About

Mental Health Conditions Common to Veterans

This course covers mental health conditions common to veterans.  Mental health disorders are more common among veterans, and there are often issues with access to resources. After returning home, these veterans may be forced to cope with Depressive Disorder, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, Suicidal Ideation, and other conditions as a result of their service to their country. Nurses are on the front line of this mental health battle, and are in a unique position to advocate for the mental health of veterans, and their families. This course is mandated by the state of West Virginia for nursing professionals.  

Introduction   

The number of military service members, Veterans, and their families’ health needs are considerable and continue to grow. Mental health disorders are more common among Veterans, and there are often issues with access to resources. The invisible wounds of war are wreaking havoc on our Veterans and their families. After returning home, these Veterans may be forced to cope with Depressive Disorder, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, Suicidal Ideation, and other conditions as a result of their service to their country. These conditions affect not only the Veteran but also their spouses, children, and extended family members. The transition from life in combat to reality can be trying. Nurses are on the front line of this mental health battle and are in a unique position to advocate for the mental health of Veterans and their families.   

Mental Health Conditions Common to Veterans

According to an article from the American Psychological Association on Mental Health Needs of Veterans, Service Members and Their Families,

“One-third of returning Operating Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members have reported symptoms of mental health or cognitive problems (1).”

This is a staggering statistic that nurses and other healthcare providers must take into consideration when screening and treating this population of patients. The IOM reports that the most common challenges experienced by service members and their families include fearing for the safety of the service member, feeling anxious or overwhelmed by deployment challenges, worry about their children, and vulnerability to other stressors that may result throughout their time in the military (1).    

War has been around for centuries. Mental health conditions common to veterans is not a new concept.

“Previous wars have demonstrated that Veterans’ needs peak several decades after their war service, highlighting the necessity of managing current problems and planning future needs (1).”

Veterans are faced with a variety of mental health conditions, including but not limited to Generalized Anxiety Disorder, Depressive Disorder, Post-Traumatic-Stress-Disorder, Bipolar Disorder, and Suicidal Ideation.  

Health service psychologists provide the appropriate behavioral and mental services including assessment, screening, counseling, diagnosis, treatment, prevention, consultation, and supervision. These specialists work in conjunction with other health professionals such as nurses and nurse practitioners collaboratively to conduct screenings, research, and program evaluation.

Screening Veterans and Families for Mental Health Conditions Common to Veterans

A military background may not always be assessed by practitioners or voluntarily shared by Veteran patients during a health history. Screening Veterans and their family members is an extremely important step in shaping a plan of care and can help to identify appropriate steps and resources. It could be the difference in preventing harm, or even more paramount, saving a life.   

It is essential to ask questions and retrieve a thorough history of a patient, determining not only if they are a Veteran but also asking if they have a loved one that has served in the military. There may be a child of a deployed parent, for example, that may exhibit behavioral health problems that would not be understood without prior knowledge of the parent’s current military experience (1). 

When reviewing a Veteran’s medical history, the provider should consider asking specifically about their military experience. Recommended questions to accurately address mental health conditions common to veterans could include (2): 

Have you or has someone close to you served in the military?
What was your branch of service and rank?
What specific jobs did you perform?
How do you feel about how your time in the military has affected you?
Were you ever injured or hospitalized?
Were you ever a prisoner of war?
Are there any other things that you would like to tell me about your time in the military?

Screening military service members and their families will ensure that this population of patients has access to health care and support services that they need to help manage potential mental health concerns.

Here are some strategies to help screen a Veteran or their family member (2):   

• Convey a willingness to listen to their experiences if they want to discuss them in the future; 
  Respect their choice not to discuss their experiences in depth;
  Ensure you have enough time available to allow the patient to expand on their answers or conversation if needed.

Importance of Encouragement from Healthcare Providers

Military personnel are known for taking care of their bodies physically, but their mental health may “fall by the wayside”. Mental health is vital to an individual’s success in their role as a veteran.

“Talking to healthcare providers about concerns as a military member as well as seeking treatment cannot affect their career (8).”

This is an important note to make when discussing a Veteran’s health history. Untreated mental illness, however, can damage a career. Military policy states that, “care providers can only share certain information and only in those situations involving safety (8).”   

It is equally important to educate family members and friends on the importance of speaking with a healthcare professional if they are concerned about their loved one. Family members may not realize that their “recognized concerns” about a family veteran are actually symptoms of a mental illness. Nurses can encourage family members to listen patiently and offer encouragement to their loved one who is experiencing these symptoms, reminding them that it can happen to anyone and encourage them to seek help.  

Despite grim numbers, the Department of Veterans Affairs (VA) has doubled their efforts to address challenges that veterans face from mental health issues. They passed the MISSION ACT of 2018, which makes aggressive efforts by extending outreach to Veterans. The MISSION ACT (14):   

• Includes provisions that enhance the recruitment of clinicians;  
  
• Authorizes access to community urgent care providers; 
  
• Expands telehealth services.  
  

Generalized Anxiety Disorder

Individuals suffering from Generalized Anxiety Disorder (GAD) typically feel worried or anxious about various activities of their daily lives and sometimes have difficulty stopping these feelings. Their worry can range from minor things such as being on time or running errands to issues involving money, relationships with others, or their health. As a result of these feelings of worry, they often experience tension, as shown by irritability, muscle tension, sleeping difficulties, and tiredness.   

Anxiety can have both physical and emotional symptoms. The signs of stress include nausea, trouble sleeping, and irritability. The troubling fact is that these symptoms are often mistaken or related to other things, and anxiety disorders may be misdiagnosed or missed entirely.   

The Generalized Anxiety Disorder Assessment (GAD-7) is a seven-item scale used to measure the severity of GAD. Each item asks the person to rate the severity of their symptoms over the past two weeks. Responses include “not at all,” “several days,” “more than half the days,” “nearly every day.”, “several days,” “more than half the days,” and “nearly every day.” The score is calculated by assigning 0, 1, 2, and 3 to the response categories (3).   

Scores of 5, 10, and 15 are the cut-off for mild, moderate, and severe anxiety. As a healthcare provider, further evaluation is recommended when the score is ten or greater (3).   

Veterans often carry many responsibilities, including the people they serve, their loved ones, and their job responsibilities. They sometimes feel as if things are out of their control and unable to manage their thoughts. GAD is often diagnosed when a Veteran is unable to control their worrying for a timeframe of at least six months and has three or more symptoms. If left untreated, GAD can lead to depressive disorders and other challenges.   

Depressive Disorder

Depression causes sadness, loss of interest in activities that were previously enjoyed, withdrawal, and lack of energy. It can also cause people to have feelings of hopelessness and, potentially, thoughts of suicide (4). Some experts believe that stressful situations in life events, combined with genetics, can cause depression. According to the National Institute of Mental Health (NIMH),

“…Major depression is one of the most common mental health disorders in the United States. It also carries the heaviest burden of disability among mental behavior disorders estimating that 15.7 million adults 18 years or older had at least one major depressive episode within the last year (4).”  

The US Department of Veterans Affairs estimated that about 1 in 3 Veterans visiting primary care clinics had some symptoms of depression; 1 in 5 had serious symptoms suggesting the need for further evaluation and 1 in 8 had major depression requiring treatment (4).   

Researchers are currently developing models of family interventions and other forms of social support to help veterans recover from mood disorders, learning which risk factors will make a person more likely to suffer from depression and how they respond to a specific medication, and identifying and testing new drugs for depression (4).    

Oftentimes, the family of a veteran can give more insight into the severity of their loved one’s depression or other mood disorder than the patient themselves.   

