2022 Texas Renewal Bundle

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The following course content

This 2022 Texas License Renewal Bundle meets renewal requirements for Texas LPNs and RNs. Upon completion of this course, you will receive a certificate of completion for 20 CNE contact hours.  

This course is accredited and approved by American Nurses Credentialing Center (ANCC) (Provider Number: P0614) and includes multiple interesting topics in one easy course. 

 Course Outline

1. Texas Nursing Jurisprudence and Ethics,
2. Texas Nursing Forensics
3. End of Life Care for Geriatric Patients
4. Alzheimer’s Nursing Care
5. Nursing Care for Pediatric Patients by Stage of Development
6. Opioid Abuse
7. Vaping Induced Lung Injuries
8. LGBTQ Cultural Competence
9. Following a DNRL An Ethical Dilemma in Nursing
10. Effective Communication in Nursing
11. Nursing Documentation 101

Texas Nursing Jurisprudence and Ethics

Introduction

The purpose of this course is to review nursing ethics and jurisprudence specifically as these relate to Texas state nursing practice and law. Each state nursing board works to promote the safety and welfare of clients in their state by ensuring nurses are competent to practice nursing safely. As outlined by Texas Board of Nursing continuing education requirements, Nursing Jurisprudence and Nursing Ethics Board Rule 216.3, all nurses, including APRNs, must complete the required two contact hours of CNE relating to nursing jurisprudence and ethics before the end of every third two-year licensing period. This requirement is applicable to licensing periods that began on or after January 1, 2014. All new nurses must also take and successfully pass the Nursing Jurisprudence Exam (NJE). (2,3) 

Requirements also outline that education include information related to the Texas Nursing Practice Act, the Board’s rules including Standards of Nursing Practice, the Board’s position statements, principles of nursing ethics, and professional boundaries. Nurses are named in negligence and malpractice lawsuits that may claim unethical behavior/conduct, practice outside the scope of licensure or lack of nursing supervision. It is important that nurses understand their state nurse practice act, scope of practice of nurse licensure, standards of practice, ethics, and professional boundaries in order to avoid litigation. (2) 

The Texas Nursing Practice Act

Registered Nurse Scope of Practice 

The Texas Nursing Practice Act (NPA) defines the legal scope of practice for professional registered nurses (RNs).  “Professional nursing” means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.  Professional nursing involves: (all from 12) 

• the observation, assessment, intervention, evaluation, rehabilitation, care, and Counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes. 
• the maintenance of health or prevention of illness. 
• the administration of a medication or treatment as ordered by a physician, podiatrist, or dentist. 
• the supervision or teaching of nursing. 
• the administration, supervision, and evaluation of nursing practices, policies, and procedures. 
• the requesting, receiving, signing for, and distribution of prescription drug samples to patients at practices at which an advanced practice registered nurse is authorized to sign prescription drug orders as provided by Subchapter B, Chapter 157. 
• the performance of an act delegated by a physician under Section 157.0512, 157.054, 157.058, or 157.059. 
• the development of the nursing care plan. 

The RN takes responsibility and accepts accountability for practicing within the legal scope of practice and is prepared to work in all health care settings and may engage in the independent nursing practice without supervision by another health care provider. The RN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws; rules and regulations; and policies, procedures, and guidelines of the employing health care institution or practice setting. The RN is responsible for providing safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs. (12)

Texas Board Rules

Texas Board of Nursing, Chapter 217, Rule §217.11, Standards of Nursing Practice (4) 

The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse’s license even if no actual patient injury resulted. (4) 

1. Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: 
   1. Know and conform to the Texas Nursing Practice Act and the Board’s rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse’s current area of nursing practice. 
   2. Implement measures to promote a safe environment for clients and others. 
   3. Know the rationale for and the effects of medications and treatments and shall correctly administer the same. 
   4. Accurately and completely report and document: 
      1. the client’s status including signs and symptoms. 
      2. nursing care rendered. 
      3. physician, dentist, or podiatrist orders. 
      4. administration of medications and treatments. 
      5. client response(s). 
   5. Contacts with other health care team members concerning significant events regarding client’s status. 
   6. Respect the client’s right to privacy by protecting confidential information unless required or allowed by law to disclose the information. 
   7. Promote and participate in education and counseling to a client(s) and, where applicable, the family/significant other(s) based on health needs. 
   8. Obtain instruction and supervision as necessary when implementing nursing procedures or practices. 
   9. Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations. 
   10. Notify the appropriate supervisor when leaving a nursing assignment. 
   11. Know, recognize, and maintain professional boundaries of the nurse-client relationship. 
   12. Comply with mandatory reporting requirements of Texas Occupations Code Chapter 301 (Nursing Practice Act), Subchapter I, which include reporting a nurse: 
       1. who violates the Nursing Practice Act or a board rule and contributed to the death or serious injury of a patient. 
       2. whose conduct causes a person to suspect that the nurse’s practice is impaired by chemical dependency or drug or alcohol abuse. 
       3. whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries. 
       4. whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse’s continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior. 
       5. except for minor incidents (Texas Occupations Code §§301.401(2), 301.419, 22 TAC §217.16), peer review (Texas Occupations Code §§301.403, 303.007, 22 TAC §217.19), or peer assistance if no practice violation (Texas Occupations Code §301.410) as stated in the Nursing Practice Act and Board rules (22 TAC Chapter 217). 
   13. Provide, without discrimination, nursing services regardless of the age, disability, economic status, gender, national origin, race, religion, health problems, or sexual orientation of the client served. 
   14. Institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications. 
   15. Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment. 
   16. Implement measures to prevent exposure to infectious pathogens and communicable conditions. 
   17. Collaborate with the client, members of the health care team and, when appropriate, the client’s significant other(s) in the interest of the client’s health care. 
   18. Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care. 
   19. Be responsible for one’s own continuing competence in nursing practice and individual professional growth. 
   20. Make assignments to others that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made. 
   21. Accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability. 
   22. Supervise nursing care provided by others for whom the nurse is professionally responsible. 
   23. Ensure the verification of current Texas licensure or other Compact State licensure privilege and credentials of personnel for whom the nurse is administratively responsible, when acting in the role of nurse administrator. 
2. Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician’s assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual’s performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: 
   1. Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: 
      1. collecting data and performing focused nursing assessments. 
      2. participating in the planning of nursing care needs for clients. 
      3. participating in the development and modification of the comprehensive nursing care plan for assigned clients. 
      4. implementing appropriate aspects of care within the LVN’s scope of practice. 
      5. assisting in the evaluation of the client’s responses to nursing interventions and the identification of client needs. 
   2. Shall assign specific tasks, activities, and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. 
   3. May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse’s experience, continuing education, and demonstrated licensed vocational nurse competencies. 
3. Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: 
   1. Utilize a systematic approach to provide individualized, goal-directed, nursing care by: 
      1. performing comprehensive nursing assessments regarding the health status of the client. 
      2. making nursing diagnoses that serve as the basis for the strategy of care. 
      3. developing a plan of care based on the assessment and nursing diagnosis. 
      4. implementing nursing care. 
      5. evaluating the client’s responses to nursing interventions. 
   2. Delegate tasks to unlicensed personnel in compliance with Chapter 224 of this title, relating to clients with acute conditions or in acute are environments, and Chapter 225 of this title, relating to independent living environments for clients with stable and predictable conditions. 
4. Standards Specific to Registered Nurses with Advanced Practice Authorization. Standards for a specific role and specialty of advanced practice nurse supersede standards for registered nurses where conflict between the standards, if any, exist. In addition to paragraphs (1) and (3) of this subsection, a registered nurse who holds authorization to practice as an advanced practice nurse (APN) shall: 
   1. Practice in an advanced nursing practice role and specialty in accordance with authorization granted under Board Rule Chapter 221 of this title (relating to practicing in an APN role; 22 TAC Chapter 221) and standards set out in that chapter. 
   2. Prescribe medications in accordance with prescriptive authority granted under Board Rule Chapter 222 of this title (relating to APNs prescribing; 22 TAC Chapter 222) and standards set out in that chapter and in compliance with state and federal laws and regulations relating to prescription of dangerous drugs and controlled substances. (4) 

The Board’s Position Statements 

15.28 The Registered Nurse Scope of Practice (See also the LVN Scope of Practice) (10) 

The Board of Nursing recommends that all nurses utilize the Scope of Practice Decision-Making Model (DMM) when deciding if an employer’s assignment is safe and legally within the nurse’s scope of practice. (10) 

The Texas Board of Nursing (BON or Board) is authorized by the Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely. The Texas Nursing Practice Act (NPA) defines the legal scope of practice for professional registered nurses (RN).  

The RN takes responsibility and accepts accountability for practicing within the legal scope of practice, is prepared to work in all health care settings, and may engage in the independent nursing practice without supervision by another health care provider. With a focus on patient safety, the RN is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, and regulations. In addition, the RN must comply with policies, procedures and guidelines of the employing health care institution or practice setting. The RN is responsible for providing safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs. (10) 

The purpose of this position statement is to provide direction and recommendations for nurses and their employers regarding the safe and legal scope of practice for RNs and to promote an understanding of the differences in the RN programs of study and between the RN and LVN levels of licensure. The LVN scope of practice is interpreted in Position Statement. (10) 

Every nursing education program in the state of Texas is required to ensure that their graduates exhibit competencies outlined in the Board’s Differentiated Essential Competencies of Graduates of Texas Nursing Programs Evidenced by Knowledge, Clinical Judgements, and Behaviors. These competencies are included in the program of study so that every graduate has the knowledge, clinical judgment, and behaviors necessary for RN entry into safe, competent, and compassionate nursing care. The DECs serve as a guideline for employers to assist RNs as they transition from the educational environment into nursing practice. As RNs enter the workplace, the DECs serve as the foundation for the development of the RN scope of practice. (10) 

Completion of ongoing, informal continuing nursing education offerings and on-the-job trainings in a RN’s area of practice serves to develop, maintain, and expand competency. Because the RN scope of practice is based upon the educational preparation in the RN program of study, there are limits to the expansion of the scope. The Board believes that for a nurse to successfully make a transition from one level of nursing practice to another requires the nurse to complete a formal education program. (10) 

The RN Scope of Practice 

The professional RN is an advocate for the patient and the patient’s family and promotes safety by practicing within the NPA and the BON Rules and Regulations. The RN provides nursing services that require substantial specialized judgment and skill. The planning and delivery of professional nursing care is based on knowledge and application of biological, physical, and social science principles as acquired by a completed course of study in an approved school of professional nursing. Unless licensed as an advanced practice registered nurse, the RN scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. RNs utilize the nursing process to establish the plan of care in which nursing services are delivered to patients. The level and impact of the nursing process differs between the RN and LVN as well as between the different levels of RN education. (10,11) 

Assessment 

The comprehensive assessment is the first step and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis, and interpretation of data. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence-based outcomes, and research as the basis for decision-making and comprehensive care. 

 Based upon the comprehensive assessment, the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed. (10,11) 

Nursing Diagnosis/Problem Identification/Planning 

The second step in the nursing process is nursing diagnosis and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary health care team. 

The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, make nursing diagnoses, and formulate goals, teaching plans, and outcomes. A nursing plan of care for patients is developed by the RN, who has the overall responsibility to coordinate nursing care for patients. Teaching plans address health promotion, maintenance, restoration, and prevention of risk factors. The RN utilizes evidence-based practice, published research, and information from patients and the interdisciplinary health care team during the planning process. (10,11) 

Implementation 

Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate certain interventions within the plan of care for patients within legal, ethical, and regulatory parameters and in consideration of health restoration, disease prevention, wellness, and promotion of healthy lifestyles.  

The RN’s duty to patient safety when making assignments to other nurses or when delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation. The RN scope of practice may include the supervision of LVNs or other RNs. Supervision of LVN staff is defined as the process of directing, guiding, and influencing the outcome of an individual’s performance and activity. The RN may have to directly observe and evaluate the nursing care provided depending on the LVN’s skills and competence, patient conditions, and level of urgency in emergent situations. (10,11) 

The RN may determine when it is appropriate to delegate tasks to unlicensed personnel and maintains accountability for how the unlicensed personnel performs the tasks. The RN is responsible for supervising the unlicensed personnel when tasks are delegated. The proximity of supervision is dependent upon patient conditions and the skill level of the unlicensed personnel. In addition, teaching and counseling are interwoven throughout the implementation phase of the nursing process. (10,11) 

Evaluation and Reassessment 

A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary. (10,11) 

Essential Skills Used in the Nursing Process 

Communication 

Communication is an essential and fundamental component used during the nursing process. The RN must communicate verbally, in writing, or electronically with members of the healthcare team, patients, and their families in all aspects of the nursing care provided to patients. These communications must be appropriately documented in the patient record or nursing care plan. Because RNs plan, coordinate, initiate, and implement a multidisciplinary team’s approach to patient care, collaboration is crucial to the communication process. When patient conditions or situations exceed the RN’s level of competency, the RN must be prepared to seek out other RNs with greater competency or other health care providers with differing knowledge and skillsets and actively cooperate to ensure patient safety. (10,11) 

Clinical Reasoning 

Clinical reasoning is another integral component in the nursing process. RNs use critical thinking skills to problem-solve and make decisions in response to patients, their families, and the healthcare environment. RNs are accountable and responsible for the quality of nursing care provided and must exercise prudent and professional nursing judgment to ensure the standards of nursing practice are always met. (10,11) 

Employment Setting 

When an employer hires an RN to perform a job, the RN must ensure that it is safe and legal. Caution must be exercised not to overstep the legal parameters of nursing practice when an employer may not understand the limits of the RN scope of practice and makes an assignment that is not safe. The RN must determine before he or she engages in an activity or assignment whether he or she has the education, training, skill, competency, and physical and emotional ability to safely carry out the activity or assignment. The RN’s duty is to always provide safe, compassionate, and comprehensive nursing care to patients. (10,11) 

Summary of Scope of Practice 

The RN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws; rules and regulations; and policies, procedures, and guidelines of the employing health care institution or practice setting. The RN functions under his or her own license and assumes accountability and responsibility for the quality of care provided to patients and their families according to the standards of nursing practice. The RN demonstrates responsibility for continued competence in nursing practice and develops insight through reflection, self-analysis, self-care, and lifelong learning. (10,11) 

The table below offers a brief synopsis of how the scope of practice for nurses differs based on educational preparation and level of licensure. These are minimum competencies but also set limits on what the LVN or RN can do at his or her given level of licensure, regardless of experience. (10,11) 

Synopsis of Differences in Scope of Practice for Licensed Vocational, Associate, Diploma and Baccalaureate Degree Nurses (4) 

Case Study

Rachel is a 13-year-old adolescent female client admitted to an inpatient behavioral health unit for bipolar disorder, alcohol and marijuana abuse, and borderline personality disorder. The client has a history of sexual promiscuity, lying, and has alleged abuse and rape by history. Rachel approaches the Charge RN at bedtime, saying that an employee and she “have been having sex” many times over the course of two weeks and that she realizes now that “she should have told someone”. The alleged employee is currently on duty.  

