Oral mucositis is an inflammatory process of the oral cavity caused by damage of the epithelium (Cawley, 2005, p.584). It is a common side effect that affects approximately 40%-100% of patients who undergo specific cancer treatments (Cawley, 2005, p.584; Eilers, 2004, p.13).
Oral mucositis may result in complications such as pain, infection, malnutrition, treatment delays and dosage reductions in cancer therapy, and decreased functional status and quality of life (Cawley & Benson, 2005, p. 584; Eilers, 2004, p. 13; Sadler et al., 2003, p. 28-29). Thus, proper management of oral mucositis is paramount in patients treated for specific cancer therapies. Nurses interact with patients during all phases of treatment, which gives them the advantage of playing a pivotal role in the proper management of oral mucositis. Cawley & Benson (2005) and Sadler et al. (2003) review the significance of nurse education and training, patient teaching, and the promotion of self-care by patients. In support, Eiliers (2004) points out that ongoing assessment and monitoring, and utilization of interventions with an evidence-based approach are efficacious and important in managing oral mucositis. Furthermore, Potting’s empirical study may prove to be a novel approach to assessing oral mucositis in daily nursing practice. Collectively, knowledge, proper and sufficient oral assessment skills and tools, and the delivery of adequate evidence-based palliative care by the nursing staff prove to be essential components of managing oral mucositis in cancer patients.
In order for nurses to properly manage oral mucositis they must first be knowledgeable about the pathophysiology. The oral mucosa is composed of rapidly-dividing epithelial cells, which are replaced approximately every two weeks from stem cells of the submucosa. Therefore, the integrity of the mucosa is dependent on the continuous reproduction of the submucosal stem cells (Cawley & Benson, 2005, p. 585).
Cawley and Benson (2005) use Sonis’ model to describe the five phases that occur with the process of oral mucositis. It begins with phase one (0-2 days), initiation, when epithelial cells are damaged by the effects of radiotherapy and chemotherapy. Next, phase two (2-3 days), upregulation and message generation, occurs. It involves increased tissue injury and cell death by inflammatory cytokines. Clinically, patients may begin to present with erythema as the mucosa starts to thin. Then, the third phase is signaling and amplification (2-10 days) in which there is cell damage below the mucosal layer. Next is ulceration (10-15 days), the fourth and most clinically observable phase. Ulcers appear deep (extends from epithelium into the submucosa) and are irregularly-shaped. The ulcers are often coated with a pseudomembrane of fibrinous exudate, which is ideal for bacterial colonization. Furthermore, nurses should recognize that nerve endings are exposed at this point. Thus, patients begin to experience pain during this phase. The final phase, phase five is healing (14-21 days). Cell proliferation begins and new tissue layers form. Although healing occurs, patients will continue to have an increased risk for developing oral mucositis because cells below the surface are permanently damaged.
Furthermore, nurses must be knowledgeable about the risk factors associated with the development of oral mucositis. This will help nurses identify high-risk patients, allow nurses to promote oral health care in high-risk patients, and assist nurses in prioritizing their care (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15; Sadler et al., 2003, p. 30). There are treatment related risk factors including chemotherapy, radiotherapy, and bone marrow transplantation (Cawley & Benson, 2005, p. 585). In addition, patient-related risk factors include age, periodontal disease and oral health, diet, tobacco and alcohol use, medications, oxygen therapy, and changes in breathing (Eilers, 2004, p. 15). Young children are at risk due to their higher epithelial cell proliferation rate, and their higher rate of hematologic malignancies which produces prolonged and intensive myelosuppression; older individuals are at risk due to physiologic declines in renal function and healing capabilities (Eilers, 2004, p. 15). Periodontal disease and alterations in oral health impair the permeability of the oral mucosa, reduces oral pH, causes tooth decay and gingivitis, and increases infection rates (Eilers, 2004, p. 15). Nurses should encourage patients to complete a comprehensive dental evaluation prior to receiving their cancer treatment (Sadler et al., 2003, p. 30). Moreover, diet is another factor that places patients at risk. Excessive sugar consumption or inadequate protein and calories in the diet contribute to tooth decay and irritation of the oral mucosa, which prolongs healing time (Eilers, 2004, p. 15). Patients should be counseled about the effects of their diet so they can actively minimize their risk. Furthermore, tobacco and alcohol use exacerbates periodontal disease and irritates and alters the oral mucosa (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15). Medications that may cause xerostomia (e.g. opioids, antidepressants, antihypertensives, antihistamines, diuretics, sedatives, phenothiazines) also promote periodontal disease and create a favorable environment for bacterial and fungal overgrowth (Eilers, 2004, p. 15). Lastly, patients who are subjected to oxygen therapy and/or have changes in their breathing (e.g. tachypnea and mouth breathing) are at an increased risk for developing mucositis because of the dry environment created in the oral cavity (Eilers, 2004, p. 15).
In addition to knowledge, nurses require proper assessment skills and tools to adequately manage oral mucositis. It is essential for nurses to incorporate thorough and ongoing assessment and monitoring throughout the treatment period so that interventions can be modified accordingly (Eilers, 2004, p. 14; Sadler et al., 2003, p. 31). Assessment of the oral cavity should begin before cancer treatment. Nurses play a key role in teaching patients the rationale and benefits of ongoing assessments. During nursing assessments, a thorough examination of the oral cavity should be implemented with appropriate lighting (Eilers, 2004, p. 17). Oral cavity assessments should include visualization of the lips, tongue, gingivae, and all other surfaces within the cavity; palpation of visible lesions; and evaluation of function (Eilers, 2004, p. 17). Interaction with patients for subjective assessment data is also important (Eilers, 2004, p. 17). Nurses should inquire about problems that patients may be experiencing, and they should also inquire about patients’ opinions about current interventions. If current interventions are dissatisfying to patients, or if patients do not understand how to adequately provide self-care, it can cause delays in the healing process and/or may cause the patient to discontinue treatment. Moreover, nurses must accurately document all observable findings gathered from each assessment. Observable findings in the oral cavity that could indicate impending complications include color changes, moisture changes, change in mucosal integrity, and edema of the lips and tongue (Eilers, 2004, p. 17).
Following this further, nurses must utilize proper assessment tools. It is critical for all nurses involved with a patient to use the same assessment tool and to be properly trained in using the assessment tool (Cawley & Benson, 2005, p. 587; Potting et al., 2005, p. 233). An ideal tool to evaluate the oral cavity should be: reliable, valid, objective, and usable in all clinical and research situations (Cawley & Benson, 2005, p. 586; Potting, Blijlevens, Donnelly, Feuth, & Van Achterberg, 2005, p. 229). Some of the instruments utilized in practice for scoring oral mucositis include the Oral Assessment Guide (OAG), Oral Mucositis Assessment Scale, Oral Exam Guide, World Health Organization Scale, and the National Cancer Institute Common Toxicity Criteria Scale for Mucositis and Stomatitis (Cawley & Benson, 2005, p. 587; Potting et al.; 2005, p. 229). Potting et al. (2005) argue that current instruments lack inter-rater reliability, practicality, and usability in daily nursing practice. Thus, Potting et al. (2005) developed a new instrument called the Nijmegen Nursing Mucositis Scoring System (NNMSS), which was tested and found to have favorable results. The goal of developing the NNMSS was to create an assessment instrument that was reliable, valid, and usable in daily nursing practice (Potting et al., 2005, p. 233). The NNMSS measures both objective (erythema, oedema, lesions) and subjective (pain, dryness of mouth, viscosity of saliva) characteristics of the oral cavity (Potting et al., 2005, p. 232). The NNMSS is still a newly developed instrument that needs further testing, but proves to be a promising assessment tool for the future.
The final component nurses should incorporate in their management of oral mucositis is the delivery of adequate evidence-based care. Nursing implementation of an oral care protocol is the key to preventing or minimizing oral mucositis and its complications (Cawley & Benson, 2005, p. 588; Eilers, 2004, p. 15). For patients who undergo cancer therapies, good oral hygiene is the most basic element in the oral care protocol (Cawley & Benson, 2005, p. 588; Eilers, 2004, p. 16). Nurses should always include patient teaching of how and when to care for the mouth to promote self-care. Nurses need to educate patients on topics such as toothbrushes (use soft-bristled/foam brushes, brush at lease twice daily, when to replace ); daily flossing; mouth rinses (avoid alcohol-based mouthwash); foods to avoid (coarse, spicy, acidic, alcohol, extremely hot or cold); ways to deal with dry mouth (rinses, sugar-free candy/gum, increase fluid intake); denture-care instructions (remove when performing oral care, avoid use except when eating, importance of regular cleaning); products to use for dry lips (water-based moisturizers); and how to examine and note changes in their oral cavity (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 16).
In addition to oral care protocol, there are various treatment therapies to manage oral mucositis (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). A common therapy to prevent and treat oral mucositis is mouth rinses (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). It helps to clean the debris, keep the oral cavity soft and moist, and offers pain relief (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). Recommended rinsing solutions include 0.9% saline solution, sodium bicarbonate, and a 0.9%/sodium bicarbonate mixture (Eilers, 2004, p. 18). There are also some rinses that can offer pain relief such as Magic mouthwash (lidocaine, diphenhydramine, magnesium or aluminum hydroxide), and Gelcair Bioadherent Oral Gel (polyvinylpyrrolidone, sodium hyaluronate, and glycyrrhetinic acid) (Cawley & Benson, 2005, p. 589). Nurses must teach patients about various rinses and instruct patients on its proper use.
Another treatment for oral mucositis is cryotherapy (Eilers, 2004, p. 18; Nikoletti, Hyde, Shaw, Myers, Kristjanson, 2005, p. 751). Cryotherapy is based on the principle of vasoconstriction, which reduces epithelial exposure (Eilers, 2004, p. 18). It is an ideal treatment for patients who receive a bolus of chemotherapy (especially with 5-fluorouracil), but it is not practical for those receiving prolonged chemotherapy infusions (Eilers, 2004, p. 18). Nikoletti et al. (2005) conducted a study of cryotherapy, using ice chips, and found that it significantly reduces the effects of oral mucositis.