The PHQ-9 is a scale that helps healthcare providers to monitor the severity of depression. It is a tool to help screen patients and can be very helpful in practice. The PHQ-9 score had a > 10 had a sensitivity of 88% and a specificity of 88% for major depression (5).   

Post-Traumatic Stress Disorder

Veterans who have served in the military and in combat have seen things that may have long-term effects on their mental health. These things can be horrific and traumatizing. These experiences can lead to Post-Traumatic Stress Disorder (PTSD).

“Post-Traumatic Stress Disorder is a serious potentially debilitating condition that can occur in people who have experienced or witnessed a natural disaster, serious accident, terrorist incident, sudden death of a loved one, war, violent personal assault, or other life-threatening events (16).”

According to the National Center for PTSD, the number of Veterans with PTSD varies by service area (9). Post-Traumatic Stress Disorder became a diagnosis from various historical events such as specific wars or the Holocaust. Research about Veterans returning from combat was very important in shaping the diagnosis of this mental health disorder (6).  

People respond to trauma in different ways. Some respond in feelings of concern, anger, or fear. Research has shown that people who have been through trauma or loss in the past may be more likely than others to be affected by new traumatic events that may happen in their lives (6).  On the anniversary of a traumatic event, some survivors may have more trouble with the increased stress that the memory of the day brings.

“About 11-20 of every 100 veterans (11-20%) who served in Operation Iraqi Freedom (OIF) and Enduring Freedom (OEF), experience PTSD in a given year (6).”   

There are other factors besides a direct combat situation that can contribute to PTSD. Sexual assault or sexual harassment is a prevalent, widespread occurrence in the military. This is known as Military Sexual Trauma or (MST). It can occur in both men and women during peacetime, training, or war. Among Veterans who use VA healthcare, 23 out of 100 women (23%) reported sexual assault when in the military; 55 out of 100 women (55%) and 38 out of 100 men (38%) have experienced sexual harassment while in the military (6). These are profound numbers that serve as hard evidence that the existence of the problem is actual and causes severe mental health problems.   

The main treatments for those with PTSD are specific short-term psychotherapies. Every person is different; therefore, a treatment that works for one person may not work for another. Some may need to try several treatments before finding one that works. They include cognitive behavioral therapy, person-centered therapy, and eye movement desensitization and reprocessing. Medications are often used in conjunction with one of the therapies above. The most common types of medicines prescribed to Veterans with PTSD are selective serotonin reuptake inhibitors (SSRIs). Benzodiazepines are sometimes used as well (15).  

Bipolar Disorder

Bipolar symptoms can change over time. In an “up” swing or manic episode, the person may feel extremely happy, energetic, on edge, or irritable. The person can also feel overly self-confident or willing to take dangerous risks. In a “down” swing, the person may feel depressed or hopeless (7). A person with bipolar disorder can experience “up” or “down” swings, and they can also feel themselves in between those experiences. They feel a constant roller coaster of emotions and often find it hard to cope with the continuous change.   

Signs of manic episodes associated with bipolar disorder may include (7):   

• Doing things they may later regret, such as big spending, engaging in a reckless activity such as sex, gambling, or heated arguments  
• Feeling as if their mind is racing  
• Appearing to be high even if no drugs have been consumed   
• Talking faster than usual   
• Taking dangerous risks or getting into unsafe situations   

Several effective treatments for this mental health disorder can allow patients to have a typical daily life. Treatments usually involve a medication regimen and counseling for the patient and the family.   

Counseling can help the patient and family members recognize early signs of ups and downs to establish steps to take to control the situations before they happen. The treatment should be tailored specifically to fit the needs of the patient. Some mood changes can still occur with treatment, so an ongoing relationship with a team of healthcare providers is the best option to cope. Bipolar disorder is a chronic condition requiring ongoing management (7).   

The Bipolar Spectrum Diagnostic Scale (BSDS) allows patients as well as providers to determine sensitivity and specificity in the detection of a wide range of presentations within the bipolar spectrum. The BSDS has two sections. The first section includes a series of 19 sentences that describe the main symptoms of bipolar disorders. Each sentence is linked to a blank space that can be checked by patients who decide that the statement is an accurate description of their feelings or behaviors. Each statement is assigned 1 point. The second portion asks the patient to select the degree to which the 19-item narrative includes their personal experience. There are four possibilities to choose from: “This story fits me very well, or almost perfectly” (6 pts); “This story fits me fairly well” (4 pts); “This story fits me to some degree, but not in most respects” (2 pts); and “This story doesn’t describe me at all” (0 pts) (9).  

Suicidal Ideation

Many Veterans do not show signs or an urge to harm themselves before doing so. Some may show signs of depression, anxiety, low self-esteem, or hopelessness (10). According to the American Addiction Center, “The suicide rate for Veterans is 1.5 times higher than that of the general population.” They also compared the rate of female veterans to non-veteran adult women, and the rate was 2.5 times higher in Veteran women (11). About 20 Veterans commit suicide every day, and nearly three-quarters are not under VA care. This number can be drastically impacted by the attentiveness of healthcare providers and the screening of patients (11).   

Information for Family, Friends, and Caregivers  

What are the signs that someone may be considering suicide?  

• Seeming sad, depressed, anxious, or agitated  
• Sleeping all the time or not at all  
• Not caring about their appearance or what happens to them   
• Withdrawal from friends, family, and society   
• Losing interest in hobbies or work   
• Expressing feelings of excessive guilt, failure, shame, or lack of purpose   

If a family member or friend of a Veteran expresses concern to you, you can help make a change as the healthcare provider.  It is important to educate them on what steps to take to save the life of their loved one.   

To connect with a Veterans Crisis Line responder anytime day or night:  

• Call 800-273-8255, then select 1.  
• Start a confidential chat.  
• Text 838255  

To speak with a VA coach:

• Call 888-823-7458, Monday through Friday, 8:00 a.m. to 8:00 p.m. EST.  

To get tips and resources for spouses, parents, and Veterans on mental health conditions common to veterans, visit the Coaching Into Care website.  

The Suicidal Ideation Attributes Scale (SIDAS) was designed to screen individuals for the presence of suicidal thoughts and to assess the severity of those thoughts. There are five items targeting elements of suicidal thoughts, including: frequency, controllability, closeness to attempt, level of distress associated with the thoughts, and impact on daily function. The responses are measured on a 10-point scale (11). 

Managing Loss Associated with Military

Losing a loved one is never an easy situation, even if one thinks they are prepared. Feelings of sadness, anger, grief, or anxiety after loss are normal parts of the process. Reactions to loss can vary by person and experience. For Veterans, grief may come from the loss of:   

• A military comrade who died in battle;  
  
• A bond that was had with fellow service members;  
  
• Identity as a member of the military;  
  
• Physical ability;  
  
• Mental health.  
  

“Some Veterans may also experience survivor guilt, which is a sense of remorse for having survived when others did not (12).”

Grief also causes those it strikes to react in various ways to different situations. Some Veterans experience traumatic grief following the sudden death of a family member or a friend after witnessing multiple casualties such as in a combat situation, natural disaster, or accident. Grief is a process. The military has an experienced notification process for informing military family members of loss with dignity and honor.   

As a healthcare provider, knowing your audience is very important. In dealing with veterans experiencing loss, or their families, who have experienced the loss of their loved one as a veteran, you must approach each situation with care. When the initial shock of loss begins to subside, many bereaved people pay tribute to their loved ones by finding a way to honor them (13). Engaging in this process is an excellent coping mechanism and can allow the person to give the loved one’s life continued meaning.   

For most people, acute grief begins to subside in the first 6 months after loss, but some people do not begin to recover from the loss. When this happens, it is known as complicated grief or “traumatic grief.” There are two important factors that put veterans and greater risk for complicated grief, and they are:

1. The sudden, violent nature of loss in a combat situation, and
2. The importance of cohesion in military closure (12).

Military bonds are extremely close, which can make loss much more devastating.   

There is currently no Veteran-specific treatment related to complicated grief. The treatment recommendations pull from existing research on this topic, which uses a Complicated Grief Tool to help manage painful and intrusive memories or thoughts of the loss process. This treatment also focuses on helping grieving individuals re-establish meaningful relationships.  It works to help them restore other functions important to everyday life, by overcoming the setbacks of mental health conditions common to veterans (12).  

Support Programs for Mental Health Conditions Common to Veterans

There are many support programs available to veterans and their families experiencing challenges after leaving the military. The VA has several resources listed on their website that help to address the stressors related to the experiences Veterans may face (18).  

Make the Connection
MakeTheConnection.net is a resource for veterans and their family members and friends who can explore information on life stressors and mental health symptoms. This resource has personal stories of Veterans on specific challenges they were faced with when transitioning from the service to civilian life, and how they addressed issues.   

Vet Centers
Vet Centers is another resource available that helps with Veterans and families related to readjustment counseling, including group, marital, and family counseling, as well as medical and benefits referrals. Please visit: VetCenter.va.gov

Veterans Crisis Line
The Veterans Crisis Line connects Veterans and active Service members in crisis as well as their family and friends with qualified responders through a confidential hotline, online chat, or text system. 24 hours a day, 7 days a week, 365 days a year.   

• Call 1-800-273-8255 and Press 1   
• Text 838255  

Women’s Veterans Call Center
This call centers provides VA services and resources to women Veterans and their families, for mental health conditions common to veterans, and beyond.   

• Call 1-855-VA-Women (1-855-829-6636)  

National Call Center for Homeless Veterans
This call center is for Veterans who are homeless or at risk of becoming homeless. The call center is also available to Veterans friends or family members, VA medical centers, VA partners, and community agencies.   

• Available 24/7 at 1-877-424-3838

Conclusion

Veterans risk everything for the sake of their country. Some return to civilian life with few difficulties, while others need a great amount of support from their families, friends, and healthcare providers. It is of great importance that Veterans themselves, their loved ones, and their providers learn to recognize signs and symptoms of mental health conditions, proper coping mechanisms, as well as interventions, to keep themselves and their families safe.  These necessary actions will allow them to have the best possible quality of life.  Anxiety, Depression, PTSD, and suicidal ideation should not be taken lightly. It is vital that friends, family members and healthcare providers work to identify risk factors and seek treatment accordingly, to give back to those who have willingly put their lives on the line for everyone around them.  In this course, you have learned about mental health conditions common to veterans, and how you can make a difference.

West Virginia Substance Abuse

Introduction   

Substance abuse is described as “a pattern of using a substance (drug) that causes significant problems or distress” (1). As of 2020, 37.309 million Americans were currently using illegal drugs (2). Medical professionals are on the front lines of recognizing, treating, and providing support to individuals who suffer from substance abuse. This West Virginia Substance Abuse course will walk you through the different types of substances abused, the prevalence of that abuse, the symptoms one experiences while using that substance, overdose symptoms, and how to counteract an overdose. You will also learn about substance abuse in adolescents and nurses and prevention methods currently being used to combat substance abuse in these populations.

Alcohol

Alcohol abuse is the second most common type of substance abuse, after tobacco use as the most common (3). While many individuals in the United States can drink alcohol in moderation and not considered abuse, there are some individuals whose drinking causes harm or distress. In the case of an alcohol use disorder, harm or distress is described as alcohol leading to health problems, or trouble while at home, work, school, or with law enforcement (3).   

This West Virginia Substance Abuse course will help you identify several signs and symptoms of alcohol use disorder. As health care providers, it is important to understand the signs and symptoms to properly help and treat those who are experiencing alcohol use disorder. Symptoms can range from mild to severe, depending on the number of symptoms experienced (5), and include: 

1. Unable to limit the amount of alcohol consumed 
2. Wanting to decrease the amount consumed, but being unsuccessful 
3. Spending a large amount of time obtaining alcohol, drinking alcohol, or recovering from alcohol use 
4. Having a strong craving or urge to drink alcohol 
5. Not completing major obligations at work, school, or home due to alcohol use 
6. Continuing to drink alcohol even though you know it is causing problems physically, at work, at home, or in relationships 
7. No participating in social activities or work-related functions to consume alcohol  
8. Developing a tolerance to alcohol so more is needed to elicit the same effect 
9. Experiencing symptoms of withdrawal, such as nausea, sweating, and shaking when you are not drinking
   

While the above signs and symptoms are typically ones that do not have a medical component attached, alcohol use disorder impacts nearly every organ and system in the body. This widespread impact can have a detrimental effect on an individual suffering from alcohol use disorder (4) such as: 

1. Neurologic
   – Ischemic stroke
   – Hemorrhagic stroke
2. Cardiac
   – Cardiomyopathy
   – Arrhythmias
   – Ischemic heart disease
   – Hypertension
3. Lung
   – Acute respiratory distress syndrome
   – Pneumonia
4. Liver
   – Steatosis
   – Steatohepatitis
   – Fibrosis
   – Cirrhosis
   – Alcohol-associated hepatitis
   – Liver cancer
5. Pancreas
   – Acute and chronic pancreatitis
6. Gastrointestinal
   – Gut leakiness
   – Microbial dysbiosis
   – Colorectal cancer

Clear patterns have emerged between alcohol use disorder and increased risk for certain types of cancers (4): 

1. Head and neck cancer
   – Oral cavity
   – Pharynx
   – Larynx
2. Esophageal Cancer
3. Liver Cancer
4. Breast
5. Colorectal Cancer
   

Knowing the effects of chronic alcohol use on the body is important in understanding the treatment methods that will be needed. Treatment options range from spiritual to medical, with many individuals utilizing more than one option (6).  

1. Detox and withdrawal
   – This treatment option is typically done in an inpatient setting. Treatment begins with detoxification, which leads to withdrawal symptoms. These symptoms can be medically managed, and occasionally require sedating medications. Detox and withdrawal generally take 2 to 7 days.
2. Psychological counseling
   – This treatment option will help the individual better understand their problem with alcohol and provide support on the psychological aspects of alcohol use disorder. This type of treatment can be done individually or in a group setting.
3. Oral medications
   – Disulfiram is a medication that helps to curb one’s want for alcohol. While the drug doesn’t remove the urge to drink, it will produce a physical reaction to consuming alcohol in the form of flushing, nausea, vomiting, and headaches.
   – Naltrexone is used to block the good feelings alcohol causes, which can aid in recovery.
   – Acamprosate is used to help curb cravings for alcohol and is generally used in combination with Naltrexone.
4. Injected medication
   – Vivitrol is the injected version of Naltrexone and is injected once a month. Injected medications may be easier, or more consistently used than oral medications.
5. Medical treatment
   – As we’ve learned, alcohol use disorder comes with a large amount of health concerns. These concerns typically require medical treatment in the form of medication, surgery, outpatient care, etc.
6. Spiritual practice
   – It has been shown that individuals involved in some type of spiritual practice find it easier to maintain recovery.