As Charge RN, how would you respond, and what are your next steps? 

Conclusion

When a nurse is named in a negligence or malpractice lawsuit, it can create stress for the client, the employee, and the employer. A nurse maintaining professional, ethical, and jurisprudent conduct will help to ensure standards of practice are consistently followed. Maintaining appropriate boundaries with clients at all times helps maintain a therapeutic employee-client relationship. It is important that nurses understand their state nurse practice act, the scope of practice of nurse licensure, standards of practice, ethics, and professional boundaries in order to maintain professionalism, meet performance standards, and avoid a breach of duty, injury, and litigation. 

Resources

Educational Requirements: 
Texas Board of Nursing (2010), Differentiated Essential Competencies (DECs) of graduates of Texas Nursing Programs. (12) 

Texas Occupations Code, Chapter 301 (12) 

Nursing Practice Act (NPA) Section 301.002, Definitions (12) 

Rule 217.11 - Standards of Nursing Practice (12) 

Scope of Practice Position Statements: (12) 

• Position Statement 15.28 The Registered Nurse Scope of Practice Web version for viewing 
• Position Statement 15.14 – Duty of a Nurse Web version for viewing 
• Position Statement 15.14 – Duty of a Nurse – HHSC/DADS/BON poster 

For the complete list of position statements, click here. (12) 

Texas Nursing Forensics

Introduction

In the United States, sexual assault was historically considered a judicial problem; however, it is now considered a major public health concern because of the health and psychological effects on individuals. The problem most notably emerged in the public eye in the 1960s with the women’s liberation movement. In recent times the #METOO movement has increased awareness of the problem, and many organizations have surfaced to assist the assaulted. This program will focus on the problem in rural areas in the state of Texas and how nurses working in these emergency departments can best assist sexually assaulted patients. 

According to the Rape Abuse and Incest National Network (RAINN) (1), in less than every 80 seconds, a person is sexually assaulted. In 2015 the Texas Statewide Sexual Assault Prevalence Study found that 33.2% of adult Texans or 413,000 individuals reported having been sexually assaulted at some point during their lives. (2)  

Assault can be the product of domestic abuse, gang violence, date rape, and incest. Assault can be inflicted on any age or gender and often occurs by someone who is related to or knows the assaulted. Sexual abuse, as described by the American Psychological Association (APA) “is unwanted sexual activity, with perpetrators using force, making threats or taking advantage of victims not able to give consent”. (3). Statistics show that more women and children are sexually assaulted than men, and that girls under 18 years of age are at the highest risk. According to RAINN (1), men and boys, especially college-age, are also at risk with transgender students at the highest risk of this group. Today many organizations deal with this issue and offer hope and assistance to those affected.  

Not only does the impact of sexual assault affect the emotional and physical health of victims, but there are also major associated costs. These costs are incurred from:  

• Emergency department visits 
• Law enforcement time and wages 
• Evidence collection and testing 
• Court fees, including civil and federal lawsuits 
• Loss of wages and health care costs of the affected 

In 1996 the national cost of this problem was approximately $450 billion per year. (4) National Institute of Justice. Those numbers have jumped into the trillions of dollars in the last two decades. In Texas alone, the costs exceed $26,000,000 annually. (2) 

In many parts of the United States, Sexual Assault Nurse Examiners (SANE), nurses who are expertly trained in performing forensic examinations and collection of evidence, are utilized (5). Since there is a lack of SANE nurses in rural Texas, registered nurses working in these emergency departments must learn the SANE process to perform the forensics exams and evidence collection by completing a 2-hour educational program.  

Nursing’s Role

Sexual assault is an extremely traumatic experience. Those affected can have a wide range of issues, emotionally, spiritually, physically, and psychologically. While we may not address all of these issues in the initial visit to the emergency department, we must consider these concerns while the patient is in our care since we are often the first responders.  

Compassion, empathy, and privacy are a hallmark of excellent practice in these situations. Many patients will experience shock and disbelief. “Why me? Will I be okay?” or “it’s no big deal, I’m fine”. (6). There may be “fear of responses from friends, family, colleagues the public and criminal justice providers.” (7) Rape victims may also have concerns about pregnancy, STDs, and HIV/AIDS. These patients may feel their world has turned upside down and fear if others know they may be scorned, told it was deserved, and fear their names could be made public (7). Patients may not want to talk about the assault, as reliving it could bring out unwanted emotions. 

Active listening, believing what the patient tells you, validating their feelings, maintaining confidentiality, and honoring their decisions around what to do about the assault are a few of the methods the interviewing nurse should use. Since nurses are taught to treat the whole person rather than the “problem” alone, this skill is vital in caring for this group of patients. Repeating information back to the patient will help to elicit more precise information. It will also help in validating what the patient is telling you so an atmosphere of trust can be obtained.  

Working with all personnel in the emergency department is also essential. From the paramedics, law enforcement officers, family, or anyone accompanying the patient to the physicians, social workers, and forensic medical examiners, each professional has a specific skill set and role in the patient’s care. Teamwork among these groups of individuals will provide for the best possible outcomes for the patient. In order to provide excellent care, all gender identities must be taken into consideration, as well as age and sexual orientation. No bias or judgment should ever be displayed to the patient. Customs, beliefs, religious and spiritual needs should also be considered during the visit.  

If the patient arrives alone, the nurse should inquire if the patient wants a companion or an advocate to be present. An advocate could be a family member, a friend, a member of the clergy or a social worker. It will always be the patient’s choice. However, care must be taken for the patient to feel comfortable as recalling the events and having a family member or friend who is also emotionally involved, or even the assaulter, may deter the patient from complete openness and honesty. An interpreter should also be arranged if needed with the patient’s consent. If the patient has not alerted the local police, the nurse should inquire if they wish to report the assault and if so, the police should then be called. If available, a sexual assault response team or SART should be immediately contacted. It is of the utmost importance to remember that it is always the patient’s choice and consent in all situations surrounding the case.  

Admitting the patient to a private room in a quiet area of the emergency department lessens interruptions from outside sources. When performing the initial assessment and gathering information, documentation must include a very detailed and complete history, including any physical trauma to the person’s body. The history should include any bruises, lacerations, or other visual injuries and how and when they occurred. The nurse should perform the interview slowly, giving the patient time to process and answer each question. The patient may or may not want to identify the person who assaulted them and should not be coerced into doing so. 

A complete medical, surgical, and gynecologic history, in the case of a female patient, and any new symptoms occurring after the assault should be asked. Drug allergies, medications, and any alcohol or illegal drugs used at the time of the event are also documented. A compassionate and empathic tone should always be used to allow the patient to feel safe and understand there is no judgment of them from any person in the emergency department. Patients should be given the opportunity and encouraged to grieve and react during this time. They will need to feel comfortable enough to ask and answer questions throughout the interview.  

In Texas, it is a law that the nurse obtains written consent from the patient. During the complete physical exam, the nurse will be charged with taking care that any physical evidence of the assault from clothing or body fluids is not disturbed. Also, during this time, suicidality and emotional supports should be assessed. Providing expert treatment for sexually assaulted patients is of utmost importance. When available, a SANE nurse will perform the forensic examination. This examination is vital to collect and preserve physical evidence from the patient while also assessing life and limb injuries. If a SANE nurse is unavailable, as in Texas’s rural areas, a “medical forensic examiner” will perform the examination.  

During the physical assessment, the patient should be advised of every step before each part of the exam and be made aware that they have total control of what is happening. It is important that the nurse help the patient understand he or she always has the right to refuse any and all of the steps in the examination. When documenting the case, the nurse should use open-ended questions to elicit the patient’s best and clearest responses. Documentation must be complete and exact, including every stage of the assault with times, dates, and descriptions considering the patient’s emotional state and ability to recall. Using motivational interviewing and repeating back what the patient has stated is very helpful.  

In the case of a minor, a parent will give the consent, and if no parent is available or is the assaulter, the child will be turned over to the appropriate child and family services in the state. If the assaulted patient has dementia or is an elder with cognitive issues and is therefore unable to consent, adult protective services should be contacted. (8) There are also rules governing military sexual offenses. Remember when documenting these cases, whether using handwritten or electronic medical records any and all information is subject to HIPPA.  

Forensic Law and Collection Process in the State of Texas

The Texas government code 420.031 (9) describes the protocol that must be taken to develop and protect evidence collection in a sexual assault case. Since a major part of Texas is rural, the code was enacted to protect and care for patients and the evidence in those areas where a SANE nurse is not available. In those cases, a medical forensic examiner may perform the exam and evidence collection.  

A medical forensic examiner is described as any practitioner Medical Doctor, Registered Nurse, Nurse Practitioner, or Physician’s Assistant who has undergone a minimum of 2 hours of training in forensic evidence collection. The law outlines requirements in the collection and preservation of evidence. In 2019 the code was amended to require written informed consent from the patient or guardian for release of the evidence and must be gained prior to the history and physical. Obtaining consent also carries important psychological implications after a sexual assault since the patient’s right to consent was violated by the assaulter. Sexual assault examination teams should always be involved as early as possible.  

In Texas, there is no statute of limitations on reporting sexual abuse of a child. For an adult (over 17 years of age) that statute ends ten years after the crime. However, during the investigation of the offense, if “biological matter” is collected and the matter:  

• has not yet been subjected to forensic DNA testing  
• has been subjected to forensic DNA testing and the testing results show that the matter does not match the victim or any other person whose identity is readily ascertained 
• probable cause exists to believe that the defendant has committed the same or a similar sex offense against five more victims” there is no statute of limitations. (9)  

Sexual assault evidence can be found in several areas, including the crime scene, the patient’s body, skin, hair, nails and clothing, and other items belonging to the patient (11). There is a specific kit used to collect this evidence. As described by RAINN, the kit is best known as a RAPE or Sexual Assault Evidence Kit (SAEK) and is inclusive of the items listed below: 

• Bags and paper sheets to put on the floor and collect clothing or other evidence that may fall off the patient while undressing, 
• A comb to collect evidence from hair, 
• Forms for documentation,  
• Envelopes and containers for the evidence 
• Instructions on use of the kit, documenting guidelines 
• Blood sampling materials and swabs.” (11) 

Types of evidence collected are usually skin samples, scrapings from fingernails, and oral, genital, and anal swabbing internal and external. Directions on how to collect this evidence is included in the kit. The forensic examiner can also use special types of photography to document internal injuries. (11) Personal cameras should never be used. Remember, it is the law that the patient consent to each part of the exam. 

As described by RAINN, prior to the forensic exam, it is best if the patient has not changed clothes, combed their hair, brushed their teeth, tried to clean the area, showered, or bathed, or used a restroom. If needing to use the restroom, a urine sample should be collected, educating the patient not to cleanse the perianal area. If they have already showered or bathed and have not arrived after the acute assault, emergency personnel need to educate the patient to keep the clothes they were wearing and any other belongings they had with them at the time of the assault in a paper bag in order to preserve the evidence. (11)  If the patient comes to the emergency department up to 7 days after being sexually assaulted, the exam can still be performed. After the 7 days, it is at the forensic examiner’s discretion whether the exam should be performed. Collecting and protecting forensic evidence is a legal, moral, and professional responsibility (12) 

Any medical witness who testifies in court is held in the highest regard and as experts in sexual assault. (5)  Courts will closely scrutinize the chain of custody, and if broken, it can cause a conflict in the case and question of validity. Cases may be heard in criminal, civil, juvenile, military courts, or grand juries. If a forensics examiner is called to be a “fact” witness, no opinions on the case will be heard. Only the procedures that were performed on the patient will be admitted, and if the testifier is not the professional who performed the examination, they may be questioned regarding SANE protocols. If called upon to be an expert witness, the SANE nurse not only has knowledge of protocols but can educate and give opinions to the court. In either case, the necessity for excellent knowledge of SANE protocols is important. Nurses must be comfortable testifying in court as it is a rigorous and stress-provoking experience. Working with your organization’s lawyers and prosecutors as well as reviewing the case extensively will prepare the nurse to testify in a case. (5) 

Chain of Custody 

In order to protect the patient and evidence for the courts, a chain of custody of the evidence must be followed precisely. Failure to comply does not mean the evidence is not admissible in the courts; however, the more complete the evidence, the better chance of conviction of the assaulter. Texas A&M’s nursing program offers a chain of evidence handbook outlining each step in the collection of evidence. The information below highlights the collection process from that handbook (8) 

“Precise chain of custody must be maintained and well documented through the entire patient assessment and evidence collection process. Chain of custody documents includes the dates and times of each individual who handles every piece of evidence, from the time it is collected to the legal proceedings.” 2. Evidence must also be labeled with the patient’s name, date of birth, a unique identifier number from the institution, the examiner’s initials, date, and time.  

Chain-of-custody documentation must include:  

1. Receipt of evidence 
2. Storage of the evidence  
3. Transfer of the evidence 
4. Date and time of each transfer 
5. The printed name and signature of each person in possession of the evidence  
6. Signatures of all persons transferring or receiving the evidence 
7. Swab and evidence collection 

There should be two swabs used from each site.” (8) 

Evidence must be kept in sight of the staff person collecting it at all times. After collected, the evidence must be dried and contained in the SAEK kit and sealed per kit instructions until it can be handed over to the appropriate law enforcement official and opened only by crime lab personnel. Each emergency department should have a locked storage space to provide temporary custody of collected evidence until it can be transferred to the appropriate persons or lab. If a patient is transferred to another facility, the chain of custody again must be documented according to the law. 

The law in Texas allows an adult to choose whether to report the assault to law enforcement. If the choice is to not report, evidence will still be collected and preserved for up to 5 years post-assault. In the case of child sexual assault, elder abuse (over 65), or disabled persons, all medical personnel must report the case to law enforcement as mandatory reporters. Texas caregivers are also required to give patients an information sheet describing where to find appropriate services for the sexually assaulted. This document can be found on the Texas consumer protection website.  

Physical and Emotional Issues Post Assault 

After a sexual assault, patients can experience anxiety and depression, PTSD and turn to alcohol and/or substance abuse. There may be feelings of fear, denial, guilt, shame, loss of self, loss of control, and anger. (8) Their world has been turned upside down, and they feel life has stopped, and they cannot move forward. They may feel ashamed and wonder if, in some way, they were responsible. They may not feel safe in their own space and may lack trust.  

In domestic cases, the patient may be concerned about their attacker. They may worry that their attacker will be prosecuted and sent away. Daily life can be disrupted to the point of self-isolation and loss of the patient’s job, family, and social life. A patient may become disabled to the point of homelessness and poverty. Many will feel the attack is transparent and that others can tell they have been assaulted just by looking at them. Flashbacks can occur at any time, and they may experience nightmares of being chased or attacked. They may also have constant thoughts of the abuse, causing insomnia and intense anxiety.  

Sexually assaulted patients are more likely to contemplate and attempt suicide than those of other assaults. These issues can extend into long periods of time, with unknown triggers bringing flashbacks or repeated negative feelings. Patients need to be educated to understand that all of their feelings are normal to the trauma and understand that these feelings are temporary. Each person heals in different ways and in different timeframes. Ongoing support and therapy will assist the patient in recovery as well as self-help and group programs. There are many online, telephone, and in-person programs for victims as well as organizations to assist with ongoing issues. For example, the RAINN program can be helpful in advocating for patients and guiding them on their journey to recovery.  

 Many psychologists and therapists deal explicitly with sexual assault patients. The attorney general of the state of Texas website has information and resources for all crime victims. Having a trained sexual assault counselor at the emergency visit time can be of great assistance with the initial contact and subsequent referrals to professionals. Compassionate, empathic, and supportive care by emergency nurses at the initial contact can positively impact the patient’s road to a safe and healthy recovery.  

Physical injuries must also be considered using clinical assessment, radiology, MRIs, and CT scans when necessary. Laboratory collection for STDs (sexually transmitted diseases), pregnancy in females, possible HIV, and other illness exposures are also a consideration during the physical exam and history taking. Follow-up care for these injuries with subsequent laboratory tests and appointments made with appropriate specialists should be made.  

Ideally, the nurse could schedule a telephone call with the patient in 2-3 days to assess how they are doing and for continued support and referrals. At that time, the patient may have more questions or concerns that the nurse can help with and provide for follow-up care and resources. A list of educational programs and therapists who specialize in sexual assault and support groups should be supplied to the patient at the time of the visit and subsequent phone calls. There is no handbook on how to recover from trauma; it is an individual journey that is experienced solely by each person; however, there are many resources to assist a sexually assaulted patient at the time of the event and long after.

Conclusion

Sexual assault has become a major and costly health problem in the United States. The state of Texas has implemented a code of laws to identify, protect and collect evidence from patients who have experienced this crisis. The utilization of SANE nurses is common in major metropolitan area hospitals, but many rural areas in that state are not equipped with the program. To properly care for these patients and collect and protect evidence appropriately, Texas has mandated education for those emergency department nurses not served by SANE personnel.  

It is imperative that emergency department nurses become educated in the use of SAEK kits for evidence collection and chain of evidence protocols. The utilization of the SANE method allows for standardized care that is safe and protective of the patient and the patient’s rights. It protects evidence for investigation while helping to keep costs down.  

End of Life Care for Geriatric Patients

What is End of Life Care? 

End of life nursing care encompasses a wide range of aspects of care, to include symptom management, appropriate pain management, ensuring patient and family education and support during the death and dying process, providing culturally sensitive care, and ensuring the decision-making process remains ethical (6). Nurses are an integral part of the end of life process and should be sure to be an active advocate for their patients and families. 

End of Life Care vs. Palliative Care 

End of life care and palliative care are two terms that are used interchangeably but are two very different things. Palliative care refers to pain and symptom management during “any time in the trajectory of serious illness or injury and does not replace curative interventions” (8). This means that anyone experiencing a serious illness or injury can receive palliative care to manage symptoms and does not necessarily mean that they are beginning the dying process. Palliative care can be delivered as either a separate service or the primary care team and can be given in a variety of settings to include intensive care, inpatient wards, outpatient clinics, and long-term care or rehabilitation facilities. In contrast, end of life care (also known as hospice care) refers to patient care before and during the dying process. It may be initiated before, during or after curative treatment and is meant to focus on a patient’s comfort rather than a cure (8). End of life care can be provided in the comfort of the patient’s home, in a long-term care facility, or in a hospital. 

End of Life Care Considerations

End of life care should be given to anyone who is “near the end of life and have stopped treatment to cure or control their disease” (13). It can also be considered for those who are undergoing a curative treatment. 

Talking frankly about end of life care planning is important and should be done often in collaboration with patients and their families. Nurses should be active in this planning phase, ensuring that the patient and all involved family members understand the death and dying process, all available treatment options that have been presented by the health care team, and all the different methods available to control pain and symptoms. Talking about end of life options early is imperative – by broaching the subject before pain and symptom management become an issue, the nurse can ensure that the patient is an active participant in creating their care plan and final wishes. 

Types of End of Life Care

End of life care planning can include a few different things: 

Hospice Care 

As was mentioned above, hospice care focuses on pain and symptom management during a chronic illness that will ultimately cause the patient to die. Also known as “comfort care,” hospice can be initiated in several instances: 

• During a curative treatment 
• If a patient wishes not to continue with curative treatment 
• The curative treatment has failed 
• The patient wishes not to pursue curative treatment 
• After withdrawal of lifesaving interventions (ventilatory support, vasopressors, etc.) 

Do Not Resuscitate (DNR)/Do Not Intubate (DNI) 

A patient has the right to refuse resuscitation or intubation and mechanical ventilation, in the event that they would need it, if they are of sound mind and are able to make their own medical decisions. A Do Not Resuscitate (DNR) order is written by a medical doctor and instructs the health care team not to initiate cardiopulmonary resuscitation (CPR) if the patient experiences a cardiac or respiratory arrest. The order is written only after discussion with the patient. If the patient is not able to make medical decisions, a doctor may discuss options with a designated healthcare proxy. A DNR order does not cover any other lifesaving interventions. A Do Not Intubate (DNI) order is also written by a doctor and states that a patient does not wish to have an artificial airway placed should they experience respiratory arrest. It is possible for a patient to be a DNI but still wish to have CPR in the case of cardiac arrest (9). 

Once a DNR/DNI order is in place, if it is at the patient’s request, the family cannot override it. If a patient has requested a DNR/DNI order but then changes their mind, they have the right to revoke it at any time. A DNR/DNI order must be respected, it is a legal, binding document. As such, verbal DNR/DNI requests from family members cannot be honored – the original signed order must be present for care providers to cease resuscitation attempts. 

Advance Directive 

An advance healthcare directive, also known as a living will, is a legal document that specifies what a person’s desires are regarding treatments and lifesaving interventions in the event that they become unconscious or are dying (9). A living will can include instructions on: 

• The use of ventilators or other artificial respiratory support 
• Initiation of CPR in the event of cardiac arrest 
• The use of vasoactive medications 
• Dialysis 
• Organ or tissue donation 

The advance directive may also name a health care proxy can make decisions for the patient if they become incapacitated. 

In order to facilitate advance directive planning, nurses may wish to use a document called “5 Wishes.” 5 Wishes is a legal advance directive document that is written in lay language and helps patients to choose their end of life care and document it appropriately. This document is widely available in hospitals and other care facilities.

The Role of the Nurse in End of Life Planning

According to the position statement on end of life care from the American Nurses’ Association, nurses “are often ideally positioned to contribute to conversations about end of life care and decisions, including maintaining a focus on patients’ preferences, and to establish mechanisms to respect the patient’s autonomy” (7). Similarly, a statement entitled “The Right to Self Determination” from the Code of Ethics for Nurses with Interpretive Statements also emphasizes the nurse’s role in end of life planning and care: 

“The importance of carefully considered decisions regarding resuscitation status, withholding and with-drawing life-sustaining therapies, forgoing nutrition and hydration, palliative care, and advance directives is widely recognized. Nurses assist patients as necessary with these decisions. Nurses should promote advance care planning conversations and must be knowledgeable about the benefits and limits of various advance directive documents. The nurse should provide interventions to relieve pain and other symptoms in the dying process consistent with palliative care standards and may not act with the sole intent of ending a patient’s life” (7). 

What these statements say is that nurses have ethical roles and responsibilities that are fundamental to nursing practice. Nurses should ensure that both patients and family members understand the options and treatments that have been presented to them and should ensure that the patient’s autonomy is being respected throughout all aspects of their care. Nurses are primarily patient advocates, and this is especially crucial during the end of life stage. Nurse advocacy during this time can encompass anything from symptom and pain management, culturally sensitive care provision, and ethical decision making (6). 

Talking to Patients and Families 

Talking to a patient and their family about end of life care can be a huge challenge for nurses. In addition to managing patients’ and families’ emotions, nurses must manage their own emotions and approach the subject with professionalism as well as empathy. 

Often, during the end of life planning phase, patients will go through the five stages of grief, as outlined in the book “On Death and Dying” by Elizabeth Kubler-Ross. The five stages of grief include (6): 

1. Denial

Usually a temporary defense, patients may say that they are fine, or that this is some mistake. 

2. Anger

Once the patient is no longer in denial, anger is often the next stage. It may be difficult to care for the patient during this stage, as they may misplace their angry feelings on their caregivers. 

3. Bargaining

At this stage, the patient seeks ways to postpone death – often in the form of promising to reform a lifestyle in exchange for more life. 

4. Depression

This stage may involve the refusal of treatments or visitors, and the disconnection from people, love, and affection. 

5. Acceptance

The final stage, which is not reached by all patients. In this stage, the patient has come to terms with their mortality and has accepted that death will happen. 

It is important for the nurse to understand these five stages, as most patients will be experiencing one or more of the stages during the end of life process. 

Here are some helpful techniques for nurses to use when talking to patients about hospice or end of life planning, according to the American Academy of Family Physicians (10): 

Make sure you have time. 

While this may seem impossible while on a shift when you have other patients, it is imperative that a nurse allow enough time to have this difficult conversation. This is not a conversation that can be rushed – rushing through the conversation may make a nurse miss crucial details that the patient has shared. 

Turn off your phone. 

Minimizing distractions during these difficult conversations will ensure that the nurse can get ample information from this patient and family interaction. 

Listen to the patient.  

Above all, listen to what the patient is saying. Begin the conversation by asking what the patient and their doctor have already discussed. Be sure that the plan of care has been reviewed with the doctor prior to this conversation, then have the patient repeat their plan of care as they understand it. If there are major differences in the plan of care and what the patient says, this may warrant further conversation with the health care team to clarify and identify knowledge gaps. 

Learn what the patient’s goals are.  

Active listening is crucial during the conversation phase of end of life care planning. Once the nurse has determined that the patient understands the options that have been presented, it is vital to ask them what their goals are for palliative and comfort care. Understanding a patient’s goals can help identify what resources will be best suited for their individual needs. 

Conversations surrounding end of life care should happen as soon as possible. Do not wait until the patient is no longer able to participate in the discussion. Encourage the presence of family members, but be sure to respect the patient’s wishes regarding who is involved in the planning process. Other members of the healthcare team that should be included in the planning process include social workers, patient navigators (if applicable in that setting), and any primary and specialist physicians involved in the patient’s care. 

Caring for an End of Life Patient

Transitioning to End of Life Care 

There may come a point during a patient’s hospital stay where it becomes evident that curative or life-supporting measures are no longer effective, thus necessitating the transition from curative treatment to comfort/end of life care. Of course, it is preferable that comfort care be initiated during the curative treatment – this makes the transition to end of life care somewhat easier, since the conversation and planning were ideally initiated before treatment began, and with the collaboration of the healthcare team, family, and patient. 

Social Considerations 

When preparing a patient and family for the end of life process, a nurse should be sure to consider several social perspectives of both the family and the patient: 

Patient and family education. 

This is crucial to ensuring that the end of life process goes smoothly for both the patient and any involved family members. It is imperative to assess the patient’s level of understanding of their diagnosis and all treatment plans. If a knowledge gap is identified, consider calling a meeting of the healthcare team to review the plan of care. The nurse should be present at as many planning meetings and patient conversations as possible. This way, the information is getting passed firsthand and nothing is lost in translation. 