Furthermore, mucosal protectants, growth factors, antiseptic agents, anti-inflammatory agents, and topical analgesics are other therapeutic agents available (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 19-20). Mucosal protectants promote mucosal healing and cell regeneration (Eilers, 2004, p. 18). According to Eilers (2004), growth factors assist with the regeneration and healing of the oral mucosa (p. 21). In addition, recombinant human keratinocyte growth factor is instrumental in treating mucositis because, it stimulates the replication and maturation of epithelial cells (Cawley & Benson, 2005, p. 589).
To conclude, it is crucial for nurses to be self-directed in seeking knowledge deficits, updating their knowledge base and skills, and utilizing evidence-based interventions to provide optimal patient care and effective management of oral mucositis. Knowledge enables nurses to anticipate the occurrence of oral mucositis and be proactive in the management of its process (Cawley & Benson, 2005, p. 585). Although visual signs of mucositis typically only appear after seven to ten days of treatment initiation, damage begins the day of treatment (Cawley & Benson, 2005, p. 585-586). Initiating patient care prior to therapeutic cancer regimens will minimize the debilitating effects of oral mucositis. Furthermore, adequately maintaining or minimizing oral mucositis will increase the likelihood for completion of therapy and improve patient outcome.
a. Intervention 1- Proper Oral Assessment
i. Disadvantage 1- Current assessment tools lack inter-rater reliability, practicality, and usability in daily nursing practice.
Some of the common scoring instruments used for the assessment of the oral cavity in cancer patients lack validity, reliability, and/or usability (Cawley & Benson, 2005, p. 586; Potting et al., 2005, p.228). A few current scoring instruments used in practice include the Oral Cavity Assessment Form (OCAF), the Oral Assessment Guide (OAG), the Oral Mucositis Index (OMI), and the Western Consortium for Cancer Nursing Research Stomatitis Staging System (WCCNR). Potting et al. (2005) revealed that some instruments base their validity on consensus statements from cooperative groups or a small number of experts in the field, and that only a few instruments were evaluated for reliability during the study of the instrument. In addition, Potting et al. (2005) state that some instruments require the assessment of several items or symptoms on specific locations in the oral cavity, which require patients with severe pain to open their mouths for prolonged periods. Various instruments require different tools to correctly inspect the oral cavity, which can be too complicated for daily nursing practice and requires a significant amount of training to be used accurately (Potting et al., 2005, p. 231). Moreover, some of the scoring instruments were developed for various purposes and from the perspective of a specialized field (e.g., dentistry, radiotherapy, oncology) (Jaroneski, 2006, p. 1086; Potting et al., 2005, p. 229). Most of these instruments focused on evaluating a particular intervention and were not developed with an emphasis on inter-rater reliability because they were only used by a few researchers (Potting et al., 2005, p.229). The lack of inter-rater reliability in these instruments is incompatible with daily nursing practice, which requires a reliable and validated instrument that offers consistency with the changing of staff during every shift (Potting et al., 2005, p. 229).
Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.
Potting, C.M.J., Blijevens, N.A.M., Donnelly, J.P., Feuth, T., & Van Achterberg, T. (2006, July). A scoring system for the assessment of oral mucositis in daily nursing practice. European Journal of Cancer Care 15(3), 228-234. Retrieved October 18, 2007 from CINAHL database.
ii. Disadvantage 2- Lack of universal standards of practice regarding oral care for cancer patients.
According to Jaroneski (2006) there are no universal standards of oral care for patients with cancer. Moreover, Eilers (2004) notes that not only are standards of oral care used inconsistently in patients who undergo cancer therapy, but standards of oral care do no even exist in many institutions. Literature regarding the frequency of performing oral assessment is inconsistent, and experts fail to agree upon the use of assessment tools in the management of oral mucositis (Jaroneski, 2006, p. 1089). Current clinical guidelines, and evidence-based guidelines developed by organizations such as the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology, for the prevention and treatment of cancer therapy fail to address the use of grading scales in the assessment phase (Jaroneski, 2006, p. 1089). Chemotherapy and biotherapy guidelines and recommendations by the Oncology Nursing Society addresses the use of an assessment tool, but does not provide a specific protocol for its use (Jaroneski, 2006, p. 1089). The lack of standards of practice in the use of assessment tools and in the frequency of performing oral assessments leads to the use of inconsistent assessment tool, inadequate documentation, and absent or inconsistent oral evaluations. Adequate and proper assessment of oral mucositis is necessary to guide clinical practice for positive outcomes.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.
b. Intervention 2- Delivery of adequate evidenced-based care.
i. Disadvantage 1- Knowledge gaps in the pathophysiology of oral mucositis, and identification of at-risk patients.
Oncology nurses must be aware of and become familiar with the current five-stage model of mucositis developed by Sonis. A review of Sonis’ five-stage model is included above. An understanding of this model can help guide clinical practice for more positive outcomes (Cawley & Benson, 2005, p. 586; Jaroneski, 2006, p. 1089). Nurses who are knowledgeable about the five stages can better anticipate the occurrence of oral mucositis and can better manage oral mucositis by incorporating proactive care, patient education, and treatment of complications in their care. Before Sonis’ research, mucositis was believed to be a result of epithelial damage caused by radiotherapy and chemotherapy (Cawley & Benson, 2005, p. 585). Sonis’ research has helped us better understand the process of oral mucositis, which targets the submucosa, as opposed to the previously believed epithelium (Cawley & Benson, 2005, p. 585).
In addition to being knowledgeable about the pathophysiology, nurses should also be able to identify at-risk populations. This knowledge will help nurses reduce patients’ risk, implement early interventions, and provide supportive care to patients who are at-risk from suffering the effects of cancer therapy (Cawley & Benson, 2005, p. 584). Cawley & Benson (2005) acknowledge differing views based on age as a risk factor, which includes both the older populations and the younger populations. Other risk factors that nurses should be aware of include gender (women more likely than men to develop oral mucositis), certain chemotherapeutic agents (5-FU, etoposide, methotraxate, antimetabolites, cyclophosphamide, bulsulfan), medications (opioids, antidepressants, phenothiazines, antihypertensives, antihistamines, diuretics, sedative), tobacco and alcohol use/abuse, oxygen therapy, poor oral health or periodontal disease, diet (high sugar intake, protein/calorie malnutrition), changes in breathing (tachypnea, mouth breathing) (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15).
Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.
ii. Disadvantage 2- Lack of an efficacious management strategy.
According to Eilers (2004) there is a widespread interest in the prevention and treatment of mucositis, but limited progress toward finding an efficacious management strategy. Eilers (2004) states that there are a few well-designed studies demonstrating the effectiveness of various treatments, but the studies are inconsistent. Thus, different institutions are using diverse regimens and are forced to make incomplete informed treatment decisions (Eilers, 2004, p. 17). In addition, although there are a variety of agents available for reducing the severity of mucositis, oral complications remain a significant source of morbidity for patients who undergo cancer therapy (Eilers, 2004, p. 17). Current treatment strategies are targeted at providing symptomatic relief, reducing the severity of mucositis, and using systemic agents that work against multiple targets (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18).
Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
References
Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Nikoletti, S., Hyde, S., Shaw, T., Myers, H., & Kristjanson, L. (2005, July). Comparison of plain ice and flavoured ice for preventing oral mucositis associated with the use of 5 fluorouracil. Journal of Clinical Nursing14(6), 750-753. Retrieved October 18, 2007 from CINAHL database.
Potting, C.M.J., Blijevens, N.A.M., Donnelly, J.P., Feuth, T., & Van Achterberg, T. (2006 July). A scoring system for the assessment of oral mucositis in daily nursing practice. European Journal of Cancer Care 15(3), 228-234. Retrieved October 18, 2007 from CINAHL database.
Sadler, G., Stoudt, A., Fullerton, J., Oberle-Edwards, L., Nguyen, Q., & Epstein, J. (2003, February). Managing the oral sequelae of cancer therapy. MEDSURG Nursing, 12(1), 28-36. Retrieved October 18, 2007 from CINAHL database.
Monday, February 4, 2008
Managing Oral Mucositis
Draft for Research Paper by M. Dempsey
Measles, also known as rubeola, is a highly contagious, airborne disease transmitted by infected people. Most people live in parts of the world where vaccinations and immunity are a way of life.
. In six countries, including the United States, measles deaths are at near zero today (Otten, Okwo-Bele, Kezaala, & Brellick, 2003). Still, many people around the world do not have access to these vaccinations, and are therefore susceptible to many diseases that have nearly been eradicated in first world countries, such as the United States. The World Health Organization recognized a need to create a new vaccination program to immunize African children and adults against the number one killer of preventable disease in their country, measles. As a united front, the World Health Organization, The American Red Cross, The United Nations Foundation, The Bill Gates Foundation, and The United States Center for Disease Control and Prevention created The Measles Initiative, as a solution for the measles epidemic in effected regions of the world. The Measles Initiative was put in motion to prevent unnecessary deaths of innocent children and adults by the simple use of a $1.00 vaccination. In addition to saving lives, this global vaccination program will help stop the spread of a highly contagious disease, in hopes of eradicating the measles virus for good.
The measles vaccine has been in use for forty years, but it was not until 1974 that global measles vaccination programs were put into effect (Wolfson, 2007). These programs have since been categorized into three phases. The first phase began in 1974, with high hopes of introducing routine measles vaccinations to almost every country in the world. UNICEF then led a universal childhood vaccination program that started the second phase. The second phase started in the 1990’s and continued to 1999 with the administration of one vaccination at 9 months old to children in 47 countries (Elliman & Bedford, 2007). The second phase found failure when school age children were found to contract the disease, due to not responding well to the vaccination at 9 months old. It was in 1999, when the WHO, UNICEF, The Bill Gates Foundation, and The American Red Cross united to create The Measles Initiative to vaccinate children age 9 months to 14 years old. The third phase would involve two vaccinations, at least three years apart, with scientific research showing that two vaccines are more effective than one (Elliman & Bedford, 2007).
