tag:blogger.com,1999:blog-72772059284282970102024-03-15T10:11:00.025-07:00Wound Care WisdomProv 3:7-8 ...obey the Lord and refuse to do wrong. If you do, it will be like good medicine, healing your wounds... woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.comBlogger32125tag:blogger.com,1999:blog-7277205928428297010.post-43784927314692138792023-08-10T14:30:00.006-07:002023-08-10T14:34:22.341-07:00Recognizing Boundaries in Medical Practice: Antivaxxer Parents<p> <strong style="color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px;">The Experience</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":2,"335551620":2,"335559685":0,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" face=""Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif" style="color: #2d3b45; font-size: 16px; margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">For this patient visit, I shared participation 50/50 with my preceptor. A 7-year-old female patient was accompanied by mother and brother for annual well-child exam. Patient scored a 28 on the Pediatric Symptom Checklist for Child 6-16, which is a positive score (greater than 27). The True-tone Hearing screening test was performed and passed. The vision wall chart was attempted, and patient is currently established with an eye doctor and has an appointment scheduled in one week. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">She has a past medical history of autism spectrum disorder (diagnosed 3.5 years ago), specific developmental disorder of motor function, mixed receptive-expressive language disorder, and today was diagnosed with hypertrophy of tonsils with hypertrophy of adenoids. Mom reported some muffled voice concerns, loud breathing when sleeping, discipline issues at home, and concerns that child struggles with anger/emotional regulation with siblings. The exam findings revealed normal vital signs, 2+ tonsils without erythema or exudate and no other significant findings. There is a family history of tonsillar enlargement. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">A release of information was signed by parent, in order to obtain diagnostic records for autism disorder for the clinic records, as school is wanting the diagnosis records to formulate the IEP or interventional education plan. I also requested in-house behavioral health counselor to visit with parent regarding emotional regulation concerns. A referral was made to the local otolaryngologist for possible tonsillectomy and adenoidectomy procedures, because of the adenotonsillar hypertrophy, muffled voice, and obstructive concerns. These issues are causing problems for sleep, which may in turn be increasing behavioral problems. According to Nationwide Children’s (n.d.), “School-aged children who do not get enough sleep are more likely to have behavior problems” (para. 4). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; margin: 12px 0px;"><span data-contrast="none"><span style="color: #2d3b45;">Upon review of her immunization record, it is notable that </span><b><span style="color: #674ea7; font-size: medium;">she is behind on all vaccinations</span></b><span style="color: #2d3b45;">, so the following were recommended to <u>begin the catch-up schedule</u>: Tdap, Hep A, Hep B, MMR, varicella, and inactive poliovirus (Advisory Committee on Immunization Practices [ACIP], n.d.). The immunizations were not carried out during this visit because of caregiver refusal, as the parent does not consent to immunizations at this time. I discussed the importance of immunization per ACIP schedule, as well as recommendations through Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatricians (AAP). Discussed concerns with risk of delaying immunization, including risk for child death due to vaccine preventable disease. Parental vaccine refusal form completed. </span></span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="color: #2d3b45; font-size: 16px; margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none" style="margin-bottom: 0px;">A reason for refusal is <u>not needed for the medical record</u>, unless there is a medical indication for not receiving the vaccinations. Why? Because regardless of the non-medical reason, the child is missing out on multiple opportunities to be protected from serious illnesses that could result in permanent disability or death. It does not matter why, because the result does not change. Public school is typically the system that requires a reason, and acceptable exemptions vary by state.</span></p><p style="background-color: white; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none" style="color: #2d3b45;">In Kansas, there is a form for medical exemption only. If parent/guardian is refusing vaccinations based on the child being</span><span data-contrast="auto"><span style="color: #2d3b45;"> “...</span><span style="color: red;"><i>an adherent of a religious denomination whose religious teachings are opposed to such tests or inoculations</i></span><span style="color: #2d3b45;">...” then they must provide a statement written and signed by one parent or guardian (Kansas Department of Health and Environment [KDHE], 2019, p. 1). I do not know of denominations that have such oppositions, honestly. I am still searching though!</span></span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 80px;"><i>Side note: Despite APRN now having authority to practice independently in Kansas, the </i><i>medical exemption form (and several other state forms) still requires </i><i>a physician’s </i><i>signature, and specifically indicates MD or DO under the signature line!</i><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">The visit note in the medical record for this patient reflected the following results:</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><ul style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 0px 0px 0px 25px; padding: 0px;"><li data-aria-level="1" data-aria-posinset="1" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559684":-2,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="5" style="margin-bottom: 0px;"><span data-contrast="none">DTAP/HIB/IPV (Pentacel) (Not administered - Refused: Parental decision).</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></li></ul><ul style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 0px 0px 0px 25px; padding: 0px;"><li data-aria-level="1" data-aria-posinset="1" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559684":-2,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="5"><span data-contrast="none">Hep A (VFC) (Not administered - Refused: Parental decision). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></li><li data-aria-level="1" data-aria-posinset="2" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559684":-2,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="5"><span data-contrast="none">Prevnar (PCV-13) (Not administered - Refused: Parental decision). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></li><li data-aria-level="1" data-aria-posinset="3" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559684":-2,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="5"><span data-contrast="none">MMR (Not administered - Refused: Parental decision). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></li><li data-aria-level="1" data-aria-posinset="4" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559684":-2,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="5"><span data-contrast="none">Varicella (Not administered - Refused: Parental decision). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></li><li data-aria-level="1" data-aria-posinset="5" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559684":-2,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="5" style="margin-bottom: 0px;"><span data-contrast="none">Hep B ped/adol (Not administered - Refused: Parental decision).</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></li></ul><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">Again, <u>the reason for refusal is not appropriate for the medical record</u> unless it is a medical reason, which is uncommon. Some instances of medical exemption may include an allergy to some immunization components, having an immune deficiency, or having an illness such as cancer. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">In Missouri, they do not mince words when describing the unexpected consequences that may befall the unvaccinated child and family. </span></p><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px;"><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px;"><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; text-align: left;"><span data-contrast="none">“</span><span data-contrast="auto">To protect those who cannot be vaccinated and the entire community, unimmunized children could be excluded from school and child care during disease outbreaks. Exclusion from care can cause a hardship for the child and parent, however no exceptions are made, regardless of the circumstances” (Missouri Department of Health and Senior Services [MDHSS], 2022, para. 3). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p></blockquote></blockquote><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>Thoughts and Feelings</strong><span data-contrast="auto"> </span><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">This is a tough one for me. I spent four months as a contractor with the CDC (through Maximus) developing scripted responses and training materials with an aim to resolve vaccination hesitancy. I thoroughly enjoyed the experience and gained great insight into those reluctant to trust governmental agencies with their health. Primarily these were folks that fall into the minority classification, and possibly with a lower health literacy level, yet with valid reasons for mistrust and even resistance. Just do an internet search on the Tuskegee study, the forced hysterectomies/mass sterilization of Native American women, and the use of Henrietta Lacks "immortal cells," just to name a few... among many other examples of abuse and deceit, which both vindicates and explains their level of mistrust. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">Anyway, those are hesitancy or refusal issues I can understand – sort of – but I am having a very difficult time maintaining rational discernment and unbiased perception when it comes to the recent years’ exemptions in the name of religion. </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">It’s not that I am unable to get on board in support of those religious freedoms and choices, but more so that I question the <u>robust increase</u> in religious exemptions over the past several years.</span></p><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px; text-align: left;"><h4 style="background-color: white; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; text-align: center;"><span data-contrast="none"><span style="color: #800180;"><b>I question whether or not they are truly grounded in religious<br /></b></span></span><span data-contrast="none"><span style="color: #800180;"><b>doctrine or if they are simply politically driven. </b></span></span></h4></blockquote><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; text-align: left;"><span data-contrast="none">I am forever bothered after learning that “...religious objection is often used by parents as an excuse to avoid the vaccination of their children...” rather than it being a real exception for vaccination (Pelcic, et al., 2016, para. 4). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>Evaluation of Strengths and Challenges</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">The challenge for me is of course not opening my mouth to challenge the parent/guardian belief system or decision. The challenge is to not create a new brain injury category called </span><i><b>shaken adult syndrome</b></i><span data-contrast="auto">. The challenge is to educate and not persuade, to inform and not antagonize, to support and enlighten rather than judge and disparage. The challenge is to not go home at the end of the day, defeated, because every well child checkup resulted in a parent’s refusal to vaccinate. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">The strengths are that I succeed in most of the above-listed dichotomies. At least for now, I keep my mouth shut, I don’t <strong style="margin-bottom: 0px;"><em style="margin-bottom: 0px;">murder-shake</em></strong> the adults. I educate, inform, and enlighten. I don’t support the decision or choice, but I <u>do</u> support the fact that they get to make a decision or that they get to choose. Unfortunately, on more than one occasion I did go home at the end of the day fully defeated, because every well child checkup resulted in the parent’s refusal to vaccinate. But my strength is wearing thin, and I feel myself slipping. I feel myself slipping into judgment and irritability because my expectations are apparently too high to be met. But why should I lower my standards? </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>Analysis and Self Reflection</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">Well in true analytical fashion, I recognize that I am powerless over another’s choice, and that <u>it is unethical for me to attempt to persuade a patient </u>or their guardian/parent into a choice they don't want. Although my wily guiles are capable of persuasion in the most challenging circumstances, I recognize that as the medical provider I must remain unbiased (as much as possible) and objective. It is so hard to sit back and watch what is happening, inevitably, to our herd immunity status. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none" style="margin-bottom: 0px;">I think the scariest, most upsetting part for me, is that I catch myself being inched closer and closer to secretly make an “instawish” that the kid catches some preventable disease and suffers - just to “teach the parent a lesson.” THIS IS NOT WHO I AM OR WHO I WANT TO BE.</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">As if it is my job to "scold" and mother the patient or family. When I think about being turned into that person, I feel sick to my stomach, and am thankfully reminded that I will do whatever I can to never become that person. </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">I actually don’t even like movies where we are rooting for a protagonist that started off the movie by breaking the law or something, because the movie implicates excuses and triggers understanding as to reasons behind their unlawful or unethical behavior. I get caught up in it and then realize I have been rooting for a bad guy the whole time - and the movie tricked us all. </span></p><p style="background-color: white; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"><i><span style="color: #c27ba0;">Take away:</span></i></span></p><p style="background-color: white; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"><i><span style="color: #c27ba0;">My hope is that you take the following terms with you as you leave this page: shaken adult syndrome and murder-shake. Those were a 3am contribution to the post and I woke up the next day not remembering and also choosing not to remove them because they just add "flare" hahah</span></i></span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>References</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":2,"335551620":2,"335559738":0,"335559739":160,"335559740":259}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Advisory Committee on Immunization Practices (ACIP). (2023, June 27). </span><i>ACIP recommendations. </i><span data-contrast="auto">Centers for Disease Control and Prevention. </span><a class="external" href="https://www.cdc.gov/vaccines/acip/recommendations.html" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.cdc.gov/vaccines/acip/recommendations.html</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-contrast="auto"> </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Centers for Disease Control and Prevention (CDC). (n.d.). Immunization schedules. </span><i>Catch-up immunization schedule for children and adolescents who start late or who are more than 1 month behind.</i> <a class="external" href="https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-contrast="auto"> </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Kansas Department of Health and Environment (KDHE). (2019, March 4). </span><i>Kansas statutes related to school immunizations.</i> <a class="external" href="https://www.kdhe.ks.gov/DocumentCenter/View/1233/Kansas-Statutes-Related-to-School-Immunizations-PDF" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.kdhe.ks.gov/DocumentCenter/View/1233/Kansas-Statutes-Related-to-School-Immunizations-PDF</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-contrast="auto"> </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Kansas Department of Health and Environment (KDHE). (n.d.).</span><i> Immunization requirements. </i> <a class="external" href="https://www.kdhe.ks.gov/324/Immunization-Requirements" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.kdhe.ks.gov/324/Immunization-Requirements</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-contrast="auto"> </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Kansas Secretary of State. (2019, July 18). </span><i>Kansas immunization regulations for school</i><span data-contrast="auto">. Kansas Register, Vol. 38 No. 29. </span><a class="external" href="https://www.kdhe.ks.gov/DocumentCenter/View/21197/Kansas-Immunization-Regulations-for-School--Child-Care-PDF" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.kdhe.ks.gov/DocumentCenter/View/21197/Kansas-Immunization-Regulations-for-School--Child-Care-PDF</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-contrast="auto"> </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Missouri Department of Health and Senior Services (MDHSS). (2022, December 1). Medical exemption - what you need to know. </span><a class="external" href="https://health.mo.gov/living/wellness/immunizations/pdf/immp12.pdf" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://health.mo.gov/living/wellness/immunizations/pdf/immp12.pdf</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> <span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Nationwide Children’s. (n.d.).</span><i> Sleep in school-aged children. </i><span data-contrast="auto">Nationwide Children’s Hospital. </span><a class="external" href="https://www.nationwidechildrens.org/specialties/sleep-disorder-center/sleep-in-school-aged-children" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.nationwidechildrens.org/specialties/sleep-disorder-center/sleep-in-school-aged-children</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-contrast="auto"> </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Pelcic, G., Karacic, S., Mikirtichan, G. L., Kubar, O. I., Leavitt, F. J., Cheng-Tek Tai, M., Morishita, N., Vuletic, S., Tomasevic, L. </span><i>Religious exception for vaccination or religious excuses for avoiding vaccination</i><span data-contrast="auto">. </span><a class="external" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5141457/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5141457/</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><div><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"><br /></span></div>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-37164998771346957442023-08-08T19:39:00.000-07:002023-08-08T19:39:02.193-07:00ICD-10 and Procedure Codes Related to ACEs <p>So when we use a screening tool for ACEs, we can use a procedure code to capture it. That code is:</p><p style="padding-left: 40px;"><strong>96160</strong> Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument</p><ul>
<li style="list-style-type: none;">
<ul>
<li style="list-style-type: none;">
<ul>
<li>Here is the screening tool for adults <a class="instructure_file_link instructure_scribd_file inline_disabled" data-canvas-previewable="false" href="https://www.acesaware.org/wp-content/uploads/2022/07/ACE-Questionnaire-for-Adults-Identified-English-rev.7.26.22.pdf" rel="noopener noreferrer" target="_blank" title="ACE Questionnaire for Adults.pdf">ACE Questionnaire for Adults.pdf</a></li>
<li><span style="font-family: inherit; font-size: 1rem;">Here is a guide for family practitioners from MacKay & Taylor (2020) <a class="instructure_file_link instructure_scribd_file inline_disabled" data-canvas-previewable="false" href="https://divisionsbc.ca/sites/default/files/Divisions/Kootenay%20Boundary/ACEs%20Toolkits/ACEs%20Booklet%20FPs%20v8-Electronic.pdf" rel="noopener noreferrer" target="_blank" title="ACEs Booklet Family Practitioners.pdf">ACEs Booklet Family Practitioners.pdf</a></span></li>
<li><span style="font-family: inherit; font-size: 1rem;">Here are the screening tools for pediatric patients from ACES Aware (n.d.)</span>
<ul>
<li><span style="font-family: inherit; font-size: 1rem;">Child: <a class="instructure_file_link instructure_scribd_file inline_disabled" data-canvas-previewable="false" href="https://www.acesaware.org/pdf_wrapper/pearls-tool-child-parent-caregiver-report-identified-english-rev-7-26-22/" rel="noopener noreferrer" target="_blank" title="PEARLS-Tool-Child-Parent-Caregiver.pdf">PEARLS-Tool-Child-Parent-Caregiver.pdf</a></span></li>
<li><span style="font-family: inherit; font-size: 1rem;">Teen: <a class="instructure_file_link instructure_scribd_file inline_disabled" data-canvas-previewable="false" href="https://www.acesaware.org/pdf_wrapper/pearls-teen-parent-caregiver-report-identified/" rel="noopener noreferrer" target="_blank" title="PEARLS-Teen-Parent-Caregiver.pdf">PEARLS-Teen-Parent-Caregiver.pdf</a></span></li>
<li><span style="font-family: inherit; font-size: 1rem;">Teen, Self Reported: <a class="instructure_file_link instructure_scribd_file inline_disabled" data-canvas-previewable="false" href="https://www.acesaware.org/pdf_wrapper/pearls-tool-teen-self-report-identified-english/" rel="noopener noreferrer" target="_blank" title="PEARLS-Tool-Teen-Self-Report.pdf">PEARLS-Tool-Teen-Self-Report.pdf</a></span></li></ul></li></ul></li></ul></li></ul><p>If you are interested in the ICD 10 coding options that may be used for ACEs in adults (and sometimes children), I did a little research and found some - there are probably more but here are a few according to ICD10Data.com (n.d.-a):</p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;">
</p><div class="bCOlv" data-ved="2ahUKEwjQ8rX-rM6AAxUClWoFHcVFD5EQ7NUEegQIERAE" id="_7OHSZNDMCIKqqtsPxYu9iAk_29">
<div class="IZE3Td">
<div class="t0bRye r2fjmd" data-hveid="CBEQBQ" data-ved="2ahUKEwjQ8rX-rM6AAxUClWoFHcVFD5EQu04oAHoECBEQBQ">
<div id="7OHSZNDMCIKqqtsPxYu9iAk__18">
<div class="wDYxhc" data-md="61">
<ul>
<li><span style="color: #843fa1;"><strong>Z00 - Z99</strong> <span style="font-family: inherit; font-size: 1rem;">Factors influencing health status and contact with health services</span></span>
<ul>
<li aria-level="3" class="LGOjhe" data-attrid="wa:/description" data-hveid="CBUQAA" role="heading"><strong>Z62</strong> <span style="font-family: inherit; font-size: 1rem;">Problems related to upbringing</span></li>
<li aria-level="3" class="LGOjhe" data-attrid="wa:/description" data-hveid="CBUQAA" role="heading"><strong>Z62.81</strong> <span style="font-family: inherit; font-size: 1rem;">Personal history of abuse in childhood</span></li>
<li aria-level="3" class="LGOjhe" data-attrid="wa:/description" data-hveid="CBUQAA" role="heading"><strong>Z62. 812 </strong>Personal history of neglect in childhood</li>
<li aria-level="3" class="LGOjhe" data-attrid="wa:/description" data-hveid="CBUQAA" role="heading"><strong>Z62.898</strong> <span style="font-family: inherit; font-size: 1rem;">Other specified problems related to upbringing</span></li>
<li aria-level="3" class="LGOjhe" data-attrid="wa:/description" data-hveid="CBUQAA" role="heading"><span style="font-family: inherit; font-size: 1rem;"><strong>Z62.9</strong> Negative life events in childhood </span></li>
<li aria-level="3" class="LGOjhe" data-attrid="wa:/description" data-hveid="CBUQAA" role="heading"><strong style="font-family: inherit; font-size: 1rem;">Z91.</strong><strong style="font-family: inherit; font-size: 1rem;">49</strong><span style="font-family: inherit; font-size: 1rem;"> Other personal history of psychological trauma, not elsewhere classified</span></li>
<li aria-level="3" class="LGOjhe" data-attrid="wa:/description" data-hveid="CBUQAA" role="heading"><strong>Z87.828</strong> Personal history of other (healed) physical injury and trauma</li>
<li aria-level="3" class="LGOjhe" data-attrid="wa:/description" data-hveid="CBUQAA" role="heading"><strong>Z91</strong> Personal risk factors, not elsewhere classified<strong style="font-family: inherit; font-size: 1rem;"></strong></li>
</ul>
</li>
</ul>
<p><span style="font-family: inherit; font-size: 1rem;">And the</span><strong style="font-family: inherit; font-size: 1rem;"> <span style="color: #843fa1;">Z59 Child Codes</span></strong><span style="font-family: inherit; font-size: 1rem;"> section has individual diagnoses codes for SDOH! </span><span style="font-family: inherit; font-size: 1rem;">From Codify (n.d.) here they are:</span></p>
<ul>
<li style="list-style-type: none;">
<ul>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59</strong> Problems related to housing and economic circumstances</span></li>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59.0</strong> Homelessness</span></li>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59.1</strong> Inadequate housing</span></li>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59.2</strong> Discord with neighbors, lodgers and landlord</span></li>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59.3</strong> Problems related to living in residential institution</span></li>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59.4</strong> Lack of adequate food</span></li>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59.5</strong> Extreme poverty</span></li>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59.6</strong> Low income</span></li>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59.7</strong> Insufficient social insurance and welfare support </span></li>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59.8</strong> Other problems related to housing and economic circumstances</span></li>
<li><span style="font-family: inherit; font-size: 1rem;"><strong>Z59.9</strong> Problem related to housing and economic circumstances, unspecified</span></li>
</ul>
</li>
</ul>
<p>Terrific, right?? </p>
<p>So, we can use the <strong>Z59</strong> codes to capture issues related to pediatrics, and the codes in the previous section are probably better used for adults, if I am understanding it correctly. Finally, here are a few more interesting codes:</p>
<ul>
<li style="list-style-type: none;">
<ul class="list">
<li><strong>R68.13</strong> Apparent life threatening event in infant (ALTE)</li>
<li><strong>R68.19</strong> Other nonspecific symptoms peculiar to infancy</li>
<li><strong>Z62. 21 </strong>Child in welfare custody</li>
</ul>
</li>