Case Study

A 35-year-old male is admitted to the medical surgical unit with acute abdominal pain a temperature of 99.7F. Upon examination and CT Scan findings, the provider diagnosed him with acute pancreatitis. During your assessment of the patient, you notice he appears anxious and is fidgeting a lot in bed. You also notice a strong alcohol odor on his breath.

• What can you ask the patient to further assess his alcohol use?
• Does your facility use a specific alcohol screening tool?
• What treatment plan do you anticipate the doctor will order?
• Will this patient require special monitoring?

One of the most widely used alcohol abuse screening tools is the CAGE screening tool. You can ask your patient the following questions. Each “Yes” answer is 1 point. A score of 2 or higher is significant for alcohol abuse.

1. Have you ever felt you ought to cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

If you suspect a patient may also be abusing illegal substances, there is a modified version of the tool called CAGE-AID. The scoring system is the same.

1. Have you ever felt you ought to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you ever felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

CIWA-AR

The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised or CIWA-AR is a common tool used in hospitalized patients with alcohol abuse like the one we discussed in the case study. The assessment scores obtained using this tool are intended to guide the treatment plan for alcohol withdrawal. The nurse will score the following categories:

• Nausea and Vomiting
• Tactile Disturbances
• Tremor
• Auditory Disturbances
• Paroxysmal Sweats
• Visual Disturbances
• Anxiety
• Headache, fullness in the head

Marijuana

Marijuana, also known as cannabis, weed, or pot, refers to the dried flowers, leaves, stems, and seeds of the cannabis plant. In one cannabis plant, there are over 100 compounds ranging from tetrahydrocannabinol (THC) to cannabidiol (CBD) (7). While THC and CBD have the same molecular structure, the difference in how the atoms are arranged accounts for the different effects on the body. THC is the main psychoactive compound in cannabis, which produces a high sensation, while CBD, although psychoactive, does not produce a high sensation (8). 

Marijuana is the most used federally illegal drug in the United States. In 2019, the CDC reported that 48.2 million, or ~18% of Americans have used marijuana at least once. There are several ways to use marijuana, including smoking in joints, blunts, or bongs, vaping via electronic vaporizing devices, mixing or infusing into foods or drinks, or inhaling oil concentrates (7).  

This West Virginia Substance Abuse course will help you identify the health risks associated with using marijuana, in any form. It is estimated that 3 in 10 people who use marijuana have marijuana use disorder (7).  

The risks include: 

Brain Health

Since marijuana is a psychoactive drug, the main effect is on brain function. Marijuana specifically affects the parts of the brain responsible for memory, learning, attention, decision-making, coordination, emotions, and reaction time.  

Heart Health 

Marijuana is known to make the heart beat faster, which can make blood pressure higher immediately after use. This can lead to an increased risk of stroke, heart disease, or vascular disease. 

Lung Health 

Inhaled marijuana can cause damage to lung tissues and small blood vessels, as well as scarring to the lung. More research is being done to understand the effects of secondhand marijuana smoke. 

Mental Health 

While the relationship is not fully understood, marijuana has been linked to social anxiety, depression, and schizophrenia. 

Unintentional Poisoning 

There is a greater risk for unintentional poisoning with edibles (marijuana baked or put into food or drinks) than with inhaled marijuana. This risk is because children can easily mistake food with marijuana in it. In some instances, emergency medical care has been required. 

The CDC reports that 37% of high school students in the United States have reported using marijuana. This use can come with impacts on their developing brains, resulting in (7): 

1. Difficulty thinking and problem-solving 
2. Problems with memory and learning 
3. Reduced coordination 
4. Difficulty maintaining attention 
5. Problems with school and social life 

Prescription Medicines

Prescription drug abuse is classified as the abuse of a prescription medication that is taken in a way not intended by the prescriber. This abuse can be by the person who the drug was initially prescribed for, or by someone taking another person’s prescription medication.

The National Center for Drug Abuse Statistics shows that 6% of Americans over the age of 12 abuse prescriptions in a year, and 12% of prescription drug abusers are addicted. This is perpetuated by 4 out of 5 pharmacy-filled prescriptions being opioids (10).  

This West Virginia Substance Abuse course will help you identify the three categories of prescription drugs: opioids, anti-anxiety medications/sedatives/hypnotics, and stimulants. Signs and symptoms of prescription drug abuse vary depending on the type of drug used (9).

Opioids are a type of medication that is used to treat pain. These medications usually contain oxycodone or hydrocodone. Opioids are the leading cause of drug overdose death, with 74.8% of drug overdose death being from Opioids (11).  The signs of symptoms of opioid drug abuse include (9): 

1. Constipation 
2. Nausea 
3. Feeling high 
4. Slowed breathing rate 
5. Drowsiness 
6. Confusion 
7. Poor coordination 
8. Increased dose needed for pain relief 
9. Worsening or increased sensitivity to pain with higher doses
   

Anti-anxiety medication, sedatives, and hypnotics are used to treat anxiety and sleep disorders. Some medications used for these disorders are alprazolam (Xanax), diazepam (Valium), and zolpidem (Ambien).  The signs and symptoms of drug abuse by these types of medications are (9): 

1. Drowsiness 
2. Confusion 
3. Unsteady walking 
4. Slurred speech 
5. Poor concentration 
6. Dizziness 
7. Problems with memory 
8. Slowed breathing
   

Stimulants are a type of medication used to treat attention deficit/hyperactivity disorder (ADHD) and certain sleep disorders. Some medications used to treat these disorders include methylphenidate (Ritalin, Concerta, and others), dextroamphetamine-amphetamine (Adderall XR, Mydayis), and dextroamphetamine (Dexedrine).  Signs and symptoms of drug abuse by these types of medications are (9): 

1. Increased alertness 
2. Feeling high 
3. Irregular heartbeat 
4. High blood pressure 
5. High body temperature 
6. Reduced appetite 
7. Insomnia 
8. Agitation 
9. Anxiety 
10. Paranoia 
    

Medical complications differ depending on the type of medication abused. Opioids can decrease respiratory rate with the potential for breathing to stop altogether. They can also cause a coma, and lead to death. Anti-anxiety/sedatives/hypnotics can cause memory problems, low blood pressure, and slowed breathing. Like opioids, they can also lead to coma or death. Abrupt withdrawal of these medications can lead to an overactive nervous system and seizures. Stimulants can increase the body’s temperature, produce heart problems, high blood pressure, seizures or tremors, hallucinations, aggressiveness, and paranoia (9).  

Opioids can be reversed with a medication called Naloxone. This medication works by binding to the opioid receptors, then reversing and blocking the effects of other opioids. It is used to restore an individual’s breathing and can be given through injection or nasal spray. If Naloxone is given outside of a medical facility, emergency personnel should be contacted immediately (18).

Naloxone Access

Depending on the state you live in, access to naloxone without a prescription may be available to you. It is recommended to have this on hand if you have a loved one that frequently uses opioid medications. When you obtain naloxone for a loved one, this is called Third Party Prescribing. This initiative was started to reduce the risk of death by opioid overdose.

SafeProject.Org offers a comprehensive list of resources and access rules for each state.

What are some ways that providers with prescriptive authority can mitigate the risks associated with opioid use?

• Ensuring that the patient meets the clinical criteria for the prescription.
• Screening for risk using an evidence-based tool before prescribing.
• Using a safe prescription drug monitoring program (PDMP).
• Completing continuing education on safe prescribing practices.
  • As of December 2022, the Drug Enforcement Administration set forth new requirements for all DEA-registered prescribers to complete 8 hours of continuing education on the treatment and management of opioid disorders and other substance use disorders.
• Discussing treatment goals and alternative pain management with the patient and/or caregiver.
• Include information about tapering off the medication if opioid therapy is discontinued.
• Follow up and monitor before refilling any controlled substance prescription.