The partnership of each group involved in The Measles Initiative is crucial because each group bears a different responsibility. The WHO designs the policies and health guidelines for each country to ensure proper, safe steps are taken during immunization campaigns. UNICEF is the only organization allowed to import the vaccine into most developing countries and has a sophisticated logistics capacity as well as great stature in the country. The CDC provides funding and the technical and scientific information to the campaign. The UN Foundation provides a substantial amount of funding as well as the financial mechanisms necessary to move funds between agencies and to countries. The American Red Cross provides funding and has the network of Red Cross volunteers to do the work, ensuring each child has a chance to be vaccinated. The Bill Gates Foundation provides funding (Measles Initiative, 2006).
With all of these groups coming together, the vaccination of over 80 million children started in Sub-Saharan Africa, an area of the world that was responsible for over half of the worlds measles deaths, causing 45% of vaccine preventable deaths (Otten, Okwo-Bele, Kezaala, & Brellik, 2003). The Measles Initiative would continue all over the world and wherever there was a need, there would be a vaccine against measles. The Measles Initiative set a goal to cut global measles deaths by 90% by 2010 (Measles Initiative, 2006).
In 2005 Otten, Kezaala, Fall, Maresha, Caimes, & Eggers (2005) found that between December, 2000- June of 2003, the average decline in the number of reported cases was 91%. The total estimated deaths averted in 2003 were 90,043. The initiative has been wildly successful and is still in progress. In 2005 the number of reported measles-related deaths around the world was at 345,000, which is a 60% decrease from 1999’s reported number of deaths of 873,000 (Irby, 2005). In continuing with this success, The Red Cross wants to ensure that The Measles Initiative steadily moves across the globe to vulnerable regions like Asia, where measles deaths are the highest outside of Sub-Saharan Africa and to smaller countries such as Pakistan, and Uzbekistan. With theses programs, health workers provide not only measles vaccines, but also insecticide-treated nets for malaria prevention, vitamin A, de-worming medication and polio vaccines (Irby, 2005).
The follow up campaigns have proven to be successful all over the world. And it has even been suggested that receiving the measles vaccine could act as a non-specific immune boost to give added protection against other diseases, but further research is needed to confirm this (Salama, Mcfarland, & Mulholland, 2003). There is still a need to continue with vaccination campaigns in Africa. Between 2003-2005, citizens of Mozambique were ravaged with a measles outbreak. There were 1,676 confirmed cases in just three years (Nshimirimana, et all, 2006). This was from failure to vaccinate enough of the population to prevent the endemic proving the absolute importance that even those in remote areas of the world must be vaccinated due to the virus’s airborne ability to infect. In 2004 and 2005, there were several large outbreaks in the European Region. The outbreaks in Romania and the Ukraine were the source of measles outbreaks in a number of EU countries, countries in which the government had reported that measles were under control (Spika, 2006). This exemplifies that measles can still effect vulnerable and non-vulnerable populations alike.
The necessity to eradicate vaccine-preventable diseases is overwhelming. Many of these diseases are highly contagious and there are no walls to protect us from the infected. Everyday people travel from region to region carrying unknown diseases. Diseases, such as measles, are capable of wiping out at-risk populations where treatment and medications are remote. We are fortunate to have access to vaccines that our bodies respond to with immunity. The measles vaccine, when given in two doses, is nearly 100% effective against the virus, but whether we can totally eradicate the virus with global vaccination is debatable. Eradication is possible due to the fact the virus in monotypic and unable to mutate (Spika, 2006). The lack of an animal reservoir and the fact that this is an acute, not chronic, illness makes eradication possible. The problem still remains that measles is a highly contagious disease, making it necessary to vaccinate every child, including those in remote areas of the world (Spika, 2006).
With continuing measles vaccination programs and with the united support of major health organizations such as UNICEF, the WHO, The American Red Cross, and the CDC, eradicating measles becomes more of a possibility every time a child is vaccinated. The measles vaccination has been shown to save tens of thousands of lives and the need to vaccinate against measles will continue until the final goal of measles eradication is met.
a. Intervention 1 Immunize every child in Africa against Measles
i. Disadvantage 1 It is extremely unlikely that every child in Sub-Saharan Africa will be found by members of the Measles Initiative due to the topography of the country
1. Sub-Saharan Africa’s climate and topography make it extremely difficult to account for its total population. “Despite colonialism, African remains powerfully itself, moulded by its hard environment.” The problems of finding those in need of medical care are usually compounded by a collapse in basic infrastructure; broken roads and bridges, and continued insecurity. It is difficult to maneuver through the terrain to find tribal groups that are “hidden” from society. The measles initiative would like to vaccinate every child in Africa, but this seems unlikely due to the fact that there are people unaccounted for in a country that is divided by desert, mountains, vast forest and war.
Otten, J. The suffering of millions. (2003, June). New African,(419), 59. Retrieved February 4, 2008, from Platinum Full Text Periodicals database.
ii. Disadvantage 2 There is knowledge deficit amongst some of Africa’s population that the immunization is necessary.
1. Many people In Africa are more concerned with short-term survival than minded to take risks for long-term development. Tribal people in the Congo region live in a warring county, their primary concern is to survive the day. These people have more eminent concerns such as what they are going to eat and drink for the day rather than the need for vaccinations. Knowledge deficit is a problem because they are surviving, but their children are dying from diseases like measles, that could have been prevented from a simple vaccine. It is important to teach the need of vaccinations not only individually but also globally as measles cannot be eradicated unless every individual is immune.
Tim Cullinan, James Welsh. (2001). The problems of medical relief agencies. The Lancet, 357(9257), 713-4. Retrieved February 4, 2008, from Platinum Full Text Periodicals database
b. Intervention 2 Give a booster shot of the measles vaccine to the same children at least three years apart from the time it was first given,
i. Disadvantage 1 Record keeping if Africa is modest due to the socioeconomic status of certain rural parts of the country.
1. Immunization records have been lost or never documented due to the fact that there is little access to computers where most records are stored safely. Paper charting has been lost. especially in tribes where travel is a way of life. This problem has led to errors in documentation of school age children who have or have not received a second booster shot to discourage a measles outbreak during early education. The booster shot is necessary to prevent further outbreaks and spread of such a highly contagious disease. As the child gets older, vaccination records have become more and more obscure, This potentiates the need to vaccinate school age children against measles and other threatening diseased where there are either no documents of incorrect document of the child’s past medical history. In Sub-Saharan Africa, there are few computers and even fewer dollars to provide accurate accounts of medical history.
.Alan R. Lifson, Dzung Thai, Kaying Hang. (2001). Lack of Immunization Documentation in Minnesota Refugees: Challenges for Refugee Preventive Health Care. Journal of Immigrant Health, 3(1), 47-52. Retrieved February 4, 2008, from Research Library database..
ii. Disadvantage 2 African tribes travel due to political unrest, making it difficult to find the children who are in need of a booster shot.
1. Political unrest and a warring state have caused people to leave their homes and communities. . Some of these people go into hiding to escape the consequences of war. This makes it extremely difficult to find those children in need of a second measles shot as well as other vacciinations. The reality of this has shown that the measles epidemic is still a problem in Africa because school age children need a booster to keep them immune from the disease. Aid workers cannot find these displaced children to give them the immunization that are necessary.
Richard Dowden (2005, March). To save Africa we must listen to it. New Statesman, 18(850), 18-20. Retrieved February 4, 2008, from Platinum Full Text Periodicals database. References
Alan R. Lifson, Dzung Thai, Kaying Hang. (2001). Lack of Immunization Documentation in Minnesota Refugees: Challenges for Refugee Preventive Health Care. Journal of Immigrant Health, 3(1), 47-52. Retrieved February 4, 2008, from Research Library database. (Document ID: 352546391)
Carlson, L. (2007, March). Immunization update: neonates to adolescents. Nurse Practitioner, 32(3), 49-57.
Fitzpatrick, M. (2007, May 24). An End to the MMR guilt trip for blameless parents. Community Care, Community Care 1674, 23.
Nshimirimana, D., Masresha, B.G., & Maumbe, T. . (2006, September 22). Effects of measles-control activities--African region, 1999-2005 MMWR: Morbidity & Mortality Weekly Reportt
55, 1017-1021.
Otten, M. W., Okwo-Bele, J. M., & Kazaala, R. (2003, May 15). Impact of Alternative Approaches to Accelerated Measles Control: Experience in the African Region. Journal of Infectious Diseases 187, 36-43.
.Richard Dowden (2005, March). To save Africa we must listen to it. New Statesman, 18(850), 18-20. Retrieved February 4, 2008, from Platinum Full Text Periodicals database. (Document ID: 810330381).
Tim Cullinan, James Welsh. (2001). The problems of medical relief agencies. The Lancet, 357(9257), 713-4. Retrieved February 4, 2008, from Platinum Full Text Periodicals database. (Document ID: 69559122).
The suffering of millions. (2003, June). New African,(419), 59. Retrieved February 4, 2008, from Platinum Full Text Periodicals database.
Adolescent HIV Prevention and Education
Sexually active young people in the United States are at persistent risk for HIV infection. This risk is especially notable for youth of minority races and ethnicities. Continual prevention outreach and education efforts are required in order for adolescents to receive clear and accurate information. Approximately 4,842cases of HIV are diagnosed yearly among people ages 15-24 years (Eaton et al., 2006). With this rate of HIV infections among adolescents it is clear that additional efforts are required as new generations replace the generations that benefited from earlier prevention strategies. Adolescents are receiving mixed messages regarding HIV due to the medications that are now available and longer life expectancy of those living with the disease. Nurses working with adolescents can be pivotal in reaching youth before high-risk behaviors are established by identifying high risk adolescent populations, promoting education, and eliminating barriers to testing.
