Archive for the ‘practice tips’ Category

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Interventions to Promote Physical Activity in Chronically Ill Adults: What Does the Evidence Tell Us?

July 14, 2010

By Sylvia Foley, AJN senior editor

It sounds like a no-brainer: physical activity can have great health benefits for people who are chronically ill. But which interventions promote physical activity in this population most effectively? Many studies evaluating such interventions have been conducted; but “without the benefit of a statistical analysis across studies it can be difficult to detect patterns and interpret results,” say the authors of this month’s CE feature, Todd M. Rupper and Vicki S. Conn.

In 2008 Conn and colleagues did just that, performing a meta-analysis that summarized the findings of 163 reports on 213 independent tests of interventions used to promote physical activity among more than 22,000 adults with various chronic illnesses. Now, in this article, Rupper and Conn discuss the implications of  the findings from that meta-analysis, describe the strategies and practices most commonly used, and identify which ones have proven most effective. Among the take-aways: Read the rest of this entry ?

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Checklist, Please!

June 28, 2010

Christine Moffa, MS, RN, AJN clinical editor

It’s embarrassing to admit how many times I’ve either locked myself out of my apartment or arrived at work and realized I’d left either my wallet or cell phone at home. That is, until someone very close to me taught me to say, “wallet, keys, cell phone, Metrocard” before walking out the door. Little did he know he was using a very powerful tool, the checklist.

As part of my money-saving strategies this year, I’ve resorted to using the New York Public Library to support my reading habit, instead of going to the various megabookstores in my neighborhood (I always fall for the “buy-two-get-one-free” deal!). That’s why I’m late to the party for The Checklist Manifesto, by Atul Gawande. After three months on hold, my turn finally came up—and boy was it worth the wait. There are so many great anecdotes about success stories (and some failures) of checklists—including patients surviving accidents and surgeries against all odds, averted airplane crashes, and well-orchestrated rock concerts—that it makes me want to start implementing checklists in every aspect of my life (including some at AJN). In fact, if I’d had a checklist for packing my bag for this weekend, I’d have remembered my flat iron, amongst other necessities. Now I’m forced to go the next 48 hours with serious frizz! 

My favorite part of the book, though, is that Gawande gives credit to nurses for being the originators of checklist usage in hospitals, citing vital sign charts, medication administration records (MARs), and care plans.

Checklists, it turns out, foster communication, which in turn leads to teamwork. Who knew? In this world of ever increasing complexity, there are so many details to focus on it’s easy for errors to happen. Often you have to focus on your own responsibilities and trust that your colleagues are taking care of theirs. The checklist brings us all back to the same page; if nobody can proceed until it’s confirmed that a particular task has been performed, we’re forced to check in with each other.

If you’d like to make a checklist of your own, you can visit Gawande’s  Web site and download a “Checklist for Checklists,” or see some examples of those used in the medical and aviation industries.

Do you have a favorite checklist that you find helpful either in your personal or professional life? Let us know about it.

Atul Gawande's "Checklist for Checklists"

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TBI Redux: ‘Signature Injury’ of Recent U.S. Wars Too Often Undiagnosed, Untreated

June 11, 2010

The military medical system is failing to diagnose brain injuries in troops who served in Iraq and Afghanistan, many of whom receive little or no treatment for lingering health problems, an investigation by NPR and ProPublica has found.

So-called mild traumatic brain injury has been called one of the wars’ signature wounds. Shock waves from roadside bombs can ripple through soldiers’ brains, causing damage that sometimes leaves no visible scars but may cause lasting mental and physical harm.

Officially, military figures say about 115,000 troops have suffered mild traumatic brain injuries since the wars began. But top Army officials acknowledged in interviews that those statistics likely understate the true toll. Tens of thousands of troops with such wounds have gone uncounted, according to unpublished military research obtained by NPR and ProPublica.

