Wednesday, September 9, 2015

A New View


A psychologist walked around a room while teaching stress management to an audience. As she raised a glass of water, everyone expected they'd be asked the "half empty or half full" question. Instead, with a smile on her face, she inquired: "How heavy is this glass of water?"

Answers called out ranged from 8 oz. to 20 oz.

She replied, "The absolute weight doesn't matter. It depends on how long I hold it. If I hold it for a minute, it's not a problem. If I hold it for an hour, I'll have an ache in my arm. If I hold it for a day, my arm will feel numb and paralyzed. In each case, the weight of the glass doesn't change, but the longer I hold it, the heavier it becomes."

She continued, "The stresses and worries in life are like that glass of water. Think about them for a while and nothing happens. Think about them a bit longer and they begin to hurt. And if you think about them all day long, you will feel paralyzed – incapable of doing anything."

Remember to put the glass down.

(I don't know who the author is so I am unable to give credit, but I did not write this myself! If you know who I need to credit, please comment or email me!)

Tuesday, June 16, 2015

Oral Nutrition Supplements: The RD Role in Wound Healing & Pressure Ulcer Prevention

I don’t really know what it was. Something in me compelled me to explore further. I knew that nutrition was important, why didn’t anyone else realize this? I had been a wound care nurse for three years, focusing in the outpatient wound clinic arena mixed with inpatient consults at 3 sister facilities.

Regardless of wound type, I always had the Braden Risk Assessment Scale on my mind as I generated the wound treatment plan, so the “prevention” thought process was there, somehow innate as a nurse. Years four through nine in wound care were spent running an inpatient wound care program for a 400-bed acute care hospital. I just knew that nutritional status had an enormous impact on patient wound healing, but I didn’t have evidence to back it up, because I hadn’t looked into it. I just knew it was more important than it got credit for… and then I began to learn about it first-hand.

I had several patient care scenarios where poor nutritional status was highlighted for me, but I couldn’t get anyone else to buy-in to the fact that it played such a huge part in the outcome. It took a few, eh-hem, serious and adverse learning opportunities, before anyone in leadership started to listen. I had the pleasure of meeting our facility’s RD early on, during the review of one such adverse event.

She was very knowledgeable, and had felt her own frustrations reach the tipping point, so it was truly a match made in heaven when we met and began to discuss an acute-care-world where nutrition was given the respect it deserves. She was so willing to learn about pressure ulcers and prevention, and she was equally open to sharing what she knew about nutrition with me. What we didn’t know, between the two of us, we sought to find out, and what each learned was shared immediately with the other. Finally! Someone who got what was in my brain! Why? Because NUTRITION was in my brain, and she was an RD!

We made a great team, each of us excited about what the other had to share. We had figured out how to improve our patient outcomes, and worked tirelessly to show that to anyone who had a role in patient care. We began to collaborate...not just talk here and there, but to actively communicate about the patients we were seeing. I began referring patients to the RD team, and she began informing the wound care team about patients with poor nutritional status. This open communication helped me to really understand what it meant to have an interdisciplinary team involved in the care of a patient.

We thought, “How can we make this better?” because by the time RD was brought in, there were already wounds present, or the patient was already malnourished. And by the time the wound care team was brought in on a patient, they already had a pressure ulcer or a wound. How could we empower the nurses to take action?? We both realized that for every Braden subscale category, there were actions the nurse could take to intervene, but for nutrition, the only action was passive: to initiate a referral to RD. We decided to change that.

What else could the nurse do for nutrition? We needed to empower the nurses with interventions that took action for the patient. So we did. We created an oral nutrition supplement protocol. The RD established criteria and I helped determine criteria for prevention of pressure ulcers or wound healing. Together we came up with 5 simple categories of triggers that the RN could easily identify, which would then be used in the decision tree for oral supplementation. The categories and triggers were:

If any of the 12 triggers were selected, the nurse was to use the decision tree to determine what oral nutritional supplement to begin for the patient. Factors considered in the decision tree included whether the patient was diabetic, if the patient had impaired renal function, and whether the patient needed tissue building. To initiate a protocol in the State of California, an MD order is required, so all it took was a TO from the MD to get nutrition initiated for the patient!