If you are not an APRN with prescriptive authority but frequently care for patients that use opioid medications, it is important for you to conduct a thorough pain assessment and report to the provider if you feel that the patient is showing signs of addiction, is misusing the medication or appears too impaired while on it.

Commonly used pain assessment scales

• Wong-Baker Faces
• Numeric Rating Scale
• Visual Analog Scale
• FLACC
• Pain Assessment in Advanced Dementia Scale

Although policies may vary depending on your workplace, it is generally best practice to assess a patient’s pain level before administering pain medication and one hour after to assess its effectiveness.

Additionally, you can provide education to your patients on alternatives to opioids or complementary therapeutic options to help reduce the amount of opioid medication they use.

Pain management is a multidisciplinary approach, you can also reach out to other team members such as physical therapists, occupational therapy, etc. for recommendations.

The 2022 CDC Clinical Practice Guidelines recommends the following non-opioid pain management options whenever indicated:

• NSAIDS
• Acetaminophen
• Ice or Heat Therapy
• Elevating affected limb/extremity
• Rest
• Immobilizing affected limb/extremity
• Exercise and/or stretching.

Case Study

You are providing discharge teaching and instructions to a female patient that recently underwent gallbladder removal surgery and her husband. The patient will be going home with a prescription for oxycodone-acetaminophen 5/325 mg for acute pain management. During the teaching, the patient states, “I don’t think I will need to take this for more than 2-3 days” to which the husband replies “I can use whatever you don’t finish for my back pain”.

• What additional information will you need to provide based on this statement by the husband?
• What are some ways to safely dispose of controlled substances?

Case Study

A patient that was recently diagnosed with metastatic prostate cancer has been admitted to your unit due to a sequelae of complications. The doctor has ordered a patient-controlled analgesic or PCA pump for pain management. The patient has been more tired than usual and his family reports they have been pressing the PCA pump button for him.

• What education will you need to provide to the family?
• If the patient is unable to press the button themselves, are they still a good candidate for a PCA?

Methamphetamine

Methamphetamine is a highly addictive, man-made, central nervous system stimulant. This drug increases heart rate, body temperature, respiration, and blood pressure. It also enhances the user’s energy, attention, focus, pleasure, and excitement (12). It has commonly been referred to as meth, ice, speed, and crystal. Research has shown that 2.5 million Americans aged 12 or older reported using methamphetamine within the past year. 53% of those individuals met diagnostic criteria for methamphetamine use disorder, but less than 1 in 3 received substance use treatment within the past year (13).  

This West Virginia Substance Abuse course will help you identify the four ways methamphetamine can be used: smoking, swallowing (pill), snorting, or injecting the powder that has been dissolved in water or alcohol. While methamphetamine produces a high quickly, it also fades quickly. This produces what is called a “binge and crash” pattern of use. This type of use is where an individual will take the drug every few hours for several days at a time, resulting in a lack of food and sleep (14). 

There is a substantial amount of long-term health effects from methamphetamine use. Those who inject methamphetamine are at a higher risk of contracting infectious diseases like HIV and hepatitis C.  

Other long-term problems include (14): 

1. Extreme weight loss 
2. Severe dental problems 
3. Intense itching which can lead to skin sores and infection from scratching 
4. Anxiety 
5. Changes in brain structure and function
   – Changes have been noted to the brain’s dopamine system which has resulted in problems with coordination and verbal learning.
   – Severe changes have also been noted to the areas of the brain that deal with emotion and memory 
6. Confusion and memory loss 
7. Sleeping problems 
8. Violent behavior 
9. Paranoia 
10. Hallucinations
    

Due to the effect methamphetamine has on the body, an overdose often leads to a stroke, heart attack, or organ problems. Because of this, it is imperative health care providers restore blood flow to the affected part of the brain for a stroke, restore blood flow to the heart in the event of a heart attack, or treat the organ issues that present (14). Treatment for methamphetamine use disorder focuses on cognitive-behavioral therapy and motivational incentives, such as vouchers or small cash rewards that encourage individuals to remain drug-free. There is currently no FDA-approved medication to treat a methamphetamine addiction (14).

Cocaine

Cocaine is a highly addictive stimulant drug that is derived from the leaves of the coco plant that is native to South America. Dealers of cocaine may add other drugs to the cocaine, such as amphetamine or synthetic opioids, like fentanyl. Adding synthetic opioids can be especially dangerous and lead to overdose and even death (15). Over 5 million Americans reported current cocaine use in 2020, with nearly 1 in 5 overdose deaths reported (13). 

This West Virginia Substance Abuse course will help you identify the several ways in which cocaine can be used. In powder form, it can be snorted or rubbed into an individual’s gums. The powder can be dissolved and injected into the bloodstream. Injecting cocaine produces a faster and more intense high but is short-lasting. If the cocaine is in crystal form, it can be heated and smoked. Cocaine affects the brain by increasing the amount of dopamine produced. This increase in dopamine floods the brain’s reward circuit, which reinforces drug-taking behavior. Repeated cocaine use can lead to the brain’s reward circuit becoming less sensitive, which leads to individuals taking stronger and more frequent doses to achieve the same high as before (15).  

The effects of cocaine are felt almost immediately and can disappear within a few minutes to an hour. There are several health effects of using cocaine (15): 

1. Extreme happiness and energy 
2. Mental alertness 
3. Hypersensitivity to sight, sound, and touch 
4. Irritability 
5. Paranoia 
6. Constricted blood vessels 
7. Dilated pupils 
8. Nausea 
9. Increase in body temperature and blood pressure 
10. Increased or irregular heartbeat 
11. Tremors/muscle twitches 
12. Restlessness 
    

There are several long-term effects of cocaine use. These effects can range from common, to being dependent on the method of use (15) 

1. Malnourished due to a decreased appetite 
2. Movement disorders 
3. Irritability 
4. Restlessness 
5. Auditory hallucinations 
6. Snorting cocaine
   – Loss of smell
   – Nosebleeds
   – Frequent runny nose
   – Problems with swallowing 
7. Smoking cocaine
   – Cough
   – Asthma
   – Respiratory distress
   – Higher risk for infections like pneumonia 
8. Consuming cocaine by mouth
   – Severe bowel decay due to reduced blood flow 
9. Injecting cocaine
   – Increased risk of contracting HIV, hepatitis B and C, and other blood-borne diseases
   – Skin or soft tissue infections
   – Scarring or collapsed veins
   

A cocaine overdose is similar to that of a methamphetamine overdose, with the inclusion of seizures. Like methamphetamine, it is critical that healthcare providers restore blood flow to the heart and brain in the event of a heart attack or stroke. If an individual presents with a seizure due to a cocaine overdose, the first action to be taken is to stop the seizure. Cocaine mirrors that of methamphetamine use in terms of increased dopamine in the brain. This leads to an addictive nature, as well as needing more drugs over time to produce the same high (15).  

Unfortunately, there is no FDA medication approved to treat cocaine use disorder.  

There are several behavioral therapy options available (15): 

1. Cognitive-behavioral therapy 
2. Contingency management or motivational incentives 
3. Therapeutic communities
   – These are residences in which people can recover from substance use disorders with other individuals who understand their addiction, all while being drug-free 
4. Community-based recovery groups 

Heroin

Heroin is a type of drug made from morphine, which is derived from the seed pod of opium poppy plants (16). According to the CDC, over 19% of all opioid overdose deaths in 2020 involved the use of heroin (17). Heroin can be found as a white or brown powder or a black tar-like substance. Like cocaine and methamphetamine, heroin can be injected into the bloodstream, snorted, or heated and smoked. Some individuals mix heroin with cocaine or alcohol, which creates an even higher risk for an overdose and potentially death (16).  

