Archive for the ‘patient perspective’ Category

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Anxiety Apps: New Fad or Worth the Download?

April 16, 2014

photo3By Amy M. Collins, editor

Today there’s an app for everything. There are find-your-keys apps, map-the-stars apps, even an app to help you hone your stapling skills. And apps exist to help patients with every kind of health care need, from managing diabetes to prenatal care. Usually, in an attempt to keep my smartphone use to a minimum, I avoid jumping on the trendy app bandwagon. But recently I came across an article touting an app to reduce anxiety. As a long-term, mostly recovered sufferer of chronic anxiety and panic, this article piqued my interest (and my skepticism).

While certainly not the first app developed to reduce stress, this particular app—called Personal Zen—has been tested by researchers who found that participants with relatively high scores on an anxiety survey showed less nervous behavior after using the app than those in a placebo group, according to a study published in Clinical Psychological Science. Developed by psychologist Tracy Dennis, a professor at Hunter College in New York City (and, it should probably be noted, one of the study’s lead authors), the app incorporates the concept of cognitive bias modification to get the user to shift their focus from a threatening stimulus to a nonthreatening one. More studies are needed to see if such an app would have the same success in those with clinically diagnosed anxiety.

And there are literally hundreds of other apps catering to those with anxiety (click here for a Healthline article on the 17 “best” antianxiety apps; and here are more from Google Play).

Is it really that easy? If only antianxiety apps were available when I was first diagnosed over a decade ago. Back in that particular Stone Age, I had limited choices: antianxiety meds, talk therapy, alternative methods, or a combination of these options. I chose therapy and alternative methods and embarked on a 10-year quest to control the disorder instead of vice versa. I read books, employed relaxation techniques, joined groups, and challenged myself to face situations that caused anxiety. Employing these tactics eventually brought me to a place where I could live relatively anxiety free without medication. Read the rest of this entry ?

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The Power of Imagination: Helping Kids with Sickle Cell Disease to Cope with Pain

April 2, 2014

By Sylvia Foley, AJN senior editor

Many people with sickle cell disease suffer from both acute and chronic pain, which can be severe. Although the exact mechanism isn’t known, the pain is believed to result when sickled erythrocytes occlude the vascular beds, causing tissue ischemia. Such pain, which often begins in early childhood, arises unpredictably. Although some pain crises may require ED visits, hos­pitalization, opioid treatment, or a combination of these, most are managed at home. Yet little is known about at-home pain management in people with sickle cell disease, especially children.

Table 2. Changes in Self-Efficacy, Imaging Ability, and Pain Perception in School-Age Children After Guided Imagery Training

Table 2. Changes in Self-Efficacy, Imaging Ability, and Pain Perception in School-Age Children After Guided Imagery Training

Cognitive behavioral therapy (CBT) has shown promise in helping patients with other chronic illnesses to cope with pain. Cassandra Elaine Dobson and Mary Woods Byrne decided to test guided imagery, a form of CBT, among children enrolled at one sickle cell treatment clinic in New York City. They report on their findings in this month’s original research CE, “Using Guided Imagery to Manage Pain in Young Children with Sickle Cell Disease.” The abstract below offers a quick overview; if you click the image above, you’ll see an enlarged view of one table showing key results.

Objectives: The purposes of this study were to test the effects of guided imagery training on school-age children who had been diagnosed with sickle cell disease, and to describe changes in pain perception, analgesic use, self-efficacy, and imaging ability from the month before to the month after training.
Methods: A quasi-experimental interrupted time-series design was used with a purposive sample of 20 children ages six to 11 years enrolled from one sickle cell disease clinic, where they had been treated for at least one year. Children completed pain diaries daily for two months, and investigators measured baseline and end-of-treatment imaging ability and self-efficacy.
Results: After training in the use of guided imagery, participants reported significant increases in self-efficacy and reductions in pain intensity, and use of analgesics decreased as well.
Conclusions: Guided imagery is an effective technique for managing and limiting sickle cell disease–related pain in a pediatric population.