</ul>
<p>The Diagnosis Related Groups (DRG) dataset 951 is for "Other factors influencing health status" (ICD10Data.com, n.d.-b, title). <span style="font-family: inherit; font-size: 1rem;">"DRGs are used for determining reimbursement and as an indicator for other types of reporting such as budgeting, physician profiling, clinical outcomes, case mix calculation and clinical research" (The University of Texas Medical Branch at Galveston, n.d., para. 13).</span></p>
<p><span style="color: #843fa1;"><strong>Additional note to remember: </strong></span></p>
<p>Z codes in general are used as secondary codes, unless it is for an encounter (Z00.00, Z00.121, Z00.129, etc).</p>
<p><span style="font-family: inherit; font-size: 1rem;">And here is a linked resource that is terrific: <a class="inline_disabled" href="https://njaap.org/wp-content/uploads/2021/10/Tips-for-Coding.pdf" rel="noopener noreferrer" target="_blank"><strong>Tips for ACEs Related Coding </strong></a> </span><span style="font-family: inherit; font-size: 1rem;">It summarizes coding practices, like I attempted to above. It was put together by the </span>New Jersey Chapter of the American Academy of Pediatrics (NJAAP) (2019). </p><p><strong>References</strong></p>
<p>ACES Aware. (2023, March 16). <i>Screening tools</i>. Learn About Screening. <a href="https://www.acesaware.org/learn-about-screening/screening-tools/" rel="noopener" target="_blank">https://www.acesaware.org/learn-about-screening/screening-tools/</a> </p>
<p>Codify. (n.d.). ICD-10-CM code for problems related to housing and economic circumstances Z59. <a href="https://www.aapc.com/codes/icd-10-codes/Z59" rel="noopener" target="_blank">https://www.aapc.com/codes/icd-10-codes/Z59</a> </p>
<p>ICD10Data.com. (n.d.-a). 2023 ICD-10-cm diagnosis code z62: Problems related to upbringing. <a href="https://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z55-Z65/Z62-/Z62" rel="noopener" target="_blank">https://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z55-Z65/Z62-/Z62</a> </p>
<p>ICD10Data.com. (n.d.-b). <i>DRG 951</i>. 2023 DRG List Page. <a href="https://www.icd10data.com/ICD10CM/DRG/951" rel="noopener" target="_blank">https://www.icd10data.com/ICD10CM/DRG/951</a> </p>
<p>MacKay, L., & Taylor, M. (2020, December 16). <i>A toolkit for practitioners</i>. ACEs Booklet FPs v8-Electronic.pdf. <a href="https://divisionsbc.ca/sites/default/files/Divisions/Kootenay%20Boundary/ACEs%20Booklet%20v5_Electronic.pdf" rel="noopener" target="_blank">https://divisionsbc.ca/sites/default/files/Divisions/Kootenay%20Boundary/ACEs%20Booklet%20v5_Electronic.pdf</a> </p>
<p>New Jersey Chapter of the American Academy of Pediatrics (NJAAP). (2019, May 20). <i>TIPS for aces-related coding </i>. Tips for ACEs Related Coding_noMark.pdf. <a href="https://njaap.org/wp-content/uploads/2021/10/Tips-for-Coding.pdf" rel="noopener" target="_blank">https://njaap.org/wp-content/uploads/2021/10/Tips-for-Coding.pdf</a> </p>
<p>The University of Texas Medical Branch at Galveston. (n.d.). <i>Description of coding and DRG assignment</i>. Revenue Cycle Operations. <a href="https://www.utmb.edu/rco/Employees/DCDA" rel="noopener" target="_blank">https://www.utmb.edu/rco/Employees/DCDA</a> </p>
</div>
</div>
</div>
</div></div>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-64432415388337347182023-08-07T18:51:00.005-07:002023-08-07T18:58:27.565-07:00ACEs - Adverse Childhood Experiences <p><strong style="color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin-bottom: 0px;"><span class="TextRun SCXW266830186 BCX0" data-contrast="none" lang="EN-US" style="margin-bottom: 0px;"><span class="NormalTextRun SCXW266830186 BCX0" style="margin-bottom: 0px;"><span style="color: #843fa1; margin-bottom: 0px;">I was assigned some courses on ACEs and there was a great TED talk on the subject. Here are links to what I was to use in preparation for answering the questions below. I highly recommend the training, it was great!</span></span></span></strong></p><p></p><ul style="text-align: left;"><li><a href="https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime?language=en" target="_blank"><b>TED Talk - Nadine Burke Harris</b></a><br /></li><li><span style="margin-bottom: 0px;"><span class="TextRun SCXW266830186 BCX0" data-contrast="none" lang="EN-US" style="margin-bottom: 0px;"><span class="NormalTextRun SCXW266830186 BCX0" style="margin-bottom: 0px;"><span style="color: #843fa1; font-family: Lato Extended, Lato, Helvetica Neue, Helvetica, Arial, sans-serif; margin-bottom: 0px;"><b><a href="https://vetoviolence.cdc.gov/apps/aces-training/#/" target="_blank">ACEs Training Modules</a><br /></b></span></span></span></span></li></ul><p></p><p><strong style="color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin-bottom: 0px;"><span class="TextRun SCXW266830186 BCX0" data-contrast="none" lang="EN-US" style="margin-bottom: 0px;"><span class="NormalTextRun SCXW266830186 BCX0" style="margin-bottom: 0px;"><span style="color: #843fa1; margin-bottom: 0px;">The questions were simple, and were meant to be a basic reflection of learning posted in a group discussion. </span></span></span></strong></p><p><strong style="color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin-bottom: 0px;"><span class="TextRun SCXW266830186 BCX0" data-contrast="none" lang="EN-US" style="margin-bottom: 0px;"><span class="NormalTextRun SCXW266830186 BCX0" style="margin-bottom: 0px;"><span style="color: #843fa1; margin-bottom: 0px;">Discuss your thoughts about what you have learned about ACE's. Did you know anything about them before this week's assignments?</span></span></span></strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span class="TextRun SCXW266830186 BCX0" data-contrast="none" lang="EN-US" style="color: black; margin-bottom: 0px;">I did know about ACEs before completing this week's assignment(s), and I have always felt very fortunate to have had a childhood that resulted in the score I have for ACEs. I first learned about ACEs in 2016 when my sister in law was completing her <em>third</em> master's degree - yep third. She is a Vice Principal now, but was initially a special education teacher, then a grade school principal in a school district filled with kids from socioeconomically challenged homes. The average ACE scores for the kids in her elementary school was seven. <em style="margin-bottom: 0px;"><strong style="margin-bottom: 0px;">Seven</strong></em>!! </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span class="TextRun SCXW266830186 BCX0" data-contrast="none" lang="EN-US" style="color: black; margin-bottom: 0px;">She was discussing it with me in 2016, and I had not heard of ACEs before, that I recall. What she shared with me, and learning about ACEs, inspired me to learn as much as I could about SDOH. I eventually went on to write my master's thesis with a focus on teaching nursing students about SDOH, and for my capstone I developed a curriculum for nursing students to learn about SDOH and I addressed ACEs and the correlation between SDOH and ACE scores throughout the curriculum.</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong style="margin-bottom: 0px;"><span class="TextRun SCXW266830186 BCX0" data-contrast="none" lang="EN-US" style="margin-bottom: 0px;"><span class="NormalTextRun SCXW266830186 BCX0" style="margin-bottom: 0px;"><span style="color: #843fa1; margin-bottom: 0px;">If so, did you learn anything new?</span></span></span></strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span class="TextRun SCXW266830186 BCX0" data-contrast="none" lang="EN-US"><span class="NormalTextRun SCXW266830186 BCX0" style="margin-bottom: 0px;">I actually did learn something new this go-around. I did not realize that the ACEs are strongly considered preventable - I mean - I guess maybe cynically speaking, I did not feel empowered to succeed in preventing most ACEs. According to Centers for Disease Control and Prevention [CDC] (2023), "<strong style="margin-bottom: 0px;">...</strong></span></span><span style="font-family: inherit; font-size: 1rem; margin-bottom: 0px;">we must understand and address the factors that put people at risk for or protect them from violence. Creating and sustaining safe, stable, nurturing relationships and environments for all children and families can prevent ACEs and help all children reach their full potential" (para. 13). </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span style="font-family: inherit; font-size: 1rem;">Who knew? "...can prevent ACEs..." </span><span style="font-family: inherit; font-size: 1rem; margin-bottom: 0px;">I certainly didn't know. </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong style="margin-bottom: 0px;"><span style="color: #843fa1; margin-bottom: 0px;"><span class="TextRun SCXW266830186 BCX0" data-contrast="none" lang="EN-US"><span class="NormalTextRun SCXW266830186 BCX0">How will what you learned affect how </span><span class="NormalTextRun ContextualSpellingAndGrammarErrorV2Themed SCXW266830186 BCX0">your</span> <span class="NormalTextRun SCXW266830186 BCX0">provide</span><span class="NormalTextRun SCXW266830186 BCX0" style="margin-bottom: 0px;"> care for your pediatric patients?</span></span><span class="EOP SCXW266830186 BCX0" data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335559738":180,"335559739":180,"335559740":259}" style="margin-bottom: 0px;"> </span></span></strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;">I suppose this new awareness entreats me to gather as much information as I can about school, community, government, and private resources that I can share with pediatric patients and their parents/caregivers, when I recognize signs of ACEs in my patients.</p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;">According to the Cleveland Clinic (2023), signs of an adverse childhood event can include:</p><ul style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 0px 0px 0px 25px; padding: 0px;"><li style="list-style-type: none; margin-bottom: 0px;"><ul class="i8Z77e" style="margin: 0px 0px 0px 25px; padding: 0px;"><li>Fear of other people</li><li>Difficulty sleeping<span style="margin-bottom: 0px;"> </span>or frequent nightmares</li><li>Bedwetting</li><li>Changes to their mood</li><li>Difficulty showing affection towards friends or family</li><li>Avoiding situations or events that relate to a traumatic experience</li><li style="margin-bottom: 0px;">Difficulty learning in school</li></ul></li></ul><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span style="font-family: inherit; font-size: 1rem;">But what are the warning signs </span><em style="font-family: inherit; font-size: 1rem;">before</em><span style="font-family: inherit; font-size: 1rem; margin-bottom: 0px;"> an ACE occurs?</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span style="font-family: inherit; font-size: 1rem; margin-bottom: 0px;">There aren't really warning signs, as much as there are common risk factors. The Cleveland Clinic (2023, para. 9) indicates the common risk factors for ACEs include:</span></p><ul style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 0px 0px 0px 25px; padding: 0px;"><li style="list-style-type: none; margin-bottom: 0px;"><ul style="margin: 0px 0px 0px 25px; padding: 0px;"><li>children<span style="margin-bottom: 0px;"> </span>assigned female at birth</li><li>minority racial or ethnic groups </li><li>children with socioeconomic challenges</li><li>children of caregivers who experience stress</li><li style="margin-bottom: 0px;">children who have family members/friends with substance use disorder or other mental health condition</li></ul></li></ul><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;">And although "<span style="margin-bottom: 0px;">ACEs are common across all populations," (CDC, 2021, para. 13), I will be more likely to help prevent ACEs for my patients if I:</span></p><ul style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 0px 0px 0px 25px; padding: 0px;"><li style="list-style-type: none; margin-bottom: 0px;"><ul style="margin: 0px 0px 0px 25px; padding: 0px;"><li><span style="margin-bottom: 0px;"><em style="margin-bottom: 0px;">maintain awareness</em> of the most common risk factors</span></li><li><em style="margin-bottom: 0px;">identify</em> the risk factors during my assessment of the patient</li><li style="margin-bottom: 0px;"><em style="font-family: inherit; font-size: 1rem;">intervene</em><span style="font-family: inherit; font-size: 1rem; margin-bottom: 0px;"> to <span style="margin-bottom: 0px;">extirpate</span> the risks I can identify </span></li></ul></li></ul><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span style="margin-bottom: 0px;">What I learned from this assignment, will strongly impact my practice moving forward, and ultimately benefit the patients that are in my care. </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong style="margin-bottom: 0px;"><span style="color: black; margin-bottom: 0px;">References</span></strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;">Centers for Disease Control and Prevention (CDC). (2023, June 29). <i>Fast facts: Preventing adverse childhood experiences</i>. Violence Prevention. <a class="external" href="https://www.cdc.gov/violenceprevention/aces/fastfact.html" rel="noreferrer noopener" style="margin-bottom: 0px; outline: transparent solid 0.125rem;" target="_blank">https://www.cdc.gov/violenceprevention/aces/fastfact.html<span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> </p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;">Centers for Disease Control and Prevention. (2021, April 6). <i>About the CDC-Kaiser ace study</i>. Violence Prevention. <a class="external" href="https://www.cdc.gov/violenceprevention/aces/about.html" rel="noreferrer noopener" style="margin-bottom: 0px; outline: transparent solid 0.125rem;" target="_blank">https://www.cdc.gov/violenceprevention/aces/about.html<span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> </p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px 0px;">Cleveland Clinic. (2023, April 4). <i>Adverse childhood experiences (aces) & childhood trauma</i>. Cleveland Clinic. <a class="external" href="https://my.clevelandclinic.org/health/symptoms/24875-adverse-childhood-experiences-ace" rel="noreferrer noopener" style="margin-bottom: 0px; outline: transparent solid 0.125rem;" target="_blank">https://my.clevelandclinic.org/health/symptoms/24875-adverse-childhood-experiences-ace</a></p>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-75251839295407450452023-08-01T20:46:00.003-07:002023-08-10T14:09:36.327-07:00FNP Student - Pediatric Rotation - Overwhelming? ...too many emotions.<p> <strong style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px;">The Experience</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":2,"335551620":2,"335559685":0,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin-bottom: 0px;"> </span></p><div class="message user_content enhanced" data-bind="message" style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; max-width: 100%; min-height: 5px; overflow-x: auto; position: relative;"><p style="margin: 12px 0px;"><span data-contrast="auto">For this patient visit, I shared participation 50/50 with my preceptor. The 5-year-old female patient was accompanied by her current guardian, presenting for annual well child exam. Change in guardian care since 06/2023 with siblings (2 brothers). Current foster parent reports that patient and siblings have moved foster homes 6 times in the past 18 months. Pt has been having allergy symptoms of sneezing and runny nose for about one month. Patient tends to have dry skin despite moisturizer use. She will sometimes have itching/scratching to genital area. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto">Her past medical history includes lactose intolerance, specific developmental disorder of motor function, mixed receptive-expressive language disorder, adjustment disorder, allergic rhinitis, xerosis cutis, and congenital preauricular pit with history of infection. She was evaluated with ENT for possible excision vs tertiary referral. She has had a cyst in right ear that comes and goes. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">On exam vital signs were within normal range, and there was a noted right preauricular pit, with no pre or postauricular swelling or discharge seen. She did not pass her Pure-tone audiometry hearing screen (MedlinePlus, n.d.), but this may be related to her age and ability to interpret instructions for screening process, more than her ability to hear. Nonpruritic skin with mild xerosis to extremities.</span></p><p style="margin: 12px 0px;"><span data-contrast="auto">Her ASQ-3 developmental screen demonstrated developmental concerns for fine motor skills, which will need monitoring. Learning activities were discussed with the foster parent/guardian, and AAP Bright Futures parenting guide was provided and discussed. A TAP-TAM book "Bears on Chairs" given. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px; padding-left: 40px;"><em>Note: TAP-TAM is the early literacy program in Kansas, and stands for, “Turn a page, touch a mind” (Kansas Chapter American Academy of Pediatrics, 2017). </em>It is an amazing program, held in high esteem along with programs like Dolly Parton's<em style="margin-bottom: 0px;"> Imagination Library </em>(The Dollywood Foundation, n.d.). </p><p style="margin: 12px 0px;"><span data-contrast="auto">The plan consisted of a referral made to Audiologist as follows: 5-year-old female with failed hearing screening 7/19/23, history preauricular sinus/cyst formation with abscess management by ENT in 2021. No current infectious concerns. Referral with audiology through ENT requested. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto">Additionally, patient was to start a daily antihistamine as instructed. She could also use saline spray in nose a few times a day to flush out allergens. Also discussed allergen reduction strategies, avoidance of strong-smelling soaps and detergents, as well as avoidance of bubble baths. Patient was to also avoid prolonged sitting in a wet swimsuit with outdoor activity. Samples of CeraVe were given for home use for routine care. Her follow up was planned for one year, for next well child exam. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><strong>Thoughts and Feelings</strong><span data-contrast="auto" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto"><span style="font-size: 14pt;"><span style="font-size: 12pt; margin-bottom: 0px;">The nature of the exam, findings, referral, and plan - <span style="margin-bottom: 0px; text-decoration-line: underline;">was not the lesson</span> for me in this situation.</span> </span>This was a shy, submissive child that sat powerless on the exam table. She intermittently made eye contact but did not hold it for more than a second or two, before looking away or down at her feet. This child had been passed around to <strong style="margin-bottom: 0px;">six different foster homes in 18 months</strong>. There was so much about this patient and her circumstances that exposed the broken systems in our country. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto">I thought pediatrics would be difficult, and that this rotation would be challenging for me on many levels, but I did not expect the emotions I have felt in caring for this population. My clinical rotation is at a Federally Qualified Health Center (FQHC). FQHC are usually located in rural or underserved communities and provide care and services for those most impacted by SDOH - social determinants of health (HealthCare.gov, n.d.).</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><strong>Evaluation of Strengths and Challenges</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">This visit was not about the medicine for me. This visit triggered compassion that overwhelmed me, and sorrow that burdened me. Despite being considered the richest and most advantaged country in the world, the United States have not done enough to care for our children. We have hungry, sick, impoverished children, yet we are living in a nation of abundance. <span style="font-size: 12pt; margin-bottom: 0px;"><em><span style="color: #843fa1; margin-bottom: 0px;">We promote birth and yet we fail to preserve the well being of those born.</span></em><span style="color: #843fa1; margin-bottom: 0px;"> <span style="color: black; margin-bottom: 0px;">Jacobson (2022) has gathered many statistics that provide further insight on just how well we are caring for the children in some areas of the country...and just how well we aren't.</span></span></span></span></p><p style="margin: 12px 0px;"><span data-contrast="none">We have children that have been removed from their homes or removed from their parents for various reasons. And then there are the children that were cast aside by their own parents, seemingly discarded. It was not just this patient either - it seemed like this patient was the tipping point for me. I remember driving home from clinic that day and just feeling discouraged...and crying for all of the kids in "the system" who get shipped around from home to home. Actually crying... like call-your-mom-crying and overcome with emotion. Crying not because this was a new revelation, but it was conspicuous and routine in this setting. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="none">Developing my skills to align more with practicing medicine has been very difficult. I don't have a clear boundary established where I give myself permission to treat the patient and not take on their problems as my own. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><strong>Analysis and Self Reflection</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="none">I asked my preceptor how he is able to separate his feelings, how he is able to do this - in this population - day in and day out. He said that there is no other way to do what we do everyday, but to establish and maintain boundaries in our profession. He said that we have to approach the care with compassion, but from a bird's eye view. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="none">I appreciate that he doesn't take on the burdens of our patients. It made me think of a quote from a book I had for my BSN, by Koerner (2011), "It is the ultimate misuse of our power to take responsibility for solving problems that belong to others. Our role as witness is to create a safe space for them to sort through the issues of the day, offering understanding & interpretation along the way" (p. 138).</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><strong>Action Plan</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto">Jones (2019) said it best in her online article, "...setting boundaries doesn’t signal you don’t care or that you are selfish...Boundaries show you value a relationship enough to be thoughtful about making sure it thrives" (para. 5). My plan is to develop and maintain trusting relationships with patients, and boundaries are a great foundation for building those relationships. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto">I cannot risk caregiver or provider burnout, by taking on the hardships of patients and thinking it is up to me to solve their problems for them. I will not allow myself to own the issues of the patients in my care. I can only provide supportive counseling, reassurance, guidance, and empathetic listening, along with feedback and encouragement regarding solution focused changes.</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><strong>References</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":2,"335551620":2,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto">HealthCare.gov. (n.d.). Federally qualified health center (FQHC). </span><a class="external" href="https://www.healthcare.gov/glossary/federally-qualified-health-center-fqhc/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.healthcare.gov/glossary/federally-qualified-health-center-fqhc/</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto">Jacobsen, L. A. (2022, August 9). </span><i>Are the states banning abortion truly pro-child or just pro-birth?</i><span data-contrast="auto">. Population Reference Bureau. </span><a class="external" href="https://www.prb.org/articles/are-the-states-banning-abortion-truly-pro-child-or-just-pro-birth/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px; outline: transparent solid 0.125rem;">https://www.prb.org/articles/are-the-states-banning-abortion-truly-pro-child-or-just-pro-birth/</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; outline: transparent solid 0.125rem; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a></p><p style="margin: 12px 0px;"><span data-contrast="auto">Jones, G. (2019, September 9). </span><i>Creating healthy clinical boundaries with patients and clients</i><span data-contrast="auto">. LeaderLive. </span><a class="external" href="https://leader.pubs.asha.org/do/10.1044/creating-healthy-clinical-boundaries-with-patients-and-clients/full/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://leader.pubs.asha.org/do/10.1044/creating-healthy-clinical-boundaries-with-patients-and-clients/full/</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-contrast="auto"> </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto">Kansas Chapter American Academy of Pediatrics. (2017, June 6). TAP-Tam: A program that Kansas should be proud of - Kansas chapter American academy of pediatrics. </span><a class="external" href="http://www.kansasaap.org/wordpress/tap-tam-a-program-that-kansas-should-be-proud-of/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">http://www.kansasaap.org/wordpress/tap-tam-a-program-that-kansas-should-be-proud-of/</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-contrast="auto"> </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto">Koerner, J., & Bender, S. (2011). Chapter 5: Quantum Healing the Power of Integration. In </span><i>Healing presence: The essence of nursing</i><span data-contrast="auto"> (2nd ed., p. 138). essay, Springer Pub. Co.</span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px;"><span data-contrast="auto">MedlinePlus. (n.d.). Hearing tests for children. MedlinePlus. </span><a class="external" href="https://medlineplus.gov/lab-tests/hearing-tests-for-children/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://medlineplus.gov/lab-tests/hearing-tests-for-children/</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-contrast="auto"> </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></p><p style="margin: 12px 0px 0px;">The Dollywood Foundation. (n.d.). <i>Dolly Parton’s imagination library</i>. Dolly Parton’s Imagination Library. <a class="external" href="https://imaginationlibrary.com/" rel="noreferrer noopener" style="margin-bottom: 0px; outline: transparent solid 0.125rem;" target="_blank">https://imaginationlibrary.com/<span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> </p><div><br /></div></div>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-13766663026070325772023-05-28T07:29:00.001-07:002023-05-28T07:42:12.086-07:00Underserved in Topeka: Is it a Choice?