Physical location. 

What are the patient’s wishes for where they want to be when they die? If the patient wishes to leave the hospital, every effort should be made to accommodate their wishes, should their clinical status allow it. At this point, social workers should be involved to coordinate home hospice care or transfer to an appropriate hospice facility. 

Advance directives. 

If the patient has an advance directive in place, what are their wishes? If the patient can participate in discussions surrounding end of life care, their autonomy should be respected. If the patient wishes to create an advance directive, the nurse should be sure to confirm the patient’s and family’s understanding of available options. 

Clinical Considerations 

Medically ineffective interventions. 

This can also be called “futility of care.”  According to the American Medical Association’s Code of Medical Ethics (11), these interventions may be requested by family members but are deemed inappropriate by the physician. According to the AMA, the following steps should be taken by the physician when dealing with a futility of care situation: 

1. “Discuss with the patient the individual’s goals for care, including desired quality of life, and seek to clarify misunderstandings. Include the patient’s surrogate in the conversation, if possible, even when the patient retains decision-making capacity. 
2. Reassure the patient (and/or surrogate) that medically appropriate interventions, including appropriate symptom management, will be provided unless the patient declines particular interventions (or the surrogate does so on behalf of a patient who lacks capacity). 
3. Negotiate a mutually agreed-on plan of care consistent with the patient’s goals and with sound clinical judgment. 
4. Seek assistance from an ethics committee or other appropriate institutional resource if the patient (or surrogate) continues to request care that the physician judges not to be medically appropriate, respecting the patient’s right to appeal when review does not support the request. 
5. Seek to transfer care to another physician or another institution willing to provide the desired care in the rare event that disagreement cannot be resolved through available mechanisms, in keeping with ethics guidance. If transfer is not possible, the physician is under no ethical obligation to offer the intervention.” (11) 

The above steps are not limited to physicians. While nurses cannot make ultimate treatment decisions for the patient, they can ensure that the patient and family understand what the physician has explained. Furthermore, the nurse can act as an advocate for the patient. This kind of advocacy ensures that the patient’s wishes are being respected and that the care they are receiving is ethical. 

How to Prepare a Family for End of Life Care 

When the dying process starts, it is important that the family members present understand what is happening. The following are common, physical signs of the end of life: 

• Increased sleeping 
• Loss of appetite 
• Labored breathing 
• Decreased urine output 
• Confusion 
• Hallucinations 
• Decreased heart rate 
• Irregular breathing patterns (Cheyne Stokes respirations) 

When you’re not a medical professional who has experienced the dying process with a patient, it can be jarring – especially when it’s your family member. Put yourself in the family members’ shoes and explain what is happening. Knowledge can be comforting for most but may not be in every case. Talk to the family members and assess how much they know and how much they would like to know. Be empathetic but do not dance around the subject. Use terms such as “die” instead of “pass away.” Using alternative terms for death and dying may leave it open to interpretation, and in some cases may give family members or patients false hope. 

Family Support 

Along with assessing the patient’s needs, the nurse should also frequently assess the needs of the family. Providing emotional support to the family member of a dying person is incredibly important, both during the dying process and afterwards (12). Be sure to involve social work if you identify any potential need for continued support for the family, i.e., support groups, social assistance, etc. 

Conclusion

Nurses are an integral part of the end of life process, both in the planning and active phases. Among the biggest responsibilities for the nurse during this challenging time is the assessment of understanding of the treatment plan and goals, as well as ensuring that the patient’s autonomy and dignity are always respected. The healthcare team should work together as a whole to ensure that the dying process is as comfortable as possible for the patient and their family. 

Alzheimer’s Nursing Care

Introduction 

Alzheimer‘s disease is a destructive, progressive, and irreversible brain disorder that slowly destroys memory and thinking. Alzheimer‘s is the most common cause of dementia in older adults (1). For most people who have Alzheimer‘s disease, symptoms first appear in their mid 60‘s (1). Studies suggest more than 5.5 million Americans, most 65 or older, may have dementia caused by Alzheimer‘s (1). It is currently listed as the sixth leading cause of death in the United States. It is important to understand the signs and symptoms of Alzheimer’s dementia and how to manage the care of a patient, family member, or friend suffering from the disease. 

Dementia is the loss of cognitive functioning-thinking, remembering, and reasoning- and behavioral abilities to such extent that it interferes with activities of daily living (1). The severity of dementia ranges from mild to severe. In its mildest stage, it begins with forgetfulness, with its most severe stage consists of complete dependence on others for general activities of daily living (1).  

History of Alzheimer’s 

Alzheimer’s disease is named after Dr. Alois Alzheimer. In the early 1900’s, Dr. Alzheimer noticed changes in the brain tissue of a patient who had died of an unknown mental illness. The patient’s symptoms included memory loss, language problems, and unpredictable behavior. After her death, her brain was examined, and was noted to have abnormal clumps known as amyloid plaques and tangled bundled fibers, known as neurofibrillary or tau tangles (1). These plaques and tangles within the brain are considered some of the main features of Alzheimer’s disease. Another feature includes connections of neurons in the brain. Neurons are responsible for the transmissions of messages between different parts of the brain and from the brain to other parts of the body (1).  

Scientists are continuing to study the complex brain changes involved with the disease of Alzheimer’s. It seems that the changes in the brain could begin ten years or more before cognitive problems start to surface. During this stage of the disease, the people affected seem to be symptom-free; however, toxin changes occur within the brain (1). Initial damage in the brain occurs within the hippocampus and entorhinal cortex, which are the parts of the brain that are necessary in memory formation. As the disease progresses, additional aspects of the brain become affected, and overall brain tissue shrinks significantly (1).  

Signs, Symptoms & Diagnosis of Alzheimer’s Disease

Memory problems are typically among the first signs of cognitive impairment related to Alzheimer’s disease. Some people with memory problems have a condition called Mild Cognitive Impairment (MCI) (4). In this condition, people have more memory problems than usual for their age; however, their symptoms do not interfere with their daily lives. Older people with MCI are at increased risk of developing Alzheimer’s disease. The first symptoms of Alzheimer’s may vary from person to person. Many people display a decline in non-memory related aspects of cognition such as word-finding, visual issues, impaired judgment, or reasoning (4).  

Providers use several methods and tools to determine the diagnosis of Alzheimer’s Dementia. To diagnose, they may conduct tests of memory, problem-solving, attention, counting, and language. They may perform brain scans, including CVT. MRI or PET to rule out other causes for symptoms. Various tests may be repeated to give doctors information about how memory and cognitive functions change over time. They can help diagnose other causes of memory problems such as stroke, tumor, Parkinson’s disease, and vascular dementia. Alzheimer’s disease can be diagnosed only after death by linking clinical measures with an examination of brain tissue in an autopsy (4). 

Pediatric Patients with Special Healthcare Needs 

As a former special education school health consultant for children in grades kindergarten through 12th grade, this author became proficient at reading students’ needs or discerning when she could not determine their needs and had to rely on other cues. This pediatric population encompasses many complex health issues that may be chronic and lifelong. Beneath all the tubes, devices, special needs equipment, there is a child who is like many children without special needs. They are longing to be seen, to be heard, and to be accepted as they are. 

Some suggestions for nurses when interacting with this population are (17): 

• To leave any labels at the door and interact with this population as individuals with distinct needs similar to the pediatric population at large. 
• Even though a child may have a cognitive diagnosis he/she still shares dreams, hopes, and feelings. These children desire to be seen as individuals who relish conversations with people and interactions. Talk in a normal tone and give them eye contact. 
• A child’s loud verbalization does not necessarily mean pain. Get to know these individuals on a personal level. Oftentimes this verbalization could be laughter. Trust in your own senses to determine the difference. 
• Respect these children’s bodies regardless of ability. Explain to this child what you are doing before doing it. 
• Even though a child with special needs might not interact or talk; provide care, respect, and compassion as you would any other patient. 
• Provide comfort as you would any patient, even though these children express themselves differently. They need love, kindness, and patience. 
• Show advocacy for each child you care for regardless of ability, diagnosis, or IQ. Involve special needs children in the conversation; even though they do not participate verbally, they understand what is happening. 
• Use the checklist developed for non-communicating children to assess the pain level of these special needs children (see non-communicating children’s pain checklist at http://www.community-networks.ca/wp-content/uploads/2015/07/PainChklst_BreauNCCPC-R2004.pdf) (6). 
• Treat each child with the special care and a patient approach that they so deserve and require. 
• Communication is vital with the child and his/her family members. 
• Nurses must not place judgments on patients but keep an open mind and an open heart to guide patients towards their best healthcare outcome. 
• Nurses have expressed concern with having adequate time to care for the special needs pediatric patient in a holistic manner (18). Nurses desire to engage in a thorough way with these patients and their families but time constraints limit over-involvement and sometimes lead to frustration and guilt on the nurses’ part. They describe it as an art to balance the time factor with the multiple needs of these patients, and the other patients on the nurses’ caseload. 

Summary 

The pediatric population requires nurses who embrace the cohesive bond between parents and child. The nurse must work well with both to enhance the best care possible for the family. Advocacy takes on many forms as a pediatric nurse; the parent, the child, and the family unit must all be promoted and supported. 

Nurses make the difference, and their care is multiplied through each patient and each hospitalization. Pediatric nurses through dedication and mutual problem solving with families show responsiveness to children’s experiences, age, and development to meet the child in his/her world. 

Opioid Abuse

What are Opiates? 

Opiates are powerful substances which are commonly used to alleviate both acute and chronic pain. The history of opiate use / abuse goes back many thousands of years. The first recorded reference is from 3,400 B.C. when opium was cultivated in southwest Asia. There were even wars fought over the previous flow in the mid 1800s (1). The most famous historical event related to opium were the advent of “opium dens.” These were underground “dens” where opium was bought, sold, and used (1). Much like today, the addictive properties of opium overcame many individuals and caused great harm to the world and communities. Indeed, the opiate epidemic of the 2000’s is not the first in modern history, though it is much different and more severe than previous epidemics. 

Today opiates are used for both acute and chronic pain. The ability to quickly, reliably, and (when used appropriately) safely reduce pain is what makes the drug class so valuable. Many common drugs are opiate derivatives or synthetics including morphine, codeine, oxycodone, heroin, hydromorphone, and fentanyl. 

In the United States Opiates are considered controlled substances and most of them are classified as schedule II (with heroin classified as schedule I) (2). Opiates will always have a place in medicine and treatment of pain and are incredibly useful, however, the current opiate epidemic in America makes clear the potential consequences of opiate abuse. 

Preventing Abuse, Misuse, and Harm 

Every day 130 Americans die of opiate overdose (3). Additionally, there are 4.3 million Americans each month who engage in the non-medical (non-prescribed or illicit) use of opiates (5).  However, it is key to remember that opiate-related deaths are not the only negative consequences. There are many overdoses which do not end in death, and on the other end of the spectrum many negative affects do not cause death. Addiction can cause loss of job, damage to relationships, psychologic distress, homelessness, and many more negative side-effects. 

So how do healthcare professionals help reduce the impact of opiate addiction and misuse? The approach must be multi-modal, aimed at primary, secondary, and tertiary prevention.  

• Primary prevention includes appropriate opiate prescribing, risk stratification with patients, and preventing opiate addiction. 
• Secondary prevention is aimed at mitigating the effects of opiate addiction. This includes rehabilitation and cessation of opiates in addicted individuals, ideally in favor of non-opiate treatment options. 
• Tertiary prevention is the reduction in harm from opiate addiction and overdose. This includes resuscitation of overdose patients and helping patients recover from the effects of opiate addiction.
  

Appropriate Prescribing 

The Centers for Disease Control and Prevention (CDC) offers excellent guidance on how to appropriate prescribe opiates, though it will continue to require a great deal of knowledge and effort from individual prescribers and managers of chronic pain. For the purposes of this article, we will focus on the CDC recommendations. Below we will discuss the 12 key points of opiate management, per the CDC. 

Opioids Are Not First-Line Therapy 

“Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.” (5) 

Author’s Input 

Many patients experience pain. Indeed, it is one of the most common complaints in primary care offices. When dealing with chronic pain, we should consider ALL non-opiate therapies for patients prior to prescribing opiates. This can include physical therapy, meditation, exercise / movement, treatment of underlying depression and/or psychiatric issues, meditation, modification of aggravating factors, and many more interventions. In some cases, none of these alone or combination will be enough to provide satisfactory relief, but we must utilize non-opiate and non-pharmacological solutions as much as possible to reduce opioid abuse, and dose (if opiates are necessary). 

Establish Goals for Pain and Function 

“Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety” (5).

Author’s Input 

Many patients erroneously believe that cessation of pain is the goal of therapy. This is not based in fact nor is it reasonable, as many patients (even with opiate therapy) will not have complete remission of pain. The goal of the clinician should be to work with the patient to provide the minimal risk intervention that will provide acceptable pain control. 

Discuss Risks and Benefits 

“Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy” (5). 

Author’s Input 

A prescription for an opiate should never be written to a patient without a through discussion of the risks and benefits. The clinician must first be convinced that the risk to benefit favors prescribing an opiate. Then, they must discuss their rationale with the patient. An individual assessment regarding the risks should be provided to each and every patient. 

Prescribe Immediate-Release Opioids First 

“When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/ long-acting (ER/LA) opioids” (5). 

Author’s Input 

Extended-release opioids have been associated with higher rates of overdose and higher potential for Opioid abuse. Immediate-release opioids should be utilized first, whenever possible. 

Clinicians Should Prescribe the Lowest Effective Dosage 

“Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.”  

Author’s Input 

The clinician must keep in mind that the “minimum required dose” may change over time. As a patient implements more non-pharmacologic interventions the required dose may decrease. Conversely, there can be some degree of tachyphylaxis with opiates and the required dose may also increase. Dose titration requires careful clinician judgement. 

Prescribe Short Durations for Acute Pain 

“Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed” (5). 

Author’s Input 

It is well established that chronic opioid therapy is not the most effective therapy for pain management. Clinicians should consider adjuncts for ongoing or chronic pain patients. 

Evaluate Benefits and Harms Frequently 

“Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids” (5). 

Author’s Input 

It is important that clinicians consider changing circumstances. A patient’s health status or life circumstances may change such that opiate therapy benefits no longer outweigh the harm, or vice-versa. 

Use Strategies to Mitigate Risk 

“Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day)” (5). 

Author’s Input 

Naloxone therapy should be considered for all patients who are at high risk of Opioid overdose. 

Review Prescription Drug Monitoring Program Data 

“Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months” (5). 

Author’s Input 

Each state has robust data regarding prescription medication; utilizing this data can help reduce opioid misappropriation and concurrent prescriptions (doctor shopping). 

Use Urine Drug Testing 

“When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs,” (5). 

Author’s Input 

The author recommends that clinicians take great care in this area. Indeed, drug testing can help identify those who are already abusing other substances, but it can also harm the trusting relationship developed between a patient and clinician. The patient should be re-assured that the testing is performed for their own good and out of concern for their own health, rather than punitively or because the clinician “mistrusts” them, as these may be the default thoughts of many patients. 

Avoid Concurrent Opioid and Benzodiazepine Prescribing 

“Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently ‘whenever possible’ “(5). 

Author’s Input 

The highest risk of overdose of opioid abuse is commonly seen when opiates and benzodiazepine (or any combination of sedating medications) are prescribed concurrently, especially in conjunction with alcohol. For this reason, clinicians should strongly consider avoiding such risks and only prescribing this combination when absolutely necessary. 

Offer Treatment for Opioid Abuse Disorder (OAD) 

“Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid abuse disorder” (5). 

Author’s Input 

In acute cares settings, clinicians often view OAD as a secondary illness and it is frequently left unaddressed. However, there are now effective treatments for OAD. Given the significant morbidity, mortality, and associated quality of life issues, patients with OAD should be offered treatment, even if it not the primary reason for treatment.

Risk Factors for Opiate Harm or Misuse 

The risk to benefit has been discussed many times previously and is often referenced by the CDC. The benefits of opiate therapy are typically obvious (reduced pain, increased quality of life, etc.), but the risks are less often discussed. So how do nurses know who is at higher risk of the negative effects of opiates? 

According to the CDC, the major risk factors are: 

• Illegal drug use; prescription drug use for non-medical reasons. 
• History of substance use disorder or overdose. 
• Mental health conditions (e.g., depression, anxiety). 
• Sleep-disordered breathing.
• Concurrent benzodiazepine use (6). 

Mortality from opiates is highest in those who are middle-aged, have psychiatric conditions, and/or have previously abused substances (7). It is important that clinicians utilize this information when consider risk and benefits associated with opiate therapy.

Signs of Abuse, Diversion, and Addiction

Clinicians should remain vigilant for signs of opiate use disorder, as it can occur in any patient (even those not prescribed opiates). Opiate use disorder is characterized in the DSM-5 as a desire to utilize opiates despite social and professional consequences (12). It includes dependence and addiction, with addiction being on the severe end of the spectrum (12). Opiate use disorder can be diagnosed when at least two of the following are observed in a 12-month period: 

1. Opioids are often taken in larger amounts or over a longer period than was intended. 
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use. 
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects. 
4. Craving, or a strong desire or urge to use opioids. 
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home. 
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. 
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use. 
8. Recurrent opioid use in situations in which it is physically hazardous. 
9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 
10. Exhibits tolerance (discussed in the next section). 
11. Exhibits withdrawal (discussed in the next section) (centers for disease control, reference 13). 

Urine drug screening can be useful in patients with suspected opiate abuse disorder as it may identify concurrently abused substances. If a patient is found to have opiate abuse disorder the “risk” side of the “risk-to-benefit” equation is now shifted, and the continued use should be carefully weighed against the potential for negative effects, including addiction. Addiction is defined as continued use despite adverse events or consequences (12). 

For those prescribed opiates, clinicians should have candid conversations about the risks of continued use for those with OAD. The CDC offers some creative examples of how to discuss the condition with patients, which nurses may find helpful in their interactions (these are only examples, and the wording depends on the patient’s specific scenario and needs): 

“Trouble controlling the use of opioid medication makes it unsafe, and long-term risk over time is substantial.” 

“The medicine has become a problem in itself. You have developed a known complication of therapy that we should not ignore.” 

“Continuing the current medication is not a reasonable option due to the risks, but there are options for treating what we call opioid use disorder, also known as OUD.” 

“It seems as if you are running out of your medication more quickly than anticipated.” 

“Sometimes people become too comfortable with the medications and start to take them for reasons other than pain.” 

“You meet the criteria for opioid use disorder, also known as OUD. It’s helpful to put a name on it because it opens up a variety of approaches to help with your specific circumstance.” (All derived from source 13). 

So, once we identify a patient with OAD, what do we do? At this point, as above, a candid conversation with the patient must occur. A treatment plan should be formulated, which would include a careful consideration for discontinuing for the opiate (if possible). This provides an excellent transition into our next section, opiate alternatives. 

Opiate Alternatives 

Opiate alternatives can be broadly classified as pharmacologic and non-pharmacologic. We will first discuss pharmacologic alternatives. 

Pharmacologic: 

Acetaminophen

Commonly known as Tylenol ™ is over the counter and has a very favorable safety profile when used correctly. Acetaminophen is considered first-line therapy in any pain management regimen (9). 

NSAIDs (Nonsteroidal anti-inflammatory drugs)

NSAIDs can be immensely powerful in pain management, as many pain conditions are related to inflammation. However, patient tolerance can be an issue with chronic NSAID exposure. Indeed, many clinicians shy away from NSAIDS due to the perceived risk profile (9). 

Tricyclic Antidepressants

TCAs provide significant pain relief to many patients, as they have the unique ability to change the perceptions of pain (5). However, tricyclics have many side-effects of their own and thus have been phased out in lieu of newer antidepressants. This in the pain realm they should be considered for certain patients, particularly those with concurrent untreated depression. 

SSRI Antidepressants

SSRIs are typically tolerated better than tricyclics (9) but again are not recommend for first-line analgesia. They are typically reserved for those with concurrent psychiatric illness which may benefit from the overall effect of the drug, and on a case-by-case basis for selected patients. 

Muscle Relaxants

Medications such as gabapentin can be extremely useful especially in pain originating from musculoskeletal causes. However, the mechanism of action is poorly understood (9) and side effects can be troublesome. In one study approximately 25% of patients taking muscle relaxants for chronic pain discontinued the agents due to adverse effects. 

Topicals

Many topical agents now exist, including NSAIDS (9). Topicals are typically considered analgesic-sparing rather than standalone treatment (9). The American College of Rheumatology has excellent and detailed guidance on how to utilize topicals, which deserves a course of its own. 

Corticosteroids

Corticosteroids have very potent anti-inflammatory effects (9) and have a proven role in pain management. Short-term therapy is typically favored over long-term therapy due to the potential issues of long-term systemic therapy (osteoporosis, immunosuppression, risk of serious or fatal infections, weight gain, muscle weakness, diabetes, Cushing’s syndrome, hypertension, glaucoma, and cataracts). Though some serious adverse events can occur with short-term therapy (psychosis, anxiety, avascular necrosis, etc.) (9). corticosteroids can be beneficial for patients with acute pain. Perhaps the best use of these agents is in targeted (injectable) delivery. 

Non-Pharmacologic: 

These therapies will be discussed less in-depth, as they typically require referrals for treatment. However, it is important that nurses are aware of the of the existence of these therapies and can make appropriate referrals and recommendations. Physical therapy consults are invaluable as they often utilize many of the tools below and are more knowledge about non-pharmacologic therapies in general. 

• psychological interventions (including distraction, stress management, hypnosis, and other cognitive-behavioral interventions) 
• acupuncture and acupressure 
• transcutaneous electrical nerve stimulation 
• physical therapies (including massage, heat/cold, physiotherapy, osteopathy, and chiropractic) (10) 

Conclusion

Nurses should view the non-pharmacologic therapies as “tools” available to help patients dealing with acute and chronic pain. Though opiate therapy is a valuable tool as well, its potential negative effects are often under-considered, and the rate of opiate prescription currently is excessive (10). 

When evaluating patients with pain, nurses should work with patients and providers to ensure that the patient is on an optimal pain regimen, which ideally should include both pharmacologic and non-pharmacologic therapies. Seeking referral and consultation from relevant professionals can also be powerful in pain management (physical therapists, chiropractors, psychiatrists, etc.). 

Vaping Induced Lung Injuries

Vaping Trends: The Appeal and the Rise in Popularity 

What started as a product designed for cigarette smokers wanting to wean off the habit while still allowing them to have the physical ritual of smoking, vaping has now become a cultural phenomenon. Minimal odor, sleek packaging, and few, if any, regulations about when and where people can vape created an appeal even to those who had never used nicotine before and the market quickly turned its attention to gaining new customers through the addition of flavors, additives like THC, and devices that look like flash drives. 

The use of electronic cigarettes involves a battery-operated device and a cartridge of nicotine-containing liquid. The liquid is heated into an aerosol which is then inhaled (or vaped). The devices are most popular among adolescents, with 27.5% of high schoolers having used e-cigarettes in the last 30 days in a 2019 survey (1). Adults are using them too, with as many as 2.8% of US adults regularly vaping in 2019, many of whom had never even been cigarette smokers (1). 

One of the main reasons vaping has become so popular so quickly is because of the common misconception that it is a low-risk alternative to cigarette smoking, with many companies claiming fewer toxins and not including complete ingredient lists. While e-cigarettes do contain fewer chemicals than traditional cigarettes, they are by no means a “healthy” alternative and contain their own slew of ingredients, including heavy metals such as nickel and lead, glycerin, carcinogens, and nicotine, which is a highly addictive substance (8). The nicotine level in the cartridges is also extremely high, with a typical “pod,” or cartridge, containing the same amount of nicotine as a package of cigarettes (6). This is enough to make even casual users quickly addicted. The FDA has cracked down on these loopholes in recent years, now requiring warning labels and attempting to regulate the production of flavors, but the popularity of vaping has already exploded and the effort to reverse the trend is an uphill battle. 

Health Risks 

EVALI (e-cigarette or vaping induced lung injury).  

Not surprisingly, the increase in vaping has been followed by a rise in health issues for the users. Most notably among emerging illnesses (and in the media recently) is lung damage referred to as e-cigarette/vaping associated lung injury, or EVALI (2). 

A recent Morbidity and Mortality Weekly Report classifies EVALI as a diagnosis of exclusion as there is currently no specific testing for the illness, but it is one that should be considered early in the presentation of symptoms to not delay treatment (3). Most patients affected presented with cough, chest pain, and dyspnea, with many others having fever, chills, weight loss, vomiting, or diarrhea. At least 30% of patients presented with an oxygen saturation of less than 95%. Tachypnea was not frequently noted, but tachycardia was common. Xray revealed abnormal lung findings in 82% of patients and CT of the lungs was abnormal in 96% (3). This emerging issue is placing significant burden on the healthcare system, as most of these patients require inpatient management with steroids and supplemental oxygen, at least for the first 24-48 hours. 

When this diagnosis resulted in several deaths in mid to late 2019, it was met with panic in the media and general public as healthcare professionals scrambled to find what exactly about vaping was causing the decrease in lung function. Emerging evidence now strongly suggests that the injury to the respiratory tract is caused by Vitamin E acetate, an additive in many e-cigarette pods (3). Fluid collected from symptomatic patients’ lungs was found to contain Vitamin E acetate in most cases and buildup over time is believed to be responsible for this lung injury (3). It is too early to rule out damage from other additives (like the glycerin used for flavoring) and researchers note that while these components are safe for oral consumption and often found in food, the effects of inhalation have not been studied and frequent exposure to the lungs should not be considered safe (4). 

For now, though, Vitamin E acetate is considered the main culprit and is most commonly found in cartridges containing THC, particularly those made informally by people at home rather than those purchased from a manufacturer (3). 

While all vaping should be avoided, for those who do use e-cigarettes it is safest to avoid cartridges containing THC and home-made cartridges. 

Other Health Concerns 

In addition to the potentially lethal complications of EVALI, routine nicotine use of any kind can have serious health implications, and e-cigarettes are no different. Cardiovascular health is affected, with increased heart rate and blood pressure within minutes of nicotine use. Risk of heart attack, stroke, chronic cough, compromised immune system, and impaired oxygenation, all are increased. Nicotine’s effects on a young, developing brain are well documented as well, with attention problems, impulse control issues, and an increased addiction response all posing serious risks to teens who vape regularly (6). Substance use of any kind is closely tied to mental illnesses such as anxiety and depression as well as ongoing struggles with addiction and substance abuse throughout adulthood (6). 

The risk of cancer is also not solely tied to traditional cigarettes, with many substances found in e-cigarettes believed to be carcinogenic. A 2018 study tested urine and saliva samples from vaping teens and found the levels of carcinogens present to be significant and concerning (7). In general, the belief that vaping is a low-risk alternative to cigarettes is grossly erroneous. 

What Can Healthcare Providers Do? 

 Screen for Vaping Use 

One of the best ways to prevent vaping related health issues is to ensure that patients do not start vaping in the first place. Pediatric providers or those working with children and teens 11 years and older are in a particularly advantageous position to start the conversations early and often. Ask questions about what they know about vaping, if they have any friends who vape, and if they themselves have tried vaping. Try to maintain a non-judgmental attitude and allow them to lead the conversation. Provide education to patients and their parents about the dangers and health risks of vaping. Talk about the strengths of the student (academics, sports, arts) and discuss how a nicotine addiction or disciplinary action for vaping at school could negatively impact these enjoyable activities. For any patients who are already vaping, create a plan for cessation (discussed below). Adult patients and established cigarette smokers should also be screened for vaping and health risks discussed (2). 

Early Detection of Vaping Related Lung Injury 

Screening for vaping is not only important at routine wellness visits, but also for acutely ill patients in the outpatient, inpatient, and emergency room settings. Any patient presenting with cough, chest pain, or other respiratory symptoms should be questioned about current or recent vaping habits, including the use of THC pods. Chest x-ray should be strongly considered in the workup for anyone with respiratory symptoms and a history of vaping, particularly those with a pulse oximetry <95%. Flu and pneumonia should be considered in the differential diagnosis, as vaping increases the risk of both illnesses. In patients hospitalized or treated outpatient for a suspected EVALI, close follow up for the first few weeks is recommended (2). 

Cessation 

For patients with or without acute lung injury related illness, vaping cessation should be counseled. For adults, many employers will offer smoking-cessation incentive programs which have been shown to be effective. Encourage your patients to ask their employer if this is offered and if they qualify. There are multiple nicotine products designed to help wean slowly from nicotine with the ultimate goal of cessation such as gum, patches, and lozenges. Either gain familiarity with prescribing these yourself or find a local provider who you can refer your patients to for these products (5). Psychotherapy or counseling can be beneficial for patients trying to break an addiction and there are typically addiction counselors available at mental health facilities. There is a Substance Abuse and Mental Health Services Treatment Locator tool that can be found at FindTreatment.samhsa.gov or patients can call 1-800-662-HELP (4357) to find the nearest resources (1). Finally, if you have patients using vaping as a method of stopping cigarette smoking, you should counsel that this is not a long-term solution and has no current supportive evidence as an effective smoking cessation tool. The risks of vaping far outweigh any perceived benefits and vaping should not be counseled as a method of smoking cessation.

Case Study 

Austin is a 19-year-old male presenting to the ED with 6 days of coughing, fever, lethargy, decreased appetite, and (in the last 2 days) increasing chest pain, particularly with deep inspiration. 

He is a student at the local university with a history of ADHD for which he takes 20mg of Adderall XR daily. No other pertinent medical history and no other medications. He reports drinking socially on the weekends. 

Vital signs are as follows: Temp: 100.9, HR: 147, BP: 134/85, RR: 20, SPO2: 87%. Physical exam reveals pallor, diaphoresis, diminished air exchange in all lung fields with crackles in the bases. Deep inspiration results in coughing fits with no improvement or clearance of crackles and rhonchi. He is most comfortable in the tripod position, but overall is restless. CBC with differential is normal, flu swab is negative. Chest x-ray reveals bilateral infiltrates. 

The nurse notices a Juul device in the clear plastic bag of the patient’s belongings and when asked, he admits to vaping ¾-1 cartridge per day for 2 years. He also states he will use a THC cartridge 2-3 times per week with friends. 

He is diagnosed with EVALI and admitted for treatment with corticosteroids and supplemental oxygen. He is discharged in stable condition after 2 days with scheduled follow up in 1 week. He is counseled on vaping cessation, particularly of THC cartridges, and makes a full recovery over the next 2 months.

Conclusion 

Vaping is a fairly new trend and health risks are still emerging as the number of people using e-cigarettes grows. Staying abreast of trends in vaping and the growing information about symptoms, treatment, and causes of EVALI are important responsibilities of healthcare providers. Early detection of vaping related illnesses is key to best treatment outcomes and screening for vaping should become a routine part of all healthcare exams, both preventive and acute.

LGBTQ Cultural Competence

Introduction

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals represent a rapidly growing segment of the U.S. population [1]. This rapid growth brings with it risk for stigmatization [1]. Implicit physician biases may result in LGBTQ patients receiving a lower standard of care or restricted access to services as compared to the general population [2]. Even when institutions and providers make commitments to equitable care explicit, implicit biases operating outside of conscious awareness may undermine that commitment. There is an urgent need to ensure that health care providers are prepared to identify and address their own implicit biases to ensure they do not contribute to the health care disparities experienced by LGBTQ and other vulnerable populations. Only by addressing their own implicit biases will health care providers be able to provide patient care in accordance with LGBTQ cultural competence. 

LGBTQ individuals face significant disparities in physical and mental health outcomes [3]. Compared to their heterosexual counterparts, LGBTQ patients have higher rates of anal cancer [4], asthma, cardiovascular disease [5,6,7,8], obesity [6], substance abuse [8,9,10], cigarette smoking [11], and suicide [12]. Sexual minority women report fewer lifetime Pap tests [13,14,15], transgender youth have less access to health care [16], and LGBTQ individuals are more likely to delay or avoid necessary medical care [17] compared to heterosexual individuals. These disparities are due, in part, to lower health care utilization by LGBTQ individuals [3, 18,19,20]. Perceived discrimination from health care providers and denial of health care altogether are common experiences among LGBTQ patients and have been identified as contributing factors to health disparities [21,22,23,24]. Disparities in health care access and outcomes experienced by LGBTQ patients are compounded by vulnerabilities linked to racial identity [25,26,27] and geographic location [28]. 

Biases among health care professions students and providers toward LGBTQ patients are common [29, 30] despite commitments to patient care equality. These biases, also known as negative stereotypes, may be either explicit or implicit [31]. These biases contribute to a lack of LGBTQ cultural competence in patient care. A large study of heterosexual, first-year medical students demonstrated that about half of students reported having negative attitudes towards lesbian and gay people (i.e., explicit bias) and over 80% exhibited more negative evaluations of lesbian and gay people compared to heterosexual people that were outside of their conscious awareness (i.e., implicit bias) [29]. Research in social-cognitive psychology on intergroup processes defines explicit biases as attitudes and beliefs that are consciously accessible and controlled; they are typically assessed via self-report measures and are limited by an individual’s awareness of their attitudes, motivation to reveal these attitudes, and ability to accurately report these attitudes [32, 33]. In contrast, the term implicit bias refers to attitudes and beliefs that are unconscious (i.e., outside of conscious awareness) and automatic [34, 35]. Implicit bias can be assessed with the Implicit Association Test (IAT) [36], which measures the strength of association between concepts [37]. 

Health care provider biases are correlated with poorer access to services, quality of care, and health outcomes [31, 38,39,40]. Explicit biases held by health professionals towards racial/ethnic minorities, women, and older adults are known to affect clinical assessments, medical treatment, and quality of care [41]. Importantly, implicit bias measures are more strongly associated with real-world behaviors than explicit bias measures [42] and are linked to intergroup discrimination [43]. Health care provider’s implicit biases towards vulnerable patient groups may persist despite an absence of negative explicit attitudes [44], resulting in preconceived notions about patient adherence, poor doctor-patient communication, and micro-aggressions, all of which can interfere with optimal care. With less time and limited information processing capacity, provider’s decisions are increasingly governed by stereotypes and implicit biases [45]. Medical student and provider biases may contribute to health disparities in vulnerable populations by negatively impacting communication with patients and decisions about patient care [33, 35]. Taken together, these findings suggest that medical students and healthcare providers are likely to underestimate or to be unaware of their implicit biases towards LGBTQ patients, particularly when they are rushed or fatigued, which could impact their behavior and judgments in ways that contribute to health disparities experienced by LGBTQ populations. By learning about and addressing their implicit biases, health care providers can work towards demonstrating LGBTQ cultural competence and providing optimal care (Introduction section courtesy of Morris, M., Cooper, R. L., Ramesh, A., Tabatabai, M., Arcury, T. A., Shinn, M., Im, W., Juarez, P., & Matthews-Juarez, P.- reference 45).

Best Practices 

Below we will list and discuss the best practices for ensuring a positive, equitable healthcare experience for LGBTQ persons, according to the Joint Commission (this is not a comprehensive list, just highlights). 

Create a welcoming environment that is inclusive of LGBT patients and demonstrates LGBTQ cultural competence. 

• Prominently display the hospital nondiscrimination policy and/or patient bill of rights. 
• Waiting rooms and common areas should be inclusive of LGBTQ patients and families. 
• Unisex or single-stall restrooms should be available. 
• Ensure that visitation policies are fair and do not discriminate (even inadvertently) against LGBTQ patients and families. 
• Foster an environment that supports and nurtures all patients and families. 

Avoid assumptions about sexual orientation and gender identity. 

• Refrain from making assumptions about a person’s sexual orientation and/or gender identity. 
• Be cognizant of bias, stereotypes, and other communication barriers. 
• Recognize that self-identification and behaviors do not always align. 

Facilitate disclosure of sexual orientation and gender identity but be aware that disclosure is an individual process. 

• Honor and respect patient’s decisions to provide or not provide sexual and/or gender information. 
• All forms should contain inclusive, gender-neutral language that allows patients to self-identify. 
• Use neutral and inclusive language when communicating with patients. 
• Listen to and respect patients’ choice of language when they describe their own sexual orientation. 
• Conduct confidential patient satisfaction surveys that include questions regarding sexual orientation and gender identity. 

*Information largely derived from Joint Commission field guide, reference 47.  

For more information on best-practices in the workforce, visit the Joint Commission website by clicking here.

Establishing Relationships with LGBTQ Patients 

When interacting with patients, one should not assume gender or sexuality. Addressing a patient who identifies as a female as a male can cause grave harm to the relationship. Instead, nurses should use open-ended questions. For example, rather than saying “Hi sir, what brings you to the hospital,” a nurse might say, “Welcome, what brings you to the hospital today (48)?” 

If a nurse uses the incorrect pronoun, the best practice is to apologize and ask the patient what pronoun and name they prefer. For example, a nurse may say, “I apologize for assuming your gender. How would you like to be addressed? (48). 

In conversation, the nurse should use the name and/or pronoun the patient prefers without drawing special attention to the subject (48). For example, if a male patient prefers to be identified as his partner’s wife, you should follow suit. 

The core of relationship-building with LGBTQ patients is no different than any other patient, fundamentally. If nurses have a basic understanding of best practices and a healthy dose of respect and compassion for LGBTQ patients, a positive relationship is likely to develop.

Health Disparities of LGBTQ Patients 

LGBT Americans are at higher risk of substance use, sexually transmitted diseases, cancer, cardiovascular disease, obesity, bullying, isolation, anxiety, depression, and suicide when compared to the general population (49). LGBT youth are frequently bullied at schools (49). In fact, early victimization and subsequent emotional distress accounted for 50% of the disparities between LGBT youth (49). In other words, LGBT Americans are discriminated against and disadvantaged from a very young age. 

When home life also reflects a lack of LGBTQ cultural competence, more problems arise. A major cause of LGBT distress is family rejection. Disclosure of gender identity or sexuality can cause very significant interpersonal conflicts among family and friends of LGBT persons (49). This explains some hesitancy and should help nurses understand the importance of respecting privacy, while giving options to patients about disclosing sexuality and gender. 

Providing an Inclusive and Accepting Care Environment 

LGBTQ patients often experience difficulty in finding healthcare environments in which they feel accepted and understood (48). Past negative experiences, lack of knowledge among healthcare providers, and limited access to healthcare in general may become major barriers for LGBTQ persons when seeking care (48). 

The core tenant of providing an inclusive environment is understanding the needs of LGBTQ patients and working diligently to create an environment which does not disadvantage or discourage them from seeking care. 

Policies and procedures at institutions should be designed to reflect a non-discriminatory environment. For example, many hospital policies dictate that only legal family spouses or partners can visit in specific circumstances. Policies such as this are inherently discriminatory toward LGBTQ patients, as they may not have legal spousal status due to social, legal, or personal reasons.

Exercises on LGBTQ Cultural Competence 

To help solidify your learning, please complete the following exercises at your own pace. The answers/guidance for each are provided below. 

Scenario 1 

A patient enters your emergency department, and you assume the patient identifies as a female. You introduce yourself and say, “Ma’am, how can we help you? What brings you in today?” 

The patient appears dismayed but answers the question. The nurse is confused and does not understand why the patient appears distressed. What is the best course of action? 

Answer: The nurse should apologize to the patient and ask the patient how they would like to be addressed. Then, the nurse should update the patient’s records to reflect such, to reduce further confusion.  

If the nurse does not address the issue, the patient may feel uncomfortable and develop a negative association with healthcare, which can lead to disparities in the future. 

Scenario 2 

A patient in your ICU has had a deterioration while his husband was in the room. After a family meeting, a member of the healthcare team makes a derogatory remark about the patient’s sexuality. What is the next best action for the nurse? 

Answer: Pre-conceived phobias and stigmatizations can cause significant distress to LGBTQ patients, even if not stated directly to them. These types of remarks are abusive and should not be tolerated. The nurse should confront the co-worker (if safe) and consider reporting the comments to the Human Resources department.  

Scenario 3 

A LGBTQ patient is being admitted and prefers not to disclose their sexuality. However, the nurse is unable to proceed with the admission process without this information. What could be done to rectify this system-level issue? 

Answer: The nurse should work with administration to ensure that all charting and paperwork allows individuals to self-report sexuality and/or gender if they want. However, healthcare systems should not force patients to “come out” unless it is absolutely medically necessary.

Conclusion 

LGBTQ cultural competence must be ingrained in our healthcare systems in order to foster excellent relationships between members of the LGBTQ community and medical staff. Hospitals and healthcare systems have a great deal of work to do in becoming LGBTQ-friendly. The efforts must continue until LGBTQ patients and families do not feel disadvantaged, anxious, or frustrated when interacting with healthcare systems. As the patient’s ultimate advocate, nurses are at the front-line and should advocate for patients both individually and from a policy perspective. Nurses should work with and spearhead efforts to ensure that healthcare policies reflect best-practice and do not discriminate against LGBTQ patients in any way.

Following a DNR: An Ethical Dilemma in Nursing

Introduction

End-of-life issues are often full of emotion and difficult to deal with for all involved. Do-not-resuscitate (DNR) orders can present many moral and ethical dilemmas in nursing. It takes the entire healthcare team, including the patient and their family, to ensure that all final wishes for the patient are followed. In order to understand this ethical dilemma in nursing, we must first define what ethical dilemmas are and what a DNR order is. 

What is an Ethical Dilemma in Nursing?

Ethics are a system of moral principles or rules of conduct recognized by a particular group; however, the American Nurses Association (ANA) has developed its own code of ethics (1). The ANA Code of Ethics with Interpretive Statements includes nine provisions that direct a nurse’s moral and ethical practice, it reads:  

Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.  

Provision 2:  The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.  

Provision 3:  The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.  

Provision 4:  The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.  

Provision 5:  The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.  

Provision 6:  The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.  

Provision 7:  The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.  

Provision 8:  The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.  

Provision 9:  The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy (2). 

An ethical dilemma in nursing arises when decisions are made that go against the ANA Code of Ethics with Interpretive Statements.  

It is important to note that the nurse’s main duty is to be an advocate for their patient, meaning that all actions should be in the patient’s best interest. Adhering to this principle will ensure a clear moral path where ethical dilemmas in nursing can be avoided.   

DNR

A DNR is an order written by a physician that is usually given to those who are critically or terminally ill. The order states that in the event of cardiopulmonary arrest, should the patient’s heart stop or should they stop breathing, cardiopulmonary resuscitation (CPR) will not be administered. The decision for a DNR order is always discussed with the patient if they are conscious and have the capacity to make informed decisions. Should the patient be incapacitated, their power of attorney (POA), health care agent, or family member may be allowed to make the decision for a DNR. If a patient is known to be gravely ill, they may already have an existing DNR order, or an advanced directive/living will. Once this document is produced for the institution, the order will go into effect. If a DNR order has been put in place by the patient and physician, the family should not have the power to lift the order once the patient deteriorates and can no longer make decisions (3). 

There was a time in the history of healthcare when there were different tiers of a DNR order. For example, there used to be a medication only/chemical code where medication could continue to be administered, but no compressions or artificial respirations could be performed by the healthcare team; in the end, this proved to be a wasted effort as the medication would be circulated and provide no effect. Many institutions have gotten away from the tires of DNR; what I mean by this is, either there is a DNR order in place for a patient, or there is not.

Ethical Dilemma in Nursing: DNR

If a DNR order is put in place by the physician in conjunction with the patient, how could there possibly be any ethical dilemmas in nursing? There should be no problems associated with a DNR order; however, ethical dilemmas arise when the team (patient, physician, healthcare workers, and family) are not all on the same page regarding the DNR. One of the main problems is that different healthcare workers have different interpretations of what a DNR means. It must be understood that a DNR means “do not resuscitate,” and does not mean “do not treat.” To better explore the ethical dilemmas in nursing associated with a DNR order, we will look at scenarios that I have come across over my 25 years of nursing: 

Scenario 1 

A patient is sent from a telemetry unit to radiology for a CT scan. The patient has severe cardiomyopathy and requests a DNR upon admission. The order is noted on the patient’s chart. When they are sent to radiology for the scan, the floor nurse neglects to place the code status on the patient hand-off form. During the scan, the patient becomes unresponsive, and a code blue is called; CPR is initiated, and the patient is intubated.   

During the resuscitation, it is discovered that the patient has a DNR order. The physician running the code continues with CPR, rationalizing that he could ‘not just stop’ the life-saving measures that they had already begun. The patient is revived and transferred to the ICU. Later, during the admission, the family withdraws life support, and the patient expires.  

In this first scenario, we can see that a communication error led to the DNR order not being followed. Once discovered, the physician in charge refused to comply with the order.  Ultimately, the patient passed after a few days on life support.   

This ethical dilemma came to play once the code team realized that the patient had a DNR. The code could have been stopped at this point, and the lead physician could have spoken with the patient’s family to explain what had occurred. Many facilities do have policies in place where if a patient goes for a procedure/surgery, the DNR order may be on hold during the time that they are in the procedure; this does not generally include diagnostic scans.   

Scenario 2

A G-tube is ordered for a terminally ill cancer patient. The patient is unable to eat and needs a G-tube for nutrition and medication administration. When the gastroenterologist comes in to do the consult, he discovers that the patient has a DNR order. He refuses to place the G-tube due to the DNR order and claims that the G-tube is a ‘life-saving’ measure. The patient is sent back up to their room without having the G-tube placed. After two days, a second consult is placed, and a different doctor approves and places the G-tube. 

The ethical dilemma in this scenario is that the provider refuses to provide treatment based on a poor understanding of what a DNR really means. Again, DNR does not mean “do not treat.”  There are many procedures that can and should be performed regardless of a patient’s code status. Though a G-tube can prolong someone’s life, it also serves as a means to keep them comfortable through both nutrition and the administration of needed medications, including analgesics. A G-tube insertion can ultimately assist the patient to die with dignity by allowing them to receive alimentation and medicines. It is not solely the provider’s responsibility to decide what measures are heroic and which are not. The entire multidisciplinary healthcare team should be involved in the care of the patient, especially when questions could arise as to if a certain procedure is ethical.   

This scenario led to a peer review of the provider’s actions.   

Scenario 3

A patient, along with his healthcare team and family, has decided to enact a DNR order. He has been gravely ill for a long time and wants “nature to take its course.” After the DNR order was placed, one of his daughters arrives from out of town; she does agree with the DNR order and wants it to be revoked. The patient refuses, and the DNR is left in place. The next day, the patient becomes unresponsive while the daughter is in the room. She insists that the nurse begin CPR and threatens legal action if the code blue is not started immediately. The nurse becomes intimidated by the daughter, as she does not fully understand the DNR order, and commences the code blue. 

The patient is revived and is transferred to the ICU. He voices his anger to the healthcare team that his wishes were not followed; CPR was not to have been administered. Three days later, he becomes unresponsive and expires; however, this time CPR was not administered, and the DNR was followed. 

Once again, the ethical issue occurred due to misunderstandings and a lack of knowledge from both the patient’s family and the healthcare team. The patient’s daughter sought to go against her father’s explicit wishes to cancel the DNR. When he would not, as soon as he became unresponsive, she demanded that the staff perform CPR. The nurse should have refused, as this daughter was not the legal decision-maker, and the patient’s expressed wishes were known prior to him falling unresponsive; instead, the nurse breached the DNR and performed life-saving measures. 

Conclusion

A DNR order is put in place when a patient does not want life-saving measures to be performed. The healthcare team and family are involved in the decision-making process, but the decision ultimately belongs to the patient. A patient with a DNR order still needs to be treated for their medical problems and, like any other patient, needs to be treated with dignity and respect. It is important that the healthcare team understands what the DNR encompasses and who can make decisions for the patient should they deteriorate. The nurse must always do what is best for the patient and follow the ANA Code of Ethics with Interpretive Statements. 

Effective Communication in Nursing

Introduction

Communication in nursing is key, and the ability to communicate effectively can be our lifeline. We depend on ourselves and others to be fluent and effective in the art of communication in order to perform our role as nurses successfully. When any link in our communication chain fails, we immediately see poor outcomes, wastage of resources, reductions in patient and staff satisfaction as well as a decline in the quality of patient care (1).

Types of Communication

In order to master effective communication in nursing, it is important to understand the various types of communication, their definitions, and the impact they can make.  

Non-Verbal 

This form of communication relies solely on the utilization of body language, including body and facial mannerisms, and completely lacks spoken words or sounds (2). We perform and identify non-verbal communication in nursing daily without giving it a second thought. We may see a newborn sucking on their hands, providing us a non-verbal cue that they are hungry. When assessing a patient holding their abdomen, we would look to initially target that area because they have communicated (non-verbally) that this is where they are experiencing discomfort. Smiling when the next shift nurse is walking in the door communicates to them that you are happy to see them, and that it’s about time for you to go home!  

Since we perform non-verbal communication so often, it can become an incredibly powerful tool or an extremely negative one. This form of communication in nursing can be used positively to show our patients and co-workers that we have compassion, and we are engaged. Negative forms can make patients uncomfortable with sharing their medical history and result in a lower quality of patient care. Additionally, it can lead to dysfunctional teamwork among staff. 

Verbal 

Verbal communication occurs when we use words or sounds to discuss concepts with others (2). This form of communication in nursing has the conception to be a very easy notion, but it can create unfavorable consequences when used ineffectively. In order to produce clear verbal messages, we should always speak concisely and with confidence. As health care professionals, we have our own language, and understanding when to incorporate our medical jargon into conversations versus when to not is crucial in providing care. When communicating among co-workers, our medical knowledge can display professionalism and it is evident that they can follow along. However, when speaking with patients and their families, this may not always be the case and we must be able to effectively gauge our audience and ensure that they have a clear understanding of what we are teaching or explaining; this is an extremely valuable tool.  

Written 

This form of communication can be either a formal or informal transcription of words that are intended to serve as a direct communication form (2). Written communication in nursing is used daily and incorporates one of our most important duties, documentation. Throughout our nursing practice, we have learned the importance and necessity of our documentation; it can be useful for legal protection or provide critical data to other health care professionals. Written communication can also be accessed through the policies and procedures we employ to perform various tasks. Having sound, written communication, and interpretation skills is vital to the overall success of our nursing career.  

Receiving Communication

The most common communication perception is usually directed to producing communication through non-verbal, verbal, or written forms. While the production of communication is important, the reception of it potentially holds even greater value. In nursing, ensuring our communication is received correctly affects every clinical, orientation, or job experience we have encountered thus far. Think about it…  

• Taking notes in class or during a shift. 
• When a preceptor or instructor educates you on a brand-new skill or piece of equipment. 
• Teaching your patient, family, or student about a new diagnosis.  
• Watching your patient breathe for rate, depth, and effort. 

We must provide and receive communication in nursing through verbal, non-verbal, or written forms successfully. If communication fails, we will experience extremely negative effects throughout our entire nursing system. 

Hearing & Listening 

Hearing describes the process or act of perceiving sounds or spoken words (2). We hear sounds upon auscultation, varying frequencies of alarms, and patient concerns when they are voiced. Hearing all these sounds are heavily dependent on how they are used. To achieve successful implementation of these sounds, we must also listen to these sounds and words. To listen, we must hear and then interpret these sounds carefully (2). We interpret these sounds and words by asking additional questions, performing additional assessments, or paraphrasing the information presented.  

Communication Transmission Threads

Communication in nursing occurs multiple times a day between a wide range of communication threads. The type of communication through non-verbal, verbal, and written communication produced and received, must be effectively performed. Success and implementation are heavily dependent on the communication between the nurse and the communication thread.  

Nurse-Nurse 

Communication among nurses is continuous throughout a shift while working within a team environment. Whether it is us passing our documentation on to another nurse for review or vice versa, there is consistent communicative flow of all variants (non-verbal, verbal, and written) between the team in order to provide care for patients. 

Nurse-Ancillary Staff 

Your team members will vary depending on your nursing career setting, but some items will remain consistently important despite wherever you are. We must provide clear verbal communication when delegating or reporting critical information from the nurse to ancillary staff participating in patient, client, or resident care.  

Charge Nurse-Team 

When stepping into a charge nurse role, there will always be unexpected tasks, staff conflicts, or emergent situations. In this position, you will be taking all the communication skills you have acquired and putting them into practice at an all-time high. As the charge nurse, you will be viewed as a leader, meaning that you are a role model for your fellow team members. Now, in addition to producing and receiving communication effectively, you will now be identifying poor communication and assisting with its correction.  

Nurse-Patient 

The nurse-to-patient communication thread is one of the ultimate and most important exchanges in the nursing profession. Patients need us, so we must be able to keep consistent and effective communication flow with them because any assessment, report, and administration of medication is contingent upon it. 

Nurse-Family 

The thread between the nurse and the patient’s family can be the foundation for your nurse-to-patient communication and its effectiveness. The family could be the responsible party or guardian for your patient and could potentially serve as your sole historian for patient information if the patient is unable to communicate at the time of data collection. Ensuring that the family is aware of and understands discharge instructions can further help them to recognize any potential signs or symptoms that could result in calling a physician or visiting the emergency room in the future. 

Barriers and Improvements to Communication

Barriers of communication in nursing happen frequently and are sometimes out of our control. These barriers include:  

Language barriers 

Utilizing available resources for language barriers through interpreter staff members or interpretation devices can ensure effective communication pathways between two individuals. 

Cultural differences 

Identification of cultural differences during admission and cultural awareness will allow for effective communication management throughout each culture you are presented with. 

Patient acuity, staffing levels, time constraints 

Patient acuity, staffing levels, and time constraints can be improved by utilizing staff huddles and working together with administration in order to overcome conflicts.  

Emergent situations 

Emergent situations that arise during your shift can be relieved through adequate knowledge of the policies and procedures and by performing debriefs after the situation resolves. Debriefings hold valuable insight into reflections of the emergent situations we face as nurses, especially on communication performance. 

In each thread and form of communication in nursing, we must remember the following items to receive information. While producing communication, we must always be clear, concise, and accurate with the correct corresponding tone when expressed to others. When we are receiving the information, we must ensure we are understanding, investigating, and acting according to the communication presented to us. Utilizing various communication platforms, including emails, boards, and group messaging apps, can help to assist in ensuring education is received. 

Benefits of Effective Communication in Nursing

When we achieve effective and therapeutic communication between both our team and patients, it will create opportunities for enhancements throughout our practice. Fostering a unity of teamwork with co-workers will increase satisfaction and reduce burnout rates. Reduced health care costs through reduced re-admissions or emergency room visits will be established by successful patient education and understanding. Our quality of patient care will be heavily influenced by the nursing communication threads created through their care. 