That’s from a story this week from National Public Radio (NPR). You can read it or download it and listen to it as a podcast, but whichever you do, you’ll come away with a vivid understanding of how much those who’ve been injured in Iraq and Afghanistan are really suffering from mild traumatic brain injury (TBI).

But how can an injury be both “mild” and “traumatic” at the same time? An excellent question. Don’t let the name fool you. This isn’t something people make up because it’s invisible and the symptoms are nonspecific enough to prevent either solid diagnosis or outright dismissal by clinicians or the military bureaucracy.

In fact, AJN ran a major feature about TBIs in the April 2008 issue (the chance for nurses to get CE credit on this article has, unfortunately, expired). It focuses in particular on those who sustain other, more obviously serious injuries, injuries that lead those treating them in the field or later to fail to assess for or treat TBI.

Nurses can expect to see these patients in every kind of practice for many years to come. Screening protocols are given, as well as a case study and a look at who is at risk for TBI and how it should be treated. We hope you’ll have a look, and then tell us your stories about either dealing with TBI or treating those who have the condition, which can be chronic and profoundly disabling. -Jacob Molyneux, senior editor/blog editor

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What to Teach Patients and Their Families About Asthma

May 6, 2010

What do you need to know about asthma, and what should you teach your patients about its prevention and management? This month’s CE article gives a comprehensive and accessible overview, with medication, symptom, and common allergen tables, as well as advice like the following about the use of “action plans,” which may be particularly helpful with patients with “moderate or severe persistent asthma, a history of exacerbations, or poorly controlled asthma.” 

Action plans should be simple and easy to use. Many use a traffic light analogy, describing green, yellow, and red zones for which specific actions are prescribed. In the green (“go”) zone, patients’ [peak expiratory flow rate] PEFR is 80% to 100% of their personal best and they have no symptoms. These patients can continue using their daily medications and taking steps to limit exposure to triggers, as described in their plan. When patients’ PEFR is 50% to 80% of their personal best and they have symptoms, they’ve entered the yellow (“caution”) zone, and practitioners may consider prescribing alternative antiinflammatory medications and, possibly, a higher dose or more frequent use of the rescue medication. Patients whose PEFR drops below 50% of their personal best and whose symptoms fail to improve significantly with prescribed rescue medications are in the red (“danger–stop”) zone. They should increase medication as indicated in their action plan and call their health care provider immediately. If unable to reach their provider, they should stop what they’re doing and go directly to the nearest ED.

How are you doing with helping your patients and their families manage asthma?

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Upper-Extremity Deep Vein Thrombosis: How Clinicians at One Hospital Achieved Lower Rates

April 30, 2010

By Sylvia Foley, AJN senior editor

Patient with upper-extremity DVT, photo by Charlie Goldberg, MD (http://meded.ucsd.edu/clinicalmed)

At a suburban hospital in Indiana, clinicians noticed that the incidence of secondary upper-extremity deep vein thrombosis (DVT) at their facility seemed to be on the rise. As Lancaster and colleagues report in the May Emergency, this was alarming: upper-extremity DVT, once thought benign, is now known to be potentially dangerous, leading to complications such as symptomatic or asymptomatic pulmonary embolism, chronic venous insufficiency, and postthrombotic syndrome. Secondary upper-extremity DVT, which accounts for a majority of cases, can be linked to an identifiable risk factor. Patients may present with pain, swelling, and bruising in the area of the thrombosis—but many patients show no symptoms. So it’s essential that nurses know which patients are at risk and how to minimize that risk.

The Indiana clinicians reviewed the literature to deepen their understanding. They also tracked all patients who underwent ultrasonography at their facility and conducted retrospective chart reviews, gathering data for a full year. Several new risk factors were identified, including

  • the use of the large veins at the antecubital fossa for peripheral IV access;
  • the use of harsh medications administered via peripheral IV; and
  • certain peripherally-inserted central catheter (PICC) flushing and care practices.

What they learned prompted several changes to nursing care, and the incidence of secondary upper-extremity DVT at this facility has since declined. To learn more about this quality improvement project and the changes that were implemented, read the article. And if you’ve cared for patients with this serious and increasingly common condition, please share your experience with us in the comments.

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To Address High Turnover Among New Nurses, A Virtual Training Tool With Real-Life Problems

April 8, 2010

(click image for larger version)

At this week’s National Student Nurses Association conference in Orlando, Johnson & Johnson’s Campaign for Nursing’s Future is unveiling a free virtual training program called Your Future in Nursing, which can be found at the Web site DiscoverNursing.com. (Sidenote: the site has many other resources for men in nursing, student nurses, and others, including a fairly vast collection of Profiles in Nursing, which is worth browsing through to get a sense of the really broad range of people who work in the nursing profession.)

You can download the virtual training program for free or order the CD through the DiscoverNursing.com Web site. Designed to address the extremely high turnover rates among first-year nurses who often feel woefully unprepared for the realities of the workplace, the program (full disclosure: we’ve watched a trailer, but we haven’t tried it yet ourselves) sounds intriguing (and a virtuous subsitute for a half hour spent on Facebook):

The interactive training tool allows nurses to select a 3D nurse character and navigate through the rooms of a virtual hospital. As they tour the hospital, nurses interact with animated versions of the people who will shape their first year on the job – hospital administrators, nurse managers, doctors, other nurses, patients and their families. Nurses work at their own pace to respond to different, real-life nursing scenarios they would normally encounter throughout the hospital. In addition to getting immediate feedback on each answer, sections close with a video message from an experienced nurse mentor who provides perspective and coaching on the new nurse’s experience. 

If you do give it a try, please (please!) let us know if you find it helpful.

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What Nurses Need to Know About Continuous Glucose Monitoring

March 30, 2010

Case 1. A 27-year-old man has had type 1 diabetes for 19 years. His hemoglobin AIc level prior to starting RT-CGM [real-time continuous glucose monitoring] was 9.4%. . . . Over the 15 months of RT-CGM use, he was able to decrease his hemoglobin AIc level to 7.7% and maintain it at that level for several months. After he stopped using RT-CGM because his insurance didn’t cover sensors, his hemoglobin AIc level rose to 8.5%. When he got a new job and was able to resume use of RT-CGM, after three months his hemoglobin AIc level had once again decreased, this time to 7.9%.

Case 2. A 10-year-old girl has had type 1 diabetes for almost three years. Her hemoglobin AIc level before starting RT-CGM was 9.8%. By five months after starting RT-CGM her hemoglobin AIc level had decreased to 7.2%. After discontinuing sensor use because of the high cost of RT-CGM supplies and a lack of insurance coverage, her hemoglobin AIc level rose to 8.2%.

The above are composite cases of patients with type 1 diabetes who used real-time continuous glucose monitoring devices as a tool to improve their blood sugar control. They’re from an article in the April issue of AJN that gives a balanced overview of this technology, including how it works, its current uses (as a diagnostic tool, a warning system for hypo- and hyperglycemia, and a way to improve long-term glycemic control), its coverage and costs—and its advantages and disadvantages, as described here:

The advantages of using a sensor include

* the availability of glucose values every few minutes.

* a possible reduction in the frequency of hypo- and hyperglycemia.

* tighter glycemic control and a possible decrease in long-term complications.

* a possible reduction in the frequency of finger-sticks.

The challenges to using a sensor are that

* it requires its own insertion site in the body, and the receiver must be within five to 10 feet of the transmitter, depending on the product, for glucose values to be detected.

* it often requires the patient to carry the receiver around, in addition to the other supplies. (Medtronic currently has a product on the market that’s both an insulin pump and CGM receiver in one unit, and Abbott’s CGM receiver also functions as a glucose meter. Other companies are also working on creating integrated products that deliver insulin and measure glucose values. Currently, two insertion sites, one for the insulin pump and one for the RT-CGM sensor electrode, are needed in the sensor-enhanced pump. Several companies are at work on combining insulin delivery and glucose measurement at a single injection site.)

* patients may need to actually do more frequent glucose testing.

* some patients will have difficulty understanding the difference between finger-stick glucose values and sensor values. There is a learning curve here

This technology is right for some, not so right for others. Nurses caring for people with diabetes will need to know more about it as it becomes more common.

Patients who decide to use RT-CGM devices may initially face frustration while getting used to the system, especially when adjusting to the differences that can occur in either direction between blood glucose and sensor values. Many will need encouragement from nurses. It’s nurses’ responsibility to give their patients the most updated information about the advantages and disadvantages of new tools that may help them better manage their diabetes.

We hope you’ll read the article, and let us know your experiences with continuous glucose monitoring, either as patients or nurses…or both.

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Want to Achieve the ‘Greatest Good’? Listen to Your Patients

February 9, 2010

Ethical dilemmas abound in nursing practice. Consider these commonplace scenarios:

* An angry patient threatens to leave the hospital against medical advice. Should you hold him against his will?

* A cancer patient fears chemotherapy. Should you give less detailed information about the effects of anticancer drugs?

* An obese home care patient with pressure ulcers refuses to cooperate in turning. Should you turn her anyway?

Such conflicts between the patient’s wishes and the nurse’s perception of the patient’s best interests occur regularly. That doesn’t make these ethical dilemmas any easier to resolve, but how nurses approach them can significantly affect clinical outcomes. Taking the time to listen to patients—and to integrate relationship skills with principles of ethical practice—can help nurses achieve solutions that are both ethical and appropriate for individual patients.

ky olsen/via Flickr

That’s from the February issue of AJN, in which nurse–ethicist Doug Olsen (who has in the past written for this blog on ethical issues related to mandated H1N1 vaccinations for nurses) offers a thoughtful discussion that may resonate for all nurses who’ve ever faced a situation like those in the above examples. It may seem obvious or cliched to say that listening to patients can help solve apparently intractable problems—but just because listening as a skill is hard to measure doesn’t mean that it’s not sometimes effective where more rigid tactics would fail.

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The Checklist – Taking Finger-Pointing Out of the Equation

February 5, 2010

By Peggy McDaniel, BSN, RN

Ok, I will admit right off that I am a huge fan of Atul Gawande’s writing. I have read his books Better and Complications, and I think much of his work should be required reading for all health care students. I haven’t read his newest book, The Checklist Manifesto: How to Get Things Right. I plan to soon, but it’s the 3rd book down in the pile on my bedside stand.

That confession aside, there has been some recent news around the use of checklists that bears some attention. Dr. Gawande helped develop a two-minute checklist that is to be done prior to surgery. 

Dr. Peter Pronovost was involved in the development of a similar checklist related to the insertion of central lines. 

Airlines and airplane manufacturers, such as Boeing, use checklists constantly to ensure consistent, high quality outcomes. 

I did a quick Google search for “checklists and nursing” and found various references to skills and competency checklists. As a nurse, my skills have been observed and validated with checklists over the years. I have also been party to filling out checklists on myself and my peers. Come to think of it, much of our charting has been done by filling out checklists. 

I guess I am a bit surprised that the use of checklists to validate competencies and keep track of specific processes and actions by doctors and multidisciplinary teams has been so long in coming.  Read the rest of this entry ?

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Normal Blood Pressure — in 1914

February 3, 2010

That’s an excerpt from an October 1914 article about blood pressure that was published in AJN (our older articles only exist in PDF versions, so click the PDF link in the upper right corner of the article landing page).

Maybe, though, in the absence of the many medications we now have to treat hypertension, these really were “normal” (that is, realistic) blood pressure levels for adults as they aged! It’s funny how, in so many areas, we keep on redefining the meaning of this oft-used phrase: “normal changes related to aging.”

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