<p style="font-size: 16px; margin: 12px 0px;"><script async src="https://pagead2.googlesyndication.com/pagead/js/adsbygoogle.js?client=ca-pub-3683100466667778"</p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto"></span></span></p><p style="font-size: 16px; margin: 12px 0px;"> crossorigin="anonymous"></script></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">There is a unique community in Topeka, Kansas, that is underserved and within a geopolitical community. Topeka has a homeless population of more than 400 people, and half of them are living in the Topeka Rescue Mission (TRM), and around 200 are living unsheltered, outside (Moore, 2019).</span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="background-color: white; margin-bottom: 0px;"><span style="color: #073763; font-family: georgia;">Those living in TRM for a temporary stay are held to rules that will accommodate respect and safety for all, including restrictions on entry and exit during the night. Additionally, they do not allow someone to stay if they are currently using illicit drugs or drinking. Although this community of residents is underserved in relation to the rest of the public, they do not represent the most underserved (Topeka Rescue Mission [TRM], n.d.).</span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">Right outside of the TRM is a collection of homeless individuals living in tents and makeshift shelters using blankets and trash cans. For some, there is only a single tarp covering multiple sleeping bags and individual spaces. This "tent community" is a truly underserved population. They do not have access to medical care, clothing, showering, bathrooms, and their personal safety is compromised. There is no safe place to store their belongings, which can include food or valuables. Although the “tent city” community of people consider themselves a “family,” there is a consistent presence of mental illness and addiction, and the danger is heightened for those who live within this phenomenological community. </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><strong><i style="margin-bottom: 0px;">Windshield Survey</i></strong><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">The tent city population would be evident in a windshield survey and this survey would also reveal many risks close by. There is no access to fresh water, plumbing, electricity, or climate control (Moore, 2019). In the harsh, snowy winters, many suffer from frostbite, and on the scorching summer days, many end up in the ER with heatstroke symptoms and dehydration.</span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="background-color: white; margin-bottom: 0px;"><span style="color: #073763; font-family: georgia;">There is visual evidence of trash, clutter, and unsanitary conditions, and the area looks like a harbor for infestations of rodents and insects – ideal vectors of disease. There are <span class="TextRun SCXW77988927 BCX0" data-contrast="none" lang="EN-US" style="margin-bottom: 0px;"><span class="NormalTextRun SCXW77988927 BCX0" style="margin-bottom: 0px;">feral</span></span>, stray animals roaming about as well as pets living within this community.</span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">There is a code among the residents of tent city, and “snitches” are swiftly dealt with under the “community rules” and there have been stabbings, beatings, and other violent actions in this little subcommunity culture, that go unreported because of “the code.” </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">Although there are protections against homelessness for children, adults are not granted those same protections. </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><strong>Partner Framework</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">To address the </span><span data-contrast="none">basic needs of this </span><span data-contrast="none">phenomenologic community within a geopolitical community</span><span data-contrast="none">, it is</span><span data-contrast="auto"> important to establish partnerships in the city. Meeting the simple daily needs for showering, toileting, first aid, clothing, and food, as well as providing basic medical services for first aid and health screening – this is the need. </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">Topeka has already developed this coalition of partners. The “Mobile Access Partnership” or MAP services, are offered through a collaboration between the Topeka Police Department, the local hospital, the rescue mission, and the local agency that provides mental health and addiction treatment services and medications.</span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">This partnership, with the funding support of many Topeka businesses, provides mobile bathrooms, showers, and laundry facilitie</span><span data-contrast="none">s, as well as a mobile health clinic, and a mobile food pantry and kitchen. The unsheltered can enjoy warm meals, a warm shower, and a fresh set of clothing, and can drop their clothing off to be laundered and returned to them the following week. </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="none">Nurses are available for important health screenings, social workers and licensed counselors are available to assist with referrals and follow up. The goal is to meet the needs where the people are, to show support and acceptance, and to help establish trust for these individuals to rejoin society again when they are ready. </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><strong>Family Relationships</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">As previously stated, this is a microcosm of interconnected people who all believe that they are a family, however dysfunctional. They share a commonality, in that they have been damaged, hurt, discarded, and treated as burdens, junkies, or menaces to society. </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">Many of this population share similar childhoods, where poverty and abuse were the norm, or similar issues in their adult life with addiction or other struggles. They have each experienced a loss of trust, in a society that has abandoned them and treated them as outcasts. In this, they find community, comfort, and unspoken understanding. </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559739":0,"335559740":480}" style="background-color: white; margin-bottom: 0px;"><span style="color: #073763; font-family: georgia;">I am personally familiar with this phenomenological community within the geopolitical community, as I have volunteered with the Topeka Rescue Mission at least one day weekly for more than 5 years. I have spent every Tuesday morning in the nurse-run pseudo-clinic/medicine-cabinet for the rescue mission. I have also served in the past year coordinating with the Mobile Access Partnership (MAP) alliance of community partners.</span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559739":0,"335559740":480}" style="background-color: white; margin-bottom: 0px;"><span style="color: #073763; font-family: georgia;">I have seen firsthand the <span class="NormalTextRun SCXW92128512 BCX0" style="margin-bottom: 0px;">dilapidated</span> tents and canvases meant to provide shelter for these individuals, and have sensed the mistrust this community feels toward society, systems, and civil services. Somehow, though, despite sometimes desperate circumstances, these individuals band together to remain a close-knit community, looking out for each other when it is needed the most. </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559739":0,"335559740":480}" style="background-color: white; margin-bottom: 0px;"><span style="color: #073763; font-family: georgia;"><b>A Personal Choice</b></span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">There are many in this community that have chosen to remove themselves from society, and choose to live this way. For those individuals specifically, it is important that they have access to services as described in the "Mobile Access Partnership" where they can turn in dirty laundry, shower, get a fresh set of clothes, and when they return the following week, their laundry is clean and ready for them. We also have nurses providing screenings and basic first aid, Medical Providers performing physicals and referring people to free assistance and resources. They can have labs drawn, xrays done, and they assist with applying to medicare or medicaid (Kancaid in Kansas). </span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">But - this community is located less than 200 feet from the railroad tracks, and unfortunately there are many who choose to die on those tracks. It is so sad, and I don't know that the Topeka population of 300,000 know much about it or worse, even care about this. There are many who do care, and want to help, but that percentage is extremely low. </span></p><p style="font-size: 16px; margin: 12px 0px;"><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">The police force attempts to "clear out the riff raff" every month or so, but they can not do anything for stabbings, beatings, drugs, theft, or sexual assaults, if these crimes are not reported. That is probably the most difficult for me to absorb - that individuals in this tightknit community do not want to come forward (fear of retaliation violence) or can not come forward, so they live by the "community rules." </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><strong>References</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">Moore, K. (2019, January 17). </span><i>Unsheltered in Topeka: Ban on camping would leave some of city's homeless with no options</i><span data-contrast="auto">. usatodaynetwork. Retrieved November 30, 2022, from </span><a class="external" href="https://stories.usatodaynetwork.com/unsheltered/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://stories.usatodaynetwork.com/unsheltered/</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg> <span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></span></p><p style="font-size: 16px; margin: 12px 0px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span data-contrast="auto">Topeka Rescue Mission (TRM). (n.d.). </span><i>Mobile access partnership</i><span data-contrast="auto">. TRM Ministries. Retrieved November 30, 2022, from </span><a class="external" href="https://www.trmonline.org/map" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.trmonline.org/map</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg> <span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></span></p>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-573956623714159442023-05-26T23:46:00.003-07:002023-05-27T08:31:22.743-07:00 The Funny Side of Depression?<p><span class="TextRun SCXW86070552 BCX0" data-contrast="auto" face=""Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif" lang="EN-US" style="color: #2d3b45; font-size: 16px;">Who knew you could ever find joy again...</span><span class="EOP SCXW86070552 BCX0" data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559738":0,"335559739":0,"335559740":480}" face=""Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif" style="color: #2d3b45; font-size: 16px; margin-bottom: 0px;"> I was required to post a final reflective discussion for Adult II Practicum for FNP program. Now I am sharing my submission here, and yes, this really happened!</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; text-align: center;"><strong>The Experience</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":2,"335551620":2,"335559685":0,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong style="margin-bottom: 0px;">Background</strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">My preceptor (Randi) and I saw a 63-yo female for an initial visit to establish care because her primary care provider moved out of state. She had just completed an annual physical last month with labs, and we had quite a lot of medical information available to us. We decided that a quick physical assessment to would suffice for this visit as she was on quite a few medications for mental health. We decided to focus more on her mental health, sleep, nutrition, and home stressors during this initial visit. It seems that Randi was using this visit to establish a relationship, and that she would take the medically driven approach during a follow up in 2 weeks. This patient was on more than a handful of psych medications, including antidepressants, stimulants, anxiolytics, sleep aids, nerve pain meds, and meds to address the extrapyramidal symptoms that all of these meds were causing! </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong style="margin-bottom: 0px;">Findings</strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">As she was telling us briefly about her childhood (ACE score was 7), and that she had 4 prior attempts at suicide, and a little about her mom and her daughter - both whom she loves dearly, she had a flat affect. Was it her? or was it the meds? A review of when-she-takes-what for her meds revealed she is taking things that bring her down, in the morning, and some meds that stimulate, she was taking at night! It seemed like her flat affect was a direct result of the many meds she was taking. Randi and I agreed that a strong improvement could be achieved by a shift in timing - when she takes her meds could start the ball rolling on an improved quality of life. This should also help with her current sleep patterns and overall abilities to cope with stressors and to perform daily activities with greater success and maybe even joy. We decided that making med changes would be high priority for this patient. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;"><em style="margin-bottom: 0px;"><strong style="margin-bottom: 0px;">The Heart of the matter</strong></em></span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">After building a rapport, we were able to get into a discussion about her current feelings, any suicidal ideations, and her goals. She said <strong style="margin-bottom: 0px;"><span style="text-decoration-line: underline; text-decoration: underline;">she </span><span style="margin-bottom: 0px; text-decoration-line: underline; text-decoration: underline;">thinks about killing herself every day</span>.</strong> This is just a part of her life, she said. These thoughts are daily - that she should just die, or that she just wants to die. "I won't do it though. I made a solemn promise to my mom and my daughter. I just won't do that to them," she professed.</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">Again, her affect was flat, and she was not complaining as she was reporting these symptoms. She was very matter of fact about the thoughts and the refusal to act. She was almost accepting of the fact she has these daily thoughts; they are a regular part of her life because “that’s just the way it has always been” or something along those lines.</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">During this time the anxiety-wrought patient began to relax; her tense, nervous body language slowly loosening. Randi and I both started this patient's visit by sitting in chairs close-by. Really, I think, it was a proximity that you would expect among a caring group of three friends; close enough to reach out and touch a hand or shoulder if needed, but far enough to allow for personal space.</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><em style="margin-bottom: 0px;"><strong style="margin-bottom: 0px;">The Beauty</strong></em></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">This part of the interaction is where the beauty lies... deeper into the patient interview... </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto">Randi asked, “so you think about it every day...tell me what you see? ...how are you doing it?” </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto">The patient said “</span><i>pills - ya, I guess pills</i><span data-contrast="auto" style="margin-bottom: 0px;">.” </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto">(</span><span data-contrast="auto" style="margin-bottom: 0px;">pause)</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto" style="margin-bottom: 0px;">(pause)</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span style="font-size: 14pt; margin-bottom: 0px;"><strong style="margin-bottom: 0px;">...</strong></span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto">She then said, “</span><i style="margin-bottom: 0px;">But I guess the last time, it was the car.”</i></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><i></i><span data-contrast="auto" style="margin-bottom: 0px;">(pause)</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto">“</span><i>You know how, now, cars have a catalytic converter</i><span data-contrast="auto">?” </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Randi and I glanced at each other, and back to the patient. </span><span data-contrast="auto">The patient was looking up in the corner of the room as if in thought, remembering the time she is talking about, reliving it...not expecting a response about catalytic converters... </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto">I said, “Ya, the catalytic converters. Aren’t those for the exhaust or something?”</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto">She said, “Yep. </span><i>Ya, that’s righ</i><span data-contrast="auto" style="margin-bottom: 0px;">t.”</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto" style="margin-bottom: 0px;">(pause)</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;">(pause)</p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto">(silence)</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto">And then, “</span><i>Well the last time, I sat in my car for about three hours</i><span data-contrast="auto">.</span><i> I sat, and I waited</i><span data-contrast="auto">.” </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":720,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span style="font-size: 14pt; margin-bottom: 0px;"><strong style="margin-bottom: 0px;">...</strong></span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto" style="margin-bottom: 0px;">(pause)</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto" style="margin-bottom: 0px;">(pause)</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto" style="margin-bottom: 0px;">(pause)</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><span data-contrast="auto" style="margin-bottom: 0px;">(another almost an awkward pause length)</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><strong style="margin-bottom: 0px;">“...<i style="margin-bottom: 0px;">and after three hours, all I had was a sore throat</i>.” </strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">It was just so unexpected. She did not say any of this to be funny, she didn’t crack a smile, she was still reliving the moment, almost... but it couldn’t be helped.</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; text-align: center;"><strong style="margin-bottom: 0px;">A stifled, abrupt chortle <i>flew out of my throat,</i></strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; text-align: center;"><strong style="margin-bottom: 0px;">before </strong><strong style="margin-bottom: 0px;">I had any chance to stop it!!</strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; text-align: center;"><strong style="margin-bottom: 0px;">This is the moment when everything </strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; text-align: center;"><strong style="margin-bottom: 0px;">proceeded in slow motion for me...</strong></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">Randi looked at me, I looked at her, my hand was covering my mouth to hold back any further assault-by-chortle... and then we both looked at the patient...and the patient looked at me and then looked at Randi.... this - all - in a matter of <u>milliseconds</u>... yet time stood still, and it was an eternity of awkwardness for me...</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">...and then... the magic.</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">We all started to giggle. </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Which then turned into unshrinking laughter...</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">...and grew into hold-your-belly, throw-your-head-back-laughter! </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Some of it was the patient laughing at her own situation, her story; some of it was each of us laughing at how she worded it, and the unexpected visual that went along with it; and some was probably because it felt so inappropriate to be laughing at all... and some of it a tension release...but here we were. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;">I couldn't stop picturing how this patient's story had just unfolded...her, sitting in a garage with the car running, for 3 hours...in an effort to die... but with the new catalytic converters, the exhaust isn't what it used to be so it only gave her a sore throat...</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px; padding-left: 40px;"><em style="margin-bottom: 0px;">Asisde: Think of the tshirts: "I sat in my car for 3 hours and all I got was a stupid sore throat"</em></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>Thoughts and Feelings</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">We had taken a journey together, and arrived at a place that broke down the barriers, opening the doors to what ended up being a very meaningful experience for our patient. This shared moment led to trust and hope for the patient, and she openly shared that with us just before leaving. We know it is true, and we have all heard it so many times before, but humor really is the best medicine. Humor, when used in the right way, can be a healing power all on its own. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>Evaluation of Strengths and Challenges</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="none">This experience validated (to me) my strength in connecting with patients, my ability to offer support, encouragement, and even hope, when available. The challenge is that I don’t always get it right. And I won’t always get it right. The challenge is learning to distinguish between the receptive patient and the patient who is a sycophant because of the perceived or inferred power dynamics in the provider-patient relationship.</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> The challenge is discernment, a skill to be honed.</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>Analysis and Self Reflection</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">It was a meaningful experience for me, as well. The patient is not the only one who came away from the meeting with hope and trust. This experience, this interaction with the patient, was my expression of deep caring and compassion for someone who has been utterly </span><i>rocked </i><span data-contrast="auto" style="margin-bottom: 0px;">by trauma in her life. I quickly grew to care about this patient’s outcome – her quality of life – her future.</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">I can only say <span style="margin-bottom: 0px; text-decoration-line: underline; text-decoration: underline;">how relieved I am</span> that this interaction had such a positive outcome, despite a terrible mistake. Laughing at something that is not humorous to the patient can destroy the relationship, and the potential for honest interaction. Laughing at the wrong thing, or at the wrong time, or sometimes even laughing at all can result in the complete opposite of “doing no harm.” </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>Action Plan</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">I have not had any experiences like this before – where my emotions betrayed me in front of a patient. Although this all worked out and turned into the best-ever patient reaction, it could have gone differently. Much differently. I plan to continue just as I had up to this point – managing my emotions when engaging with patients – to provide them with respectful, supportive, professional care.</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;"><br /></span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;"><b>Addendum: </b></span></p><div style="-webkit-tap-highlight-color: rgba(0, 0, 0, 0); -webkit-text-size-adjust: auto; caret-color: rgb(45, 59, 69); color: #2d3b45;"><span style="font-family: helvetica;">So what I didn’t write in the reflection, was that after all of this laughing, she had made a few other comments and remarks, in her very <i>flat-affect-overmedicated </i>monotone… that were also just kind of hilarious, unintentionally. </span></div><div style="-webkit-tap-highlight-color: rgba(0, 0, 0, 0); -webkit-text-size-adjust: auto; caret-color: rgb(45, 59, 69); color: #2d3b45;"><span style="font-family: helvetica;"><br /></span></div><div style="-webkit-tap-highlight-color: rgba(0, 0, 0, 0); -webkit-text-size-adjust: auto; caret-color: rgb(45, 59, 69); color: #2d3b45;"><span style="font-family: helvetica;">I told her “Wow. You are so funny, you’re such a survivor. You are amazing and you have important, relevant stories to tell, and you HAVE to share them with the world! Can you please do this? You need to write a book!”</span></div><div style="-webkit-tap-highlight-color: rgba(0, 0, 0, 0); -webkit-text-size-adjust: auto; caret-color: rgb(45, 59, 69); color: #2d3b45;"><span style="font-family: helvetica;"><br /></span></div><div style="-webkit-tap-highlight-color: rgba(0, 0, 0, 0); -webkit-text-size-adjust: auto; caret-color: rgb(45, 59, 69); color: #2d3b45;"><span style="font-family: helvetica;">…and her comment was “Ya, ‘<i>The Funny Side of Depression</i>’” </span><span style="color: var(--color-textDarkest);"><span style="font-family: helvetica;">and I thought, “oh my gosh that’s perfect, I would totally buy that book” </span><span style="font-family: Lato-Regular;">😂</span></span></div>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-84078312932105066192023-05-21T10:58:00.010-07:002023-06-01T10:28:10.251-07:00Championing for Providers in Rural Areas<p><span style="background-color: white; font-family: georgia;"><span style="margin-bottom: 0px;">How can we champion for more providers in rural areas and expand the network of access?</span></span></p><p><span style="background-color: white; font-family: georgia;"><span style="margin-bottom: 0px;">We need to get the word out that Nurse Practitioners (NPs) are trained to practice medicine, and are highly advanced in the practice of nursing. This combination enables the NP to provide a high level of care unmatched by other disciplines. </span>So I believe it first begins with policies that allow nursing at all levels to practice to their full scope, and advanced practice nurses to practice medicine, also to the full scope of their training and capabilities.</span></p><p style="margin: 12px 0px;"><span style="background-color: white; font-family: georgia;">The patients needing care in these rural areas, are typically older, in worse health, and have lower incomes than those in urban areas. Many don't understand what NPs are capable of, what they are trained for. They don't understand the "whole iceberg" approach to care that NPs provide versus the "tip of the iceberg" care generally provided by Medical Doctors and Doctors of Osteopathic medicine. Many MD and DO direct their care on or at the illness, not with or for the patient. A response to disease or abnormalities, rather than prevention of the disease and acute management. </span></p><p style="margin: 12px 0px;"><span style="background-color: white; font-family: georgia;">The current AMA campaign (n.d.) <em style="margin-bottom: 0px;">#FightingforDocs </em><b>doesn't really help</b> the matter either. This campaign is spreading the idea that NPs are not equipped, trained, or experienced enough to provide Primary Care or lead a healthcare team. The AMA has been preaching about "preventing scope creep" which fosters further mistrust in these rural areas, effectively grooming the population to feel they are getting less than optimal care when being treated by an NP versus MD or DO. I do believe that not all MD, DO, or NP fit into the “typicals” I am discussing, but generally speaking about these disciplines…well, this is my opinion.</span></p><p style="margin: 12px 0px;"><span style="background-color: white; font-family: georgia;">Finally, limited access to programs of study and local, advanced training programs for nurses who are currently practicing in rural areas, may be a result of faculty shortages, community support, or financial limitations that coincide with a current state of economy. Increasing that training access and quality would enable those already living rurally, to continue practicing in their locale, at an advanced level. </span></p><p style="margin: 12px 0px;"><strong style="margin-bottom: 0px;"><span style="background-color: white; font-family: georgia;">Reference</span></strong></p><p style="margin: 12px 0px 0px;"><span style="background-color: white; font-family: georgia;">American Medical Association (AMA). (n.d.). <i style="margin-bottom: 0px;">AMA recovery plan for America's physicians: Fighting scope creep</i>. American Medical Association. Retrieved November 11, 2022, from https://www.ama-assn.org/amaone/ama-recovery-plan-america-s-physicians-fighting-scope-creep</span></p>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-41741885731862599552023-05-21T10:48:00.001-07:002023-05-21T10:48:11.878-07:00Mononucleosis<p><strong style="font-size: 16px; margin-bottom: 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">Surprising Facts</span></strong></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">One click to get to the article by <a href="http://kidshealth.org/en/teens/mono-long.html">Ben-Joseph (2020)</a> and there, in very simple terms, is the astonishing information about this wily disease. Mono is a tricky, sneaky, and sometimes silent contagion. One can be exposed to it, then is immediately contagious, without symptoms or knowledge of exposure. Is this not incredible? </span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">Someone can be a carrier and <u>never</u> appreciate any symptoms, while the virus lies dormant for the rest of their life. Even if they experience symptoms and recover well, the contagion can still be spread by that host <span style="margin-bottom: 0px;"><span style="margin-bottom: 0px; text-decoration-line: underline;">for months</span></span>. In fact, experts are not sure how long someone remains contagious after symptoms are gone! </span></p><p style="font-size: 16px; margin: 12px 0px;"><strong style="margin-bottom: 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">The Awakening</span></strong></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">Specifically regarding infectious mono caused by the Epstein-Barr virus (EBV), it is possible for the dormant virus to awaken and find its way once again to the saliva of the host. The host may or may not experience symptoms, but they can still spread this Machiavellian contagion! And by Machiavellian, I do mean this official definition "<span style="margin-bottom: 0px;"><em style="margin-bottom: 0px;">characterized by subtle or unscrupulous cunning, deception, expediency</em>..." (Dictionary.com, LLC, 2022).</span></span></p><p style="font-size: 16px; margin: 12px 0px;"><strong style="margin-bottom: 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">But Wait, There is More </span></strong></p><p style="margin: 12px 0px;"><span style="background-color: white; margin-bottom: 0px;"><span style="color: #073763; font-family: georgia;">As if all of this was not shocking enough for those learning about it for the first time, or refreshing after a long time, t<em style="font-size: 16px;">here are other contagions that can cause mononucleosis (</em>Centers for Disease Control and Prevention [CDC], 2020). I do not fully grasp this, and am not sure that I want to, but there are <em style="margin-bottom: 0px;"><strong style="margin-bottom: 0px;"><span style="font-size: medium;">eight other viruses that can cause infectious mono</span></strong></em>! Here they are: cytomegalovirus, toxoplasmosis, HIV, rubella, adenovirus, and the sisters - Hepatitis A, B, or C (CDC, 2020). Yes, I do not know how or why, and did more than a fair amount of searching and reading and digging, but each one can cause infectious mononucleosis as well. Go figure.</span></span></p><p style="font-size: 16px; margin: 12px 0px;"><strong style="margin-bottom: 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">Conclusion</span></strong></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; margin-bottom: 0px;"><span style="color: #073763; font-family: georgia;">First of all, I have more questions than answers after following Alice the way I did, way down into that rabbit hole...and boy did I find a crazy tea party.</span></span></p><p style="font-size: 16px; margin: 12px 0px; text-align: center;"><span style="background-color: white; margin-bottom: 0px;"><span style="color: #073763; font-family: georgia;"><img alt="hole-rabbit-hole.gif" data-api-endpoint="https://canvas.south.edu/api/v1/users/43879/files/5645656" data-api-returntype="File" height="174" src="https://canvas.south.edu/users/43879/files/5645656/preview?verifier=177mvZ7iZcNLuaZdDZIwgJ4sd3va7PjC9G5CRmsH" style="border: 0px; height: auto; margin-bottom: 0px; max-width: 100%; vertical-align: middle;" width="249" /></span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; margin-bottom: 0px;"><span style="color: #073763; font-family: georgia;">Someone please explain this to me. I am not even sure how to write my biggest question... so is the word "mononucleosis" more of a <i>descriptor</i> of what occurs with the infection? Why do we call it a mononucleosis infection - instead of an EBV infection? ...or a human herpesvirus 4 infection? It is a fact that when someone talks about "mono" or "mononucleosis" they are referring to the EBV viral infection, the most common cause of mono (National Center for Immunization and Respiratory Diseases [NCIRD], 2020). </span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">I looked into the pathology of infectious mononucleosis and then looked at the virology and genetics, and most resources primarily focus on EBV because that is the causative agent 90% of the time (Smatti, et al., 2018). Also according to Smatti, et al. (2018), "...[EBV] <span style="font-size: 1rem;">is a</span><span style="font-size: 1rem;"> </span><span style="font-size: 1rem;">DNA lymphotropic herpesvirus</span><span style="font-size: 1rem;"> </span><span style="font-size: 1rem; margin-bottom: 0px;">and the causative agent of infectious mononucleosis" (para. 1).</span></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; margin-bottom: 0px;"><span style="color: #073763; font-family: georgia;">Riddle me this, medicine...riddle me this!</span></span></p><p style="font-size: 16px; margin: 12px 0px;"><strong style="margin-bottom: 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">References</span></strong></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">Ben-Joseph, E. P. (Ed.). (2020, January). <i>How long is mono contagious?</i> KidsHealth For Teens. Retrieved December 13, 2022, from <a class="external" href="https://kidshealth.org/en/teens/mono-long.html" rel="noreferrer noopener" style="margin-bottom: 0px; outline: transparent solid 0.125rem;" target="_blank"><span style="color: #073763;">https://kidshealth.org/en/teens/mono-long.html</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">Centers for Disease Control and Prevention (CDC). (2020, September 28). <i>About infectious mononucleosis</i>. Epstein-Barr Virus and Infectious Mononucleosis. Retrieved December 13, 2022, from <a class="external" href="https://www.cdc.gov/epstein-barr/about-mono.html" rel="noreferrer noopener" style="margin-bottom: 0px; outline: transparent solid 0.125rem;" target="_blank"><span style="color: #073763;">https://www.cdc.gov/epstein-barr/about-mono.html</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentcolor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a></span></p><p style="font-size: 16px; margin: 12px 0px;"><span style="background-color: white; color: #073763; font-family: georgia;">Dictionary.com, LLC. (2022). <i>Machiavellian definition & meaning</i>. Dictionary.com Unabridged, Based on The Random House Unabridged Dictionary © Random House, Inc. Retrieved December 13, 2022, from <a class="external" href="https://www.dictionary.com/browse/machiavellian" rel="noreferrer noopener" style="margin-bottom: 0px; outline: transparent solid 0.125rem;" target="_blank"><span style="margin-bottom: 0px; outline: transparent solid 0.125rem;"><span style="color: #073763;">https://www.dictionary.com/browse/machiavellian</span></span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px; outline: transparent solid 0.125rem;"><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a></span></p><p style="margin: 12px 0px 0px;"><span style="font-family: georgia;"><span style="background-color: white; color: #073763;">National Center for Immunization and Respiratory Diseases (NCIRD). (2020, September 28). About infectious mononucleosis. Epstein-Barr Virus and Infectious Mononucleosis. </span><a href="https://www.cdc.gov/epstein-barr/about-mono.html" target="_blank"><span style="color: #073763;">https://www.cdc.gov/epstein-barr/about-mono.html</span></a></span></p><p style="margin: 12px 0px 0px;"><span style="color: #073763; font-family: georgia;"><span style="background-color: white;">Smatti, M. K., Al-Sadeq, D. W., Ali, N. H., Pintus, G., Abou-Saleh, H., & Nasrallah, G. K. (2018, May 24). </span><i style="background-color: white; font-size: 16px;">Epstein–Barr virus epidemiology, serology, and genetic variability of LMP-1 oncogene among healthy population: An update</i><span style="background-color: white;">. Frontiers in Oncology. Retrieved December 13, 2022, from </span><a class="external" href="https://www.frontiersin.org/articles/10.3389/fonc.2018.00211/full" rel="noreferrer noopener" style="background-color: white; font-size: 16px; margin-bottom: 0px; outline: transparent solid 0.125rem;" target="_blank"><span style="background-color: white; outline: transparent solid 0.125rem;"><span style="color: #073763;">https://www.frontiersin.org/articles/10.3389/fonc.2018.00211/full</span></span><span class="external_link_icon" role="presentation" style="background-color: white; font-size: 16px; margin-bottom: 0px; margin-inline-start: 5px; outline: transparent solid 0.125rem;"><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a></span></p>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-27133071998576963122023-05-21T10:15:00.002-07:002023-05-21T10:54:16.082-07:00Infectious Disease Highlight: Monkeypox<p class="p2" style="font-size: 12px; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><br /></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Monkeypox has resurfaced recently, with outbreaks occurring in non-endemic countries, creating a worldwide public health emergency (Conger, 2022). These outbreaks have brought contemporary public health concerns in the United States, and new fears to a public still recovering from the siege of SARS-CoV2. Awareness and understanding of the monkeypox virus have been limited in the public, as they have grown numb to the threats of infectious disease because of pervasive assaults from the 2020 Covid-19 pandemic. Monkeypox slipped into mainstream public knowledge in May of this year with the first case in the U.S. reported on May 18<span class="s1" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"><sup> </sup></span>in Massachusetts (Assistant Secretary for Public Affairs [ASPA], 2022).<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Because of the associated stigmatism and other negative connotations from online language throughout this year, the World Health Organization (WHO) (2022d) has officially adopted <i>mpox </i>as the preferred term for the disease, a decision made after careful consultation and stakeholder input. For the next year, mpox will be used interchangeably with monkeypox, with the goal of phasing out the term <i>monkeypox </i>completely. The Centers for Disease Control (CDC) (2022a) is currently working to align their website pages with this terminology change, as indicated in an alert box at the top of every page related to the mpox infection. The remainder of this informational review will refer to the disease as mpox.</span></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">This work will present an overview of mpox that will cover a brief history of the disease, public health policy, and future projections. Further review will provide insight on the endemic nature of mpox, herd immunity potential, and will indicate the current stance on the disease as an epidemic, a pandemic, or as a well-mitigated viral infection with limited reach and impact. Finally, the chain of infection, vulnerable populations, and current treatment recommendations and options will be presented.</span></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><b style="text-align: center;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></b></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><b style="text-align: center;"><span style="background-color: white; color: #073763; font-family: georgia;">History of Mpox</span></b></p><p class="p4" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-align: center;"><b><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">According to WHO (2022b), mpox was first discovered in humans in 1970, in the Democratic Republic of the Congo, despite the eradication of smallpox taking place in 1968. Since the 1970 case, the mpox virus has been found in 11 African countries, and there was an outbreak in 1996-1997 in the Congo, and in 2017 in Nigeria. The disease traveled outside of Africa in 2003, when an outbreak took place in the United States where 70 cases were reported, said to have originated from imported rodents from Africa. The disease has since spread to Israel and the United Kingdom in 2018, 2019, 2021, and 2022, and to Singapore in 2019. In 2020 and 2021, the disease had returned to the United States, before the most recent outbreak in May 2022 involving multiple nonendemic countries (WHO, 2022b). The WHO declared the mpox outbreak to be an international public health emergency on July 23 (Conger, 2022; Huang, et al., 2022) and the US Department of Health and Human Services (USDHHS) declared mpox in the US to be a public health emergency on August 4, 2022 (Conger, 2022; Philpott, et al., 2022).<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">A review of multiple resources informs that the infective agent of mpox is a non-variola Orthopoxvirus<i>,</i> a zoonotic virus with a reservoir of unknown origin (Huang, Mu, & Wang, 2022). Figure 2 reflects the chain of infection using data retrieved from WHO (2022a). According to WHO (2022a) the portal of exit, mode of transmission, and portal of entry include direct or intimate contact with an infected human or animal or through respiratory droplets; close, personal, or skin-to-skin contact with material from skin lesions, scabs, saliva, mucus, or upper respiratory secretions; or by touching the genitals, anus, rectum, or vagina. Additionally, mpox can be transmitted by intimate contact through hugging, massage, kissing, prolonged face-to-face contact, or oral, anal, or vaginal sex, and can be spread to the fetus during pregnancy.</span></p><p class="p5" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; min-height: 15px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><span style="background-color: white; color: #073763; font-family: georgia;">Endemic Countries<span class="Apple-converted-space"> </span></span></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Although all countries are currently on alert for the mpox outbreak, it is endemic to at least 10 countries in Africa (WHO, 2022b). In June, the recent outbreak was found to include 27 non-endemic countries that had confirmed cases of mpox (WHO, 2022b). According to Conger (2022), by late August, 91 countries that previously did not report any cases, reported current cases, and each of the 50 United States had reported at least one case.<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><span style="background-color: white; color: #073763; font-family: georgia;">Current Status of Mpox</span></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Currently, mpox is not a pandemic, but concerns are heightened related to the outbreak of mpox in non-endemic countries that began May of this year. According to the CDC (2022a), in mid-September there were nearly 58,000 confirmed cases, in more than 90 countries and territories.<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">As reported by <span class="s2">Phillpot, et al. </span>(2022), the data collected on the cases in the United States from this year suggest that gay, bisexual, and men that have sex with other men make up most of the infections (99%) and racial and ethnic minority groups this population are disproportionately affected (para.1). Of the 99%, 94% reported recent male-to-male intimate contact. The recent outbreak in the US began in May and was declared an outbreak in the first week of August. Enhanced surveillance then began with detection and reporting of cases.<span class="Apple-converted-space"> </span></span></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Nearly one-fifth of the infections were travel-associated, and three-fourths were acquired locally (Philpot, et al., 2022). Outside of the United States, this virus has been of global importance since 2017 when Nigeria had an outbreak, and it then spread to Israel, the United Kingdom, and Singapore, before coming to the United States (<span class="s2">Silenou</span>, et al., 2020). In 2022, several cases of mpox with no epidemiological link to imported animals or travel have been identified in multiple countries.</span></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;">Public Policy <span class="Apple-converted-space"> </span></span></i></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></i></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">After the first known case in May, the USDHHS initiated a response to increase vaccine stock, availability, testing for the virus, treatment options, and public awareness and education (ASPA, 2022). WHO (2022b) supported information sharing early on with this outbreak and the incident response system was activated to collaborate and share case findings, clinical management practices, infection control and prevention measures, and isolation practices.<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">The WHO is bound by International Health Regulations, which established criteria that must be met to decide if an outbreak represents an international health emergency (Ghebreyesus, 2022). The criteria include reviewing data provided by countries, 3 components that are required for declaring a public health emergency, the advice from the emergency committee, scientific principles and evidence, and finally the risk to human health, spread of the contagion, and risks for impacting international travel (Ghebreyesus, 2022). The risk was high in European regions, but moderate globally (Ghebreyesus, 2022).<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;">Future Projections<span class="Apple-converted-space"> </span></span></i></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></i></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Based on the November basic reproduction number calculated on the CDC (2002c) website, it is expected that the incidence of mpox infections in the US will continue to decline, as the R<span class="s1" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"><sub>0</sub></span> number has been less than one since the end of July this year. There could be several reasons that the infection rate is declining, but it is difficult to determine which factors had the greatest impact. It may be that behaviors have changed, vaccinations, or simply that there is an increase in the infection-acquired immunity at this point (CDC, 2002c).<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">The future is geared toward development of an mpox vaccine, (WHO, 2022d). Philpott, et al. (2022) suggested that public health direct efforts to prioritize men who have sex with men, whether gay, bisexual, or other, as well as those who are affected disproportionately. This effort should include addressing health equity and offering increased testing and prevention services. Additionally, they wanted to minimize the stigma associated with mpox and the population most effected by the disease, which the WHO (2022d) and CDC (2022a) have started to work on with the name change and upcoming change to the ICD-10 code identifying the disease as mpox. The current assessment by WHO (2022b) places us at a moderate risk globally.</span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;">Herd Immunity</span></i></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></i></b></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Herd immunity does not comprehensibly apply to this disease. Although it is true that anyone can host the virus and be stricken with the infection, there are distinct risk factors that are known to increase an individual’s risk. It can then be presumed that avoiding those risk factors will provide sufficient protection from the disease at this time. There is just not enough of the population immune to the infection, to protect those who are vulnerable. As for those seeking vaccination, there are criteria that must be met to determine eligibility; this will be addressed in greater detail later in this report. If the mpox virus begins to mutate rapidly, increases in virulence, or if transmission modes change or increase, expansion of the eligibility requirements for vaccination may be warranted. <span class="Apple-converted-space"> </span></span></p><p class="p3" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p4" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-align: center;"><b><span style="background-color: white; color: #073763; font-family: georgia;">Chain of Infection</span></b></p><p class="p4" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-align: center;"><b><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Conger commented in her 2022 article, how the “longest documented chain of infection” was only six people (para. 3). This makes it seem as though transmission of the virus from one person to another is not a common occurrence, which is likely. Transmission rates are higher in men who have sex with men, and highest among those who have close contact through sexual activity, with one or more lesions on the skin or in the mucous membranes of someone with the infection (CDC, 2022b). An overview of the epidemiological triad is represented in Figure 1.<span class="Apple-converted-space"> </span></span></p><p class="p7" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; min-height: 15px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><span style="background-color: white; color: #073763; font-family: georgia;">Figure 1</span></b></p><p class="p8" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><i><span style="background-color: white; color: #073763; font-family: georgia;">Epidemiologic Triad for Monkeypox</span></i></p><i><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUhk4zKSavwn9zowdEKgUtYUnpxKTZv1KjqyTYYGEg-hAB5bb-c66XcZBjy4YkN3Uia4jWgkwzhzK9XsWp1m7bWxCGgWEqTd_749qe1GqKLUdtC4BE0xtOeyhDmkDVbgttoNBUf0F1JRtVKyRcw5NL6VWY09ybauRsANjAkr-vdiPeRQnRiGnt3_mxWg/s1292/Epidemiologic%20Triad%20for%20Monkeypox.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="780" data-original-width="1292" height="294" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUhk4zKSavwn9zowdEKgUtYUnpxKTZv1KjqyTYYGEg-hAB5bb-c66XcZBjy4YkN3Uia4jWgkwzhzK9XsWp1m7bWxCGgWEqTd_749qe1GqKLUdtC4BE0xtOeyhDmkDVbgttoNBUf0F1JRtVKyRcw5NL6VWY09ybauRsANjAkr-vdiPeRQnRiGnt3_mxWg/w487-h294/Epidemiologic%20Triad%20for%20Monkeypox.png" width="487" /></a></div></i><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span class="Apple-converted-space"> <span class="Apple-tab-span" style="white-space: pre;"> If any aspect of</span></span> the chain of infection is broken, the outcome will improve. For a visual representation of mpox chain of infection, see Figure 2.<span class="Apple-converted-space"> </span></span></p><p class="p5" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; min-height: 15px;"><span class="Apple-tab-span" style="background-color: white; white-space: pre;"><span style="color: #073763; font-family: georgia;"> </span></span></p><p class="p8" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><b>Figure 2<span class="Apple-converted-space"> </span></b> <span class="Apple-converted-space"> </span></span></p><p class="p8" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><i><span style="background-color: white; color: #073763; font-family: georgia;">Chain of Infection for Monkeypox</span></i></p><p class="p8" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"></span></p><div class="separator" style="clear: both; text-align: left;"><span style="background-color: white; color: #073763; font-family: georgia;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirZbzaEOYkJeBgrcdlGNw0vRiTuVQJirKhFPTePbgW9HZUOi33Lqi5iZZxaSG4r8Wqgu_T_pJfIKawJVFaukwDHrYxSbyF_K4IEQGPhhiuwryPMn_1pgSeDBiepr1eCt4qCJOPyD983Y5m2pvWdRSX6S9SeU4GEBi78rzohsSv5xqsPoLnP8qldseNZA/s1328/Chain%20of%20Infection%20Monkeypox.