The Centers for Disease Control and Prevention (CDC) has conducted biennial Youth Risk Behavior Surveillance (YRBS) studies since 1991 in order to identify priority risk behaviors among youth. The results for the YRBS are obtained from students in grades 9-12 who participate in national, state, or local surveys. Of the students surveyed, 46.8% had engaged in sexual intercourse at least once in their life (Eaton et al., 2006). Male students were consistently ranked higher in risk taking behaviors than female students. Minority students (African American and Hispanic) predominately had more risk behaviors than Caucasian males or Caucasian females. These behaviors included multiple sexual partners, unprotected intercourse, and injection drug use (Eaton et al., 2006). Although most students receive some form of preventative health care annually, few discuss STD, HIV, or pregnancy prevention at those visits (Burstein, Lowry, Klein, & Santelli, 2003).
Understanding and identifying adolescent populations that are statistically at higher risk for HIV is a key strategy for nurses. Beedy-Morrison, Nelson, and Volpe (2005) provide evidence that Caucasian adolescent girls engage in higher HIV risk behaviors and receive less HIV testing compared with African American adolescent girls. Although HIV prevalence is higher among African American adolescents, the authors emphasize the implications the result of this study has on health care professionals. According to the findings, if Caucasian girls are more likely to engage in risky sexual behaviors and yet are less likely to be tested, there may be many undiagnosed HIV cases. In addition to the undetected HIV cases, the information health care professionals utilize to identify high risk groups may be inaccurate. Authors Goodenow, Netherland, and Szalacha (2002) found significantly high rates of HIV risk behaviors among bisexual adolescents. A study conducted in Seattle and British Columbia supports the previous research but also found a higher likelihood of HIV risk behaviors among sexually abused students in all sexual orientation categories (Saewyc et al., 2006). Nurses must promote greater community awareness of at-risk adolescents and seek to educate those populations. Education can occur through street outreach, pamphlets with referrals, posters, and classes where youth are located such as the YMCA or Boys and Girls Clubs of America.
Another key strategy for nursing professionals is to provide reality based education. HIV education should include “skills in negotiation, conflict resolution, critical thinking, decision-making and communication, which improves their self-confidence and ability to make informed choices such as postponing sex until they are mature enough to protect themselves from HIV, other STIs and unwanted pregnancies” (Unicef, 2002, p.26). Rew, Whittaker, Taylor-Seehafer, and Smith (2005) suggest that nurses must make sure confidentiality boundaries are established in order to build trust. Adolescents are more receptive to nurses that are open and direct and move from less sensitive topics to more sensitive topics during an assessment. Nurses must assist youth in establishing clear goals for preventing HIV and focus on specific health behaviors related to those goals. Adolescents need to be encouraged to talk with their parents and delay sexual intercourse. If delaying sexual intercourse is not an option adolescents must be taught about the risks and effective contraception methods that will protect against pregnancy, STD’s, and HIV.
An additional strategy nurses need to utilize is to eliminate barriers to sexual health promotion in order to provide effective HIV education. Barriers such as embarrassment, worries about confidentiality, previously bad experiences, and access problems can prevent an adolescent from seeking care. Lindberg, Lewis-Spruill, and Crownover (2006) found that African American adolescents “viewed available healthcare systems as formidable and unwelcoming and healthcare providers as judgmental and disrespectful” (p.85). The adolescents pointed to lack of privacy, having to discuss the problem with multiple personnel including the receptionists, and long waiting times as major barriers. In order to target adolescents, they need a place where they can receive competent care in a relaxing, private, and adolescent focused environment. A teen health clinic with a non-medical environment and open staff is one solution to this problem. Other options include private entrances for teens or a prescribing nurse available at schools.
Currently, we do not yet have a cure or vaccine to prevent HIV. This disease is still winning the war but there is an arsenal of weapons at our command. Nurses must have the know-how and the ability to utilize the resources available. The key to making a difference for adolescents is the adoption of successful HIV prevention interventions, paired with ongoing evaluation of their effectiveness in reducing risky behaviors or increasing safer behaviors. The key strategies addressed provide a foundation to prevent adolescent HIV infection rates. However, many more strategies will be required in order to find success. Young people need the tools to protect themselves from HIV infection and it is going to require a community collaborative effort.
Intervention I- Provide Reality Based Education
Disadvantage I- Limited and Inconsistent HIV Education
HIV prevention work cannot take place without certain ‘tools’ – things that can be used by those at risk of HIV to prevent infection. Ongoing discrimination against HIV positive people and a high number of annual infections suggest that AIDS education in the US is not as effective or as widespread as it could be. A 2006 survey for example found that 10% of Americans thought that there were drugs that could cure HIV, and 29% thought HIV could be transmitted through kissing. Although comprehensive sex education in schools is generally considered the best context in which to teach about AIDS, only around 60% of teachers report using a comprehensive (or abstinence-plus) system. About 34% teach strict abstinence-only programs, while at least 6% teach absolutely nothing at all. The exact content of what is taught can also vary considerably, and many have reported that even in schools where comprehensive education is theoretically taught, a lot of important information can be missed out or glossed over.
UNICEF (2002). Young people and HIV/AIDS: Opportunity in crisis. New York, NY: Author. Retrieved October 2, 2007, from http://www.unicef.org/publications/files/pub_youngpeople_hivaids_en.pdf
Disadvantage II – Outside Variables Can Affect HIV Curriculum Success
Important factors other than curriculum characteristics may dramatically affect their success. In general, at least three groups of factors may affect whether a curriculum-based program produce behavior change: 1) the characteristics of the curriculum and its implementation; 2) the needs, deficits (and assets) of the youth being served by the program; and 3) the characteristics of the youths’ environment, especially the prominence of AIDS, other STDs or teen pregnancy. In some communities in the United States where few young people hear messages to delay sex until older and where HIV is a salient issue, programs that encourage young people to delay sex in order to avoid HIV may be effective, whereas they might not be effective in other communities where youth already hear those messages or where HIV is not a salient issue.
Kirby, D., Laris, B.A., & Rolleri, L. (2006). Sex and HIV education programs for youth: Their impact and important characteristics. Family Health International, 1-76. Retrieved from www.etr.org on January 28, 2008
Intervention II – Eliminating Barriers to HIV Prevention Education
Disadvantage I – Health Care Access and Poverty Prevent Youth From Seeking Care
Studies have found that young people face a host of barriers to health care, including limited access to transportation, lack of confidentiality and youth-friendly service delivery environments, fear about seeking care, and lack of information about services available. Nearly 1 in 4 African Americans and 1 in 5 Hispanics live in poverty. The socioeconomic problems associated with poverty, including lack of access to high-quality health care, can directly or indirectly increase the risk for HIV infection.
Burstein, G.R., Lowry, R., Klein, J.D., & Santelli, J.S. (2003). Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics, 111(5), 996-1002. Retrieved January 3, 2007, from Expanded Academic ASAP database.
Disadvantage II- Less Effort to Reaching “Other” At-Risk Populations
There is a need to pay more attention to the needs of specific groups of young people like young parents, young lesbian, gay and bisexual people, as well as those who may be out of touch with services and schools and socially vulnerable, like young refugees and asylum-seekers, young people in care, young people in prisons, and also those living on the street. Young people who drop out of school are more likely to become sexually active at younger ages and to fail to use contraception.
Rew, L., Whittaker, T.A., Taylor-Seehafer, M.A., & Smith, L.R. (2005). Sexual health risks and protective resources in gay, lesbian, bisexual, and heterosexual homeless youth. Journal for Specialists in Pediatric Nursing, 10(1), 11-19. Retrieved October 2, 2007, from EBSCO Research database.
References
Beedy-Morrison, D., Nelson, L.E., & Volpe, E. (2005). HIV risk behaviors and testing rates in adolescent girls: Evidence to guide clinical practice. Pediatric Nursing, 31(6), 508-513. Retrieved January 14, 2007 from Expanded Academic ASAP database.
Burstein, G.R., Lowry, R., Klein, J.D., & Santelli, J.S. (2003). Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics, 111(5), 996-1002. Retrieved January 3, 2007, from Expanded Academic ASAP database.
Eaton, D.K., Kann, L., Kinchen, S., Ross, J., Hawkins, J., Harris, W.A., & et al. (2006). Youth risk behavior surveillance-United States 2005. Morbidity and Mortality Weekly Report, 55(SS-5), 1-112. Retrieved January 31, 2007, from http://www.cdc.gov/mmwr
Goodenow, C., Netherland, J., & Szalacha, L. (2002). AIDS-related risk among adolescent males who have sex with males, females, or both: Evidence from a statewide survey. American Journal of Public Health, 92(2), 203-210. Retrieved January 9, 2007, from PubMed central database.
Kirby, D., Laris, B.A., & Rolleri, L. (2006). Sex and HIV education programs for youth:Their impact and important characteristics. Family Health International, 1-76Retrieved from www.etr.org on January 28, 2008.
Lindberg, C., Lewis-Spruill, C., Crownover, R. (2006). Barriers to sexual and reproductive health care: Urban male adolescents speak out. Issues in Comprehensive Pediatric Nursing, 29(2), 73-88. Retrieved October 2, 2007, from EBSCO Research database.
Rew, L., Whittaker, T.A., Taylor-Seehafer, M.A., & Smith, L.R. (2005). Sexual health risks and protective resources in gay, lesbian, bisexual, and heterosexual homeless youth. Journal for Specialists in Pediatric Nursing, 10(1), 11-19. Retrieved October 2, 2007, from EBSCO Research database.
Saewyc, E., Pooh, C., Murphy, A., Skay, C., Richens, K., Reis, E. (2006). Sexual orientation, sexual abuse, and HIV risk behaviors among adolescents in the pacific northwest. American Journal of Public Health, 96(6), 1104-1110. Retrieved October 2, 2007, from EBSCO Research database.
UNICEF (2002). Young people and HIV/AIDS: Opportunity in crisis. New York, NY: Author. Retrieved October 2, 2007, from http://www.unicef.org/publications/files/pub_youngpeople_hivaids_en.pdf
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Paste the rest of your old paper plus the new part and all the references over these words. Leave the following text intact.
