery, and other procedures that aim to slow and restore the heart's regular rhythm and help prevent blood clots (15). In addition to the oral anticoagulants listed above, other medications may include beta-blockers (e.g., atenolol and metoprolol), calcium channel blockers (e.g., diltiazem and verapamil), and digoxin (15). If those treatments fail to treat the AFib effectively, other medications like amiodarone, dofetilide (Tikosyn), flecainide, procainamide, and others may be given, but they all require careful monitoring and dosing (15). Surgical and procedural treatments generally include electrical cardioversion, AV node ablation, and implanted pacemakers (15).

Ways to prevent the risk of stroke in people with AFib include, but are not limited to (15):

• Controlling blood pressure, cholesterol and triglyceride levels, and weight
• Taking all medications as prescribed and informing the primary care provider of any other drugs or herbal supplements used
• Eating a diet low in saturated and trans fats and high in fruits, vegetables, and whole grains
• Getting daily exercise of at least 30 minutes
• Quitting smoking and reducing alcohol and caffeine consumption
• Maintaining overall health by scheduling regular physical examinations
• Monitoring and treating other comorbidities
• Reporting all instances of dyspnea or angina immediately to a physician

Conclusion 

By the nature of atrial fibrillation, all patients with this condition have risk factors for stroke. The clinical team's responsibility is to assess each patient’s unique risk and then educate them in making decisions regarding stroke prevention. The risk of stroke from atrial fibrillation is a genuine concern as the population ages, and the number of patients diagnosed with these comorbid conditions is on the rise.

For patients presenting with ischemic stroke, the causal factors must be investigated to prevent stroke reoccurrence, which will likely include proper management of anticoagulants for atrial fibrillation. The nurse is responsible for providing information and resources for the patient to manage these conditions. As part of ongoing care, the nurse can also help reduce morbidity and mortality in patients who might otherwise succumb to AFib and stroke.

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