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="826" data-original-width="1328" height="307" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirZbzaEOYkJeBgrcdlGNw0vRiTuVQJirKhFPTePbgW9HZUOi33Lqi5iZZxaSG4r8Wqgu_T_pJfIKawJVFaukwDHrYxSbyF_K4IEQGPhhiuwryPMn_1pgSeDBiepr1eCt4qCJOPyD983Y5m2pvWdRSX6S9SeU4GEBi78rzohsSv5xqsPoLnP8qldseNZA/w495-h307/Chain%20of%20Infection%20Monkeypox.png" width="495" /></a></span></div><p></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><span style="background-color: white; color: #073763; font-family: georgia;"><span class="Apple-converted-space"> <span class="Apple-tab-span" style="white-space: pre;"> </span></span>The incubation period is the time from infection to the onset of symptoms, and there were variances in the incubation period across multiple references. Sources suggested an incubation period of several days, up to a few weeks. The Maine Center for Disease Control & Prevention (MeCDC) (n.d.) indicated an incubation period of three to 17 days, while Huang, et al., (2022) indicated an incubation period of five to 21 days.<span class="Apple-converted-space"> </span></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">According to WHO (2022a), the incubation period is “usually from 6 to 13 days but can range from 5 to 21 days” (para. 10). They have also divided the infection into an invasion period, which lasts from zero to five days, and the skin eruption period, which begins within one to three days of fever onset. The symptoms of the infection can last from two to four weeks, but illness can last longer if complications arise including pneumonia or encephalopathy. Ultimately, a person with the virus can spread it to others starting with onset of symptoms, through complete epithelialization or healing of the rash (CDC, 2022a).</span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><span style="background-color: white; color: #073763; font-family: georgia;">Vulnerable Populations</span></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Relating to the causation, there are identifying factors that place some at a higher risk than others, but these factors are unrelated to race, age, gender, religion, marital status, or family background. They are currently associated with occupation as a healthcare worker caring for an infected person, and as a sex worker. Personal choices for intimate activities, number of partners and frequency can also be sources of increased risk (MeCDC, n.d.).<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Vulnerable populations consist primarily of those engaging in riskier sexual behaviors including multi-partner sex, unprotected sex, and/or anonymous sexual partners or sex with someone engaging in sexual relations with someone previously mentioned (MeCDC, n.d.).<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p4" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-align: center;"><b><span style="background-color: white; color: #073763; font-family: georgia;">Current Treatment Recommendations and Options<span class="Apple-converted-space"> </span></span></b></p><p class="p4" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-align: center;"><b><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">There is no direct or specific treatment for mpox currently. Symptom management and prevention from spreading the virus seem to be the primary focus for care of an infected individual. Symptoms, symptom management, antiviral treatments, prevention of spread, and vaccination options will be discussed in this section.<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;">Symptoms</span></i></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></i></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Mpox can present with several symptoms including fever, chills, headaches, muscle aches, backaches, swollen lymph nodes, exhaustion, itching, pain or sores in mouth, sores in the genital or anal regions, nausea, vomiting, or diarrhea (Cleveland Clinic, 2022; Huang, et al., 2022; MeCDC, 2022). Some may have many of the symptoms, while others may have one or none, prior to developing the skin rash. Patients may also present with bacterial infections secondary to the pox, which form a rash of pimple-like, pus-filled lesions that rupture and crust over before healing. Table 1 has been created to provide a summary of recommendations for symptom management.</span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><span style="background-color: white; color: #073763; font-family: georgia;">Table 1</span></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><i><span style="background-color: white; color: #073763; font-family: georgia;">Symptom Management Recommendations</span></i></p><p class="p1" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; min-height: 15px;"><span style="color: #073763;"><a class="CIDb7c22ba0-21d6-4bce-8db1-4ac27adc8fe7" data-sessionid="7f41a73b-83a7-ebd2-e874-a85d1079178a" data-shapeids="3" data-slideid="" style="font-family: georgia;"></a></span></p><div class="separator" style="clear: both; text-align: left;"><span style="color: #073763;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgl_WuvBMadXzamwCnc_xifHXN9ooaD6CB7FCpHQusm66ERNoVu_fC214W82fFAXuc6TeZv3hoNbFww6plDrOiSzOuRYC_isOWGan6WRZIViuh562FxTEfsIXkrPlDpD1FuI9H3J2VYC99u6GPygTKhOWuUt7dHLjdZB1PBPpiGq-b2CKk3H_M5CKdmHQ/s1024/symptom%20mgmt%20kristie%202023.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="806" data-original-width="1024" height="380" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgl_WuvBMadXzamwCnc_xifHXN9ooaD6CB7FCpHQusm66ERNoVu_fC214W82fFAXuc6TeZv3hoNbFww6plDrOiSzOuRYC_isOWGan6WRZIViuh562FxTEfsIXkrPlDpD1FuI9H3J2VYC99u6GPygTKhOWuUt7dHLjdZB1PBPpiGq-b2CKk3H_M5CKdmHQ/w483-h380/symptom%20mgmt%20kristie%202023.png" width="483" /></a></div></span></div><div class="separator" style="background-color: white; clear: both; font-family: georgia; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><span style="color: #073763;"><span style="font-size: small; text-indent: 36px;">Content SourcesL Cleveland Clinic, 2022; Huang, et al., 2022, Maine Center for Disease Control & Prevention, n.d. </span></span></div></div><p></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;">Antivirals</span></i></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></i></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">In some instances, the infected individual may be at considerable risk for complications or already have a compromised immune system and may develop a severe form of the disease, which can include extensive lesions in the mouth or eyes, or the urethra or rectum (Conger, 2022). These individuals would be appropriate candidates for treatment using antivirals. There are some antivirals that can reduce the impact of the disease, but there is no treatment leading to a cure. “Despite the fact that monkeypox has no specific treatment, smallpox antiviral drugs such as brincidofovir, tecovirimat, and cidofovir may have effect against monkeypox because of their similar genetics” (Huang, et al., 2022, pg. 8).</span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;">Basic Prevention</span></i></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></i></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">The best option for treating mpox, is preventing infection with the mpox virus. As stated in previous sections, there are several ways to spread the disease and there are several ways to prevent the spread of the disease. The CDC (2022d) suggests that prevention can be achieved by avoiding close contact with someone who has the mpox rash, avoiding contact with items that an infected person has used, and thorough and frequent handwashing as a standard. Hand sanitizers containing alcohol work well, but soap and water should be used after using the bathroom.<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;">Vaccination</span></i></b></p><p class="p6" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px;"><b><i><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></i></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">A vaccinia virus-based vaccine used for other orthopoxviruses including smallpox, can be effective against mpox for those at increased risk (WHO, 2022d). These vaccines are not designed for protection against the mpox virus but have been shown to reduce the spread of the disease, as initially noted in the epidemiology reports on the 1980-1984 outbreak in what is currently known as the Democratic Republic of the Congo (Huang, et al., 2022). Jynneos is a vaccine that is given in two doses, 28 days apart, with effective protection approximately two weeks after the second dose. The vaccinia virus has been modified in this vaccine so that it cannot replicate in the cells of humans (Conger, 2022).<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Another option, given as a one-time dose that provides peak protection after 28 days, ACAM2000 is a vaccine that contains a vaccinia virus that has not been altered, so the vaccinia virus can spread from the site of injection to other parts of the body or to others (Conger, 2022). It is also thought that a childhood vaccination against smallpox may offer some protection, but the vaccine originally only provided three to five years of immunity, with protection decreasing after immunity timeframe (New York State Department of Health, n.d.).</span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Additional options include MVA-BN, a “highly attenuated” vaccinia virus vaccine which is approved in Canada and the European union (Timm, et al., 2006) and LC16m8, also an attenuated smallpox vaccine, that is licensed for use in Japan, and is prepared as a “freeze-dried cell culture” vaccine for smallpox and mpox (Precision Vaccinations Staff, 2022, para. 1).<span class="Apple-converted-space"> </span></span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span class="Apple-converted-space" style="background-color: white;"><span style="color: #073763; font-family: georgia;"><br /></span></span></p><p class="p4" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-align: center;"><b><span style="background-color: white; color: #073763; font-family: georgia;">Conclusion</span></b></p><p class="p4" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-align: center;"><b><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></b></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Mpox is a newer-known contagion that has shown considerable ability to spread, given the right conditions. Mpox does pose a threat to the health of humans, although currently limited to the more vulnerable populations taking part in riskier activities – for now. However, the virus can spread across the globe, as it has, moving from the 11 endemic countries in Africa to over 91 countries since spreading outside of Africa in 2003. The CDC and WHO have stepped in quickly to make plans for future risk of outbreaks, and have established surveillance, monitoring, and reporting systems to stay atop the trends with the mpox infection rates across the world. </span></p><p class="p2" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px; text-indent: 36px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><b><span style="background-color: white; color: #073763; font-family: georgia;">References </span></b></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;"><br /></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Assistant Secretary for Public Affairs (ASPA). (2022, August 17). <i>Fact sheet: U.S. Department of Health and Human Services Response to the Monkeypox outbreak</i>. HHS Press Office. Retrieved December 18, 2022, from <a href="https://www.hhs.gov/about/news/2022/07/21/fact-sheet-us-department-of-health-and-human-services-response-to-the-monkeypox-outbreak.html"><span class="s3">https://www.hhs.gov/about/news/2022/07/21/fact-sheet-us-department-of-health-and-human-services-response-to-the-monkeypox-outbreak.html</span></a><span class="Apple-converted-space"> </span></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Centers for Disease Control and Prevention (CDC). (2022a, September 30). <i>2022 outbreak cases and data</i>. Centers for Disease Control and Prevention. Retrieved December 10, 2022, from <a href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/index.html"><span class="s3">https://www.cdc.gov/poxvirus/monkeypox/response/2022/index.html</span></a><span class="Apple-converted-space"> </span></span></p><p class="p11" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 28.4px; text-indent: -28.4px;"><span style="background-color: white; color: #073763; font-family: georgia;">Centers for Disease Control and Prevention (CDC). (2022b, October 18). <i>Science brief: Detection and transmission of monkeypox virus</i>. Mpox. Retrieved December 19, 2022, from <a href="https://www.cdc.gov/poxvirus/monkeypox/about/science-behind-transmission.html"><span class="s3">https://www.cdc.gov/poxvirus/monkeypox/about/science-behind-transmission.html</span></a><span class="Apple-converted-space"> </span></span></p><p class="p11" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 28.4px; text-indent: -28.4px;"><span style="background-color: white; color: #073763; font-family: georgia;">Centers for Disease Control and Prevention (CDC). (2022c, November 18). <i>Technical report 4 supplementary analysis: Multi-national MPOX outbreak, United States, 2022</i>. Centers for Disease Control and Prevention. Retrieved December 19, 2022, from <a href="https://www.cdc.gov/poxvirus/monkeypox/cases-data/technical-report/technical-report-4-supplement.html#section1"><span class="s3">https://www.cdc.gov/poxvirus/monkeypox/cases-data/technical-report/technical-report-4-supplement.html#section1</span></a><span class="Apple-converted-space"> </span></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Centers for Disease Control and Prevention (CDC). (2022d, December 8). <i>Mpox: How it spreads</i>. Centers for Disease Control and Prevention. Retrieved December 10, 2022, from <a href="https://www.cdc.gov/poxvirus/monkeypox/if-sick/transmission.html"><span class="s3">https://www.cdc.gov/poxvirus/monkeypox/if-sick/transmission.html</span></a><span class="Apple-converted-space"> </span></span></p><p class="p11" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 28.4px; text-indent: -28.4px;"><span style="background-color: white; color: #073763; font-family: georgia;">Cleveland Clinic. (2022, June 17). <i>Mpox: Causes, symptoms, treatment & prevention</i>. Cleveland Clinic Diseases & Conditions. Retrieved December 19, 2022, from <a href="https://my.clevelandclinic.org/health/diseases/22371-monkeypox"><span class="s3">https://my.clevelandclinic.org/health/diseases/22371-monkeypox</span></a><span class="Apple-converted-space"> </span></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Conger, K. (2022, September 6). <i>Answers to your questions about monkeypox</i>. Stanford Medicine News Center. Retrieved December 18, 2022, from <a href="https://med.stanford.edu/news/all-news/2022/06/monkeypox.html"><span class="s3">https://med.stanford.edu/news/all-news/2022/06/monkeypox.html</span></a><span class="Apple-converted-space"> </span></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Ghebreyesus, T. A. (2022, July 23). <i>WHO director-general's statement at the press conference following IHR emergency committee regarding the multi-country outbreak of monkeypox - 23 July 2022</i>. Retrieved December 19, 2022, from <a href="https://www.who.int/news-room/speeches/item/who-director-general-s-statement-on-the-press-conference-following-IHR-emergency-committee-regarding-the-multi--country-outbreak-of-monkeypox--23-july-2022"><span class="s3">https://www.who.int/news-room/speeches/item/who-director-general-s-statement-on-the-press-conference-following-IHR-emergency-committee-regarding-the-multi--country-outbreak-of-monkeypox--23-july-2022</span></a> <span class="Apple-converted-space"> </span></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Huang, Y., Mu, L., & Wang, W. (2022, November 2). <i>Monkeypox: Epidemiology, pathogenesis, treatment and prevention</i>. Signal transduction and targeted therapy. Retrieved December 17, 2022, from <a href="https://doi.org/10.1038/s41392-022-01215-4"><span class="s3">https://doi.org/10.1038/s41392-022-01215-4</span></a><span class="Apple-converted-space"> </span></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Maine Center for Disease Control & Prevention (MeCDC). (n.d.). <i>Monkeypox (mpox)</i>. Monkeypox - Disease Surveillance Epidemiology Program - MeCDC; DHHS Maine. Retrieved December 10, 2022, from <a href="https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/zoonotic/monkeypox.shtml"><span class="s3">https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/zoonotic/monkeypox.shtml</span></a><span class="Apple-converted-space"> </span></span></p><p class="p11" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 28.4px; text-indent: -28.4px;"><span style="background-color: white; color: #073763; font-family: georgia;">New York State Department of Health. (n.d.). <i>The smallpox vaccine - what you need to know</i>. Department of Health. Retrieved December 19, 2022, from <a href="https://www.health.ny.gov/publications/7022/#:~:text=Smallpox%2520vaccination%2520provides%2520full%2520immunity,in%252095%2525%2520of%2520those%2520vaccinated"><span class="s3">https://www.health.ny.gov/publications/7022/#:~:text=Smallpox%20vaccination%20provides%20full%20immunity,in%2095%25%20of%20those%20vaccinated</span></a>.<span class="Apple-converted-space"> </span></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Philpott, D., Hughes, C. M., Alroy, K. A., et al. (2022, August 5). <i>Epidemiologic and clinical characteristics of monkeypox cases - United States, May 17–July 22, 2022</i>. Morbidity and Mortality Weekly Report (MMWR). Retrieved December 10, 2022, from <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7132e3.htm"><span class="s3">https://www.cdc.gov/mmwr/volumes/71/wr/mm7132e3.htm</span></a><span class="Apple-converted-space"> </span></span></p><p class="p11" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 28.4px; text-indent: -28.4px;"><span style="background-color: white; color: #073763; font-family: georgia;">Precision Vaccinations Staff. (2022, September 20). <i>LC16 KMB (LC16m8) monkeypox (smallpox) vaccine</i>. Precision Vaccinations. Retrieved December 18, 2022, from <a href="https://www.precisionvaccinations.com/vaccines/lc16-kmb-lc16m8-monkeypox-smallpox-vaccine"><span class="s3">https://www.precisionvaccinations.com/vaccines/lc16-kmb-lc16m8-monkeypox-smallpox-vaccine</span></a><span class="Apple-converted-space"> </span></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">Silenou, B. C., Tom-Aba, D., Adeoye, O., Arinze, C. C., Oyiri, F., Suleman, A. K., Yinka-Ogunley, A., Dörrbecker, J., Ihekweazu, C., & Gérard Krause, G. K. (2020). Use of surveillance outbreak response management and analysis system for human monkeypox outbreak, Nigeria, 2017–2019. <i>Emerging Infectious Diseases</i>, <i>26</i>(2), 345–349. <a href="https://doi.org/https://doi.org/10.3201/eid2602.191139"><span class="s3">https://doi.org/https://doi.org/10.3201/eid2602.191139</span></a><span class="Apple-converted-space"> </span></span></p><p class="p11" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 28.4px; text-indent: -28.4px;"><span style="background-color: white; color: #073763; font-family: georgia;">Timm, A., Enzinger, C., Felder, E., & Chaplin, P. (2006, May 24). <i>Genetic stability of recombinant MVA-BN</i>. PubMed. Retrieved December 17, 2022, from <a href="https://pubmed.ncbi.nlm.nih.gov/16157428/"><span class="s3">https://pubmed.ncbi.nlm.nih.gov/16157428/</span></a><span class="Apple-converted-space"> </span></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">World Health Organization (WHO). (2022a, May 19). <i>Fact sheet: Monkeypox</i>. World Health Organization: Newsroom. Retrieved December 10, 2022, from <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox"><span class="s3">https://www.who.int/news-room/fact-sheets/detail/monkeypox</span></a><span class="Apple-converted-space"> </span></span></p><p class="p11" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 28.4px; text-indent: -28.4px;"><span style="background-color: white; color: #073763; font-family: georgia;">World Health Organization (WHO). (2022b, June 4). <i>Multi-country monkeypox outbreak: Situation update</i>. World Health Organization. Retrieved December 18, 2022, from <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON390"><span class="s3">https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON390</span></a><span class="Apple-converted-space"> </span></span></p><p class="p11" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 28.4px; text-indent: -28.4px;"><span style="background-color: white; color: #073763; font-family: georgia;">World Health Organization (WHO). (2022c, November 16). <i>Vaccines and immunization for monkeypox: Interim guidance, 16 November 2022</i>. World Health Organization Overview. Retrieved December 18, 2022, from <a href="https://www.who.int/publications/i/item/WHO-MPX-Immunization"><span class="s3">https://www.who.int/publications/i/item/WHO-MPX-Immunization</span></a><span class="Apple-converted-space"> </span></span></p><p class="p10" style="font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal; margin: 0px 0px 0px 36px; text-indent: -36px;"><span style="background-color: white; color: #073763; font-family: georgia;">World Health Organization (WHO). (2022d, November 28). <i>WHO recommends new name for monkeypox disease</i>. World Health Organization. Retrieved December 10, 2022, from <a href="https://www.who.int/news/item/28-11-2022-who-recommends-new-name-for-monkeypox-disease"><span class="s3">https://www.who.int/news/item/28-11-2022-who-recommends-new-name-for-monkeypox-disease</span></a><span class="Apple-converted-space"> </span></span></p>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-12237520953603122512023-05-21T09:41:00.001-07:002023-05-21T09:41:42.953-07:00<p><strong style="color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px;">Skin Changes with Covid</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":2,"335551620":2,"335559685":0,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto" style="margin-bottom: 0px;">I decided I needed more information to discuss this with any semblance of knowledge. This posting is an opinion piece, with some validated resources for your review as well. </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>Initial Thoughts</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Before I read this article, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273098/">Cutaneous signs in COVID-19: A review</a>, I thought it was funny in an ironic way, that the authors of this article are all associated with dermatology. The Covid-19 disease process is not a “surface organ” problem – it is an immune response and hematological problem involving inflammation and coagulation challenges, and therefore the resulting skin changes that come with compromised circulation. The coronavirus causes swelling of endothelial cells. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;">The swelling of the endothelial cells has a huge impact on circulation, as every vessel in the human body is lined with these cells. "Endothelial cells form a single cell layer that lines all blood vessels and regulates exchanges between the bloodstream and the surrounding tissues" (Alberts, et al., para. 15). </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Insults to the integumentary system that originate from circulatory deficiencies, are not typically – well, not ever – a dermatology concern, rather these insults call for the interventions by a wound care, vascular, or general surgeon or medical provider that specializes in wound care, vascular diseases, or infectious diseases. The exanthems that occur with Covid-19 would be more of a petechial presentation rather than a confluent, a sporadic, or a satellited, pinpoint, macular rash. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">According to Starkman (2022), when writing about the ‘Covid toe” skin condition, “These skin changes have shown up in people who’ve tested negative for COVID” (para. 5). Additionally, symptoms just like those found in “Covid toes” have actually been around for quite some time, referred to as </span><span data-contrast="auto" style="margin-bottom: 0px;">chilblains. Chilblains present as itchy red patches on the toes (sometimes fingers too), as a result of cold temperatures (NHS 24, 2020). Additional risk factors for chilblains include: poor circulation, poor diet or low body weight, exposure to cold, Lupus, and Raynaud's phenomenon (NHS 24, 2020).</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Rochman (2021) quoted the lead author of a study as saying, “Like other dermatologists, we began to see an increase in patients with chilblains during the pandemic” (para. 3). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>My Experiences with Covid Skin Issues</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">I have only provided care for two patients with “Covid toes” as I stopped working in acute inpatient care in March of 2021. The skin changes were like any of the pictures you will find when you “Google” Covid toes images. See Image 1 and Image 2 below.</span><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":720,"335559739":0,"335559740":480}"> <img alt="11.png" data-api-endpoint="https://canvas.south.edu/api/v1/users/43879/files/6532610" data-api-returntype="File" height="364" src="https://canvas.south.edu/users/43879/files/6532610/preview?verifier=t5VT8YS2EGNroBpzresu1qKjFB7KmSjDEetAaGqf" style="border: 0px; height: auto; margin-bottom: 0px; max-width: 100%; vertical-align: middle;" width="364" /></span><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"><strong> Image 1 </strong>Skin changes seen with Covid-19 (Rabin, 2020) <b> </b></span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"><br /></span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"> <img alt="22.png" data-api-endpoint="https://canvas.south.edu/api/v1/users/43879/files/6532613" data-api-returntype="File" height="357" src="https://canvas.south.edu/users/43879/files/6532613/preview?verifier=ssMJglYS5REVZxoov6yowDNrIULsgKgVWzBKZ3Q3" style="border: 0px; height: auto; margin-bottom: 0px; max-width: 100%; vertical-align: middle;" width="536" /></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong> Image 2 </strong><span data-contrast="auto">Skin changes with Covid-19 (Rochman, 2021)</span><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong><i style="margin-bottom: 0px;">Type of Rash </i></strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">There was no rash present for either of my patients. They both had nonblanchable discoloration and the presence of swelling and intermittent pain on areas of the toes of both feet that did not feel "itchy" until 12-24 hours after initial onset. Both described the pain as a burning or stinging sensation, which occurs in chilblains (NHS 24, 2020). After reviewing several different publications, all symptoms are present for some, and for others, only the discoloration is present. Some will have other symptoms including blisters and raised, painful red bumps (Starkman, 2022). The American Academy of Dermatology (AAD) (n.d.-a) reports, “If you have swollen, discolored toes or fingers, you may have chilblains instead of COVID toes” (para. 16). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> At my recommendation, both of these patients were treated with a moderate strength topical corticosteroid (Triamcinolone 0.1%) to reduce the itching and swelling, and the symptoms resolved within 72 hours of onset.</span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong><i style="margin-bottom: 0px;">Manifestation Timeline</i></strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">In children, the “Covid toes” may appear in the fingers actually and may be the only sign of a Covid infection (AAD, n.d.-b). The two patients I had were in the late stage or over the virus, and were ready for discharge soon after the condition appeared. For many, according to Noakes & Majoe (2020), the toe issues occurred post-Covid infection. Discolored “Covid toes” are reported to typically occur in children, teens, and young adults, as the only indication that they may have been infected with the SARS-CoV2 virus (Starkman, 2022). Other sources suggest this odd set of symptoms occurs in the early stages of the virus as well as in the late or post stages of acute viral infection (Ketchum, 2021).</span><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong><i style="margin-bottom: 0px;">Severity of Associated Illness</i></strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Both patients had been in the ICU, but that is where all of the Covid patients went, in our hospital. One of my patients had been intubated for a portion of his hospitalization and the other had mask and/or CPAP oxygen only. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>Cutaneous Signs as Indicators of the Disease</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">As stated previously, some publications indicated that this may be the only sign in children, teens, and young adults. I do not think that this discoloration is an appropriate indicator of the Covid-19 virus or severity. </span><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p aria-level="2" style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>Conclusion</strong><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":2,"335551620":2,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Ultimately, I have not seen any conclusive data that supports "Covid toes” or cutaneous rashes as a Covid-19 disease indicator or indicator of Covid infection severity. As I stated previously, Covid is a disease process that affects the immune system and has hemotological implications. The swelling of the endothelial cells in response to the SARS-CoV2 virus, has a huge impact on circulation, because every vessel in the human body is lined with endothelial cells. As a Certified Wound, Ostomy, Continence nurse, I see this as acute tissue changes resulting from the impairment in the circulatory system, which can happen in those that were infected with SARS-CoV2, but can also occur in other inflammatory, circulatory conditions. </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">In my opinion, <b>this is</b><strong style="margin-bottom: 0px;"> in <span style="margin-bottom: 0px; text-decoration-line: underline;">no way</span> an indicator of Covid severity, nor a finding that would prognosticate a Covid-19 infection. </strong></span><strong style="margin-bottom: 0px;"> </strong></p><p aria-level="2" style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><strong>References<span data-contrast="auto" style="margin-bottom: 0px;"> </span></strong><span data-ccp-props="{"201341983":0,"335551550":2,"335551620":2,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;">Alberts, B., Johnson, A., Lewis, J., Raff, M., Roberts, K., & Walter, P. (2002). Blood Vessels and Endothelial CellsVersion (4th edition). In <i>Molecular biology of the cell: A problems approach</i> (4th ed.). Garland Science. Retrieved May 19, 2023, from <a class="external" href="https://www.ncbi.nlm.nih.gov/books/NBK26848/" rel="noreferrer noopener" style="margin-bottom: 0px; outline: transparent solid 0.125rem;" target="_blank">https://www.ncbi.nlm.nih.gov/books/NBK26848/<span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> </p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">American Academy of Dermatology. (n.d.-a). </span><i>Covid toes, rashes: How The coronavirus can affect your skin</i><span data-contrast="auto">. Coronavirus Resource Center. </span><a class="external" href="https://www.aad.org/public/diseases/coronavirus/covid-toes" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.aad.org/public/diseases/coronavirus/covid-toes</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> <span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">American Academy of Dermatology. (n.d.-b). Rash: Sign of coronavirus in kids. </span><a class="external" href="https://www.aad.org/public/diseases/coronavirus/coronavirus-rash-signs-kids" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.aad.org/public/diseases/coronavirus/coronavirus-rash-signs-kids</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> <span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Ketchum, D. (2021, March 39). Are covid toes and hands an early sign of covid-19? </span><a class="external" href="https://www.getbrio.com/post/purple-covid-toes-and-hands" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.getbrio.com/post/purple-covid-toes-and-hands</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> <span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">NHS 24. (2022, November 25). Chilblains. </span><a class="external" href="https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails/chilblains" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails/chilblains</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> <span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Noakes, A., & Majoe, S. (2020, June 24). </span><i>Understanding the role that “covid toe” has in recognizing the potential extent of covid-19 infections: A case study</i><span data-contrast="auto">. Pathogens and global health. </span><a class="external" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480604/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480604/</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> <span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Rabin, R. C. (2020, May 1). </span><i>What is “covid toe”? maybe a strange sign of coronavirus infection</i><span data-contrast="auto">. The New York Times. </span><a class="external" href="https://www.nytimes.com/2020/05/01/health/coronavirus-covid-toe.html" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.nytimes.com/2020/05/01/health/coronavirus-covid-toe.html</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> <span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Rochman, S. (2021, June 23). </span><i>“Covid toes” were likely not caused by covid-19, in most cases</i><span data-contrast="auto">. NCAL Research Spotlight. </span><a class="external" href="https://spotlight.kaiserpermanente.org/covid-toes-not-caused-by-covid/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://spotlight.kaiserpermanente.org/covid-toes-not-caused-by-covid/</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a> <span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Starkman, E. (2022, December 24). Covid toes: What you should know. </span><a class="external" href="https://www.webmd.com/covid/what-are-covid-toes" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.webmd.com/covid/what-are-covid-toes</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"> </span></p><p style="background-color: white; color: #2d3b45; font-family: "Lato Extended", Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px; margin: 12px 0px;"><span data-contrast="auto">Wollina, U., Karadağ, A. S., Rowland-Payne, C., Chiriac, A., & Lotti, T. (2020, September). </span><i>Cutaneous signs in COVID-19 patients: A Review</i><span data-contrast="auto">. Dermatologic therapy. Retrieved May 6, 2023, from </span><a class="external" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273098/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273098/</span><span class="external_link_icon" role="presentation" style="display: inline-block; margin-bottom: 0px; margin-inline-start: 5px; text-indent: initial;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg><span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"> </span></p><div><span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"><br /></span></div>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-45836141581956592592023-01-01T22:52:00.001-08:002023-01-01T22:52:43.365-08:00 Hurricane Katrina: A Response Worse than the Disaster? <p><span style="background-color: white; font-family: georgia;"><span data-contrast="auto" style="color: #2d3b45;">In August 2005, Hurricane Katrina hit the southeast coast of the United States, causing loss of life and damage to property in excess of $100 billion (Gibbens, 2019). This Category 3 storm took the lives of at least 1200 people, and countless others suffered years of destitution as a direct result of the damage, which increased with the failed response efforts by the government (Gibbens, 2019). The common theme emerging from each of the sources reviewed - and many that are not referenced in this work – is that although the Katrina storm was a natural disaster that did a great deal of damage on its own, the true devastation and resulting catastrophe was caused by the disastrous response by government authorities, specifically the </span><span data-contrast="none" style="color: #2d3b45;">Federal Emergency Management Agency</span><span data-contrast="auto" style="color: #2d3b45;"> (FEMA). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="color: #2d3b45; margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">The National Response Framework contains 29 different federal agencies that have a role in disaster relief (Edwards, 2015). There is also a National Incident Command System, so there may be too many “nationally” focused systems, and these may not be as effective in a local or state-level response need. Is it possible that the delay in federal response and subsequent dysfunctional coordination of relief, was driven by the race or socioeconomic status of the residents? Is it conceivable that local and state response systems would provide more successful outcomes than the national or federal red-tape-laden agencies? Let us further explore the inequities of this disaster response. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><strong>Minimizing or Preventing the Disaster in Advance</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">The first failure lies within the warnings about the strength and design of the levees, that we now know were dismissed repeatedly for several years prior to Katrina. The southern border of Louisiana was supposed to be safe from flooding because of a network of levees that made up the federal flood protection system. This system, though, was redesigned and a rebuilding process began in 1965. After years of budget cuts and diversion of funding to other projects, the rebuild was only 60-90% complete when Katrina hit (Pruitt, 2020). When levees broke in more than 50 locations, almost 80% of the city of New Orleans was under water (Pruitt, 2020). The city sits uniquely below sea level already, according to McMahan (2022). This was not the first time for severe flooding though, as hurricanes had previously flooded New Orleans five times since 1915, according to History.com Editors (2022). </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">A population of roughly 100,000 remained in the city during the storm despite evacuation orders, but one must consider how many residents were physically unable to evacuate, could not afford to evacuate, did not know to evacuate, or did not have the transportation necessary to evacuate (McMahon, 2022). According to the History.com Editors (2022), over 110,000 of the New Orleans residents (approximately 500,000) did not have access to a car. </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><strong>Weaknesses in the Response</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">In a catastrophe of this magnitude, there are so many working parts that need to be addressed and yes, it starts with prevention, but beyond that there should be a process in place as soon as possible to mitigate loss of life and property. These are just a few considerations that come to mind:</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><ul style="color: #2d3b45; margin: 0px 0px 0px 25px; padding: 0px;"><li data-aria-level="2" data-aria-posinset="1" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559683":1,"335559684":-2,"335559685":1440,"335559991":360,"469769226":"Symbol","469769242":[9675],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="2"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">Is there a warning/alert/announcement system in place? Is it accessible to all members of the public? Is it audible/visible without power supply? Who would potentially </span><span data-contrast="none">not</span><span data-contrast="none"> receive the alerts?</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></li><li data-aria-level="2" data-aria-posinset="2" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559683":1,"335559684":-2,"335559685":1440,"335559991":360,"469769226":"Symbol","469769242":[9675],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="2"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">What is the evacuation need? Is there a plan for evacuation? What is the timeline? How quickly can residents be evacuated? Where will they be directed to go?</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></li><li data-aria-level="2" data-aria-posinset="3" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559683":1,"335559684":-2,"335559685":1440,"335559991":360,"469769226":"Symbol","469769242":[9675],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="2" style="margin-bottom: 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">What search and rescue resources are available for those who did not, could not, or would not evacuate? Where can those affected go after the fact, to gather? Where can the remaining residents commune for food, shelter, water, clothing, supplies, and medical aid? </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></li></ul><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">Suggested disaster risk management steps include components of prevention, mitigation, transfer, and preparedness (United Nations Office for Disaster Risk Reduction [UNDRR], n.d.). During Katrina, there were extreme limitations in assistance available to the victims, and tragically, the response by the federal government was also delayed. The government response turned out to be too little, too late. The worst of the disaster came not from the storm itself, but from the response (or lack thereof) by the government. It should be noted that much of the damage from the storm was unavoidable, but the ripple-effect disasters that followed could have been prevented. </span><span data-ccp-props="{"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">There was plenty of time to begin evacuation efforts prior to the storm and subsequent flooding. Because of the confusion and lack of proactive engagement by officials, faulty information was provided to the public (Edwards, 2015). Edwards goes on to report that “</span><span data-contrast="none">there was general confusion over mission assignments, deployments, and command structure” (2015, para. 3). Despite simulation exercises performed the prior year, officials failed at learning and implementing the key lessons from that drill (Edwards, 2015). During Katrina, there were breakdowns in communication, supply chains, and decision making (Edwards, 2015). Those put in key leadership positions for FEMA were inexperienced in disaster management (Edwards, 2015). </span><span data-ccp-props="{"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">In the aftermath, there were instances of excessive fraud and abuse regarding distribution of relief funds (Edwards, 2015). Millions were left homeless and more than 400,000 ended up leaving New Orleans for good (Pruitt, 2020). Probably the most appalling aspect of this entire disaster response system is reported by Edwards in his 2015 article. He notes that FEMA blocked relief from the people of New Orleans and he provided examples of actions taken by FEMA. The following bullet points are directly quoted or minimally altered from the Edwards (2015) article, depicting actions taken by FEMA (para. 9): </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><ul style="color: #2d3b45; margin: 0px 0px 0px 25px; padding: 0px;"><li data-aria-level="2" data-aria-posinset="4" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559683":1,"335559684":-2,"335559685":1440,"335559991":360,"469769226":"Symbol","469769242":[9675],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="3"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">repeatedly blocked delivery of emergency supplies ordered by Methodist Hospital in New Orleans</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></li><li data-aria-level="2" data-aria-posinset="5" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559683":1,"335559684":-2,"335559685":1440,"335559991":360,"469769226":"Symbol","469769242":[9675],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="3"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">turned away volunteer doctors because they were not listed in the government records as emergency volunteers</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></li><li data-aria-level="2" data-aria-posinset="6" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559683":1,"335559684":-2,"335559685":1440,"335559991":360,"469769226":"Symbol","469769242":[9675],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="3"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">actively blocked flights intended to emergently evacuate residents and offered no assistance in coordinating evacuation services</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></li><li data-aria-level="2" data-aria-posinset="7" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559683":1,"335559684":-2,"335559685":1440,"335559991":360,"469769226":"Symbol","469769242":[9675],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="3"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">refused Amtrak offers for evacuation assistance and would not return calls from the American Bus Association or even the Motorcoach association, who were offering evacuation assistance</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></li><li data-aria-level="2" data-aria-posinset="8" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559683":1,"335559684":-2,"335559685":1440,"335559991":360,"469769226":"Symbol","469769242":[9675],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="3"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">denied necessary access for the Red Cross to deliver emergency supplies to the Superdome</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></li><li data-aria-level="2" data-aria-posinset="9" data-font="Symbol" data-leveltext="" data-list-defn-props="{"335552541":1,"335559683":1,"335559684":-2,"335559685":1440,"335559991":360,"469769226":"Symbol","469769242":[9675],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" data-listid="3" style="margin-bottom: 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">turned away trucks from Walmart loaded with water for New Orleans and prevented the Coast Guard from delivering diesel fuel </span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></li></ul><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">This list is not exhaustive but depicts the abhorrent inequities of this disaster response. So again, is it possible that these actions occurred because 69% of the New Orleans population is black (Sastry, 2009)? Was it race or socioeconomic status of the New Orleans residents that caused those in power to dismiss the emergent nature of the disaster? It must be considered based on the extreme negligence and inequity that anathematized the city of New Orleans.</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><strong>What Went Right</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="none">Despite all the atrocities listed in the previous section, many things went right with some of the response to Katrina. The local Coast Guard response was integral to the rescue of more than 30,000 people, after they deployed 4,000 service members (Edwards, 2015). The state-commanded National Guard was there to establish and reinforce law and order, when the police force was incapacitated by the storm (Edwards, 2015). The strength of the private sector was revealed with the Red Cross, The Salvation Army, Walmart and its employees, and the Home Depot, all coming through with provisions and supplies for food, shelter, water, clothing, and support (Edwards, 2015).</span><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":1,"335551620":1,"335559685":0,"335559731":720,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><strong>Preventing Future Occurrences</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":6,"335551620":6,"335559685":0,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span data-contrast="none" style="background-color: white; margin-bottom: 0px;"><span style="font-family: georgia;">In looking at the potential for preventing or minimizing a disaster like this from happening again, certainly community risk assessments could be performed. For this Katrina disaster, the well-studied failures offer more insight than anything else on how to prevent or respond in similar situations. For New Orleans, a rebuild was required for hurricane defenses and “...cost $14.6 billion...” to complete by 2018 (Gibbens, 2019, para. 19). Federal, state, and local governments spent more than $20 billion to construct new levees along more than 350 miles of coastline (Pruitt, 2020). Prior to Katrina, funding for the United States Army Corps of Engineers (USACE) which would have allowed for the addition of safety measures in their design and upkeep of the levee system was not provisioned (McMahon, 2022). This funding decision was made based on a risk analysis that was conducted, which weighed the costs of installing new levees against the cost of coping with the after-effects of a major disaster (McMahon, 2022). The risk analysis performed in this instance did nothing to benefit the community when it came to the Katrina disaster. </span></span></p><p aria-level="2" style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><strong>Conclusion</strong><span data-ccp-props="{"134233117":false,"134233118":false,"201341983":0,"335551550":2,"335551620":2,"335559685":0,"335559731":0,"335559737":0,"335559738":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">All-in-all, Hurricane Katrina was a terrible natural disaster that garnered a slow, dismissive, and poorly constructed federal response effort that failed to help the people who needed help the most. As if there were not enough lessons from other past failures, this disaster set the bar at an all-time-low for government response in the United States. </span> <span data-ccp-props="{"201341983":0,"335559731":720,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p aria-level="2" style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><strong>References </strong><span data-ccp-props="{"201341983":0,"335551550":2,"335551620":2,"335559731":0,"335559739":0,"335559740":480}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">Edwards, C. (2015, August 27). </span><i>Hurricane Katrina: Remembering the federal failures</i><span data-contrast="auto">. Cato.org. Retrieved December 30, 2022, from </span><a class="external" href="https://www.cato.org/blog/hurricane-katrina-remembering-federal-failures" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.cato.org/blog/hurricane-katrina-remembering-federal-failures</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg> <span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":0,"335551620":0,"335559685":720,"335559731":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">Gibbens, S. (2019, January 16). </span><i>Hurricane Katrina facts and information</i><span data-contrast="auto">. Environment. Retrieved December 30, 2022, from </span><a class="external" href="https://www.nationalgeographic.com/environment/article/hurricane-katrina" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.nationalgeographic.com/environment/article/hurricane-katrina</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg> <span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":0,"335551620":0,"335559685":720,"335559731":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">History.com Editors, H. E. (2019, August 9). </span><i>Hurricane Katrina</i><span data-contrast="auto">. History.com. Retrieved December 30, 2022, from </span><a class="external" href="https://www.history.com/topics/natural-disasters-and-environment/hurricane-katrina" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.history.com/topics/natural-disasters-and-environment/hurricane-katrina</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg> <span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":0,"335551620":0,"335559685":720,"335559731":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">McMahon Last Modified Date: December 21, M. (2022, December 21). </span><i>What caused the levees to break in New Orleans during hurricane Katrina?</i><span data-contrast="auto"> UnitedStatesNow.org. Retrieved December 30, 2022, from </span><a class="external" href="https://www.unitedstatesnow.org/what-caused-the-levees-to-break-in-new-orleans-during-hurricane-katrina.htm" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.unitedstatesnow.org/what-caused-the-levees-to-break-in-new-orleans-during-hurricane-katrina.htm</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg> <span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":0,"335551620":0,"335559685":720,"335559731":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">Pruitt, S. (2020, August 27). </span><i>How levee failures made hurricane Katrina a bigger disaster</i><span data-contrast="auto">. History.com. Retrieved December 30, 2022, from </span><a class="external" href="https://www.history.com/news/hurricane-katrina-levee-failures" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.history.com/news/hurricane-katrina-levee-failures</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg> <span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":0,"335551620":0,"335559685":720,"335559731":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">Sastry, N. (2010, August 1). </span><i>Tracing the effects of hurricane Katrina on the population of New Orleans: The Displaced New Orleans Residents Pilot Study</i><span data-contrast="auto">. Sociological methods & research. Retrieved December 30, 2022, from </span><a class="external" href="https://pubmed.ncbi.nlm.nih.gov/20161061/" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://pubmed.ncbi.nlm.nih.gov/20161061/</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg> <span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"201341983":0,"335551550":0,"335551620":0,"335559685":567,"335559731":720,"335559739":160,"335559740":480,"335559991":567}" style="margin-bottom: 0px;"> </span></span></p><p style="color: #2d3b45; margin: 12px 0px;"><span style="background-color: white; font-family: georgia;"><span data-contrast="auto">United Nations Office for Disaster Risk Reduction (UNDRR). (n.d.). </span><i>Disaster risk reduction & disaster risk management</i><span data-contrast="auto">. PreventionWEB. Retrieved December 30, 2022, from </span><a class="external" href="https://www.preventionweb.net/understanding-disaster-risk/key-concepts/disaster-risk-reduction-disaster-risk-management" rel="noreferrer noopener" style="outline: transparent solid 0.125rem;" target="_blank"><span data-contrast="none" style="margin-bottom: 0px;">https://www.preventionweb.net/understanding-disaster-risk/key-concepts/disaster-risk-reduction-disaster-risk-management</span><span class="external_link_icon" role="presentation" style="margin-bottom: 0px; margin-inline-start: 5px;"><svg style="fill: currentColor; height: 1em; vertical-align: middle; width: 1em;" version="1.1" viewbox="0 0 1920 1920" xmlns="http://www.w3.org/2000/svg"><path d="M1226.66667,267 C1314.88,267 1386.66667,338.786667 1386.66667,427 L1386.66667,427 L1386.66667,853.666667 L1280,853.666667 L1280,693.666667 L106.666667,693.666667 L106.666667,1493.66667 C106.666667,1523 130.56,1547 160,1547 L160,1547 L1226.66667,1547 C1256.10667,1547 1280,1523 1280,1493.66667 L1280,1493.66667 L1280,1280.33333 L1386.66667,1280.33333 L1386.66667,1493.66667 C1386.66667,1581.88 1314.88,1653.66667 1226.66667,1653.66667 L1226.66667,1653.66667 L160,1653.66667 C71.7866667,1653.66667 0,1581.88 0,1493.66667 L0,1493.66667 L0,427 C0,338.786667 71.7866667,267 160,267 L160,267 Z M1584.37333,709.293333 L1904.37333,1029.29333 C1925.17333,1050.09333 1925.17333,1083.90667 1904.37333,1104.70667 L1904.37333,1104.70667 L1584.37333,1424.70667 L1508.96,1349.29333 L1737.86667,1120.38667 L906.613333,1120.38667 L906.613333,1013.72 L1737.86667,1013.72 L1508.96,784.706667 L1584.37333,709.293333 Z M1226.66667,373.666667 L160,373.666667 C130.56,373.666667 106.666667,397.666667 106.666667,427 L106.666667,427 L106.666667,587 L1280,587 L1280,427 C1280,397.666667 1256.10667,373.666667 1226.66667,373.666667 L1226.66667,373.666667 Z" fill-rule="evenodd" stroke-width="1" stroke="none"></path></svg> <span class="screenreader-only" style="border: 0px; clip: rect(0px, 0px, 0px, 0px); height: 1px; margin: -1px -1px 0px; overflow: hidden; padding: 0px; position: absolute; transform: translateZ(0px); width: 1px;">Links to an external site.</span></span></a><span data-ccp-props="{"134233118":false,"201341983":0,"335551550":0,"335551620":0,"335559685":720,"335559731":720,"335559739":0,"335559740":480,"335559991":720}" style="margin-bottom: 0px;"> </span></span></p>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-47867378292775045692019-10-05T03:21:00.000-07:002019-10-05T03:21:03.874-07:00Thoughts on a College EducationFound this quip in my iPhone notes, it was dated October 5, 2014... exactly 5 years ago today. Just think it is interesting to review prior thoughts and writings every once in a while to see how you may have grown or how you may have departed, from past thoughts. Or in this case, how the past 5 years in my growth and experience has validated my thoughts from 5 years ago. I hope to expand on these thoughts in the future, developing a practical metaphor to convey the true spirit of learning in a college setting.<br />