What we learned through this active, engaged collaboration between RD and Wound Care, was that we could make a big difference in the outcomes for our patients, if we opened up to each other and started utilizing the talents we each have, to focus our care for the patient.

Monday, June 8, 2015

Lippincott Stepping It Up with "How Caitlyn Jenner's Transition Affects Nursing Care"

Monday, June 8, 2015

I just received the greatest email in my inbox. Kudos to Lippincott for addressing current events and the effect on health care, specifically nursing practice. I hadn't thought of this being anything at all, but after receiving this email, I guess I have to expand my way of thinking. Again, KUDOS to them!! Here is what the email said:

Caitlyn Jenner, formerly known as Bruce Jenner, recently completed gender transition changing her physical appearance to align with her self-identification as a female. Last week Vanity Fair tweeted its latest cover featuring Jenner. This story has raised awareness of the struggles and misperceptions that are often faced by the lesbian, gay, bisexual, and transgender (LGBT) population. In our role, we need to be aware of special considerations in order to provide culturally-sensitive care to all patients.

On Lippincott NursingCenter, we have many resources that will provide you with the information you need to understand the unique health concerns of this population and overcome healthcare disparities.

Read the following CE articles free:

Caring for...Transgender Patients
Open the door for LGBTQ patients
Addressing Health Care Disparities in the Lesbian, Gay, Bisexual, and Transgender Population: A Review of Best Practices
Compassionately Caring for LGBT Persons in Your Faith Community
Culturally-Sensitive Care for the Transgender Patient

Additional resources can be found under the LGBT topic area on our site and for CE credit, we've bundled a selection of this content at a discounted rate in our LGBT CE Collection.

Also, be sure to check out our eBook, LGBTQ Cultures: What Health Care Professionals Need to Know About Sexual and Gender Diversity. This eBook serves as an overview and introduction to the health concerns and care for the LGBT community.

Thank you,
Lisa M. Bonsall, MSN, RN, CRNP
Clinical Editor
Lippincott NursingCenter

HOW COOL IS THAT EMAIL?? Thank you #Lippincott!!! Helping us all to become #better nurses and to continually show compassion for things we may otherwise not. I appreciate it!

Monday, April 13, 2015

Please vote to remove this add! Raises negative awareness toward ostomates!

Many nurses work very hard to help patients deal with the psychosocial challenges they face after having an ostomy. This ad does NOT support our efforts to enhance the patient's body image after ostomy!!!! The add suggests that an ostomy makes this woman "lesser" or unworthy. It associates feelings of guilt by suggesting it is her "punishment." This is not the image the public needs to have of any ostomate. We don't need this negative light shining on people with ostomies. The add portrays her as fearful to leave her home because it is "smelly" and she is afraid of leaks.

Please sign the petition to remove the add, by copying and pasting this link in your browser:

There are ways to target smoking cessation without causing undue judgment on someone who may already be suffering with concerns about body image and mortality. Don't give the public ammunition to further discrimination practices.

Thursday, February 12, 2015

CDPH Changes Mandatory Reporting of Pressure Ulcers

CDPH is the California Department of Public Health

Though this posting contains facts and attachments to support these facts, please be advised that the final paragraphs are only this authors opinion and commentary, meant to initiate the conversation we all should be interested in having right about now.

When the National Pressure Ulcer Advisory Panel (NPUAP) collectively determined revised definitions of pressure ulcers in 2007 to include the new categories of Unstageable and Deep Tissue Injury (DTI), it wasn't long before the Centers for Medicare & Medicaid Services (CMS) followed suit with reimbursement regulations for Pressure Ulcers diagnosed after admit to the hospital. Ulcers that were Stage 3, Stage 4, or Unstageable, were designated as adverse, and classified as one of the 27 (at that time) "Never Events" -- events that are preventable and therefore should never happen after someone is admitted to a hospital facility.

The California Department of Public Health (CDPH) sent out a mandated reporting clarification letter in May of 2008, indicating per statute that "hospitals are mandated to report all Stage 3 and 4 pressure ulcers acquired after admission to the health facility..." The reporting of DTI pressure ulcers was left unclear, as it was not discussed in this letter.

Many wound care clinicians and experts were clear on one fact: the DTI pressure ulcer was a full thickness injury to the tissues, reaching degradation at the bone, muscle, or subcutaneous levels, without an opening at the surface of the skin. There was no clear directive to report DTIs acquired after admit though, so many went unreported.

