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We Want You, or Someone You Know! Tell Us About Nurses Making a Difference

January 25, 2016

Uncle_Sam_(pointing_finger)Nurses in all settings are doing important work and making a difference, and we want to highlight them and the good work they do. AJN’s Profiles column highlights the diverse ways in which nurses contribute their leadership, compassion, and talent to enhance patient care directly in their institutions or through innovations in policy, research, or education that have had far-reaching impact.

Our profiles include:

We’re inviting suggestions for nurses to feature in Profiles. If you know of a nurse who is doing great work, let us know. Or if you have developed an interesting or unique program, tell us about it. Read the rest of this entry »

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Ethical Practice with Patients in Pain

January 20, 2016
Photo @ AJ Photo / Hop Americain / Science Photo Library

Photo @ AJ Photo / Hop Americain / Science Photo Library

Pain is difficult to define and hard to convey. The way both patients and clinicians respond to it can be influenced by a multitude of possible biases. This month’s Ethical Issues column in AJN is by Doug Olsen, PhD, RN, an associate professor at Michigan State University College of Nursing. In “Ethical Practice with Patients in Pain,” Olsen summarizes the challenge nurses and other clinicians face in treating patients’ pain:

Responding to a patient’s pain is a fundamental ethical obligation in nursing. However, nurses caring for patients in pain can run into ethical conflicts from both over- and undertreatment of pain. Undertreatment of pain represents a failure to fulfill the core nursing obligation to alleviate suffering—but overtreatment may ultimately harm the patient, contradicting a core nursing value, nonmaleficence. The complex nature of pain complicates efforts to provide treatment that is ‘just right.’ Nurses must understand that complexity if they are to make ethical decisions in the care of patients who experience pain.

Read the rest of this entry »

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Nurses and Latent TB Infection

January 18, 2016

By Betsy Todd, AJN clinical editor, MPH, RN, CIC

Mantoux skin test/CDC PHIL

Mantoux skin test/CDC PHIL

Are you “PPD positive”?

In December, a California maternity nurse was diagnosed with active tuberculosis. More than 1,000 people, including 350 infants, may have been exposed. In infants, tuberculosis can be hard to diagnose and is more likely than in newly infected adults to progress to active disease and to disseminate to extrapulmonary sites. Therefore, a course of isoniazid was recommended for each of these exposed infants, as well as for any parents, visitors, or staff who tested positive after the exposure.

Some of the details of this incident weren’t released to the media. In my experience, active infection in a health care worker who has not recently traveled to a TB-endemic area is almost always the result of reactivated latent infection. That was the case in a similar exposure more than 10 years ago, when a New York City maternity nurse exposed more than 1,500 infants and adults to active tuberculosis.

And in three of the largest TB exposure investigations on which I’ve worked, the index cases were nurses in oncology, transplant, and the ED whose latent tuberculosis infection progressed to active infection. In these three cases, neither the RNs nor their own primary care providers connected their persistent febrile respiratory infections with their latent TB status.

A positive purified protein derivative (PPD) skin test or TB blood test isn’t simply a benign occupational hazard; it’s an important part of your medical history. For your own safety and that of your family, patients, and coworkers, this information should always be shared with personal health care providers.

While latent disease is most likely to become active within the first two years after infection, many factors can cause later activation, including immunosuppression from drugs or disease, poorly controlled diabetes, certain cancers, chronic renal failure, and malabsorption syndromes, including those precipitated by gastric bypass surgery. The likelihood of reactivation also increases with age. Read the rest of this entry »

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Managing the All-Too-Real Symptoms of Fibromyalgia Syndrome

January 15, 2016

By Sylvia Foley, AJN senior editor

Capture

(click image to expand)

Fibromyalgia syndrome (FMS) is one of the most common rheumatic disorders, affecting as many as 15 million people in this country, the vast majority of them women. People with FMS typically experience chronic widespread pain, as well as various concurrent symptoms that can include fatigue, cognitive disturbances (such as memory problems, confusion, and difficulty concentrating), distressed mood (especially anxiety and depression), nonrestorative sleep, and muscular stiffness. One study found that up to 65% of patients experienced lost workdays as a result.

Yet as author Victoria Menzies reports in one of our January CE features, “Fibromyalgia Syndrome: Current Considerations in Symptom Management,” many health care providers “doubt the syndrome’s validity.” Diagnosis is often delayed for years.

Menzies provides a concise overview of the illness, which has no known cure, and then focuses on what can be done to alleviate symptoms and improve patients’ quality of life. Here’s a brief overview of the article:

Symptom management appears to be best addressed using a multimodal approach, with treatment strategies tailored to the individual. While medication may provide adequate symptom relief for some patients, experts generally recommend integrating both pharmacologic and nonpharmacologic approaches. Some patients may benefit from the adjunctive use of complementary and alternative medicine (CAM) modalities. Because symptom remission is rare and medication adverse effects can complicate symptom management, well-informed nursing care practices and patient education are essential. This article describes the existing treatment guidelines, discusses pharmacologic and nonpharmacologic approaches (including CAM-based modalities), and outlines nursing approaches aimed at enhancing patient self-management.