Nursing Documentation 101

Introduction

“I just love charting,” said no nurse, ever. If you ask most people why they want a career in healthcare, their response is that they wanted to help people. They did not want to spend hours in front of a computer clicking boxes. This time-consuming task of documenting in the medical record, or charting, is dull, repetitive, and sometimes disconcerting. It takes time away from being able to provide care for the patient. Yet documentation in the medical record is truly a vital part of patient care. 

Nursing documentation fills a significant portion of the medical record. Nurses need make sure what they are adding is accurate and complies with the guidelines set by their facility and the state board. This principle is the same, even though there are differences to be aware of now that the electronic medical record has become the standard. 

The Who, What, When, Where, and How

Who: 

There are approximately 2.9 million working RNs in the United States, with about 1.6 million working in hospitals (1). Nurses on a med-surg unit typically spend about one-third of their total working hours documenting (2). Considering a nurse on a med-surg floor spends about 2.5 hours per shift charting, that roughly translates into 7 billion hours spent charting each year. And that is only for the nurses! 

Every discipline of the healthcare team contributes to the patient’s medical record. These different clinicians may not have the opportunity to report off to one another, and they must refer to the medical record to gather the information they need in order to care for the patient. Even kitchen staff responsible for preparing meals for patients must be able to see the dietary order for the patient. The following are a few examples of the clinicians who contribute to or review the patient’s medical record: 

• Medical Team: physicians, nurse practitioners, physician assistants, surgeons, specialists, residents 
• Nurses and LPNs 
• Medical Assistants, CNAs, patient care assistants or technicians 
• Specialty technicians: radiology, anesthesia 
• Therapists: physical, speech, occupational, respiratory 
• Pharmacists 
• Dieticians 
• Case managers or social workers 
• Coding and billing specialists 
• Researchers 

What:

The primary purpose of the medical record is to communicate data about the patient and care provided between different members of the healthcare team. The bulk of the medical record is a collection of assessment data obtained from the patient. Details concerning assessments and results from lab tests or radiology comprise a large portion of the data. Assessment data is usually collected on a flow sheet system. Progress notes are written by the medical team or therapists help to guide the intended plan of care for the patient. This is considered narrative charting. The medical record also includes orders for prescribed medications and treatments from the medical team. The following are typical components found in a patient’s medical record. 

• Patient demographics: name, age, gender, contact information, language, insurance information. 
• Past medical history: surgeries, chronic conditions, family history, allergies, home prescriptions. 
• History and Physical (H&P): this can contain information about admitting diagnosis or chief complaint and narrative of the story leading to admission. 
• Flowsheet of assessment data: vital signs, head-to-toe assessment, intake and output record 
• Laboratory test results. 
• Diagnostic test results: from radiology or procedures. 
• Clinical notes: progress notes from the medical team, procedure notes, notes from consulting clinicians, education provided, discharge planning. 
• Treatment Orders. 
• Medication Administration Record (MAR). 

When:

The medical record should document every interaction the patient had with a member of the healthcare team. An encounter is created upon admission and everything occurring during a particular admission becomes part of the medical record. Phone calls made to patients and/or families may also become a part of the medical record. 

Where:

Medical records are stored in various ways depending on their format and the facility. Paper records from small outpatient offices may be kept onsite. Records are now largely kept electronically. This is referred to as the electronic medical record (EMR) or electronic health record (EHR) and consists of Protected Health Information (PHI). They will be stored on a secure server, typically only accessible by authorized personnel. 

Why:

The medical record is essential for several reasons. The primary reason for the medical record is that it allows members of the healthcare team the ability to review and analyze data in order to deliver appropriate care. It allows clinicians to keep track of all the care that has already been completed for the patient. It also provides the patient with a record of the treatment they received for as part of their lifetime medical history. The medical record is used for coding and creating a bill for the services the patient received. Medical records may also be used for process review and research. Ultimately, it is also a legal document and may be used in a court of law as applicable. 

How: 

Medical records are in the final stages of evolution from a paper chart to an electronic medical record system (EMR). By 2017, 96% of acute care hospitals and over 80% of physician offices possessed certified health IT (3). This migration of medical records from paper to electronic format was made possible with advances in technology in the last 30 years. The EMR allows members of the healthcare team to access the medical record instantaneously and improves continuity of care. Utilization of the EMR ultimately reduces costs in healthcare (4) and increases efficiency. 

While EMR does have some drawbacks, the benefits that it provides are substantial enough that the government has encouraged its adaptation. The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009. This program provided tens of billions of dollars in financial incentives for healthcare facilities to adopt an EMR system (5,6). 

Privacy and Security

Since 1996, HIPAA, The Healthcare Information Portability and Accountability Act, has been the governing legislation that provides for the privacy protection of medical records. Compliance with HIPAA mandates that anyone who interacts with patients receives training that will ensure that they will maintain privacy for the patient. Part of the HIPAA legislation also allows the patient to request their medical records. 

The patient also has the right to request to amend their medical record. Patient permission must be given prior to a third party’s access to their medical record (7). HIPAA legislation was introduced at the advent of EMR technology. A provision of HIPAA provided a framework to ensure privacy of electronic health records (8). However, breaches in security by hackers or cyberterrorists remains a potential threat. 

Benefits of EMR: 

• Immediate data accessibility and communication of patient status.  
• Clinicians can view records remotely, analyze the findings, and place orders immediately for faster patient treatment. 
• Multiple clinicians can view the chart at one time. 
• Records can be viewed from previous admission and/or outpatients visits easily. 
• Records can be instantly shared between facilities (in instances of shared systems). 
• Reduction in errors.  
• Errors due to misinterpretation of handwriting are eliminated. 
• Allows for increased safety checks. The EMR can be set to flag missing components of information, tasks that were not yet completed or are overdue, recognize duplicates, and present warnings if documentation has not yet been validated or “signed.” 
• Scanning medications is possible with EMR systems to reduce the risk of medication administration errors. 
• Assists with appropriate billing by capturing charges of services provided to the patient. 
• The EMR can provide reminders for necessity of certain preventative health screenings or vaccines. 
• Automatic “signature” of data is completed simply by the user logging in with a unique ID and password. All entries are date and time stamped. If a correction is made, the original data can be accessed. 
• Accessing patient EMR is tracked and can be audited to protect patient privacy from unnecessary viewing. 

Downsides of EMR: 

• It is expensive to convert records system to an electronic system.  
• The initial cost of the EMR software is very expensive. 
• More workhours must be paid for staff training and coverage of patients during initial implementation of the program. 
• Maintaining appropriate encryption and cybersecurity technology against viruses and hacking are also a costly component. 
• Computer systems can be temporarily inaccessible, for example when updates and reboots are required. Paper charting is still necessary in the interim. 
• Template charting has limitations (9)  
• Templates may not exist for a specific problem and does not accurately reflect the patient’s condition. Atypical patients may have multiple problems or extensive interventions that must be documented in detail. 
• Templates may also encourage cloned or copied documentation. It creates unnecessary redundancy and at times inaccurate information in the EHR. Some EHR systems are designed to facilitate cloning with such popular features as:  
• “Make me the author” to assume the content of another person’s entry, 
• “Demo recall” of “Duplicate Results” to copy forward vital signs or assessment data. 
• “Smart phrases” pulls in specific identical data elements. 
• Automated insertion of previous or outdated information through EHR tools, when not modified to be patient-specific and pertinent to the visit, may raise significant quality of care and compliance concerns. 

The Legal Requirements

If it wasn’t documented, it wasn’t done. Every healthcare practitioner has had this mantra ingrained in them from the very beginning of their career. Nurses are trained to document defensively, that is, if they are taught at all. 

In a 2014 study, only 20% of new graduate nurses had received electronic medical record training as a part of their nursing school curriculum (6). It is not uncommon for clinicians to have the tendency to view the medical record as a defense tool against potential legal problems, rather than its more significant role as a communication tool for patient care. 

Regardless, accurate and complete documentation is an essential. Your career, and more importantly, patient care, depends on it. 

When Documentation Becomes Your Defense

In the dreaded event of a legal problem, medical record will be scrutinized to every detail. It is usually the primary source of evidence for the case. A malpractice lawsuit requires four elements to be proven (10): 

• That a medical professional assumed a duty to provide care for the patient. 
• The clinician failed to provide appropriate care within their scope of practice for the patient. 
• The failure in appropriate care caused an injury to the patient. 
• The injury resulted in damage to the patient. 

Potential legal problems that may arise include the following (11): 

• Administrative liability – Professional licensure discipline, discharge (firing) from position. 
• Civil Liability – Malpractice lawsuit, failure to provide necessary care. 
• Criminal liability – Misdemeanor or felony charges for cases of gross negligence. 

The Cost

Fortunately, medical malpractice claims have begun to drop since 2001. In 2004, the medical practitioners involved, the defendants, won the case 83% of the time. The legal fees can still amount to $18,000 if the case is dropped, to as much as $93,000 even when the case is won (12,13). 

In 2018, there were 8,718 malpractice cases that resulted in payments to injured patients (14). Of those events, 310 reports of malpractice suits that resulted in payments related to nursing care. 

However, 180 of those, about 60% of those had payments to the injured patient that were over $50,000 (14). However, there were nearly 15,000 adverse action reports filed against nurses, which was more than the number combined filed against physicians, NPs, and PAs combined. 

The majority of medical malpractice cases primarily target the physician and the facility. However, anyone who made an entry into the patient’s medical record may be required to participate in legal proceedings. 

Most common malpractice claims against nurses include failure to (15): 

• Follow standard of care.  
• Follow safety protocols. 
• Perform procedures according to guidelines. 
• Use equipment properly.  
• Use or operate equipment within the manufacture’s details. 
• Failure to correctly document  
• Communication with the provider 
• The care you completed. 
• Follow assess and monitor.  
• Report a change in status of the physician. 
• Assess a patient with change in status. 
• Communicate pertinent data. 
• Provide appropriate discharge education and information. 
• Communicate properly and completely between shifts. 

What is Required for Nursing Documentation

Necessary medical record documentation can vary significantly depending on the care area. For example, the documentation a circulating nurse in the operating room completes will be very different from what is documented on an emergency room patient. While the basic principles of documentation stay constant, the nurse needs to be familiar with the documentation requirements for that area based on the requirements of the state board of nursing, the facility, and the unit. 

There are standard requirements for medical record documentation that are applicable in all patient care settings, and in both paper and EMR systems. These standards include the following (16): 

• Accurate: Clinicians must be careful to proofread documentation to make sure it is free from errors. A small typo can have serious repercussions, as it is more likely to be misinterpreted by others. 
• Relevant, concise, organized, and complete: It is important to keep the information concise and relevant so that other care providers can quickly find the pertinent information that they need. Assessment data should be entered in a systematic way. Complete documentation ensures all of the unit policies for documentation are addressed. 
• Free of bias: Clinicians should only include information that is pertinent to the care of the patient and remain free from personal bias. Direction quotations should be utilized with proper context. 
• Factual: Clinicians should not exaggerate or minimize findings. Charting is to be completed after completing a task, not before. Do not speculate data. Observations need to include exact times and measurements. Avoid approximations. Make sure to chart on the correct patient. 
• Timely: What occurred during the shift should be documented during the shift. Documentation should be done as soon as possible after task completing. If something needs to be added in after the shift was completed, it should be denoted as a late entry with a reason as to why. Your facility likely has strict requirements regarding late entries. 
• Legible/decipherable and clearly written: Paper documentation must be clearly legible. Writing must clearly convey meaning. 
• Standardized: Clinicians must use appropriate medical terminology and approved acronyms and abbreviations. 
• Labeled and Auditable: Paper documentation must be signed with credentials and must include the date and time of the entry. When charting in the EMR, all entries and corrections are recorded and time-stamped. Password sharing or having another clinician assist in documenting under an incorrect username is fraudulent. 

Examples of Good and Bad Charting

The following will show some examples of these principles in action. These are based on the scenario of a patient admitted in the Emergency Department for chest pain. 

Common Documentation Errors

• Falsification of a record. This can happen from charting an action was never done, or from charting information before the action was completed. 
• Fraudulent charting is the act of knowingly making a false record. Criminal charges of forgery can result if the misrepresentation was done for personal gain. An example of this would be a nurse documenting administration of controlled substance but was instead diverting the medication. 
• Inappropriate use of cloning features. Information “copied and pasted” from a different patient’s record or that was completed by another provider. Data copied from previous shift assessments that isn’t updated to reflect current status is also a false record (9). 

• Fail to document communication. Notification of the medical team of a change in patient status or critical lab values should always been included. Clarification or confirmation of orders should also be documented (17). Include notification of other providers who assisted with patient are. This includes failure to document transfer of care to another nurse. 
• Failing to document a reason why something wasn’t done. If a patient doesn’t receive a prescribed medication, the reason why the medication wasn’t given needs to be described. If you communicate with the provider, this should also be included. 

Conclusion

Including all of the necessary information into each patient’s medical record is a daunting task. The nurse must make sure that they have included all of the relevant and accurate information that is required by their facility guidelines. It must usually be done in a loud environment and is frequently interrupted by actually having to provide care to the patients. 

It is not only a tedious chore, but it also tends to cause a lot of apprehension. There is usually a worry of “did I chart enough?” or “did I chart everything I needed to?” This is due to the defensive practices and attitudes healthcare workers have adapted to protect against malpractice lawsuits. In this way, charting is a lot like paying taxes. No one likes it, but it still has to be done. 

Perhaps a way to develop a healthy perspective toward charting is to change the focus back to its original purpose: to communicate care about the patient. The purpose of charting is to relay to the other healthcare team members what is going on with the patient. With this objective in mind, the nurse will inevitably cover all the necessary details. It may also be a bit more satisfying to know that even though they are in front of the computer, they are still doing something important for the patient. 

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