The technique was easily taught in training sessions lasting 15 to 45 minutes, with no child needing more than one session. The authors concluded that “the use of guided imagery in this population assumes that a child’s imagination has the potential to affect health, and our findings support that assumption.” Because this was a small study, they urged further large-scale clinical trials.

To learn more, read the article, which is free online. As always—and especially if you have experience caring for children with sickle cell disease—we welcome your comments.

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Questions Dementia Patients Can’t Answer

February 11, 2014
by Ann Gordon, via Flickr

Photo by Ann Gordon, via Flickr

By Amy M. Collins, editor

A few weeks ago I visited my grandmother, who suffers from dementia, at her assisted living home. In her room, my family and I noticed a complicated form with instructions for residents to get their flu vaccination. Residents had to fill it out, sign it, and bring it to the person administering the vaccine on a certain date. For my grandmother, this would be impossible—she can no longer remember what day it is, when or if she has eaten, who she’s spoken to within the last five minutes, or where her room is located.

When this concern was broached with the front desk of the facility, they seemed to be adamant that she needed to have the form with her on the day of vaccination. We could, of course, help her fill it out—but since it had been given directly to my grandmother, who was to say we would have ever learned of it except by chance? And who would make sure she brought it with her on the day of vaccination?

While the facility offers assisted living, they often remark that they are not a “dementia facility.” Looking around, however, one is hard-pressed to find a resident without some form of dementia. In our case, something was eventually worked out about the form, but it was frustrating that a home that deals so regularly with people with memory issues can’t understand why certain requests are unreasonable.

And it’s not just the home that has this problem—many health care facilities do as well. A large responsibility is placed on people with dementia when they are asked by a clinician to give an account of what brought them to the facility. Depending on the person’s stage of dementia, she or he may not be capable of answering, of being a proactive patient navigating the complicated health care sea. These patients are not likely to remember their personal histories. They don’t remember where they have to be and when, or what happened to warrant their hospital visit.

Last summer, for example, my grandmother had a fall. As part of her facility’s protocol, she was brought to the ED, where, until I got there, she was left alone to give her own personal account of the event. Dementia is listed in her health record, but I’ve seen multiple providers still ask her what’s happened or what seems to be wrong—questions she cannot accurately answer. On this particular occasion, I caught the end of what she was telling the nurse when I arrived. Read the rest of this entry ?

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The Hospital as Foreign Country

February 7, 2014

Capture“A Foreign Place,” the February Reflections essay by Barbara Sosman, delves into one patient’s experience of the sometimes inscrutable, sometimes terrifying, sometimes humorous events and encounters in one small corner of a hospital.

Below are the first two paragraphs, but as always, it’s worth clicking through and reading the entire essay (the PDF version is best). This one would be particularly hard to summarize; it takes us to unexpected places.—Jacob Molyneux, senior editor

The flow of life and death in a hospital is mysterious, like the sound of a foreign language, and the mysteries that bring us here are profound. Stretched out in an unfamiliar hospital bed, I suppress realities, aware that tomorrow a scalpel will remove an enlarged node for a biopsy. The biopsy will show what I sense, a cellular chaos that threatens my life. Soon my disease will be presented like an offering. What will I do with it?

A room can become a universe and time there an infinity. This room is inhabited by women, of whom I am the youngest by decades  . . .

As always, comments are welcome.

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Patient Decisions: When You’re Just Not Up to Making the Call

January 17, 2014

By Karen Roush, MS, RN, FNP, clinical managing editor

Photo by the author

Photo by the author

For most patients and in most clinical situations, decision making is and should be a shared process between the patient and the clinician (and often the family). But there are some cases when we, expert clinicians versed in scientific and experiential knowledge, need to make a decision for the patient—not out of some paternalistic idea of our authority or superiority, but because the patient really wants or needs us to take on that burden.

I was six months pregnant with my second child. The pregnancy had gone smoothly, which was a blessing after having delivered my first child 10 weeks premature following two weeks spent in a tertiary care center. That pregnancy had been problematic from the beginning—early bleeding, and then a hemorrhage at five months, at which time they’d diagnosed me with placenta previa. It was one of those pregnancies where you were thankful for each additional day that brought you closer to the nine-month mark.