<br />
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">I believe that college is a place, a lifestyle, an action, and a mode of transportation. </span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;"><br /></span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">Place</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">attend</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">participate</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">learn</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">grow</span></div>
<div class="p2" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal; min-height: 27.4px;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;"></span><br /></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">Lifestyle</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">way of life</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">absorb</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">expose</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">enrich</span></div>
<div class="p2" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal; min-height: 27.4px;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;"></span><br /></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">Action</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">be</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">do</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">see</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">think</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">feel</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">experience</span></div>
<div class="p2" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal; min-height: 27.4px;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;"></span><br /></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">Mode of transportation</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">past</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">present</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">future</span></div>
<div class="p2" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal; min-height: 27.4px;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;"></span><br /></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">Kristie Hartig</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<span class="s1" style="font-family: ".SFUIDisplay"; font-size: 23pt;">10/5/14</span></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<br /></div>
<div class="p1" style="-webkit-text-size-adjust: auto; color: #454545; font-family: ".SF UI Display"; font-size: 23px; font-stretch: normal; line-height: normal;">
<br /></div>
woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-18355744106989445992019-06-20T07:23:00.000-07:002019-06-20T07:23:00.268-07:00What kind of nurse are you?I believe the world needs nurses, nurse educators, and nurse leaders who are <b><i>idealistic motivators</i></b>, leading the way for the future of nursing, through education, support, collaboration, and service. <br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWUuRqLKYyB2kkaIVrUTLq1VsSaPTecua9NLKtOyb9AJugXK3IA6H8UD9XNHEpkNHuA7-kNIPECEpnc3p9mS3ATGYA-VAGe5og6pb9pLmbikZVZ1rEp5aQqyw4NGWwPuP5f9WvZ1s2Tl_S/s1600/inspire.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWUuRqLKYyB2kkaIVrUTLq1VsSaPTecua9NLKtOyb9AJugXK3IA6H8UD9XNHEpkNHuA7-kNIPECEpnc3p9mS3ATGYA-VAGe5og6pb9pLmbikZVZ1rEp5aQqyw4NGWwPuP5f9WvZ1s2Tl_S/s200/inspire.jpg" width="200" height="88" data-original-width="199" data-original-height="88" /></a></div><br />
I think I am <i>one of them</i>. My passion for authenticity, integrity, transparency, ethics, advocacy, and tolerance, drives my desire to motivate and encourage new nurses along a similar path. <br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNoSv1zGnDu_fw8XKjG-Fw-9staRo6ZEo9JE9unRtzmr50B3ervM3KsXjR8IE_M9G0JsFHEm9BiuCFIIwhdm7gZApeN2pJnTmbxKDD8fxVVi5Z-n45mm8TpD6Jfr5yb1TUz-wS8ZNJbGlu/s1600/mentoring.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNoSv1zGnDu_fw8XKjG-Fw-9staRo6ZEo9JE9unRtzmr50B3ervM3KsXjR8IE_M9G0JsFHEm9BiuCFIIwhdm7gZApeN2pJnTmbxKDD8fxVVi5Z-n45mm8TpD6Jfr5yb1TUz-wS8ZNJbGlu/s200/mentoring.jpg" width="200" height="153" data-original-width="960" data-original-height="736" /></a></div>If we reach nursing students early in their nursing program and hold onto them in a mentor-to-mentee capacity throughout the curriculum, we may be able to introduce them to a world of professional nursing where they still have a solid grasp on compassion and equity in practice and peer relationships. (Image credit: Forbes.com) <br />
<br />
There has to be some way to circumvent the cynicism of well, <b>so many</b> nurses. For those who are cynical new grads, maybe you have been mistreated and have experienced what it feels like when "nurses eat their young." Maybe you aren't to blame for your negative, judgmental attitude.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikaGvgWKfujAcs9ZA9Tj18nzehFj-D3F2cuzCQJf2BEdvwdkf5cOpT7mZ3qeRuNFTWWwsOw6JkVjygJHNTibp2R07u3_zc5WIPNk-5u21UYcHa-UQaFSIRnnmCpN2ZIoQXYDB2IwpvNTWF/s1600/walk-a-mile-in-my-shoes-see-what-see-hear-7182852.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikaGvgWKfujAcs9ZA9Tj18nzehFj-D3F2cuzCQJf2BEdvwdkf5cOpT7mZ3qeRuNFTWWwsOw6JkVjygJHNTibp2R07u3_zc5WIPNk-5u21UYcHa-UQaFSIRnnmCpN2ZIoQXYDB2IwpvNTWF/s200/walk-a-mile-in-my-shoes-see-what-see-hear-7182852.png" width="188" height="200" data-original-width="500" data-original-height="533" /></a></div><br />
Maybe you are among the misguided who somehow believe that RNs, you know, <i><b>real nurses</b>, only work in hospitals</i>. Ha! Good grief, give me a break. Real nurses take care of people. All people. No matter the facility, no matter the person. How are you missing that? All I can say is walk a mile, sweetheart, walk a mile!<br />
<br />
<br />
Cynical nurses are like a vortex...the Coriolis force leading to an infinite abyss of broken spirits. These cynics purloin energy from nurses who believe and practice as I do. They drain the life force of others and even push some to burnout. Since many can't beat you and your nasty attitude, they join you, only to find that there is nothing sweet about the energy created at a <i>negative nancy convention</i>.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8ipJ0lsoSsrKTTcJOYxQwogQhYz65246jn1ZPTjo21VYdgRUvA-yadjGSo2eyPh5ZS4hYGpGyS8Gn7yDq2iFG6SBmSVK54rfY27GuEfV-Wv81JwvIgd3YQWO99ahq2UqGHLXEZrKZi0-G/s1600/i+was+told+there+would+be+cake.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8ipJ0lsoSsrKTTcJOYxQwogQhYz65246jn1ZPTjo21VYdgRUvA-yadjGSo2eyPh5ZS4hYGpGyS8Gn7yDq2iFG6SBmSVK54rfY27GuEfV-Wv81JwvIgd3YQWO99ahq2UqGHLXEZrKZi0-G/s400/i+was+told+there+would+be+cake.jpg" width="400" height="298" data-original-width="600" data-original-height="447" /></a></div><br />
Redirect your energy. It's never to late to change your attitude. Life already sucks most of the time, don't make it worse by feeding into the negativity. #EmbraceTheSuck<br />
<br />
<i>Where your thoughts are,<br />
your energy is.<br />
Where your energy is, <br />
you will be.<br />
What you think about,<br />
you bring about,<br />
automatically!<br />
</i>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-5181698198352066712019-06-19T20:42:00.000-07:002019-06-19T21:34:51.015-07:00Free CEUs for NursesHere are a few websites offering a bit of free training and CEUs for nurses! Some are more than just 1 education credit!! FREE! From this list alone, there are <b>more than <i>25 free CE units</i> </b>waiting for you to grab!<br />
<br />
For your first free CE unit, check out <b><i>my publication</i></b>, on the use of nutrition supplements and how they enhanced patient outcomes. (CE Hours: 1.00)<br />
<a href="https://anhi.org/education/course-catalog/83223D52C57B4343BFF3CEE508A56ABF">https://anhi.org/education/course-catalog/83223D52C57B4343BFF3CEE508A56ABF</a><br />
<br />
Next...here is a website with <b><i>tons</i></b> of free CE courses available <i>all the time</i>. They change out pretty often so get them while you can and keep checking back on the site. Just search "free" and you will see a list of free CE available at that time. <b>https://www.nurse.com/ce/free-courses?p=2</b><br />
<br />
For access to additional free CEU courses, check out <i>NurseCEU.com</i>, <i>QuantumUnitsEd.com</i>, and <i>Nurse.com</i>.<br />
<br />
Here are a few examples from <i>Nurse.com</i> that were <i>free as of <b>June 19, 2019</b></i> (<i>copy and paste the links into your browser</i>):<br />
<br />
1) Keep It Clean: Hand Hygiene and Skin Antisepsis (CE Hours: 1.00) <br />
http://ce.nurse.com/RVignette.aspx?TopicId=5133<br />
<br />
2) Using Emotional Intelligence to Create the Work Environment You Desire (CE Hours: 1.00)<br />
https://www.nurse.com/ce/using-emotional-intelligence-to-create-the-work-environment-you-desire<br />
<br />
3) Do You Reflect a Positive Image of Nursing? (CE Hours: 1.00)<br />
https://www.nurse.com/ce/do-you-reflect-a-positive-image-of-nursing<br />
<br />
4) Unlock Your Creativity: Be an Innovator! (CE Hours: 1.00)<br />
https://www.nurse.com/ce/unlock-your-creativity<br />
<br />
5) Work Life Balance: Learning to Say \\"No\\" Strategically! (CE Hours: 1.00)<br />
https://www.nurse.com/ce/work-life-balance-learning-to-say-no-strategically<br />
<br />
6) Promoting a Culture of Safety to Prevent Medical Errors (CE Hours: 1.00)<br />
https://www.nurse.com/ce/promoting-a-culture-of-safety-to-prevent-medical-errors<br />
<br />
7) Family Caregivers: Doing Double Duty (CE Hours: 1.00)<br />
https://www.nurse.com/ce/family-caregivers-doing-double-duty<br />
<br />
8) Transitions of Care (CE Hours: 1.00)<br />
https://www.nurse.com/ce/transitions-of-care<br />
<br />
9) The Healing Power of Humor (CE Hours: 1.00)<br />
https://www.nurse.com/ce/the-healing-power-of-humor<br />
<br />
10) Compassion Fatigue (CE Hours: 1.00)<br />
https://www.nurse.com/ce/compassion-fatigue<br />
<br />
11) What's on the Inside: An Overview of Blunt Chest Trauma (CE Hours: 1.00)<br />
https://www.nurse.com/ce/whats-on-the-inside-an-overview-of-blunt-chest-trauma<br />
<br />
12) Motivational Interviewing (CE Hours: 1.00)<br />
https://www.nurse.com/ce/motivational-interviewing<br />
<br />
13) Recognizing Drug-Seeking Behavior (CE Hours: 1.00)<br />
https://www.nurse.com/ce/recognizing-drugseeking-behavior<br />
<br />
14) Evidence-Based Approaches to Pain Control (CE Hours: 2.50)<br />
https://www.nurse.com/ce/evidence-based-approaches-to-pain-control<br />
<br />
15) Opioid Use Disorder and Pregnancy: What Does Evidence-Based Care Look Like? (CE Hours: 1.00) <br />
https://www.nurse.com/ce/opioid-use-disorder-and-pregnancy-what-does-evidence-based-care-look-like<br />
<br />
16) Health Literacy and Discharge Education: I Didn’t Understand (CE Hours: 1.00)<br />
https://www.nurse.com/ce/health-literacy-and-discharge-education-i-didn-t-understand<br />
<br />
17) Patient Counseling: Preventing and Combating Opioid Misuse (CE Hours: 1.00)<br />
https://www.nurse.com/ce/patient-counseling-preventing-and-combating-opioid-misuse<br />
<br />
18) Responsible Opioid Prescribing, Chronic Pain, and Addiction (CE Hours: 1.50)<br />
https://www.nurse.com/ce/responsible-opioid-prescribing-chronic-pain-and-addiction<br />
<br />
19) Chemotherapy-Induced Nausea and Vomiting as a Barrier to Good Patient Outcomes (CE Hours: 1.00)<br />
https://www.nurse.com/ce/chemotherapy-induced-nausea-and-vomiting-as-a-barrier-to-good-patient-outcomes<br />
<br />
20) Effective Pain Management is More Than Just a Number (CE Hours: 1.00)<br />
https://www.nurse.com/ce/effective-pain-management-is-more-than-just-a-number<br />
<br />
21) Meeting the Challenge of Pediatric Pain Management (CE Hours: 2.90)<br />
https://www.nurse.com/ce/meeting-the-challenge-of-pediatric-pain-management<br />
<br />
woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-68414087820616296042019-06-19T19:47:00.001-07:002019-06-19T19:47:23.179-07:00Just keep learning!My journey to become "educated" has been long and winding, and the path continues far ahead of where I am now. I either can't <b><i>see</i></b> the end, or I just don't <b><i>want</i></b> to. (Photo retrieved from <i>The Wilderness Road</i>, a blog on wordpress)<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3YHIPLSv1YxeI_u_Au6aBFsuexjYDtL_d-Ppj_JQkYZl4SK300hKGP1xQI454nlbJmEzI1VjH0eeYJVzZn8B_jiu6NBGKcyvIyOlMyQNKKRyeA066KINiDkpXhm-ythp7ugLMDXG-NQx4/s1600/winding-road.jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3YHIPLSv1YxeI_u_Au6aBFsuexjYDtL_d-Ppj_JQkYZl4SK300hKGP1xQI454nlbJmEzI1VjH0eeYJVzZn8B_jiu6NBGKcyvIyOlMyQNKKRyeA066KINiDkpXhm-ythp7ugLMDXG-NQx4/s320/winding-road.jpeg" width="213" height="320" data-original-width="410" data-original-height="616" /></a></div>I initially went to college at age 17, only three days after my actual high school graduation day. I made it somehow through five semesters of college (Summer, Fall, Spring, Summer, Fall) without having any direction or goals, without a plan or purpose. I married, left college, went to beauty school, moved to another state, had kids, worked here and there, then divorced... <br />
<br />
Rough time...through the divorce. I can't imagine it is ever easy when kids are involved. But I had to do something to earn a decent living and provide for the kids, so I decided to go back to school. After all, I was now an experienced adult who could finally appreciate the process of learning. <br />
<br />
So, I "restarted" college 15 years ago as a single parent of two. Whoa, that was so hard. Balancing bills, parenting, school, being broke, and being the oldest in class... I don't think I could do that again, as I don't even know how I did it to begin with! I was 32 years old, so that probably helped as far as energy and motivation...but it was still pretty tough!<br />
<br />
After completing a certificate program at a vo-tech training center to become a licensed vocational nurse (LVN) in 2005, I decided to continue with school. I worked as much as possible, hungry for stabilized income, but decided to enroll in prerequisite courses for an RN program. I think half of the reason I kept going to school was that I was able to borrow enough money to help with living expenses while I did my pre-req courses, and the other half was that my previous loans were deferred while I was enrolled in school!<br />
<br />
And okay, I admit it. I did the same thing when I went to a university where I was enrolled in a nontraditional nursing program. Yep, that's how I survived financially, scraping money together from full time work, financial aid loans, and scrooge-like spending practices. I finally graduated with a BSN degree in 2013. I remember being so excited to finally be accepted and starting in an RN program.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhz89Ts0OjeeZgh64R1ICnnTpSU-v7bGWlnNZ7zXl-ZBkbPE6Qmfwxr9ytqwIV5EIVS0s-YvztHBGqrxK0WF-_C_YjfvOZCUMlWri-hHSXvNx3nNvmh2GIJLE2ZcXweFZBicLUGmn6vpqqg/s1600/storm-cloud-clipart-38.gif" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhz89Ts0OjeeZgh64R1ICnnTpSU-v7bGWlnNZ7zXl-ZBkbPE6Qmfwxr9ytqwIV5EIVS0s-YvztHBGqrxK0WF-_C_YjfvOZCUMlWri-hHSXvNx3nNvmh2GIJLE2ZcXweFZBicLUGmn6vpqqg/s200/storm-cloud-clipart-38.gif" width="200" height="100" data-original-width="1000" data-original-height="500" /></a></div>But boy, oh boy! Every single quiz, paper, exam, and clinical simulation, turned into such a <b>high-stakes event</b>--the threat of being booted "out of the program" was such a giant, dark, heavy storm cloud, always looming, even on the sunny days. <br />
<br />
I am currently enrolled full time in an MSN program with Education as my designated specialty. I was so gung-ho to start but ooophf -- it is so hard to <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJw4JRwZ7bLAhaLKVlEd_6Gp2nygSUayI2yq8Xoc-MegjW-tKMWj0vpZUfaM1SCpfm_0I8ZyI0GaSkjlDcDZj5McmO0nWuuAivvPSmVb2xa9COv1zLX9ugTkt8VaaYCdIISFW8fmCIi6_-/s1600/first-semester-vs-last-semester.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJw4JRwZ7bLAhaLKVlEd_6Gp2nygSUayI2yq8Xoc-MegjW-tKMWj0vpZUfaM1SCpfm_0I8ZyI0GaSkjlDcDZj5McmO0nWuuAivvPSmVb2xa9COv1zLX9ugTkt8VaaYCdIISFW8fmCIi6_-/s200/first-semester-vs-last-semester.jpg" width="200" height="129" data-original-width="600" data-original-height="388" /></a></div>stay motivated and see this thing through. <br />
<br />
The end is so close but I am so over it! I am in my last semester and I only have two classes left to go. I can <i><b>DO</b></i> this, right?<br />
<br />
<br />
Dare I say that I will probably continue with schooling until I receive a terminal degree in nursing (PhD or DNP)... <br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2HhPiGGHFrGZkgJZcxGXaLAaHmDSTHqbhqMUe0pwTDv_87aBesoW4kUac8STnW8gEEPS-KQwxIB0lxjG1ZAL5n-swrIwFwj5lgeTBbFRQ41hGzI9qfDBKvMONU09PQSTHARbfETE2YcF1/s1600/omg-letters-scribble-animation-doodle-4k_sb8vmstul_thumbnail-full01.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2HhPiGGHFrGZkgJZcxGXaLAaHmDSTHqbhqMUe0pwTDv_87aBesoW4kUac8STnW8gEEPS-KQwxIB0lxjG1ZAL5n-swrIwFwj5lgeTBbFRQ41hGzI9qfDBKvMONU09PQSTHARbfETE2YcF1/s200/omg-letters-scribble-animation-doodle-4k_sb8vmstul_thumbnail-full01.png" width="200" height="113" data-original-width="1600" data-original-height="900" /></a></div>Yep, I think I have to. Heck, it sure beats <br />
having to start payments on the student loans I racked up while trying to survive school as an adult (who already had bills, kids, car troubles, and lots of other responsibilities).<br />
<br />
woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-16294982871333080422019-04-03T08:41:00.001-07:002019-04-03T09:16:26.001-07:00The Affordable Care ActOh wow. This is great! It is the best summary of the Affordable Care Act (ACA) purpose and intent that I have seen to date. It is from the article The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice by Sarah Rosenbaum, in the Public Health Reports journal Vol. 126 No. 1, published in 2011. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001814/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001814/</a> <br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgWgtMZQerpeRLSa0Nmv-0jaTWBsF22KUOvBWEK7le-MHg64qr2w2MG0h37fTEN3pAX-qtW6cnHn9zS_94jDWpDHC6IyecN_s1vmM86QxtiGN2h2tTVu53iSkk5ZTPdcxQPpVO0r1StEi52/s1600/Capture2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgWgtMZQerpeRLSa0Nmv-0jaTWBsF22KUOvBWEK7le-MHg64qr2w2MG0h37fTEN3pAX-qtW6cnHn9zS_94jDWpDHC6IyecN_s1vmM86QxtiGN2h2tTVu53iSkk5ZTPdcxQPpVO0r1StEi52/s200/Capture2.JPG" width="200" height="62" data-original-width="373" data-original-height="115" /></a></div><br />
“Consisting of 10 separate legislative Titles, the Act has several major aims. <br />
<br />
The first—and central—aim is to achieve near-universal coverage and to do so through shared responsibility among government, individuals, and employers. <br />
<br />
A second aim is to improve the fairness, quality, and affordability of health insurance coverage. <br />
<br />
A third aim is to improve health-care value, quality, and efficiency while reducing wasteful spending and making the health-care system more accountable to a diverse patient population. <br />
<br />
A fourth aim is to strengthen primary health-care access while bringing about longer-term changes in the availability of primary and preventive health care. <br />
<br />
A fifth and final aim is to make strategic investments in the public's health, through both an expansion of clinical preventive care and community investments.”<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkpMEmpb9YkeV79aXbPt2pDF_4N0gOxVESOEtk4p7bZJck6YYZP4v7Y_46e_Hwu1i3zF4FQhccb2EX8zRqoNYCEe27Fl-xmGD3itpkSbNeBOoR7dQA6z7Qgm68crmeieSGf9wR9r0_02lb/s1600/omg-letters-scribble-animation-doodle-4k_sb8vmstul_thumbnail-full01.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkpMEmpb9YkeV79aXbPt2pDF_4N0gOxVESOEtk4p7bZJck6YYZP4v7Y_46e_Hwu1i3zF4FQhccb2EX8zRqoNYCEe27Fl-xmGD3itpkSbNeBOoR7dQA6z7Qgm68crmeieSGf9wR9r0_02lb/s320/omg-letters-scribble-animation-doodle-4k_sb8vmstul_thumbnail-full01.png" width="320" height="180" data-original-width="1600" data-original-height="900" /></a></div><br />
<br />
This is not what people understand, and there is just no way to educate those that don’t want to know more. I will leave you with something I read in a book I am reading for school (reference is Nickitas, below). It is a quote that completely strikes my funny bone, as probably the most ignorant comment about the Affordable Care Act… <br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpmGidioFO213x9xQy-nMW_AkJZdxRsALfjtiQ7fR0ChWXz8IKgSnd5k6MyT1e79JNP-nNs7_-7VPYo3ND1X83P7ej0EJ7W6iQWW7-4MgM0GWXJv7XE6dxGNoyktyhzDLbl04M6DL3atyo/s1600/Capture.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpmGidioFO213x9xQy-nMW_AkJZdxRsALfjtiQ7fR0ChWXz8IKgSnd5k6MyT1e79JNP-nNs7_-7VPYo3ND1X83P7ej0EJ7W6iQWW7-4MgM0GWXJv7XE6dxGNoyktyhzDLbl04M6DL3atyo/s200/Capture.JPG" width="200" height="77" data-original-width="339" data-original-height="131" /></a></div><br />
Early in President Obama’s first term, when healthcare reform was being proposed, he reported receiving a letter from a woman who did not know the difference between a government and a private health insurance plan. She said, “I don’t want government-run health care. I don’t want socialized medicine. And don’t touch my Medicare” (Cesca, 2009)<br />
<br />
<br />
Ok, she takes the cake for sure...<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMeAVlCBnynhWZla2Qir9H6qGOJ8O8BRCK8JYC-hPVIIFpn5JVZ-dzvE7PYoCzGE3zH38zIhSPT2WuWKyjTEw4_I21sxAxhbqc_70dN0FFDF-G_0Ir9BOY4g6IvtjY876o_h3V8gQp5JoH/s1600/Capture3.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMeAVlCBnynhWZla2Qir9H6qGOJ8O8BRCK8JYC-hPVIIFpn5JVZ-dzvE7PYoCzGE3zH38zIhSPT2WuWKyjTEw4_I21sxAxhbqc_70dN0FFDF-G_0Ir9BOY4g6IvtjY876o_h3V8gQp5JoH/s200/Capture3.JPG" width="200" height="54" data-original-width="169" data-original-height="46" /></a></div><br />
<br />
<br />
<br />
<br />
<br />
...and then for her official winner's certificate...<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmoYjdokVMkpytX0lohmDyfHUbxwpBE2hKM1bWqfJpl522CjcA2uXRxhzxbpCjdVD-nidal4aPMXYfe6kV-RoM_kLAFaaSJg_EWIIee6XMpltuV1WU9KtFDRVvjxbFh-g9Rjqce91YoW63/s1600/Capture1.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmoYjdokVMkpytX0lohmDyfHUbxwpBE2hKM1bWqfJpl522CjcA2uXRxhzxbpCjdVD-nidal4aPMXYfe6kV-RoM_kLAFaaSJg_EWIIee6XMpltuV1WU9KtFDRVvjxbFh-g9Rjqce91YoW63/s200/Capture1.JPG" width="200" height="198" data-original-width="81" data-original-height="80" /></a></div><br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
References:<br />
<br />
Nickitas, D. M. Policy and Politics for Nurses and Other Health Professionals, 2nd Ed. Chapter 2, page 15. Retrieved from an e-book online through Western Governors University. <br />
<br />
<br />
Rosenbaum, S. (2011). The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice. Public Health Reports, 126 (1). Retrieved from <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001814/">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001814/</a><br />
woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-84131793329977504142019-01-30T12:58:00.000-08:002019-01-30T13:06:02.263-08:00Nursing: Professional Presence and a Healing Environment Achievement of success is reliant upon a winning merger of professional and personal life, and maintaining the healthy balance between them. One way you can attain this balance is to develop a professional presence plan that can be used to bridge the two worlds. Professional success in nursing depends upon the nurse’s self-knowledge and awareness, as well as the technical training and experiential practices. Various personality tools can be used to identify your your personality type, which can provide insight about how you think, plan, react, and self-manage. <br />
<br />
This post will help you to explore self-awareness practices to increase the presence of mindfulness in your life and health care practice, by encouraging you to understand your strengths and weaknesses. It will also focus on professional presence, mindfulness practice, and healing environments. Utilizing the awareness gained from analyzing your thoughts, beliefs, and values, as well as your activities, relationships, and experiences, you can transform... and create a healing environment through the use of self-knowledge, active listening, authentic leadership, and mentoring.<br />
<br />
<br />
<b>Models of Health and Healing</b><br />
<br />
According to Larry Dossey there are three eras of medicine between the 1860’s and current times (Koerner, 2011). Initially, illness was thought to exist as a physical response to brain functions. In the 1950’s we began to understand that illness presented with the culmination of physical, emotional, spiritual and mental aspects, internal to the patient. <br />
<br />
It wasn’t until the 1990’s that the care models began to integrate external, social and spiritual components and how this metaphysical energy, both intangible and invisible, has a direct impact on patient health and healing. The core differences can be identified in the approach to care. <br />
<br />
In Era I, providers sought only to reverse or correct the physical properties of the illness and used scientific facts and objective data to provide care. In Era II, providers began to understand that the subjective data the patient provided also had an impact on care—how and what the patient thought, felt, and understood resulted in variant outcomes. In the modern era of practice, there is a deeper understanding of the impact that the environment of care has in patient healing, and the patient’s own power in healing. <br />
<br />
To be human is not just to have power over the mechanical or chemical components of the brain. It is the culmination of the physical, mental, spiritual, social, emotional, cultural, theoretical, and mechanical components that pertain to that patient. <br />
<br />
Era III ushers a practice where there is greater consideration for the environment of care, and in order to promote a “healing environment” we must consider the human, and all that this means, to positively impact on patient’s health. The core difference in the eras then is based on consideration of internal versus external powers and the persuasion they have over the outcome of healing. <br />
<br />
<b>Models and Professional Presence</b><br />
<br />
The environment of care has such an impact on patient outcome, as does the patient’s current human state. “[Mind-mediated phenomena] should inspire doctors to find more ways of treating the ills of the body by taking advantage of the powers of the mind and convince patients that those powers are always available to help restore lost health” (Weil, 2004, p. 234). <br />
<br />
The Era I practices are comparable to the practices you have as a novice nurse, where you use a mechanical, textbook approach to care. You are not yet experienced enough to incorporate anything other than completing tasks, recording and reporting data, and advocating for patients in small ways. You may have since progressed through the levels of nursing experience to become a proficient clinician, and may have emerged to practice with intention, incorporating the needs of the patient and family in a meaningful way to promote an environment of healing. <br />
<br />
Does your practice recognize the multitude of factors affecting patient outcome, including your beliefs, thoughts, and attitudes, and those of the patient? You must not allow your own beliefs or attitudes to obstruct the progress of patient healing, because your sole purpose as a nurse is to advocate for the patient in any way necessary. <br />
<br />
<b>Influence on Nursing Practice</b><br />
<br />
Certainly your professional presence influences your nursing practice. If you are perceived to be competent, calm, self-assured and poised, it will promote an environment of trust and collaboration, which will in turn result in an increase of self-assurance, poise, competency, and composure. When this is perceived by the patient or fellow staff, it promotes a healing environment. <br />
<br />
Many principles are used to promote healing presence in nursing practices. With self-knowledge, you begin to understand how you perceive your surroundings, and how you tend to react to situations. Knowing your personality type can be of great benefit as you learn to facilitate a healing environment. Knowing your personality traits as determined by the Meyers & Briggs typology test, enables you to be mindful in your practices. Use the principle of authentic leadership to influence the practices of others, and to unite in the common purpose of providing a healing presence to your patients.<br />
<br />
Koerner defines healing presence as “the difference between safety and quality,” (p4 Koerner, 2011). I disagree with this definition and believe that healing presence is the bridge between safety and quality, not the difference. When I ask myself ‘what is the difference between the two,’ I think about how I define the two terms in this context. Safety, simply stated, is determined by the technical or mechanical aspects of providing patient care. Quality can then be determined by how that care was provided, focusing more on an emotional or mental application. Therefore the nurse’s healing presence does not differentiate between safety and quality, but rather bridges the obvious gap between the two. <br />
<br />
<b>Whole Person Goals</b><br />
<br />
Mindfulness in essence, is self-reflection-in-action (Sherwood & Horton-Deutsch, 2012, p.80). In developing your own practice of mindfulness, you can create a plan to strengthen your health and balance in the physical, vital, mental, and spiritual bodies/aspects. <br />
<br />
To be more mindful physically, it is important that you nourish your body and provide it with adequate exercise. You could prepare a menu on a weekly basis, to increase the opportunity to make smart and healthy food choices rather than fast food or processed foods. <br />
<br />
To be more mindful in the vital/rhythmic aspect, you can institute a specific curfew for yourself by setting an alarm on your phone/watch. At that time, you would stop what you are doing and begin your bedtime routine. This cut-off time for you nightly, will enable you to achieve the recommended 6-8 hours of sleep each night. <br />
<br />
You can also begin the practice of meditation using a phone app like Headspace. You can use the app daily as it suggests, and evaluate the effectiveness after seven days. Meditation will help to ease anxiety and focus your thoughts, and can help to prevent burnout as a nurse (Lichtenberg, et al., 2013). <br />
<br />
To account for the mental and emotional balance, you can incorporate breathing exercises as an adjunct to the meditation. You can integrate the use of the 4-7-8 (Relaxing Breath) breathing exercise several times throughout the day and thoughtfully begin to practice it when you recognize that your stress level is high (Gonzalez, 2016). The act of intentional breathing is a “bridge between the conscious and unconscious minds” (p62, Weil, 2004). You can also read books for pleasure, to gain mental and emotional balance. <br />
<br />
To achieve and maintain spiritual balance, you can look into attending church weekly, or complete daily scripture readings, or daily religious/gratitude journaling. This will help to restore a positive attitude and bring the realization that you are loved, cared for, and watched over. <br />
<br />
<b>Achievement of Goals</b><br />
<br />
The wholeness of being human, involves attention to all of the aspects of mind, body, and spirit health. In order to achieve the goals you set for myself, you must continue to grow in the understanding that only balance among those aspects will bring ultimate health and allow you to help others in their pursuit of health and wellness. You can make a chart for yourself, to help sort the practices you plan to implement and to help meet the goal of mindfulness. Here is an example of a goal chart:<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMWRa4pyQwAp7blRs5r6_UeIW50JQPbWbGB-Nbr5lNA3M42guSY8dPgqVG1I4I_30rxEtAConR5lSwWdyrRabgWLPDFOOpdqnawyIA_YrmvB0DHUvOZOls_x6VtnZ_IHNft69k8l-JnYX0/s1600/goal+chart.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMWRa4pyQwAp7blRs5r6_UeIW50JQPbWbGB-Nbr5lNA3M42guSY8dPgqVG1I4I_30rxEtAConR5lSwWdyrRabgWLPDFOOpdqnawyIA_YrmvB0DHUvOZOls_x6VtnZ_IHNft69k8l-JnYX0/s400/goal+chart.JPG" width="400" height="205" data-original-width="554" data-original-height="284" /></a></div><br />
To adjust to the changing of your “whole person,” you will have to keep in mind why you chose to observe mindfulness. In order to become an agent of change you need to carry out changes in your own life.<br />
<br />
<b>Healing Environments: Best Practices</b><br />
<br />
There are two facilities I have found in particular, that stand out in their patient care optimal healing environments. Their goal is to promote healing environments that reduce stress, anxiety, to speed healing, to shorten hospital stays, and to reduce the need for additional medications. Grinnell Regional Medical Center (GRMC) offers many different benefits in internal (spiritual care, meditation room), interpersonal (massage therapy, essential oils, café and dining options), behavioral (guided imagery, art therapy), and external environments (healing garden, bird aviary) (Grinnell Regional Medical Center, 2017).<br />
<br />
The Johns Hopkins Hospital works to reduce the stress of hospitalization for the patient and family, incorporating artistic and aesthetic elements into the environment of care. They have rooms designed to be filled with sun, public spaces that are peaceful and elegant, ceiling tiles that absorb sound over patient care areas, gardens that are lush with landscaping designed for reflection and meditation, an art collection on display throughout their buildings, and animal sculptures in the children’s center. They have even included art images on the window shades in private patient rooms (Hopkins, n.d.). <br />
<br />
<b>Professional Presence Promotion</b><br />
<br />
You can apply self-awareness and insights from review of the healing environments that were discussed, to promote professional presence in your current health care setting. As discussed in Management Learning by Becker, Jordan, and Messner in 2009, reflection plays a key role in organizational learning and has been based more on reflection-on-action than reflection-in-action. To engage staff in learning, it is important that they be enabled to learn and reflect as they go, so allowing time for review and reflection is a necessary element. Staff should be offered education on mindfulness practices, and encouraged to develop their own sense of mindfulness. <br />
<br />
In the optimal healing environments discussed above, noise reduction was a key component to promotion of the healing process, both for the patient and for the family. Partnering with the patient, and allowing them time and space to “sort through the issues of the day, offering understanding and interpretation along the way” (p138, Koerner, 2011) is imperative to patient healing. You can begin to offer a quieter, safer, more supportive environment to your patients as a result of this research. There are areas where we can reduce stress for our patients through noise reduction on the unit, during changes of shift and nurse-to-nurse reporting practices. We can create an enhanced healing environment simply by ensuring that the patient room and bedside table are clean and free of debris and clutter. <br />
<br />
We can begin to guide patients through their own mindfulness practices, and teach them non-medicinal techniques to manage their stress and pain – such as breathing exercises, meditation, darkening the room, decreasing environmental stimuli, or repositioning. There are many ways to initiate the use of mindfulness, self-awareness, and healing environments in your organization. <br />
<b><br />
In Conclusion</b><br />
<br />
Achievement of success is reliant upon a winning merger of professional and personal life, and maintaining the healthy balance between them. Adhering to a professional presence plan can bridge the two worlds. There is power in knowing that professional success in nursing can be secured through your own self-knowledge and awareness, as well as the technical training and experiential practices you have and those you will encounter. <br />
<br />
In using personality tools to identify your personality type, you can explore self-awareness practices to increase the presence of mindfulness in your life and your health care practice, by understanding your strengths and weaknesses. You can more clearly focus on your professional presence, mindfulness practice, and the healing environment. You can transform and create a healing environment through the use of self-knowledge, active listening, authentic leadership, and mentoring.<br />
<br />
<b>References</b><br />
George, B., Sims, P., McLean, A.N., and Mayer, D. (2007). Discovering your authentic leadership. Harvard Business Review. Reprint R0702H.<br />
<br />
Gonzalez, B. (Ed.). (2016, May). Three Breathing Exercises And Techniques. Retrieved November 5, 2017, from Andrew Weil M.D. website: https://www.drweil.com/health-wellness/body-mind-spirit/stress-anxiety/breathing-three-exercises/ <br />
<br />
Grinnell Regional Medical Center (Ed.). (2017, December 9). Optimal Healing. Retrieved from https://www.grmc.us/patients/optimal-healing-environment<br />
<br />
Gustafson, C. (2016). James Gordon, MD: The Potential of Mind-Body Self Care to Free the World From the Effects of Trauma. Integrative Medicine: A Clinician’s Journal. 15(2), 54-60. <br />
<br />
Hopkins Medicine. (n.d.). A healing environment. Retrieved November 12, 2017, from https://www.hopkinsmedicine.org/the_johns_hopkins_hospital/about/enhanced_facilities/healing_environment.html <br />
<br />
Jordon (2009). Reflection & mindfulness in organizations. Management Learning.<br />
<br />
Matsuo (2012). Leadership of learning and reflective practice: An exploratory study of nursing managers. Management Learning.<br />
<br />
Koerner, J. (2011). Healing presence: The essence of nursing 2e. Springer Publishing Company. New York, NY. ISBN: 9780826107541<br />
<br />
Lichtenberg Heard, P., Hartman, S., & Bushardt, S. C. (2013). Rekindling the flame: Using mindfulness to end nursing burnout. Nursing Management, 44 (11), 24-29.<br />
<br />
Mendes, A. (2015). The role of nurses’ and patients’ beliefs in nursing care. British Journal of Nursing (Mark Allen Publishing), 24 (6), 345. Doi:10.12968/bjon.2015.24.6.345<br />
<br />
Rassin, M. (2008). Nurses’ professional and personal values. Nursing Ethics, 15(5), 614-630 17p. doi: 10.1177/0969733008092870<br />
<br />
Reid Ponte, P., & Koppel, P. (2015). Cultivating Mindfulness to Enhance Nursing Practice. American Journal of Nursing, 115(6), 48-55 8p. doi:10.1097/01.NAJ.0000466321.46439.17<br />
<br />
Sherwood, G., & Horton-Deutsch, S. (2012). Reflective practice: Transforming education and improving outcomes. Indianapolis, IN, USA: Sigma Theta Tau International. ISBN: 9781935476795<br />
<br />
The Myers & Briggs Foundation (Ed.). (2017). The 16 MBTI® Types. Retrieved November 22, 2017, from The Myers & Briggs Foundation website: http://www.myersbriggs.org/my-mbti-personality-type/mbti-basics/the-16-mbti-types.htm <br />
<br />
Weil, A. (2004). Health and healing: The philosophy of integrative medicine. Houghton Mifflin Co, New York, NY. ISBN: 9780395344309<br />
woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0Topeka, KS, USA39.0473451 -95.67515759999997738.8499411 -95.997881099999972 39.2447491 -95.352434099999982tag:blogger.com,1999:blog-7277205928428297010.post-55216451143757908792015-09-09T23:59:00.001-07:002023-05-21T11:15:00.010-07:00A New View<br />
<div class="separator" style="clear: both; text-align: center;"> <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_yWuHzCRFFoYtJDIZ586fbNveF4sKOJzV9Y5EJluTTFaSq96Th2zOhc1tmz7FeF8hgmdi-82ZnM0fFXuiTfxGY0AxvC4mp9anHmVtp672QkcViHhjhFsQdZ0myOyLGb3GMG015uh6MrAK-xrE0pl49vM7Jc7MotdR1PH_P0sBQDU0bLpqwIm2EVkNrw/s1302/Screenshot%202023-05-21%20at%201.14.00%20PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="724" data-original-width="1302" height="178" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_yWuHzCRFFoYtJDIZ586fbNveF4sKOJzV9Y5EJluTTFaSq96Th2zOhc1tmz7FeF8hgmdi-82ZnM0fFXuiTfxGY0AxvC4mp9anHmVtp672QkcViHhjhFsQdZ0myOyLGb3GMG015uh6MrAK-xrE0pl49vM7Jc7MotdR1PH_P0sBQDU0bLpqwIm2EVkNrw/s320/Screenshot%202023-05-21%20at%201.14.00%20PM.png" width="320" /></a></div><br /></div><br />
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?"<br />
<br />
Answers called out ranged from 8 oz. to 20 oz.<br />
<br />
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."<br />
<br />
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."<br />
<br />
Remember to put the glass down.<br />
<br />
(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!)<br />
woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-21538541377256449522015-06-16T21:05:00.001-07:002015-06-16T21:13:06.712-07:00Oral Nutrition Supplements: The RD Role in Wound Healing & Pressure Ulcer PreventionI 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. <br />
<br />
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.<br />
<br />
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. <br />
<br />
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! <br />
<br />
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. <br />
<br />
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.<br />
<br />
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: <br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSV2drwf_JYBHKAZlvG_h5Es4jV1Y_wcRkb51iRUXnFAoT-EjErwAwaX9ZEpI-pYEnbgvx5uyOBGLWsWxMme665pPhcg2bs_EpT190SLujXAqJ2KDHma34OBsRZ7UC7Avzh4NCC4WYDjS_/s1600/Screen+Shot+2015-06-16+at+9.11.50+PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSV2drwf_JYBHKAZlvG_h5Es4jV1Y_wcRkb51iRUXnFAoT-EjErwAwaX9ZEpI-pYEnbgvx5uyOBGLWsWxMme665pPhcg2bs_EpT190SLujXAqJ2KDHma34OBsRZ7UC7Avzh4NCC4WYDjS_/s640/Screen+Shot+2015-06-16+at+9.11.50+PM.png" /></a></div><br />
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! <br />
<br />
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. <br />
woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com2tag:blogger.com,1999:blog-7277205928428297010.post-57883103863644749872015-06-08T20:26:00.001-07:002023-05-21T11:16:51.989-07:00Lippincott Stepping It Up with "How Caitlyn Jenner's Transition Affects Nursing Care"Monday, June 8, 2015<br />
<br />
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:<br /><br />
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.<br />
<br />
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.<br />
<br />
Read the following CE articles free:<br />
<br />
Caring for...Transgender Patients<br />
Open the door for LGBTQ patients<br />
Addressing Health Care Disparities in the Lesbian, Gay, Bisexual, and Transgender Population: A Review of Best Practices<br />
Compassionately Caring for LGBT Persons in Your Faith Community<br />
Culturally-Sensitive Care for the Transgender Patient<br />
<br />
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. <br />
<br />
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.<br />
<br />
Thank you,<br />
Lisa M. Bonsall, MSN, RN, CRNP<br />
Clinical Editor<br />
Lippincott NursingCenter<br />
<br />
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!<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvphbYJoW1mIpZz1S2BzgWEF9oLMhQ3PswsXr_EKYdpMOHuiCfdVPoe_ZKDHkwrzhHFaR6Nqw2lU7XIwtcP6JCGkwGO33yfDx_oYwuezxwFk9cOo-sroCiVpDWmhArl2_cEfM6S3vPetUL/s1600/Screen+Shot+2015-06-08+at+8.08.27+PM.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvphbYJoW1mIpZz1S2BzgWEF9oLMhQ3PswsXr_EKYdpMOHuiCfdVPoe_ZKDHkwrzhHFaR6Nqw2lU7XIwtcP6JCGkwGO33yfDx_oYwuezxwFk9cOo-sroCiVpDWmhArl2_cEfM6S3vPetUL/s640/Screen+Shot+2015-06-08+at+8.08.27+PM.png" /></a></div>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-3840816602738178602015-04-13T23:45:00.001-07:002015-04-13T23:54:00.925-07:00Please vote to remove this add! Raises negative awareness toward ostomates!<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGnDRrZmIaNVEcyYwbf-WPtAJoqcW-ClKwI75TWh6QrYaok7ZjdBWwyIHxm9iRA77r2x-luxvfxwCjRAAWGrgFrbruDQ2GPUtYtphzF_CWcRsDdsrR1pQ2h_fhS9_70ngJYXk_i0mQ5iG-/s1600/it+would+smell.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGnDRrZmIaNVEcyYwbf-WPtAJoqcW-ClKwI75TWh6QrYaok7ZjdBWwyIHxm9iRA77r2x-luxvfxwCjRAAWGrgFrbruDQ2GPUtYtphzF_CWcRsDdsrR1pQ2h_fhS9_70ngJYXk_i0mQ5iG-/s400/it+would+smell.jpg" /></a></div><br />
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. <br />
<br />
Please sign the petition to remove the add, by copying and pasting this link in your browser: <br />
https://www.change.org/p/centers-for-disease-control-and-prevention-remove-tobacco-colon-cancer-advertisement#petition-letter<br />
<br />
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.<br />
woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-49778160591339667422015-02-12T19:54:00.002-08:002023-05-21T11:28:26.148-07:00CDPH Changes Mandatory Reporting of Pressure Ulcers<div><span style="background-color: white; color: #4d5156; font-family: Roboto, arial, sans-serif; font-size: 14px;">CDPH is the </span><span style="background-color: white; color: #5f6368; font-family: Roboto, arial, sans-serif; font-size: 14px; font-weight: bold;">California Department of Public Health</span></div><div><br /></div>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.<br />
<br />
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. <br />
<br />
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. <br />
<br />
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. <br />
<br />
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."<br />
<br />
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..."<br />
<br />
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.<br />
<br />
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.<br />
<br />
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. <br />
<br />
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. <br />
<br />
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. <br />
<br />
Read the letter at this link:<br />
http://www.cdph.ca.gov/certlic/facilities/Documents/LNC-AFL-15-03.pdfwoundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-89640279314583117852015-01-05T11:32:00.001-08:002015-01-05T11:32:40.928-08:00Skin, Wound, and Ostomy Certification -- upcoming courseSkin, Wound, Ostomy Certification course for LVN/LPN/RN near Los Angeles in February. Call now for a special rate! <br />
<br />
Check out the website by copying and pasting into your browser:<br />
<br />
http://www.skilledwoundcare.com/educational-resources/college-of-longterm-care<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVtr6rawQcR0hcJghlXN4kNMZkHXa5_VwtTDgindfWZ2Xei2ZILxpGVYqHDi-RSn2mIQ97dvnc1FrakqLN2Jl4Uv4z5YNs89Ab-HOI1tUgfYutgSos8DQgo7f43__XJrWxY8Prf4ebAkxA/s1600/SWOC+Feb+2015.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVtr6rawQcR0hcJghlXN4kNMZkHXa5_VwtTDgindfWZ2Xei2ZILxpGVYqHDi-RSn2mIQ97dvnc1FrakqLN2Jl4Uv4z5YNs89Ab-HOI1tUgfYutgSos8DQgo7f43__XJrWxY8Prf4ebAkxA/s400/SWOC+Feb+2015.jpg" /></a></div>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com1tag:blogger.com,1999:blog-7277205928428297010.post-23481428635083403482014-10-16T18:27:00.001-07:002023-05-21T11:21:30.243-07:00Vote NO on Prop 46 #CaliforniaI am hoping that if you are voting in the upcoming election, you vote NO on prop 46. The reason, is that yes, on the surface it appears to be a drug testing requirement for physicians, however, the true underbelly of the proposition is to eliminate the MICRA cap on medical malpractice claims. The current cap is $250,000 and if prop 46 passes, the new liability potential goes to 1 million dollars.<br />
<br />
Now, to any non-physician, that may seem like a fair deal, to lift the cap, but really one must look at the consequences of this. First consequence, the cost of liability insurance for physicians will also increase, putting a strain on providers in small clinics and outpatient programs.<br />
<br />
Next, look at the reasons the cap was originally in place. It was appropriate then, and is still appropriate now.<br />
<br />
Finally, any clinician providing care to a patient, only has a cap of $250,000 liability, but this changes for EVERYONE if the patient is a senior citizen, due to the Elder Abuse laws. If any negligence occurs on a senior, the liability is automatically increased to $1 million... so the cap of $250k doesn't apply here anyway.<br />
<br />
Please vote NO on prop 46, and send a letter or note to your congressman and state representative, as well as your local council members and government reps, that we love the idea of drug testing for docs, but not when it is combined with a removal of the liability cap.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi20OmOGGhhS1i8c8NcRysijhHyOWV-z0kF8ZZvayUNJ38cTlqPysbt3ElwrxHHioWEDSSRk4n8L7aKbKE5WEWBzb-9SPc7fYvar7_tTBISE-0Wb3IeB6lgzo2zXQkgkLqQO60CJD9SuioB/s1600/site_logo.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi20OmOGGhhS1i8c8NcRysijhHyOWV-z0kF8ZZvayUNJ38cTlqPysbt3ElwrxHHioWEDSSRk4n8L7aKbKE5WEWBzb-9SPc7fYvar7_tTBISE-0Wb3IeB6lgzo2zXQkgkLqQO60CJD9SuioB/s320/site_logo.png" /></a></div>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0tag:blogger.com,1999:blog-7277205928428297010.post-30624161863824741922014-10-04T14:55:00.001-07:002014-10-04T14:55:16.209-07:00Free CEU with my Adult Oral Nutrition article!http://anhi.org/courses/adult/oral-nutrition/83223D52C57B4343BFF3CEE508A56ABF<br />
<br />
<a href="http://anhi.org/courses/adult/oral-nutrition/83223D52C57B4343BFF3CEE508A56ABF"></a><br />
</a>Here is a link to my article, on the Abbott Nutrition education website. Read it and take the post test to get 1 free nursing CEU.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEielMW9i2VaLWRk5tVMwmDkE-nH1MkFHPpoZTt9sTjsJZ7R2eDz7JP_c2D6eSIVRh2K5vHMw0rHqyj18CO828D8zDW_iEhplEDmsQ_FSndPpG6X8EO1m2AyCWnGTNwN1J5uJ08P3CSPLEEU/s1600/nursing-currents-july-2013.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEielMW9i2VaLWRk5tVMwmDkE-nH1MkFHPpoZTt9sTjsJZ7R2eDz7JP_c2D6eSIVRh2K5vHMw0rHqyj18CO828D8zDW_iEhplEDmsQ_FSndPpG6X8EO1m2AyCWnGTNwN1J5uJ08P3CSPLEEU/s400/nursing-currents-july-2013.gif" /></a></div>woundcarewisdomhttp://www.blogger.com/profile/09192051984091371583noreply@blogger.com0