The effects of heroin on the body are like those of prescribed opioids. When heroin reaches the brain, it is turned into morphine, which binds to opioid receptors. This causes the user to feel what is described as a rush, or a pleasurable sensation. How intense the rush is, is determined by how much drug has been taken and how quickly it attaches itself to the opioid receptor (16).   

This West Virginia Substance Abuse course will help you identify the several short-term effects that people may experience when using heroin (16): 

1. Dry mouth 
2. Warm, flushing of the skin 
3. Heaving feeling in their arms and legs 
4. Nausea 
5. Vomiting 
6. Severe itching 
7. Clouded mental functioning 
8. Being in a back-and-forth state of consciousness and semi-consciousness
   

Individuals with heroin use disorder may experience some of the following long-term health effects (16): 

1. Insomnia 
2. Collapsed or damaged veins from injecting the drug 
3. Damaged tissues on the inside of the nose due to snorting the drug 
4. Infection in the lining of the heart and the valves 
5. Abscesses 
6. Constipation and stomach cramping 
7. Liver and kidney disease 
8. Lung complications, like pneumonia 
9. Mental disorders like depression and antisocial personality disorder 
10. Sexual dysfunction in men 
11. Irregular menstrual cycle in women 
12. Increased risk for blood-borne diseases such as HIV and hepatitis C 

Heroin overdoses, along with opioid overdoses, have been increasing in the United States. A heroin overdose depresses the user’s heart rate as well as breathing, leading to hypoxia. Those who suffer from heroin use disorder have a wider variety of treatments at their disposal. Behavioral therapies include cognitive-behavioral therapy as well as contingency management. It has been shown that these behavioral therapies work best when used in conjunction with medications.  

Naloxone is a medication that can reverse opioid overdoses if given the correct way. Naloxone can be injected or snorted and has recently been approved for over-the-counter dispense in several states (18).  

There are three other types of medications available to those with heroin use disorder (16):

Methadone

This is an opioid receptor full agonist, which means it attaches itself to and actives an opioid receptor to help ease withdrawal symptoms of heroin cravings.

Buprenorphine

This is an opioid receptor partial agonist, which means it attaches itself to and partially activates opioid receptors to help ease withdrawal symptoms and heroin cravings. 

Naltrexone

This is an opioid receptor antagonist, which means it prevents heroin from binding to opioid receptors, blocking the effects. 

Hallucinogens

Hallucinogenic drugs are described as a group of drugs that alter a person’s awareness of their surroundings, thoughts, and feelings (19). In 2019 it was estimated that 5.5 million people in the United States used hallucinogens within that past year (20).

This West Virginia Substance Abuse course will help you identify the two categories of hallucinogenic drugs: classic hallucinogens and dissociative drugs. As the name suggests, both types of hallucinogens can cause the user to experience hallucinations, but dissociative drugs can also cause the user to feel out of control or disconnected from their body (19).  Common classic hallucinogens include (19):

D-lysergic acid diethylamide (LSD)

Considered one of the most powerful mind-altering chemicals. This drug is a clear or white odorless material, made from lysergic acid. Lysergic acid is found in fungi that will grow on rye and other grains.

4-phosphoryloxy-N, N-dimethyltryptamine (Psilocybin)

This hallucinogenic is also referred to as “magic mushrooms” or “shrooms” since it is found on certain types of mushrooms in South America, Mexico, and the United States.

Mescaline (Peyote)

Peyote comes from a small, spineless cactus, but may also be synthetic. While it is illegal in the United States, it can be used in religious ceremonies in the Native American Church.

N, N-dimethyltryptamine (DMT)

A chemical found in some Amazonian plants. It can be made into a tea called Ayahuasca or smoked if synthetically made.

251-NBOMe

This is a synthetic hallucinogen that is like LSD and MDMA but is more potent. It was originally developed for use in brain research. It has also been referred to as “N-Bomb” or “251”.

Common dissociative drugs include (19):

Phencyclidine (PCP)

This drug was initially developed for surgery in the 1950s, but due to its serious side effects, it is no longer used. It can be found in several forms, such as tablets, liquid, and white crystal powder.

Ketamine

This drug is used as an anesthetic for both humans and animals and is typically stolen or sold illegally from veterinary offices. Ketamine comes in powder, pills, or liquid form.

DXM (Dextromethorphan)

This drug is used as a cough suppressant and mucus-clearing ingredient in over-the-counter cold and cough medicines. It can be found in syrup, tablet, or gel capsule form.

Saliva divinorum (Salvia)

This is a plant that is common in southern Mexico and Central and South America. Its leaves are typically chewed, or the juice that is extracted from them is ingested. Saliva can also be inhaled.

The short and long-term side effects of hallucinogens are different depending on the type and category of hallucinogenic used. Short-term side effects for classic hallucinogens are (19):

1. Hallucinations 
2. Increased heart rate 
3. Nausea 
4. Intensified feelings and sensory experiences 
5. Changes in the user’s sense of time 
6. Increased blood pressure, breathing, and body temperature 
7. Loss of appetite 
8. Dry mouth 
9. Sleep problems 
10. Uncoordinated movements 
11. Excessive sweating 
12. Panic  
13. Paranoia 
14. Psychosis
    

There are two specific long-term side effects of classic hallucinogens. These side effects are typically seen in individuals with a history of mental illness but can happen to anyone (19).

Persistent Psychosis

• This refers to a series of continuing mental problems that include:
• Visual disturbances
• Disorganized thinking
• Paranoia
• Mood changes

Hallucinogen Persisting Perception Disorder (HPPD)

This is a recurrence of certain drug experiences like hallucinations or visual disturbances. These typically happen without warning and can occur any time after drug use.

Antidepressants and antipsychotic medicals have been used to improve an individual’s mood, as well as treat psychosis. Behavioral therapies have been used to help individuals cope with fear or confusion associated with visual disturbances.

Short-term side effects for dissociative drugs have been known to appear within a few minutes of taking the drug and can last hours or days. If the dosage is low, dissociative drugs can cause the following effects (19):

1. Numbness
2. Disorientation and loss of coordination
3. Hallucinations
4. Increase in the user’s blood pressure, heart rate, and body temperature

If higher doses of dissociative drugs are taken the following side effects may occur (19):

1. Memory loss
2. Panic and anxiety attacks
3. Seizures
4. Psychotic symptoms
5. Amnesia
6. Inability to move
7. Mood swings
8. Trouble breathing

The long-term side effects of dissociative drugs are still being researched. However, repeated and prolonged use of PCP has been known to result in addiction. The following long-term effects may continue for a year or more after the drug use stops (19): 

1. Speech problems
2. Memory Loss
3. Weight Loss
4. Anxiety
5. Depression and suicidal thoughts

Most hallucinogens will not typically result in an overdose but do tend to have extremely unpleasant side effects when taken in higher doses. There have been some serious medical emergencies and fatalities that have been reported by 251-NBOMe. Overdose becomes more likely with dissociative drugs. High doses of PCP have been known to cause seizures, coma, and death (19).  

Due to the nature of hallucinogens, there is a high risk of bodily harm due to the alteration of the user’s perception and mood (19):

1. Users could attempt things they wouldn’t normally do when not under the influence, such as jumping out of a window or off a building. 
2. Users could experience a profound sadness or feeling of hopelessness leading to suicidal feelings and/or suicidal actions. 
3. Psilocybin users could accidentally consume a poisonous mushroom that looks like psilocybin, which can result in severe illness or death. 

Substance Abuse in Adolescents

Substance abuse and opioid overdose deaths are beginning to affect school systems. In 2017, 2.2 million adolescents between the ages of 12-17 stated they were currently using illicit substances (21).

Brain growth and development, particularly during one’s adolescent years, has been highly studied and reviewed. One area of the brain that is still developing during adolescents is the prefrontal cortex. This area of the brain is responsible for allowing one to assess situations, make decisions, and keep emotions and desires under control (21). Because this area of the brain is still developing, it places adolescents at an increased risk of trying drugs and continuing them (21).

Substance use during one’s adolescent years has the potential to create several long-term negative effects. It is estimated that 90% of individuals with addictions began using substances during their adolescent years (22). There are several factors that can lead to substance use. These risk factors include a family history of addiction, mental health concerns, behavioral or impulse control problems, exposure to trauma, and environmental factors (22).

Multiple studies have shown that the science of prevention may affect the probability of later problems (23). The main goal in adolescent substance abuse prevention is to reduce risk factors and overall enhance/reinforce protective factors (23). Depending on the addiction, medication may be used in combination with a form of behavioral therapy or counseling. This West Virginia Substance Abuse course will help you identify the types of behavioral therapies:

Cognitive-Behavioral Therapy

Helps individuals recognize, avoid and cope with situations in which they may use drugs.

Contingency Management

Uses positive reinforcement for attending counseling sessions, remaining drug-free, or taking prescribed medications.

Motivational Enhancement Therapy

Focuses on strategies that make the most of an individual’s readiness to change their current behavior and enter treatment.

Family Therapy

Focuses on utilizing the family to address influences on drug patterns and improve overall family function.

Twelve-Step Facilitation

Delivered in 12-week sessions. There are no medical treatments but allow the individual social and complementary support.

Substance Abuse in Nurses

It is estimated that the prevalence of substance abuse among nurses is equal to the larger population. It’s a subject that a lot of nurses want to avoid, but it is nonetheless necessary to discuss. A nurse suffering from a substance use disorder may feel a lot of shame and guilt. Because nursing is frequently cited as the most trusted profession, the pressure to uphold those standards and maintain that image to the public can make a nurse with a substance use disorder feel like they are failing morally and professionally.

Fear of losing their job or their nursing license prevents many nurses from self-reporting substance abuse, and it can go unnoticed for a long time, potentially impacting patient safety. Physiological symptoms in nurses will be the same as with anyone else with a substance abuse disorder, so it is important to look for patterns in behavior.

Signs of Substance Use in Nurses

• Controlled substance discrepancy
• Wasting controlled substances without a witness
• Frequent mistakes
• Customer service issues
• Frequent absences
• Errors in documentation
• Paranoia

Contributing Risk Factors

• Being a new graduate nurse
• Identifying as a woman
• Identifying as part of the LGBTQ community
• High nurse-to-patient ratios
• Working night shift
• Working frequent overtime
• Floating to other specialty areas/unfamiliar units
• Working in Med-Surg, Long-term care, or Outpatient Services.
• Unsupportive Work Environment

Contrary to popular belief that most nurses with substance use disorders get drugs from their workplace, only an estimated 25% of nurses do this (31). The act of misappropriating controlled substances from the workplace is known as drug diversion.

Drug Diversion

According to the Department of Health and Human Services (2016), nurses and other healthcare professionals that engage in drug diversion do this mainly to feed their addiction or for recreation. But in some cases, drug theft occurs for monetary gain, with nurses stealing drugs to illegally sell them.

Drug diversion is a criminal offense, which is why most medication dispensing systems in healthcare facilities require permission to be accessed, secure fingerprinting, and are even monitored via camera. Even so, some nurses find their way around these precautions. Depending on which state you live in, the repercussions for engaging in drug diversion will vary. It is important to become familiar with your state’s regulations regarding drug diversion and your Board of Nursing’s disciplinary actions.

What are some ways you can help reduce drug diversion in the workplace?

• Witnessing a controlled substance waste in person – instead of just signing for it without verification.
• Wasting controlled substances in a timely manner and with a witness present.
• Ensuring access to the medication dispensing system is restricted to only those with permission.
• Avoiding distractions when counting controlled substances.
• Notify your supervisor immediately if you find a drug discrepancy, make an error during your count, or witness someone diverting drugs.

It is important to become familiar with your facility’s policy regarding suspected drug diversion reporting, as well as your board of nursing stance on it. Recently many boards have initiated programs to support nurses with a substance abuse disorder by helping them find treatment, keep the matter confidential and have an opportunity to practice nursing again when sober.

Once we recognize and accept that substance abuse is a disease that needs to be treated, not judged, we can take the necessary steps to help lead our community of nurses on a path towards healing and recovery.

Case Study

You are working a regular 7:00 am-7:00 pm shift in a busy medical-surgical unit. Because of recent callouts and staffing issues, the nurse-to-patient ratios have increased from 5 to 6. Everyone is stressed out and trying to get through the shift.

One of your coworkers appears frazzled and asks you if you can witness her controlled substance waste later, she explains she must give the drug now because the patient has been asking for pain medication all morning and to just “trust her” and sign off on the waste when you both have time. You agree to do this.

Unfortunately, the day continues to keep getting busier, and you both forget to document the waste. Days later you are called into your manager’s office, there is a drug discrepancy, and they want your statement because your coworker explained that you witnessed her waste the medication in person.

• What are possible repercussions in your facility for failing to witness a controlled substance waste in person?
• How does your unit or facility handle drug discrepancies?
• How could you have avoided this situation from escalating to management?
• What can you do to avoid being placed in this situation again?

Resources for Nurses and the Public

• NCSBN Substance Use Resources
• Substance Abuse and Mental Health Services Administration 
• National Institute on Drug Abuse
• National Institute on Alcohol Abuse and Alcoholism

Conclusion

Substance abuse in the United States is on the rise, with many hospitals and healthcare centers seeing an increase in patients. Understanding the different types of substances used, their short- and long-term symptoms, overdose symptoms, and medication options will help prepare you to care for these individuals. It is equally important to understand the behavioral therapy options for those with substance use disorders and advocate for them while they are in your care.

Quality Improvement for Nurses

Introduction   

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

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

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

What is Quality Improvement?

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

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

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

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

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

History and Background of Quality Improvement 

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

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

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

Models 

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

Model for Improvement 

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

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

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

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

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

Lean Model 

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

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

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

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

Six Sigma model  

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

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

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

TeamSTEPPS model 

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

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

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

IOM Six Domains of Patient Care 

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

Definitions  

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

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

Measures 

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

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

Nursing Quality Indicators 

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

Patient Falls 

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

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

Medication Administration Errors 

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

Pressure Ulcers (Bedsores) 

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

Patient Satisfaction 

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

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

Data Collection 

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

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

Types of Data 

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

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

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

Identification Stage  

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

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

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

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

Gathering Stage  

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

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

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

Analysis stage  

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

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

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

Benchmarking 

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

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

Change Models in Healthcare 

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

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

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

Implementing Change 

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

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

Evaluating Change 

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

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

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

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

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

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

Conclusion

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

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

Final Reflection Questions 

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

Workplace Violence Against Nurses

Introduction   

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

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

Workplace Violence  

Definitions 

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

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

Types of Violence  

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

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

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

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

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

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

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

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

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

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

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

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

Epidemiology 

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

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

Impact on Nurses Well-Being 

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

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

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

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

Barriers to Reporting 

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

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

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

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

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

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

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

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

Culture of Safety 

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

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

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

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

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

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

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

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

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

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

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

ANA Zero Tolerance Policy 

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

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

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

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

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

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

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

Strategies to Prevent Workplace Violence 

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

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

Know the definition of abuse.  