But this time, everything was going smoothly—no bleeding or cramps, an active baby that ultrasounds confirmed was growing well . . . until one morning in February, when I started with cramps that progressed to pain and a lot of pressure. An hour later, I was in the labor and delivery suite. The cramping and pain had stopped, but an exam revealed that the amniotic sac had slipped down through a dilated cervix.

I was only at 20 weeks’ gestation; if born, the baby would have no chance of survival. The key was time. If I could get to 24 weeks—at that time considered the earliest point of viability—they would send me down to Albany Medical Center, the tertiary care center where my first son was born.

The plan was to keep me in Trendelenburg position in the hope that the amniotic sac would slide back into the uterus by gravity, at which point my obstetrician would do a cervical cerclage to hold it there until the baby was viable outside the womb.

Or maybe my obstetrician wouldn’t. There was a risk that cerclage would stimulate my already irritable uterus, sending it into contractions that couldn’t be stopped. I knew this because my obstetrician had told me the risks of both watchful waiting and cerclage, informing me that if gravity accomplished what we wanted, I would have to choose between them. Every morning, he would come into the room, assess me, and remind me that soon I would have to decide. Read the rest of this entry ?

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What Ever Happened to a Good History?

January 10, 2014
ky olsen/via Flickr

ky olsen/via Flickr

By Karen Roush, MS, RN, FNP, clinical managing editor

What ever happened to a good history? We were taught as NP students that the history portion of the exam was as important as the physical. In fact, in most cases it’s what you learn in the history—from asking the right questions and really listening to the patient’s answers—that gives you the information you need to figure out what is going on. The physical findings either support what you’re thinking or lead you to ask more specific questions.

A good history isn’t just listening to the patient’s answers to your questions; it’s listening to all the information they offer. Take for example, the middle-aged construction worker who takes his lunch hour to come in to the clinic complaining of a cold. He lists the usual symptoms, cough, fatigue, a little shortness of breath, and then as you’re starting the exam he casually mentions that he hasn’t been to a doctor in 15 years.

Someone who’s managed to stay out of a doctor’s office for 15 years and now shows up, on his lunch hour, because of a simple cold? So, you ask some more questions and learn about some chest pressure he attributes to the coughing he’s been doing and about his father’s death at 58 of a heart attack. And you realize it’s not a cough that has brought him in; it’s something more that doesn’t fit a neat checklist of symptoms. An ECG shows some nonspecific changes—nothing dramatic—but knowing what you do based on the history, you start an IV, give him an aspirin to chew, a little nitro, call an ambulance, and he’s off to the ED. Later you learn that he was immediately sent to a regional care center and into surgery for a triple bypass.

True story.

Any good NP can tell you their own version of this story. It was just something the patient said, or the way they said it, that heightened their alertness and led them to a diagnosis that could so easily have been missed.

But taking a good history is a skill that is in danger of getting lost in this age of computer checklist care. (That and eye contact, but we’ll save that for another blog post!) Two recent visits I made to clinics, one for primary care and one for urgent care, found me looking at the backs of nurses’ heads as they ran through standardized lists of questions, dutifully clicking them off a checklist on the computer. The provider at the urgent care center took a look at the answers and then proceeded, silently, with the exam. This may seem extreme, but unfortunately it or something very much like it is too often the norm. Read the rest of this entry ?

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The ‘Dialectic at the Heart of Healing’

December 13, 2013

Capture
By Jacob Molyneux, senior editor

Here are the opening paragraphs of the short intro I wrote for our special December edition of the Reflections column. Since the illustrations are an important part of this column’s presentation, I’d suggest clicking through to the PDF versions of the articles linked to below:

“There is a dialectic at the heart of healing that brings the care giver into the uncertain, fearful world of pain and disability and that reciprocally introduces patient and family into the equally uncertain world of therapeutic actions.” —Arthur Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condition

In recent years, the role of narrative in medicine and nursing has gained (or perhaps regained?) a certain amount of respect.

Some advocates value the stories of patients and practitioners because they bring us in from the cold, reminding us of the human side of an increasingly technology-driven field. Others argue for narrative as a crucial source of knowledge about disease processes and best practices, yet another form of evidence in the constant quest to improve outcomes. Others focus on the therapeutic aspect of such writing, our deep need to make sense of encounters shaped by loss, pain, and suffering, whether witnessed or experienced.

The Reflections column has been appearing monthly, with rare gaps, since 1983, when AJN debuted this and other new columns (as well as its editorial board). Reflections essays exist to give a voice to those who have a story to tell about health care, whether they be nurses, patients, physicians, or family members of patients. Read the rest of this entry ?

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When There’s a Disconnect Between Good Nursing Practice and Reality

December 6, 2013

Recently I spoke with other nurses about our personal experiences with hospitalization and those of family members, and the conversation turned to disappointment with nursing practice and nursing care. In fact, whenever I’ve asked, every colleague has disclosed a similar experience. Some say that they’d never leave a family member alone in a hospital.

We need to acknowledge that there is a disconnect between what we know to be good practice and what is often the reality—even in facilities with Magnet accreditation. There are far too many instances in which nursing practice is substandard.

shawnkennedyThis is a heads-up about Shawn Kennedy’s editorial in this month’s issue of AJN, excerpted above. You should read it. The article, “Straight Talk About Nursing,” is free. There are no easy answers to the issues it raises. That’s all the more reason to discuss them openly.

In AJN, we often focus on examples of best practices and insightful, compassionate, engaged care. And we get that there are many institutional obstacles that undermine nurses in their attempts to provide quality care to patients. But even so, we’d be remiss to pretend we don’t hear about, and sometimes personally experience, care that simply falls short. This is scary, at least to me. Patients depend on nurses in so many ways. So have a look at the article and let us know your thoughts, as a nurse or as a patient.—Jacob Molyneux, senior editor

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Family Pet Visitation: A Nurse-Led Project at One Illinois Hospital

December 4, 2013

AJN1213.Cover.Online

We hear a lot about therapy dogs that are specially trained to visit patients in the hospital. But I for one would want to see not just any dog but my own dog, if I were gravely ill and in the hospital. I know I’m not alone, and some nurses set out to determine the pros and cons of making pet visits happen for some patients in their hospital. What safety concerns might there be? According to the current available research, what benefits might patients experience? What protocols would be necessary if it were to happen?

Nurses from Memorial Hospital in Belleville, Illinois, set out to answer these questions and bring such a program to life. They give the details in “Family Pet Visitation,” a feature article in the December issue of AJN (free for a month), along with some moving photos of patients and their pets. Here’s a quote from the start:

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A Focus on Meaning and Attitude: This Week’s Nursing Blog Post Suggestions

November 13, 2013

By Jacob Molyneux, AJN senior editor

'Autumn Washed Away,' Diane Hammond/ via Flickr

‘Autumn Washed Away,’ Diane Hammond/ via Flickr

Here are a few recent posts by nurses that you might find of interest. As I put this together, a theme emerged, so it seemed fair to just go with it. Maybe the approach of these bloggers has to do with the time of year, the shorter days and colder weather as we approach the winter holidays . . .

At the intriguingly titled Nursing Notes of Discord blog, there’s a short reminder post with a fairly straightforward descriptive title: “Anyone Can Make a Positive Difference.” And, the author points out, you “don’t even have to be a nurse” to do so.

At Digital Doorway, Nurse Keith has a recent post that also focuses on positivity, this time about one’s profession: “For Nurses, ‘Just’ Is a Four-Letter Word.”

At HospiceDiary.org, in the lovely post “Leaves, Geese and Other Ramblings”—as the below quote may suggest—we find another angle on this theme of being present and focusing on the good in the midst of sometimes constant, poignant awareness of change, loss, dying, and rebirth:

Fall moves into winter. Unequivocal  fact. The furrowed fields and leftover husks are what remains of a harvest of work . . .

Read the rest of this entry ?

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