Why Didn’t Physicians Know What Nurses Know?

By Shawn Kennedy, AJN interim editor-in-chief

A recent post on our blog highlighted the experience of AJN’s associate editor Amy Collins in trying to get someone to diagnose the underlying reason for acute confusion in her grandmother. Over a two-week period, Amy’s grandmother was seen by various private and ED physicians, none of whom seemed to have an adequate diagnosis or a suggestion for treatment. Finally, nurses suggested that a urinary tract infection (UTI), fecal impaction, or some other infection might be a factor. It was a fecal impaction and yet none of the five physicians who previously evaluated Amy’s grandmother had thought about or assessed for it.

What the nurses said. Amy’s post generated many comments, both on the blog and on our Facebook page. What was interesting to me was how many nurses knew to first check for a UTI, electrolyte disturbance, or fecal impaction as a reason for confusion. Here are a few samples:

“Though not conclusive, in every case I have seen a change in cognition or behavior it was either a UTI or fecal impaction. I work in home health as a CNA and I am a nursing student.”

“The first thing I think to check is infection (UTI) with elderly, confused patients.”

“I’m a senior nursing student…and this material is on our exam that we are taking Friday. With acute confusion, always check for UTI and constipation.”

“Possible UTI. Possible dehydration &/or  constipation. Poor nutrition. All can (and do) manifest as “altered mental status.” Think I’d start with […]

2016-11-21T13:15:35-05:00September 27th, 2010|healthcare social media, nursing perspective|1 Comment
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When Delirium Is Mistaken for Dementia

We hope you had a chance to read “No Country for Old Women,” yesterday’s moving post by AJN associate editor Amy Collins, in which she described the failure of multiple providers to assess and treat the underlying cause of her grandmother’s rapid acceleration of already existent dementia symptoms (or what were assumed to be dementia symptoms).

It so happens that several years ago we ran an article on a frequently undiagnosed condition in older adults; the article was called “Delirium Superimposed on Dementia.” Maybe this is why two of our nurse editors were able to point Amy in the right diagnostic direction as to possible hidden causes of her grandmother’s crisis. Here’s an excerpt from that article:

A systematic review . . . found that prevalence rates of delirium in people with dementia ranged from 22% among older adults who lived in the community to 89% in hospitalized patients . . .  It’s more difficult to recognize delirium in people with dementia than in those without because of overlapping symptoms, difficulty in ascertaining baseline mental status and the acuteness of symptoms, and the tendency to attribute symptoms of delirium to a worsening of dementia symptoms.4 Yet early recognition is essential in order to determine and treat underlying causes; institute interventions to maintain safety; [and] restore prior cognitive function and improve short- and long-term outcomes.

The article gives a useful algorithm for recognizing as well as managing this condition. There’s also a video which discusses the condition and shows a […]

2016-11-21T13:15:36-05:00September 23rd, 2010|nursing research|0 Comments
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No Country for Old Women

By Amy M. Collins, associate editor

For the past few weeks, my family has been living a health care nightmare. My 85-year-old grandmother, physically fit and as beautiful as an old-time movie star, but suffering from the first stages of Alzheimer’s disease, had a major meltdown. Her assisted living facility called to say she was harassing the residents and staff, claiming her belongings had been stolen, shouting at people at random, and even calling the police. Clearly not equipped to handle this level of agitation, the facility turned to us to pick her up and keep her for a few days.

The week that followed proved arduous—nobody seemed to know what to do with her. Her GP was at a loss, suggested that we bring her to the ED. Her neurologist prescribed Seroquel (after having to tackle and physically restrain her from the subsequent episode of screaming and pounding her fists on the wall, we called to tell the neurologist that the pill wasn’t working; he said to give her more; four pills later, she was still mildly agitated.) This went on for over a week. She came to live with us, where we listened, exhausted, to constant chatter that didn’t make sense. The talking never stopped—her voice grew hoarse […]

2016-11-21T13:15:38-05:00September 22nd, 2010|nursing perspective, patient engagement|7 Comments
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What Nursing Independence? And Other Notes from the Nursosphere…

Here’s some stuff we’re reading online this week:

In one of the health systems that I interface with nurses can no longer document that they held a patient’s medications based on ‘nursing judgment’. Such an instance might be when a patient had hypotension from pain medication and thus the morning anti-hypertensive is held. Instead, they need an order from a physician to hold such medication. Further, something like ‘Tylenol’ on a patient’s medication record ordered for fever could not be administered by the nurse for a headache if the patient requested it because that would be ‘practicing medicine without a license’.  A nurse cannot order a social services consult, flush a urinary catheter should it become clogged, refer a patient for diabetes education, etc., etc., without an order from the supervising physician.

That’s from a smart, if somewhat depressing, blog post at Nurse Story called “Independent Nursing Practice: Reality or Still the ‘Physician’s Hand’?” The writer, Terri Schmitt, goes on to wonder just how nurses can carve out areas of independent practice, even in the most basic matters. Good questions.

And here’s a question of interpretation raised by an incident in Colorado involving a nurse and the policeman who stopped her for speeding:

When Colorado Springs cardiac nurse Miriam Leverington was stopped for speeding, she grumbled to the police officer.

“I hope you are not ever my patient,” she reportedly told him.

What happened next has become a topic of widespread debate in Colorado and on the blogosphere. The police officer, Duaine Peters, complained to the […]

2016-11-21T13:15:39-05:00September 21st, 2010|career, nursing perspective|0 Comments
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A Nurse Cartoonist Worth Checking Out

Drawing on Experience is a blog run by a student who’s been completing an accelerated BSN program in nursing and who illustrates his education and personal life with remarkably subtle and witty cartoons. Hat tip to a recent Change of Shift blog roundup at Emergiblog for letting us know about his work. It would be wrong to reproduce this artist’s work here without permission, and he might not like it, so I’m just including a really really tiny version of a recent cartoon illustrating his induction into the nursing honor society. It links back to his original Web site, where you can see this and many other cartoons in full, legible size (and of course, upon request, we’ll gladly remove the thumbnail image here!).

What makes this artist’s work so much fun? The tongue-in-cheek, martial-arts-disciple-and-wise-man narrative? The humility and sense of pleasure in life’s ironies and challenges? The quality of line? The attention to apparently trivial details? The way his mini-narratives play with genre conventions? At any rate, it’s a welcome addition to the nursosphere; I don’t see any contact info on this artist’s blog, but we hope he’ll find time to continue (and consider letting us publish one of his drawings on the blog or in AJN).—JM, senior editor/blog editor

2016-11-21T13:15:41-05:00September 17th, 2010|career, nursing perspective, students|1 Comment
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Views expressed on the blog are solely those of the authors or persons quoted. They do not necessarily reflect AJN’s views or those of Wolters Kluwer Health/Lippincott Williams and Wilkins.
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