Medication Errors
Maggy Eldridge
Administration of medications is an important nursing function and one that if not properly carried out, can lead to a host of problems for the patient and nurse. It is estimated that over 1.5 million preventable medication errors occur annually in the United States (Neal, 2006), leading to death, patient disability, increased length of hospital stays and costs.
Cause and Prevention: Medication Errors
Administration of medications is an important nursing function and one that if not properly carried out, can lead to a host of problems for the patient and nurse. It is estimated that over 1.5 million preventable medication errors occur annually in the United States (Neal, 2006), leading to death, patient disability, increased length of hospital stays and costs. According to Abudato (2004), medical errors (including medication administration errors and others) kill approximately 44,000 people yearly costing hospitals up to $30 billion annually. Medication errors can result in consequences for both the patient and the nurse; death for the patient and legal troubles for the nurse. By following some basic strategies, nurses play an important role in the reduction of such errors. These strategies include following established safety procedures, utilizing team communication to ensure safety, and using technology to reduce errors.
There are many factors that contribute to medication errors resulting in consequences to both patient and nurse. Factors that can contribute to errors include illegible handwritten drug orders, confusing drug names, and the use of nonstandard or unclear abbreviations (Neal, 2006). For the patient, the effect of drug errors can range from no side effects to death. For the nurse who commits a medication error the consequences can range from additional training and supervision to lawsuits and revocation of licensure. Medication errors can occur at any stage in the process of delivering medications to patients, from the originating prescriber to the pharmacy, but the majority of medication errors occur during administration.
Adherence to established safety procedures by all healthcare professionals can help to reduce medication errors. Errors occurring during the administration process are likely due to one of the steps of the five rights of medication administration being omitted: the right patient, medication, dose, route, and time, with the most frequent errors resulting from omission, wrong dose, and wrong medication (Davidhizar & Lonzer, 2003). Factors that can exacerbate errors include problems with the drug distribution system, inadequate staffing levels, environmental factors (e.g., distraction), nurses working in unfamiliar units, and not following standard policy and procedure. According to Davidhizar and Lonzer (2003), the following strategies are useful in addressing safety issues that revolve around medication errors: 1) reporting and analyzing errors using a multidisciplinary approach; 2) providing adequate staffing and training; 3) establishing and monitoring policies and procedures to ensure effectiveness and safety; and 4) all members of the healthcare team should have an awareness of how medication errors occur and be conscientious when administering medications. Attention to safe drug administration and safety guidelines is of particular importance in efforts to reduce medication errors and increase patient safety; it is an issue that is of concern across the various healthcare disciplines and nurses are essentially the final check and balance in the system.
Communication is a key function for nurses in providing safe and effective healthcare to their patients, and includes communicating effectively with patients and other healthcare team members. Abudato (2004) states that 90% of errors that occur within the healthcare industry are due to communication that breaks down at the nurse-physician level. Often, dysfunctional communication patterns between professionals in healthcare entities results from the organizational structure which determines how professionals interact with each other, who has the power (individual and group), and the cultural norms of the organization. RN’s are accountable to provide safe care to the point of questioning physician orders in order to fulfill the role of patient advocate. This can lead to dysfunctional communication because it represents a challenge to the authority and power of the physician, especially those who feel that they are where the “buck stops” when deciding what is and is not appropriate patient care (Arford, 2005).
Johns Hopkins has adopted a three-step model that focuses on assertiveness as a strategy for communication. This model advocates that when nurses communicate it is appropriate to use the first name of the person they are addressing in order to get their attention. The model further stresses that it is important to not only present the problem, but also present a solution and seek agreement to what has been proposed. Finally, the model suggests that if satisfactory resolution is not attained, move the problem up to the next level of authority (Abudato, 2004). Organizational structure often dictates the way communications occur and it is important to remember that no matter the situation, mutual respect must be maintained. Effective communication among all team members is an important aspect of delivering appropriate patient care and advocating for the patient, and is an area where things can often go wrong.
There is no substitute for common sense and diligence, but technological advances may be of use in helping to prevent medication errors. Technological measures include automated medication dispensing machines, computerized IV administration, and the bar coding of both patients and drugs. A research study conducted among a select group of nursing students at a suburban New York university was designed to answer the question: Does the use of PDAs (personal digital assistants) with drug and medication calculation software improve the accuracy and efficiency of medication administration (Greenfield, 2007)? Results of this study upheld the hypothesis that the use of PDAs and medical software did, overall, improve the accuracy and efficiency of medication administration. The author of the study recommends that all nursing students be required to have PDAs with drug and calculation software on them. There is evidence to suggest that use of technology is helpful in reducing medication errors, nonetheless, a strong human component remains and does not replace the need for carefulness and good judgment.
Medication errors represent a serious issue for the healthcare community as a whole. Errors can result for a variety of reasons; however, the majority of errors occur during administration of the medications. Because the nurse is the final link in the process of administering medications, it is the responsibility of the nurse to ensure accurate delivery of medications to patients. Strategies that the nurse can use to accomplish this include attention to policies and procedures, effective communication with other healthcare team members, and using available technological resources to complement other safeguards and individual competence.
a. Staffing and reporting
i. Staffing
1. Because of the high acuity of patients in the hospital setting today, with nurses possibly discharging and admitting several patients within a shift, adequate staffing levels are critical to providing safe patient care. With repeated interruptions nurses may find it difficult to establish and maintain a routine that may be critical to the delivery of appropriate and timely medications. In addition to disruptions in the work flow, the complexity of the work performed by nurses as they balance their workload along with managing the goals of the organization and goals of patient care, contributes to the problem.
2. Aebersold, M., Kalish, B.J. (May/June 2006). Overcoming barriers to patient safety. Nursing Economics 24(3), pp. 143-155. Retrieved from ProQuest on February 2, 2008.
i. Reporting of errors
1. Reporting of errors relies on voluntary reporting. Traditionally, the nursing profession has operated based on a culture of fear and blame that focuses on individual culpability rather than looking at problems from a system-wide perspective. There can also be some ambiguity with regards to what actually constitutes a medication error (e.g., is late delivery of a dose a medication error?) and there is often reluctance to report errors that do not result in patient harm. Often nurses feel that reporting medication errors will be personally and professional damaging and are also reluctant to report errors made by others such as physicians, pharmacists and other nurses.
2. Groves, M., Pafford, L., Stetina, P. (June 2005). Managing medication errors – a qualitative study. MEDSURG Nursing 14(3), pp 174-178. Retrieved from Expanded Academic ASAP on April 6, 2007.
j. Communication & organizational structure
i. Interpersonal communication
1. Historically, health care has been organized in a hierarchical fashion with physicians at the top of the hierarchy and seen as the authority when it comes to patient care. This type of culture has become so ingrained in our health care system that we don’t even question it. According to Abudato (2004), the acceptance of this culture can result in physicians subconsciously ignoring important information provided by nurses because they view them as subordinate. When this type of response is the norm, nurses may feel irrelevant and stop communicating, which only serves to further dysfunctional communication styles and may have an impact on the quality of patient care, including medication administration.
2. Abudato, S. (2004, September). Making the communication connection: To minimize miscommunication with colleagues and patients, get assertive. Nursing Management 35(9), pp. 33-35. Retrieved from ProQuest on October 24, 2007.
ii. Organizational structure
1. While each nurse should have accountability in delivering safe and competent care including medication administration, often the organization itself leads to problems. It is the organization that provides the context in which nurses and physicians communicate because it directs the behavioral norms and determines how nurses and physicians communicate with each other. Conflict can arise in the context of nurses performing their roles as independent practitioners which can result in dysfunctional nurse-physician communication when individual authorities are challenged. Organizations often do not provide environments that are conducive to fostering teamwork and collaborative communication between nurses and physicians.
2. Arford, P.H. (2005, March-April). Nurse-physician communication: An organizational accountability. Nursing Economics 23(2), pp. 72-77. Retrieved from Expanded Academic ASAP on April 6, 2007.
References
Abudato, S. (2004, September). Making the communication connection: To minimize miscommunication with colleagues and patients, get assertive. Nursing Management 35(9), pp. 33-35. Retrieved from ProQuest on October 24, 2007.
Aebersold, M., Kalish, B.J. (May/June 2006). Overcoming barriers to patient safety. Nursing Economics 24(3), pp. 143-155. Retrieved from ProQuest on February 2, 2008.
Arford, P.H. (2005, March-April). Nurse-physician communication: An organizational accountability. Nursing Economics 23(2), pp. 72-77. Retrieved from Expanded Academic ASAP on April 6, 2007.
Davidhizar, R., Lonser, G. (2003, July-September). Strategies to decrease medication errors. Health Care Manager 22(3), pp. 211-218. Retrieved from Expanded Academic ASAP on April 6, 2007.
Greenfield, S. (2007, March). Medication error reduction and the use of PDA technology. Journal of Nursing Education 46(3), pp.127-131. Retrieved from ProQuest on April 6, 2007.
Groves, M., Pafford, L., Stetina, P. (June 2005). Managing medication errors – a qualitative study. MEDSURG Nursing 14(3), pp 174-178. Retrieved from Expanded Academic ASAP on April 6, 2007.
Harrington, S., Lilley, L., and Snyder, J. (2007). Pharmacology and the nursing process (5th ed.). St. Louis: Elsevier Saunders.
Neal, T. (2006, September 19). Preventing medication errors. The Seattle Times. Downloaded from seattletimes.nwsource.com on April 6, 2007.
Sunday, February 3, 2008
Anaphylaxis
Anaphylaxis and its treatment
Gary Darley
Nursing 211
John Miller
3 February 2008
Anaphylaxis and its treatment
Anaphylaxis is a rising threat to the lives of many people. Recent increases in the number of serious reactions seen in emergency rooms, have led to the need for an increased awareness of the causes and treatment of anaphylaxis (Sampson, 1601).
Anaphylaxis and its treatment
Anaphylaxis is a rising threat to the lives of many people. Recent increases in the number of serious reactions seen in emergency rooms, have led to the need for an increased awareness of the causes and treatment of anaphylaxis (Sampson, 1601). The intent of this paper is to explain what is happening during an anaphylactic reaction and what the protocol is to correct it. The science of treating anaphylaxis is relatively well understood, and when established protocols are followed, treatment of anaphylaxis is highly successful.
To start, anaphylaxis is defined by Brown as, a severe, life-threatening generalized or systemic hypersensitivity reaction (157). Finney states that, anaphylaxis is a severe allergic reaction, where the body’s immune system over-reacts to a harmless substance. The reaction becomes so strong that it threatens imminent death through hypotension, bronco-constriction and hypovolemia, if no action is taken to negate the effect (50).
While anaphylaxis can be mistaken for other conditions such as, an asthma attack, arrhythmia, myocardial infarction, pulmonary embolism, insulin reaction or vaso-vagal response, it is important to note, that most anaphylactic reactions occur within minutes of exposure to an antigen (Finney, 52). Signs and symptoms include pallor, hypotension, anxiety, respiratory distress, pulmonary edema, angio-edema, stridor, tachycardia, urticaria, wheezing and tightness of the chest (53).
Among the chief causes of anaphylaxis are food-induced causes, namely peanuts, tree nuts, fish and shellfish (Sampson, 1601). It is important to note that these are the major foods that cause anaphylaxis, but not the only ones. Other causes include exercise induced, venom reactions or reactions to therapeutic drugs (Brown, 158). In 15-32% of reactions according to Brown, no causative agent was identified. This makes preventing reactions from reoccurring more difficult (157).
There are two major parts of the immune system which are responsible for anaphylactic reactions. First are basophils and second are mast cells. Basophils are a type of white blood cell that carries histamine, heparin and other inflammatory factors. They are found in the blood stream. Mast cells are basophils that have left the blood stream for body tissues, such as loose connective tissue, gastrointestinal mucosa, lungs and the area around blood vessels. In addition to histamine, heparin and inflammatory factors, mast cells also carry spasmogens (Bryant, 24). When working properly these two cell types effectively aid your body in combating invading organisms and keep you healthy. They do this by working with lymphocytes and memory cells. As lymphocytes react to an antigen they produce antibodies and memory cells. The antibody attaches to the antigen inactivating it. Memory cells stay in the vascular system, ready to rapidly produce antibodies, so as to put a quick stop to any identical antigens that may invade. The combination of antigen and antibody attaches to the basophil or mast cell, which then releases chemical signals, primarily histamine. The release of these chemicals attracts another type of white blood cell, an eosinophil for phagocytosis (Bryant, 24-25).
In an individual who is prone to anaphylaxis the basophils and mast cells over produce histamine and other inflammatory factors, or degranulate releasing their entire chemical stores (Bryant, 25). This causes a cascade of events to occur. Vessels dilate and become more permeable to fluids, causing third spacing of fluid and edema. A decrease of up to 35% of blood volume can occur in ten minuets or less, resulting in hypotension and hypovolemia. Airway constriction due to direct histamine action on smooth muscle and edema in the airway decrease a patient’s ability to effectively breathe. Without immediate intervention, most patients will asphyxiate or go into cardiac arrest (Brown, 159).
Several factors exist which predispose an individual to having an anaphylactic reaction, a history of asthma, food allergy (especially to nuts and sea food), history of anaphylaxis, pubescent patients and patients on beta-blockers or angiotensin-converting enzyme inhibitors. As the majority of reactions come from a foreign substance entering the body, the keystone to anaphylactic therapy is prevention (Sampson, 1606). On those occasions when a reaction does occur, treatment must be immediate.
Treatment of anaphylaxis follows the airway, breathing and circulation rule. Epinephrine is the cornerstone of initial treatment for anaphylaxis. Formerly called adrenaline, epinephrine counter-acts the anaphylactic reaction by relaxing the smooth muscles of the airway, constricting blood vessels and suppressing the release of histamine (Finney, 54). 0.15mg for children and 0.3mg of epinephrine for adults can be carried in an easy to use auto-injector called an Epi-pen. The longer it takes to treat the patient with epinephrine, the greater the incidence of complications and fatal reactions. Once initial treatment is performed, an assessment of the patient’s oxygen saturation, overall perfusion and cardiac output must be performed (Sampson, 1604-1605). While epinephrine does a good job initially, additional therapy may be needed in the form of oxygen, to maintain adequate blood saturation, and IV fluids to combat circulatory fluid loss (Brown, 161). Oxygen via mask or nasal canula maybe used, or if necessary artificial ventilation can be used (Brown, 164). Albuterol is sometimes employed to aide in opening the airway. While normal saline may be used, the preferred fluid replacement is an isotonic crystalloid such as Lactated Ringers (Bryant, 161). After treatment has been successful, a four hour observation period is recommended. This is to ensure the reaction does not recur after the epinephrine wears off (Brown, 163). The figure on the following page is a step by step process taken from Brown, showing anaphylactic treatment (164).
Once a patient has been diagnosed with an anaphylactic reaction, education on what to do is essential. A trigger needs to be isolated by an allergist, so that avoidance is possible. The patient needs to be taught the signs and symptoms of an anaphylactic reaction. They then need to understand how to use a portable epinephrine injector, such as the Epi-Pen. Once the Epi-Pen has been used, transport to an emergency room needs to follow, even if the patient seems to recover, as they may still have the antigen in their system. A medical bracelet should be worn, advising any emergency personnel of the patient’s allergy. It must be reiterated, especially to young patients and their care givers, that avoidance of the antigen is vital, but that a normal life is possible.
In conclusion, anaphylaxis is a treatable condition that all medical personnel need to be aware of. It is being seen on a more frequent basis throughout the United States. The reactions are primarily caused by severe food allergies, which can be controlled through avoidance. The cornerstone of treatment is epinephrine, with other therapeutic measures taken as needed. While anaphylaxis complicates a patient’s life, it does not have to stop it. Medical personnel everywhere should be prepared to successfully combat anaphylaxis when it comes knocking at the door.
Intervention #1: Epinephrine Use
While epinephrine is often considered a miracle drug in the treatment of anaphylaxis, there are several disadvantages that surround it. Two of these disadvantages will be discussed. The first is education for patients who use Epi-Pens. In an article by Kumar et al, the authors cited a study that found that in 90% of fatal anaphylactic reactions, patients were not carrying their epinephrine injectors (Epi-Pens). Another cited study showed that some patients had prescriptions for Epi-Pens but never carried them, some carried them but didn’t know how to use them and others carried and used expired equipment, which failed to perform when needed (284). These studies show that patient education is at least as valuable as having the needed supplies to treat an anaphylactic reaction.
Kumar, A., Teuber, S., & Gershwin, M. (2005, December). Why do people die of anaphylaxis: A clinical review. Clinical & Developmental Immunology, 12(4), 281-287. Retrieved February 3, 2008, from Academic Search Premier database.
The second problem found was in the availability of trained staff to recognize an anaphylactic reaction and use epinephrine appropriately. Rankin and Sheikh conducted a survey in the UK that found that epinephrine was available in 97% of schools surveyed. Of those schools with an identified at risk child 80% had staff trained to use epinephrine, while only 48% of schools without an at risk child had staff trained to use epinephrine. 59% of all the schools surveyed did not feel confident in their ability to properly treat and manage an anaphylactic reaction. These numbers become significant when you realize that the highest incidence of anaphylaxis occur due to food sensitivity reactions and those reactions become known when a person is in the primary to high school levels of schooling (1429).
Rankin, K., & Sheikh, A. (2006, August). Serious Shortcomings in the Management of Children with Anaphylaxis in Scottish Schools. PLoS Medicine, 3(7), e326. Retrieved February 3, 2008, from Academic Search Premier database.
Intervention #2: Allergen Avoidance
Another problem with treating anaphylaxis is avoiding the trigger to a reaction. Two difficulties regarding avoidance will be discussed here as well. The first is in non-patient education. One of the major causes of anaphylaxis is an allergy to peanuts (Munoz-Furlong, 33). It seems like such a harmless thing, a peanut. But to some it is deadly.
The Grecos understand because they saw it almost happen to Colby over Labor Day weekend. The toddler, who had safely eaten peanuts before, got three peanut M&Ms as a potty-training reward. "Within 20 minutes, he was sick to his stomach," his grandmother says. "Then he started swelling up and developing hives." Then Colby started struggling to breathe; his face turned pale and his lips turned blue from lack of oxygen. "They did arrive at the hospital in time to save his life," Maureen Greco says. Doctors said Colby had suffered a severe allergic reaction. It could happen again, they said, if he ever touched or ate something containing peanuts. (Even children who have had mild reactions in the past are at risk for severe incidents.) So, Julie Greco has done what any mother would do: She has asked the parents at Colby's preschool to avoid sending in snacks made with peanuts -- and taken him home from one class birthday party because the cake contained them anyway (Painter).
As people who live in this world with others, education is needed so that we can be good neighbors and citizens. Believing a child when they say, “I can’t have that” maybe the difference between attending that child’s funeral or not (Painter).
Munoz-Furlong, A. (2006, February). Going Nuts Over Allergies. Education Digest, 71(6), 33- 34. Retrieved February 3, 2008, from Academic Search Premier database.
Painter, K. (n.d.). In the shadow of the peanut. USA Today, Retrieved February 3, 2008,from Academic Search Premier database.
The second difficulty lies in patient education. In a world where we eat what comes in a box, we have no idea what may have been used in the manufacturing process for that food. Label reading becomes imperative for someone with a known allergic reaction. The food item in question may not even contain the ingredient needing to be avoided, but the plant where it was made can have a risk for cross contamination with other products that do. Labels contain warnings that need to be headed in order to avoid a reaction (Schmit).
Schmit, J. (n.d.). More food labels take an ominous tone on allergens. USA Today, Retrieved February 3, 2008, from Academic Search Premier database.
In summary, anaphylaxis can be treated successfully, but that success rests largely on education. Epinephrine can save a patients life, when used appropriately or it can also cause death when not used or used inappropriately. Avoidance of an allergen is essential to living a wonderful life. When not avoided, allergens can cause a loss of quality of life in the short term as well as the long term in the form of death. Understanding these things becomes a vital necessity to those of use living here on this blue rock we call Earth.
References
Brown, S. (2006, April). Anaphylaxis: Clinical concepts and research priorities. Emergency Medicine Australasia, 18(2), 155-169. Retrieved November 5, 2007, from CINAHL database.
Bryant, H. (2007, May). Anaphylaxis: Recognition, treatment and education. Emergency Nurse, 15(2), 24-28. Retrieved November 5, 2007, from CINAHL database.
Finney, A., & Rushton, C. (2007, May 23). Recognition and management of patients with anaphylaxis. Nursing Standard, 21(37), 50. Retrieved November 5, 2007, from CINAHL database.
Kumar, A., Teuber, S., & Gershwin, M. (2005, December). Why do people die of anaphylaxis: A clinical review. Clinical & Developmental Immunology, 12(4), 281-287. Retrieved February 3, 2008, from Academic Search Premier database.
Munoz-Furlong, A. (2006, February). Going Nuts Over Allergies. Education Digest, 71(6), 33-34. Retrieved February 3, 2008, from Academic Search Premier database.
Painter, K. (n.d.). In the shadow of the peanut. USA Today, Retrieved February 3, 2008, from Academic Search Premier database.
Rankin, K., & Sheikh, A. (2006, August). Serious Shortcomings in the Management of Children with Anaphylaxis in Scottish Schools. PLoS Medicine, 3(7), e326. Retrieved February 3, 2008, from Academic Search Premier database.
Sampson, H. (2003, June). Anaphylaxis and emergency treatment. Pediatrics, 111(6), 1601-1608. Retrieved November 5, 2007, from CINAHL database.
Schmit, J. (n.d.). More food labels take an ominous tone on allergens. USA Today, Retrieved February 3, 2008, from Academic Search Premier database.
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Saturday, February 2, 2008
Substance abuse among nurses
The prevalence of substance abuse among nurses is rising and continues to rise. The American Nurses' Association (ANA, 2002) estimates that six to eight percent of nurses use alcohol or other drugs to the extent that they impair their professional performance (ANA, 2002). Because of the incidence of drug abuse among nurses, it is important all nurses to be aware that drug abuse exists among nurses and should know the proper steps to assist their co-worker get the support they need. Rachael Warren
Some startling recent statistics show that in the United States, the problems in productivity and employment among individuals with substance abuse problems cost the American economy $80.9 billion. Of this, $66.7 billion was attributed to alcohol and $14.2 billion to other drugs (NIH, 2007). Of course, this does not include the emotional costs to families and individuals such as divorce, alcohol, and drug-related domestic and child abuse, automobile injuries, etc. One out of every ten nurses has engaged in substance abuse and this is a defiant problem for the nursing community. A great strategy for combating substance abuse is being aware of the signs of drug abuse; new nurses can be better equipped to take action against an ever growing issue. An additional strategy is knowledge of factors that contribute to drug abuse among nurses. Finally, learning early on how to manage one’s own stress level can greatly decrease the pervasiveness of drug abuse in the nursing community.
The majority of nurses who receive treatment for problems related to chemical abuse became addicted as students, and were academically in the top third of their class. A majority also hold advanced degrees. It has been estimated that approximately ten percent of nurses are chemically impaired and most disciplinary problems that are addressed by Boards of Nursing are related to nurses in this ten percent (Uris, 2002). Nurses should be educated on the signs and symptoms of substance abuse among their peers. It is important for all nurses to be aware of signs and symptoms of substance abuse, such as, mood swings, diminished alertness, increasing forgetfulness, defensiveness, decreased concentration. Additionally signs of withdrawal, impaired cognition, isolation or withdrawal from colleagues. Substance abuse issues in nursing usually are first noted by staff members. Whether a staff nurse acts on his or her knowledge or chooses to remain silent, directly affects patient care, safety and the reputation of the institution. It also ultimately affects the impaired colleague's level of functioning (Dunn, 2005). By the time a nurse demonstrates negative or inappropriate work habits, the problem already has reached a serious stage. It is advantageous for institutions to create systems that allow for reporting and tracking substance-abuse incidents and provide education and support to help nurses participate in rehabilitation and avoid placing patients in harm's way (Blair, 2003).
Being aware of signs and symptoms is important; however being aware of factors that contribute to substance abuse is another important step in understanding its prevalence. Some of the factors that have been identified as contributing to substance abuse are: psychological or physical pain, emotional problems, a demanding high-pressure and stressful work environment, and family problems. Additional factors that have been known to contribute are previous emotional or mental health problems, family members with chemical dependency, depression, anxiety, or mental, emotional, or sexual abuse (George, 2003). Some recent studies have shown that nurses who work in oncology have overall high substance use rates. One theory for this behavior is that controlled substances serve as a coping mechanism to help nurses distance themselves from the emotional pain they may experience while working with dying patients (Dunn, 2005). Psychiatric nurses also experience high levels of substance use. Nurses working in psychiatric areas may consider self-medication more acceptable because they work in a culture that accepts using psychotropic medications to cope with life (Anderson, 2004). Additionally, psychiatric nurses may be more willing to report their use of substances than other specialty nurses because they perceive this as an acceptable form of treatment. Pediatric and women's health nurses report the lowest use of addictive substances. This could be due to the lack of availability of these substances on their units, or it could be that this population of nurses is emotionally expressive (NIH, 2003). People who are able to express their feelings may have less need for substance use.
Learning about the signs and symptoms and knowledge about contributing factors are great ways to decrease the prevalence of substance abuse Furthermore, increasing education about management of stress levels is another strategy that can help reduces substance abuse in the workplace. Stress provides another explanation for why some nurses abuse substances. Increased workloads, decreased staffing, double shifts, mandatory overtime, rotating shifts, and floating to unfamiliar units all contribute to feelings of isolation, fatigue, and, ultimately, stress (Ponech, 2005). Each person feels stress and handles it in different ways; learning early on how to effectively manage stress can be extremely beneficial in finding alternative ways to decrease stress. Chronic stress can result in increased sensitivity to stress and cause more susceptible to the effects of stress. Research indicates that increased sensitivity to stress actually alters physical patterns in our brain, thus if stress is uncontrolled it can lead to emergency measure to decrease it, and thus leading to the use of substance abuse (Anderson, 2004). To aid in learning how to decrease stress here are a few strategies for decreasing stress: learning to take time out for self care, regular exercise, good communication with family, friends and co-workers, planning productive solutions to problems, ask for support when feeling stressed out, and learning to set clear limits.
To actively combat this issue of substance abuse that imperils patients and gives rise to a bad reputation toward nurses, all nurses should be aware of the signs and symptoms of substance abuse; to strive for better communication in their homes and within the work place. To find out what helps them manage their stress levels and to fervently practice self care that will aid in the decrease of physical, emotional, and psychological stress. By being aware of the signs and symptoms nurses’ know what signs may point to the need for intervention for their co-worker. By being knowledgeable about factors that contribute to substance abuse nurse can identify those factors if present in their own lives and can get help before those issues become uncontrolled. Understanding how stress correlates with substance abuse nurses’ can utilize alternative means to reduce stress in their life, ultimately reducing the prevalence of substance among the nursing community.
“Helping the impaired nurse is difficult, but not impossible. The choices for action are varied. The only choice that is clearly wrong is to do nothing.”
National Council of State Board of Nursing
Intervention # 1 Being aware of signs & symptoms of substance abuse.
Intervention # 2 Knowledge of factors that contribute.
Intervention #1
~ Disadvantages
a) If nurses are aware of signs and symptoms they may be better able to hide there problem. Nurses may become more capable of masking there substance abuse by being more cautions not to exhibit the signs and symptoms that they were taught are associated with substance abuse in the workplace.
Dunn, D. (2005). Substance abuse among nurses-defining the issue. Association of operating room nurses. (82) 592-596. Retrieved from Proquest October 1, 2007.
b) While researching this paper it became unambiguous to see all the many different, well thought out, techniques nurses use to steal medications. It is outlined in many different articles step-by-step how nurses go about obtaining controlled substances. By merely researching the signs and symptoms it could potential lead to an open door for someone who might be interested in obtaining medication to be aware of techniques that others have tried.
National Institute of Health (2007) www.drugabuse.gov/infofacts/costs.html
Intervention # 2
~ Disadvantages
a) By being aware of the all the contributing factors, nurses might tend to think that anyone that has some of these factors are suspicious of substance abuse. Therefore, being untrusting of their colleague, and constantly watching over there back, which in turn may bring down the units trust and moral.
Ponech, S. (2005). Telltale signs. Nursing Management. (31) 32-37. Retrieved from Proquest October 12, 2007
b) Nurses that may have contributing factors, or who are at high risk for substance abuse may feel that they are being targeted or looked down on by their nursing peers. Thereby, discouraging them form asking for help if needed, or feel un-apart of the team because they don’t feel comfortable discussing their personal life with any of their co-workers; which may lead to depression and feelings of inadequacy in their careers.
American Nurses Association (2002). ANA code of ethics for nurses. Washington DC.
References:
American Nurses Association (2002). ANA code of ethics for nurses. Washington DC.
Anderson, J. (2004). Treatment considerations for the addicted nurse. Behavioral Health Management. (14) 22-26. Retrieved from Proquest September 30, 2007
Blair, P. (2003). Report impaired practice-stat. Nursing management. (33) 23-25. Retrieved from Proquest October 12, 2007
Dunn, D. (2005). Substance abuse among nurses-defining the issue. Association of operating room nurses. (82) 592-596. Retrieved from Proquest October 1, 2007.
George, M. (2003). Substance abuse among healthcare professionals. Nursing Ethics. (14) 843-849. Retrieved from Proquest October 9, 2007
National Institute of Health (2007) www.drugabuse.gov/infofacts/costs.html
Ponech, S. (2005). Telltale signs. Nursing Management. (31) 32-37. Retrieved from Proquest October 12, 2007
Uris, P. (2002). Chemical dependency handbook for nurse managers. National Council of State
Boards of Nursing. Retrieved from www.dora.state.co.us/nursing October 12, 2007
Leave the following text intact.
Friday, February 1, 2008
Meg Goodfellow Nurses and Breastfeeding
The American Dietetic Association [ADA] (2005) recommends that all infants be breastfed for the first 12 months of life with the addition of complimentary foods after 6 months of age (Spear, 2005). Yet in the United States, the percent of infants being breastfed for the first 12 months is only 17% to 20%. (ADA, 2005).
Nurses are often the people entrusted to provide lactation education and support to new mothers. Despite this, lactation education can be and often is lacking. More thorough breastfeeding education in nursing schools can help to better equip nurses for providing effective breastfeeding counsel and support (Spear, 2005). Nurses employed in hospitals should advocate for the development of a hospital wide policy regarding breastfeeding (Wallis & Harper, 2007). In addition, nurses involved in caring for new mothers should receive continual training on breastfeeding counseling and lactation through continuing education coursework, clinical experiences and in-service training (US Department of Health and Human Services [USDHHS], 2000). When these strategies are implemented, the nurse, as a client educator, will be effective in increasing exclusivity and duration of breastfeeding, thereby promoting wellness in both mother and infant.
Breastfeeding provides many benefits to both mother and child. Maternal benefits can include reduced postpartum bleeding, decreased uterine involution time, improved bone density and reduced risk of breast and ovarian cancer. Some of the numerous benefits for the child are protection against infectious and non-infectious diseases, decreased risk of childhood obesity, reduced risk for heart disease, enhanced immune system, and decreased risk of diarrhea and respiratory infections (ADA, 2005). Breastfeeding also offers an economic way to provide optimal nutrition to the baby (ADA, 2005). Notwithstanding, there are many barriers to breastfeeding among all populations. Many women do not breastfeed because they lack a full understanding of its benefits. Others refrain because of embarrassment and social disapproval, especially when it comes to breastfeeding in public. Some feel that breastfeeding will make them less attractive, and others feel they cannot breastfeed due to work or school responsibilities (ADA, 2005).
A nurse who has been prepared can help a woman overcome these barriers with information, resources and counsel on breastfeeding. Unfortunately, many nurses do not have the education necessary to be able to educate others on breastfeeding. This is evidenced by a survey done on students who had successfully completed their obstetric nursing courses. Only 22% of surveyed students knew that breast milk has antibacterial properties, 85% did not know that breastfeeding is recommended for the first year of life. Forty-one percent thought that formula and breast milk were nutritionally equivalent (Spear, 2005). In order to correct this educational deficit, students interested in working in obstetrics or pediatrics can be offered breastfeeding and human lactation seminars. These seminars can help students learn to identify and overcome barriers to breastfeeding. Possible seminar supplements include a maternal breastfeeding panel to help students see the mother’s perspective on breastfeeding initiation, and participating in clinical experiences with lactation specialists (Spatz, 2005).
After thorough education on lactation in nursing school, a nurse in the hospital setting can continue to improve breastfeeding success rates by advocating for the development of an effective hospital policy on breastfeeding. All staff should be aware of and follow this breastfeeding policy (Wallis & Harper, 2007). Appropriate policies should address a number of topics including, staff training in the skills needed to implement the policy, early initiation of breastfeeding, education of pregnant women about the benefits of breastfeeding, education of mothers on how to breastfeed and maintain lactation, limited use of any food or drink other than human breast milk, rooming-in, breastfeeding on demand, limited use of pacifiers and artificial nipples, and fostering of breastfeeding support groups and services (USDHHS, 2000).
Once a breastfeeding policy is in place, all involved staff members should receive the necessary training to enable them to follow that policy. Many nurses on staff in maternal and newborn units lack experience, and therefore confidence, in helping a new mother breastfeed. This anxiety can inadvertently be communicated to the mother and be detrimental to the breastfeeding process (Wallis & Harper 2007). One option for this training is through the requirement of continuing education coursework on human lactation and breastfeeding (USDHHS, 2000). Wallis and Harper (2007) reference a hospital that holds three breastfeeding workshops a year; which all employees are encouraged to attend. These workshops focus on practical management of breastfeeding, advantages of breastfeeding, and initiating and maintaining lactation. In addition, a new mother always attends to share her experience with breastfeeding. New staff should receive immediate training on breastfeeding and human lactation as well as on the hospital breastfeeding policy (Wallis & Harper, 2007). This will allow for hospital staff to provide continuity of care to the woman and child.
Breastfeeding is not “popular” in the United States. The nurse, as a client educator, can increase exclusivity and duration of breastfeeding, thus reversing this trend. This will result in improved wellness in both mothers and infants. When nurses receive adequate education on lactation in nursing schools, help develop hospital policy on breastfeeding, and participate in continuous on-the-job training to improve their skill and knowledge in helping women breastfeed, they become more effective at their role in helping mothers initiate and maintain breastfeeding.
a. Intervention 1 -More thorough breastfeeding education in nursing schools.
i. Disadvantage 1 - Offering extra classes will not provide enough education to change the current trends.
Providing extra courses and seminars for those students who plan on going into fields that involve mother and baby will be beneficial to these particular students, if they choose to take them. However, many nurses do not have a specific are of nursing in mind while still in school, but later on will switch to maternal and newborn nursing. Breastfeeding information and training must become a larger part of basic nursing curricula (Spear, 2005). This will help to provide all nurses with the skills and current information to provide support to the breastfeeding mother. If the general nurse is prepared to support mothers in breastfeeding, outcomes for exclusivity and duration will likely improve.
Spear, H. J., (2005). Baccalaureate nursing students’ breastfeeding knowledge: A descriptive survey. Nurse Education Today, 26, 332-337. Retrieved January 3, 2007 from Expanded Academic ASAP database.
ii. Disadvantage 2 - Incorporating more breastfeeding education into the basic curricula will be ineffective with the current general nursing textbooks.
Nursing students have several textbooks that might contain information on breastfeeding such as a maternal and child or nursing fundamentals textbook. Trying to improve students’ knowledge of breastfeeding best practices could be very ineffective with these texts. Phillipp, McMahon, Davies, Santos and Jean-Marie (2007) discovered upon analyzing the breastfeeding information in six maternal newborn nursing textbooks, that many textbooks are deficient in the area of breastfeeding. All of the books that were reviewed had important breastfeeding information that was inaccurate, inconsistent, or omitted. In order for incorporating breastfeeding education in to the basic curricula to be effective, new textbooks with accurate and complete information will need to be used.
Phillipp, B.L., McMahon, M.J., Davies, S., Santos, T., & Jean-Marie, S. (2007). Breastfeeding information in nursing textbooks needs improvement. Journal of Human Lactation, 23(4), 345-349.
b. Intervention 2 –Nurses in hospitals should advocate for a hospital-wide breastfeeding policy.
i. Disadvantage 1 –A policy to give no other food and drinks to newborns besides human milk unless medically necessary is discriminatory.
Contemporary evidence has shown that initiating breastfeeding within the first hour of birth is beneficial to both mother and child. The first days of life for the newborn is when many babies receive colostrum from their mothers. This colostrum is the source of maternal antibodies for the babies and is beneficial to them in many other ways as well. Conversely, in many Asian cultures, colostrums is viewed as old milk and not good for the babies health (Kaeswarn, Moyle, & Creedy, 2003). This cultural conflict can cause difficulty for both the nurse and the new mother who share these cultural beliefs about colostrums. The nurse must put her beliefs aside and do as the hospital policy states. The new mother can be put in a vary uncomfortable situation where she can choose to confirm to hospital rules or defy them and stay true to her beliefs and perhaps be labeled as a difficult patient (Kaeswarm et al., 2003). An effective policy would also need to address the cultural issues surrounding breastfeeding.
Kaeswarn, P., Moyle, W., & Creedy, D. (2003). Thai nurses’ beliefs about breastfeeding and postpartum practices. Journal of Clinical Nursing, 12, 467-475. Retrieved January 31, 2008 from Expanded Academic ASAP database.
ii. Disadvantage 2 –Mothers who choose not to breastfeed can be labeled as poor mothers.
There is much research stating that breast milk is the optimal food for a newborn. Despite this, there are many reasons for which a mother might choose to not breastfeed her child. Even though breastfeeding is best for the child in most cases, the mother still has the right to choose whether she will breastfeed the child. Strict policy against using formula in hospitals can alienated the mothers who do not want to breastfeed. Nurses and doctors, in some instances, have tried to convince the mother to change her mind using tactics that border on coercion. These mothers can be made to think that death will be eminent for her child if she does not breastfeed. All mothers should be educated on the benefits of breastfeeding, but if they choose to use formula they should be provided with information on how to choose formula and successfully nourish her baby. Not providing any type of formula education could actually cause harm to some children (Kent, 2006).
Gerorge, K. (2006). Child feeding and human rights. International Breastfeeding Journal, 1(27).
References
American Dietetic Association. Promoting and supporting breastfeeding (2005). Journal of the American Dietetic Association, 105, 810-818.
Spatz, D.L. (2005) The breastfeeding case study: a model for educating nursing students. Journal of Nursing Education 44(9), 432-437. Retrieved September 24, 2007 from Proquest database.
Spear, H. J., (2005). Baccalaureate nursing students’ breastfeeding knowledge: A descriptive survey. Nurse Education Today, 26, 332-337. Retrieved January 3, 2007 from Expanded Academic ASAP database.
US Department of Health and Human Services. (2000). HSS blueprint for action on breastfeeding. Washington, DC: Author. Retrieved January 19, 2007 from www.4women.gov/breastfeeding/bluprntbk2.pdf
Wallis, M. & Harper, M. (2007) Supporting breastfeeding mothers in hospital: part 1. Paediatric Nursing. 19(7), 48-52. Retrieved September24, 2007 from EBSCO Host database.