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

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

Report Abuse 

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

Change Your Culture 

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

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

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

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

Communicate with your Legislator! 

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

Nurse-led Strategies 

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

Regarding Your Legislators 

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

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

Below are some links to help you find elected officials: 

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

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

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

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

Resources 

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

The Joint Commission: Workplace Violence Prevention Resources 

Local law enforcement  

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

Legal Counsel 

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

Educate and Train Yourself 

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

Practice Self-Awareness 

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

Conclusion

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

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

Telemetry Basics - Rhythm Recognition

Introduction   

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

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

Heart Anatomy 101

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

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

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

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

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

(20)

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

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

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

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

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

Types of Telemetry

EKG

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

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

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

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

Bedside Monitor

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

(14)

The placement of the five leads consists of the following:

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

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

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

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

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

Remote Monitoring

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

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

Mobile Cardiac Monitor and Event Monitor

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

Event monitoring consists of the following methods (23):

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

Insertable Monitor

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

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

Holter Monitor

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

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

Lead Placement

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

12 Lead EKG

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

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

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

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

15 Lead EKG

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

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

Right Sided EKG

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

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

V4R Lead Placement

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

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

Limb Leads

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

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

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

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

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

Reading EKGs: EKG Components

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

P wave

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

PR Interval

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

PR Segment

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

QRS Complex

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

ST Segment

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

T Wave

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

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

(4)

Reading EKGs: EKG Paper

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

(15)

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

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

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

(51)

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

Rhythm Recognition

Normal Sinus (41):

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

(29)

Sinus Bradycardia (87):

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

(87)

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

• Electrolyte imbalances

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

Sinus Tachycardia (55):

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

(42)

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

1st Degree AV Block (68):

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

(32)

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

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

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

(27)

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

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

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

(40)

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

3rd Degree AV Block (78):

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

(33)

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

Premature Ventricular Contraction (PVC) (88):

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

(38)

• Biomorphic: PVCs are shaped differently

(64)

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

(35)

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

(9)

• Ventricular Couplet: Two PVC beats in a row.

(9)

• Ventricular Triplet: Three PVC beats in a row.

(9)

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

Premature Atrial Contractions (PAC) (54):

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

(37)

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

Ventricular Tachycardia (V Tach) (45):

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

(11)

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

Torsades de Pointes (V Fib) (25):

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

(12)

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

Supraventricular Tachycardia (SVT) (72):

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

(30)

• Wide complex, regular SVT

(79)

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

 Ventricular Fibrillation (V-Fib) (3):

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

(39)

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

Asystole (59):

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

(21)

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

Pulseless Electrical Activity (PEA) (22):

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

(22)

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

Atrial Flutter (73):

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

(31)

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

Atrial Fibrillation (AFib) (89):

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

(28)

• A Fib RVR

(34)

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

Idioventricular Rhythms (47):

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

(36)

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

Junctional Rhythms (52):

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

(52)

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

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

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

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

(71)

• • • • LBBB

(71)

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

Identifying Ischemia and Infarction

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

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

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

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

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

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

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

(84)

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

(82)

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

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

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

Sgarbossa criteria (77):

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

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

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

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

Cardiac Assessment:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

Heart Failure Updates

Introduction   

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

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

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

Statistical Evidence/Epidemiology

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

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

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

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

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

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

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

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

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

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

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

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

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

Etiology and Pathophysiology  

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

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

There are two main types of HF:

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

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

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

Systolic (LHF) 

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

Diastolic (RHF) 

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

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

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

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

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

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

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

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

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

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

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

Diagnostic and Screening Tools for Heart Failure (HF) 

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

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

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

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

(13)

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

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

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

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

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

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

Medication Management 

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

The classes are as follows:

Angiotensin-Converting Enzyme (ACE) Inhibitors 

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

Some common ACE inhibitors are: 

• Captopril 
• Enalapril 
• Lisinopril 
• Ramipril  

Angiotensin-Receptor Blockers (Arbs)

• Losartan
• Valsartan
  

Angiotensin-Receptor Neprilysin Inhibitors (Arnis) 

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

Beta Blockers  

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

Common Beta Blockers are: 

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

Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors 

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

Diuretics 

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

Most common diuretics are: 

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

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

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

Other Interventions 

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

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

Hypertension Updates

Introduction

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

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

Statistical Evidence/Epidemiology 

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

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

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

[31] 

Etiology/Pathophysiology of Hypertension 

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

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

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

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

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

Secondary hypertension often involves: 

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

The typical secondary causes of hypertension include: 

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

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

Diagnostic and Screening Tools 

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

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

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

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

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

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

Imaging and Other Diagnostic Tests 

Ultrasound of the Kidneys: To rule out kidney abnormalities. 

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

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

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

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

Medication Management 

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

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

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

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

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

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

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

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

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

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

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

[32] 

Other Interventions  

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

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

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

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

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

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

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

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

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

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

Upcoming Research 

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

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

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

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

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

Awareness and Patient Education 

What your patients should know: 

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

Nurses and healthcare professionals should be aware of the following: 

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

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

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

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

Conclusion

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

GI Bleed: An Introduction

Introduction   

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

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

Epidemiology  

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

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

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

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

Etiology/ Pathophysiology

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

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

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

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

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

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

Upper GI Bleeding (UGIB) Etiology 

Underlying conditions that may be responsible for the UGIB include: 

• Peptic ulcer disease 

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

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

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

(1, 4, 5, 8. 9) 

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

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

Lower GI Bleeding (LGIB) Etiology

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

(1, 4, 5, 9)

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

Laboratory and Diagnostic Testing

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

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

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

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

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

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

Signs and Symptoms 

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

Mild vs. Severe Bleeding  

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

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

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

History and Physical Assessment

History

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

Assess for the following:

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

Physical Assessment

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

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

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

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

Treatment and Interventions

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

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

(8) 

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

Subjective Data (Client verbalizes)

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

Objective Data (Clinician notes during assessment)

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

Nursing Interventions

Ineffective Tissue Perfusion:

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

Acute Pain:

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

Risk for Decreased Cardiac Output

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

Risk for Deficient Fluid Volume:

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

Nursing Goals / Outcomes for GI Bleed:

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

Case Study

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

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

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

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

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

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

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

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

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

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

Conclusion

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

Constipation Management and Treatment

Introduction   

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

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

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

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

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

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

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

Epidemiology  

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

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

Etiology/Pathophysiology  

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

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

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

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

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

Signs and Symptoms  

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

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

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

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

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

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

Pharmacological/Non-Pharmacological Treatment 

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

Pharmacological 

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

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

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

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

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

Non-pharmacological 

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

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

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

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

Complications 

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

Hemorrhoids 

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

Anal Fissure 

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

Fecal Impaction 

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

Rectal Prolapse 

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

Nausea and Vomiting 

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

Bowel Obstruction 

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

Prevention  

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

Dietary Adjustments 

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

Hydration 

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

Exercise 

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

Lifestyle Awareness 

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

Patient Education 

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

Nursing Implications 

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

Holistic Assessment 

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

Effective Communication 

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

Collaboration with Multidisciplinary Teams 

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

Patient-Centered Care Plans 

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

Education and Empowerment 

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