Read the rest of this entry »

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Health Technology Hazards, 2016: Inadequate Disinfection of Flexible Endoscopes Tops ECRI List

January 14, 2016
hazard/jasleen kaur, via Flickr

hazard/jasleen kaur, via Flickr

The ECRI Institute has released its Top 10 Health Technology Hazards for 2016 report, highlighting health technology hazards for health care facilities and nurses to focus on this year.

Although alarm hazards, which topped the list for the past four years, still pose a significant threat, topping the list at number two, a different repeat offender has claimed the number one spot: inadequate cleaning of flexible endoscopes before disinfection.

Proper reprocessing and cleaning of biologic debris and other foreign material from instruments before sterilization is key, according to the report. And flexible endoscopes, especially duodenoscopes, are difficult to clean because of their long, narrow channels. Failure to clean properly can result in the spread of pathogens. The report points to a series of fatal carbapenem-resistant Enterobacteriaceae infections in the last two years to illustrate this particular threat, and recommends that facilities emphasize to their reprocessing staff that inattention to proper cleaning steps can lead to deadly infections.

Some hazards, such as those arising from health information technology (HIT) issues, insufficient training of clinicians in operating room technologies, and failure to appropriately operate intensive care ventilators, have been touched on in previous years. (See our past posts on ECRI top 10 health technology hazards from 2013, 2014, and 2015.) Here is a brief overview of other hazards that made the cut.

Read the rest of this entry »

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‘I’m Worried About People in Pain’: A Nurse’s Take on Opioid-Prescribing Regulation Changes

January 12, 2016
by frankieleon/ via flickr

by frankieleon/ via flickr

Many patients and clinicians have strong feelings about opioids: they’ve seen a loved one denied adequate pain control, or they’ve seen a family member or friend’s son or daughter lost to prescription pill and/or heroin addiction, or they’ve worked in an ED with too many drug-seeking patients, or they’ve seen a patient in terrible pain waiting for a new analgesic order from an unavailable or uncompassionate physician.

But feelings don’t solve complex problems, and an excessively punitive or permissive approach can do more damage than good. Recently, there have been almost daily headlines and policy recommendations about the importance of restricting opioid-prescribing practices. The trend is alarming a number of clinicians with expertise in working with patients in pain. Clinical nurse specialist and pain management consultant Carol Curtiss addresses what’s at stake in “I’m Worried About People in Pain,” the Viewpoint essay in the January issue of AJN:

According to a 2011 Institute of Medicine report, chronic pain is a public health crisis . . . Well-intended efforts to address prescription drug abuse—another public health crisis—may place heavy burdens on people with pain who benefit from opioids and use them responsibly as part of a comprehensive treatment plan. . . . Gains made in pain treatment are at risk. New regulations threaten access to opioids for people with pain.

The essay details other unintended consequences resulting from a host of new or proposed regulations about opioid prescribing, including stigmatization of patients at times when they are most vulnerable and unrealistic regulatory burdens on clinicians, leading some to avoid prescribing opioids even when they are clearly indicated.

No ‘quick fix.’ No one denies that a subset of patients use prescription opioids inappropriately, or that a subset of clinicians and clinics in certain states prescribed for personal gain or in a spirit of recklessness. According to Curtiss, there’s much that can be done or is already being done to mitigate such concerns:

Controlling prescription drug abuse is critical, as is improved access to mental health and addiction treatments. But there is no “quick fix” for these complex problems. State prescription drug monitoring programs must collaborate to make databases available to clinicians across state lines. Prior authorization processes must be more efficient and more transparent. Clinicians should follow current guidelines that recommend comprehensive assessment and ongoing screening before and during opioid therapy; initiating opioids after risk–benefit analysis and as part of an individualized plan; measurable treatment goals, etc. . . .

But, says Curtiss, “denying or making access to pain medications more difficult for people with pain is not the solution.” Read the rest of this entry »

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A Nursing Perspective on a Recent NEJM Palliative Care Article

January 8, 2016

Pam MolloyBy Pam Malloy, RN, MN, FPCN, director and co-investigator of the ELNEC Project, American Association of Colleges of Nursing (AACN), Washington, DC.

I just read a New England Journal of Medicine article by Drs. Craig D. Blinderman and the late J. Andrew Billings that came out on Christmas Eve, 2015. “Comfort Care for Patients Dying in the Hospital” was a thoughtful, informative article and I am grateful that it appeared in a journal that wasn’t focused solely on hospice/palliative care.

2016_ELNECLogoWhile the information in the article is essential for all health care professionals, I would like to take this opportunity to remind my nursing colleagues that we have a tremendous opportunity and privilege to plan, provide, and orchestrate the care that was described in this article—and we have been doing so for some time.

Nurses spend more time at the bedside and out in the community assessing and managing patients with serious, complex illness than any other health care professional. Our interdisciplinary colleagues depend on our assessments and we play a major role in developing plans of care with our diverse team. We are there having difficult conversations with patients—many times in the middle of the night when they cannot sleep.  We are entrusted with their care. It is an awesome responsibility and opportunity to care for the most vulnerable in our society, to alleviate suffering, and to provide attention to grieving families. Read the rest of this entry »

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