The 2008 letter from CDPH addressed the Unstageable pressure ulcer by stating, "Unstageable ulcers are either Stage 3 or Stage 4 ulcers that cannot be definitively placed in either category because of the eschar that is obstructing the clear observation of the wound. Unstageable ulcers are not stage 2 or stage 1. Thus all unstageable ulcers are reportable by hospitals as adverse events if acquired after admission, excluding progression from Stage 2 to Stage 3 if Stage 2 was recognized and noted upon admission."

After many inquiries into the nature of the Deep Tissue Injury pressure ulcer, CDPH sent out another clarification letter to acute care facilities in February of 2010. The letter stated, "Based upon the NPUAP’s definition of a DTI, the tissue involvement of a DTI does not support a Stage 3 or 4 pressure ulcer. Thus, CDPH [Licensing & Certification] does not require the reporting of a DTI as an adverse event." Though they went on to state, "However, should the DTI progress to a Stage 3 or 4 ulcer after admission to the hospital, the hospital would then be required to report the ulcer as an adverse event..."

Only 2 days ago, on February 9, 2015, CDPH sent out another letter to the acute care facilities. In this letter, we come to learn that there is no longer a mandate to report Unstageable or DTI pressure ulcers as adverse events. In the letter it clearly states, "CDPH recommends the careful documentation of skin conditions and instances of suspected deep tissue injuries or unstageable/unclassified wound conditions in the patient’s medical record. If the unstageable ulcer or suspected deep tissue injury progresses and is classified as a Stage 3 or 4 pressure ulcer, it becomes an adverse event reportable to CDPH." So basically, find the DTI or Unstageable, document it clearly in the medical record, but don't worry about reporting it to any authority, because we don't really care about them, we only care about Stage 3 and Stage 4 ulcers.

Wow! I suppose this should be a celebration, a deep sigh of relief, and a "thank God" moment, but I am deeply disturbed to hear this, knowing what I do about the characteristics of DTI and Unstageable ulcers. These are full thickness assaults on the integrity of the skin and underlying tissues. If there is negligible care given that results in the formation of either of these conditions, apparently there is no longer accountability to the State. Ok I guess. Right? NO!! This is not right.

Hospital Administration is thrilled, Quality Assurance is relieved, and Risk Management is cautiously optimistic--as families may still pursue legal action for this, but hey! "the State is off our back now" right? Well, I hope that facilities strengthen their own internal reporting practices, to maintain some sort of care and practice standard. It must be understood that these ulcerations create potential for severe detriment to the patient, with risks that include scarring, pain, blood loss, infection, and even death due to sepsis from a wound infection.

Well, imagine this scenario: A male 48 year old patient is admitted for cardiac issues, and is now in the Intensive Care Unit. He slowly recovers and is transferred to a Step Down unit. Because this guy seems so much better, the staff doesn't worry about him as much, and they only peek in here and there but never really perform a full skin assessment. You know, they don't want to cause any possible embarrassment to him by asking to inspect his genital or buttock areas...that's a good excuse right? Ok, now he's well enough to be discharged, but he will be sent to a Rehab facility for a few weeks before being allowed to return to his home. Upon arrival to the Rehab facility, they discover a thick leathery dried coat of dark brown eschar measuring 6 x 9 cm over his sacrum. This is a pressure ulcer, and it is full thickness. This massive wound was created IN THE HOSPITAL, but there will be no accountability, no penalty, and no hope for changing the culture of care at that hospital, because no one really cared enough to enforce the minimal standard of care expectation. And it won't do any good to tell on them for it, because now there is no one to tell.

I think this recent letter is a sad indication of how inundated CDPH really was, with too many reports of adverse pressure ulcer events, and not enough funding to support the necessary investigation of the event by a State reviewer. It is just sad, and likely to get a "whole lot" worse, before it gets better.

Read the letter at this link:

Monday, January 5, 2015

Skin, Wound, and Ostomy Certification -- upcoming course

Skin, Wound, Ostomy Certification course for LVN/LPN/RN near Los Angeles in February. Call now for a special rate!

Check out the website by copying and pasting into your browser: