Dementia Staging – Focus of Care

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In 2011 an estimated 298,000 Australians had a dementia and by 2050 this number is expected to triple.

People living with a diagnosis of dementia vary widely in their individual experience of symptoms and the progression of their condition.

Dementia is incorrectly thought of as a disease in its own right. Dementia is in fact a set of symptoms caused by several degenerative disorders.

Various stages and their descriptors have been developed in response to research and a better understanding of dementia. We now know the four most common types of dementia are:

• Alzheimer’s Dementia
• Vascular Dementia
• Dementia with Lewy bodies
• Frontotemporal Dementia (including Pick disease)

Less common is Creutzfeldt-Jakob Dementia and dementias associated with

• Huntington’s disease (HD)                         image
• Parkinson’s disease (PD)
• Alcohol
• HIV/AIDES
• Metabolic causes and
• Trauma

Staging dementia provides a guide for clinicians in determining the focus for treatment. In addition staging also helps in optimising communication among the person with dementia initially, the carers and clinicians.

There are multiple versions of dementia scales which ultimately increases the risk for miscommunication among all parties. The individual dementia scales have been developed focusing on a symptom or group of symptoms and progression through each stage is relative to symptom deterioration.

Alzheimers Australia provides information to health professionals and consumers describing a classical phasing system of Early, Moderate and Advanced Dementia. This scale is based on symptoms associated with cognitive decline although people with dementia do not experience all the symptoms within each of the phases. Cognitive fluctuations make it difficult to articulate clearly at which phase the person is in.

The grouping of symptoms within a four stage framework is described by Dementia Care Australia. This model is based on a social psychology construct rather than a medical one which is based on brain changes.

Progression through the four stages is relative to how the person with dementia is responding and interacting socially within their environment. Research has shown little correlation between brain changes and the symptoms and deterioration experienced by individuals with dementia.

The Clinical Dementia Rating (CDR) scale describes five stages of dementia progression and is based on a persons ability to perform in six areas of function and cognition:orientation, memory, judgement, home and hobbies, personal care and community. Stages are rated as no impairment, questionable, mild, moderate and severe impairment.

A common seven stage scale in assessing primary degenerative dementia is the Global Deterioration Scale (GDS). The GDS focuses on the amount of memory decline and is more relevant and useful in Alzheimer’s Disease (AD). It’s not as useful in some of the other dementias such as frontotemporal dementia as memory loss does not always occur relative to the progression of the dementia.

The descriptive language utilised in the stages and phases of dementia is prolific:early onset, pre-Alzheimers, early, middle, late, mild, moderate, severe,advanced and end stage. Any wonder clinicians find it difficult in clearly communicating with one another and consumers regard the extent of the dementia.

Australian health expert Dr. Jane Tolman describes a dementia scale in her work in this specialised field of healthcare. The model can be used in all types of dementia and has the ability to clearly articulate for clinicians the progression of decline. Focus of care underpins this three stage model.

The first stage is Dignity and Autonomy and the primary focus of care is to maintain independence and enjoyment.

Goal of care in the second stage is about Safety and maintaining quality of life often requiring 24/7 care either in a residential aged care facility or extensive support at home.

Providing Comfort and Dignity is the third and final stage. Symptom management and ongoing reassessment of the need for medications and interventions prolonging life, investigations which do not aide comfort and avoiding hospital presentations is the focus of care.

Just as with other dementia scales progression and the rate of progress through the three stages are variable and individualistic for each person.

Tolmans’ dementia scale is ideal for use in nursing practice and should be considered for use in acute, sub/non-acute and community settings. The focus of care at each stage independence, safety and comfort provide a clear direction for nurses to plan with family/carers ongoing care management for the person with dementia.

Dementia is a progressive and degenerative condition. The focus of care throughout the person/carers dementia journey is to plan for the inevitable palliative aspects of this disorder.

Malnutrition and Hypoalbuminemia – a predictor for illness prognosis

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40% patients are known to be malnourished on admission to hospitals in Australia. According to Australian Dietetics Association this increases to 70% in residents in Residential Aged Care Facilities (RACF). Malnutrition is clinically suspected in patients with a BMI < 18.5 and unintentional weight loss > 5% body weight.

 

Malnutrition is screened on admission to many Australian hospitals using the Malnutrition Screening Tool (MST) a simple three question tool designed for use by non-dietetic staff.  Patients are referred to Dietetics if they have a score >2 for assessment, review and implementation of a nutrition management plan.  Overweight and obese patients are similarly at risk for malnutrition and benefit from dietetic intervention particularly during times of illness and surgery.

 

General causes contributing to malnutrition are related to

  • inadequate oral intake (NIL by mouth peri-operatively, nausea\vomiting)
  • increased nutritional requirements (wound healing, pressure injuries)
  • impaired absorption
  • altered transport
  • altered nutrient utilisation

 

Malnutrition increases morbidity and mortality. Additionally malnutrition impairs functional recovery, increases muscle loss, impairs wound healing, increases the risk for infection and complications,  increases length of stays (LOS), affects quality of life and increases financial cost for hospitals and organisations. Significant oedema associated with decreased albumin blood levels impacts negatively on mobility and functional recovery. Hypoalbuminemia is also a predictor for morbidity more frequently cardiovascular morbidity, infection and organ dysfunction.

Albumin is a negative acute-phase protein which plays a major role in fighting infections, building and repairing muscle tissue. If the body is not taking in enough dietary protein the liver is less able to make new albumin further decreasing albumin levels. Normal range of albumin in blood is 3.5-5.5 g\l.  Maintaining levels of serum albumin within the normal range prevents the development of tissue oedema through maintenance of the colloid osmotic plasma pressure. The rate of loss of albumin to the tissue spaces (transcapillary escape rate) increases significantly when infection and sepsis if present.

A number of the more complex protocols that have been developed to detect malnutrition in adults rely on changes in acute phase proteins such as serum albumin and prealbumin as primary diagnostic indicators of adult malnutrition.

 

Monitoring albumin levels has been advocated as a prognostic tool to identify higher-risk patients because of the strength of the association and low cost of serum albumin assays. The acute-phase proteins—in particular C-reactive protein (CRP) may help identify the risk of infection or sepsis. Strong correlation between serum albumin and CRP with has been reported.

Studies suggest that administering sufficient exogenous albumin to achieve serum albumin level of more than 3.0 g/L lessens morbidity in hypoalbuminemia patients. Parenteral albumin solutions (200 or 300 mls of 20% albumin) have a good safety record. The ALBIOS study protocol stipulated that albumin administration should be titrated to maintain serum albumin > 3.0 g|l with albumin levels being measured on a daily basis.

Individual factors contributing to malnutrition

  • Age
  • Limited mobility
  • Inability to chew or swallow
  • Sensory loss (taste, smell)                                      th5R8LOT6Q
  • Lack of adequate intake
  • Apathy/depression
  • Treatment (ventilation, surgery, drain tubes)
  • Drug therapy
  • Inability to buy, cook or consume food

Organisational factors contributing to malnutrition

  • Failure to recognise malnutrition
  • Lack of nutritional screening or assessment disease (e.g., cancer, diabetes, cardiac, gastrointestinal)
  • Lack of nutritional training
  • Confusion regarding nutritional responsibility
  • Failure to record height and weight
  • Failure to record patient intake
  • Lack of staff to assist with feeding
  • Importance of nutrition unrecognised

 

Malnutrition and hypoalbuminemia corrective strategies include the screening of all patients on admission to hospitals for malnutrition with a full nutritional assessment for patients identified at risk.  Prescribing of oral supplemental high protein high energy drinks and frequent small meals of choice should form part of a nutritional management plan. Integration of new practises such as protected meal times provides the opportunity for staff to facilitate and monitor oral intake.

Regular blood analysis and review is recommended for patients considered high risk. Studies suggest that for post-operative patients an increased CRP level day 3 post op is a strong predictor for hypoalbuminemia on day 7.

Malnutrition and hypoalbuminemia continues to be unrecognised as such contributing factor in clinical deterioration of patients. Further awareness and education is needed for both nurses and medical staff if prevalence rates are to improve.

Salt – the good, the bad and the confusion

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75% of the daily consumption of dietary sodium intake are from prepared, packaged and processed foods. Added salt from the salt shaker accounts for a further 6%.

A successful Australian health promotion campaign in the 1970s was aimed at consumers to reduce salt in their diet during cooking processes and from adding additional quantities at the table for better health outcomes.

The word salt and sodium is used interchangeably in health language which has created some confusion within the community. Salt is made up of 40% sodium. Our body requires sodium for the maintenance of extracellular and serum osmolarity.

Excess sodium intake is excreted by the kidneys as sodium build up in the body is fatal. The kidneys excrete excess sodium more rapidly in the presence of higher blood pressure.

Sustained high blood pressure over a long period of time affects blood vessels by causing stiffening of the wall of the vessels. The damage to the blood vessels increases the risk for cardiovascular disease and stroke.

Sodium is naturally occurring in unprocessed foods – fresh fruimageit, vegetables, meat and dairy products. Australian dietary sodium recommendation for adults is 1.2 g/day. Currently the Australian adult daily average consumption is 3.5g/day.

Sodium does not act alone. Potassium works very closely alongside sodium. The ideal sodium:potassium ratio has not yet been clearly established, however it is thought to influence blood pressure more strongly than sodium on its own.

A study published in 2014 suggests that whilst a diet high in sodium (>6 g/day) is unhealthy, so too is a diet too low in sodium (<3 g/day). The ideal range of dietary sodium intake was considered to be between 3 g – 6 g/day.

A 2013 World Health Organisation (WHO) study found that almost all countries inhabitants exceeded the recommended sodium daily intake of 1.5g/day.

More than 25% of the world’s population over the age of 25 years suffer from hypertension. Hypertension is ranked as the leading cause of cardiovascular disease.

Concensus amongst hypertension experts is that the beneficial effect of salt reduction starts at daily intake levels of 5 gms or less and relatively high levels potassium in the low salt diets may have additional effects on
blood pressure.

Debate around sodium and salt intake is not around the effect on blood pressure and consequences to health, but around determining the right level of sodium intake to maintain optimal health.

Have Your Bowels Moved – Postoperative Constipation

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Constipation postoperatively is common. So too is the “have you moved your bowels today” catch cry from nurses everywhere. Many factors increase the risk for constipation in patients who have undergone a general anaesthetic.

Change in routine and diet, reduced fluid intake perioperatively, nausea and vomiting postoperatively, reduced mobility, pain, opioid medications and use and type of anaesthetic agents all have an effect on reducing gut motility increasing the risk for constipation.

Constipation is defined on the basis of stool frequency, stool consistency and difficulty passing stools. It is the accumulation of old hardened faces that is so tightly packed together that the bowel movements are infrequent and incomplete, causing much difficulty and strain, producing dry, hardened feces. The hardened feces will then stick to the walls of the colon and inhibit proper nutrient absorption.

Screening the patient prior to or on admission for chronic constipation is an important aspect to consider for minimising the risk for constipation. Ideally patients with a history of constipation should be flagged as high risk for developing constipation postoperatively.

Gathering information from the patient preoperatively is most likely to include their usual patterns of bowel movements, including the frequency, consistency, size or amount, and also amount or degree of straining when passing bowel motions.

A management plan could be implemented immediately paying very close attention to hydration perioperatively. Including the patient preoperatively in the development of their bowel management plan ensures that the patient has a voice in what works well for them. As part of developing the plan is patient education on risk factors which can exacerbate constipation.

Patients need to understand the importance of bowel movements in general and particularly postoperatively. Nursing staff can play a significant role in educating patients on appropriate level of fluid intake and the importance of moving and mobilising as much as possible. The use of the Bristol Stool chart is helpful in educating patients of appropriate stool consistency.

Postoperative nausea and vomiting (PONV) if not adequately treated can result in dehydration which impacts on fluid absorption and consistency of the bowel motion. Prolonged periods of fasting preoperatively has a similar effect if not adequately managed. The elderly are particularly vulnerable to perioperative dehydration.

Mobility restriction postoperatively due to type of surgical procedure performed and or pain adds an additional aspect impacting on constipation. Studies on the effects of physical activity in healthy subjects on colonic transit suggests accelerated transit time after physical activity . All patients should be encouraged to physically move as much as possible within the restrictions in place medically.

Optimising pain relief for mobility is a balancing act that is at times complex. Opioids reduce gastrointestinal propulsion and increases fluid absorption. Decreased mobility reduces gut motility. Ensuring the patient has the right amount of pain medication to maximise physical mobility is the goal here.

Medications may be used to assist in the prevention and treatment of constipation. Emollient stool softeners are easy to use and are best used prophylacticly in the short-term particularly for the patient receiving a postoperative opioid medication.

Many health professionals do not give bowel management the focus and the respect it requires. Constipation is uncomfortable and distressing for patients. Constipation postoperatively can lead to faecal impaction and gut obstruction which are possible serious consequences of untreated constipation.

Patient and staff education regards risks associated with constipation and how to prevent it postoperatively are the key to ensuring patients respond more often and with confidence “Yes my bowels have moved today thank you nurse”.

Nursing Measures to Counteract Orthostatic Hypotension

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“Just sit there on the side of your bed and get your head together first before we stand you up”image

This or something very similar would have to be one of the most common words of advise nurses give to patients who complain of being a bit faint or dizzy on getting up. Is that it though? Is that the extent of our collective nursing wisdom that we have to offer? Are there other interventions that nurses can consider implementing.

 

Firstly nurses of all levels caring for patients need to have a good understanding of the mechanics of orthostatic hypotension (OH). OH is defined as:

A reduction of systolic blood pressure of at least 20mm Hg
or a reduction of diastolic blood pressure of at least 10mm Hg
within 3 minutes of standing

Nearly all instances of OH is detected within 1 minute and instances beyond 2 minutes provides information regards OH severity. OH is more likely to be detected by the measuring of lying and standing blood pressures in the early morning and also postprandially.

Prevalence of OH in the elderly in the community >70 years is estimated to be 30%. Complaints of symptomatic OH are more prevalent in elderly with Type 2 diabetes or cardiovascular diseases and in females. Symptoms include dizziness, faintness, light-headed and syncope. Not all cases of OH are symptomatic.

Managing OH is complex and difficult to treat. The aim of treatment is to increase blood volume, decrease venous pooling and increase vasoconstriction while minimising supine hypertension.

Informing medical staff of the presence of OH (symptomatic and asymptomatic) is the first nursing action. Part of the medical role is to identify the cause of OH, review current medication regime and determine if pharmacological intervention specifically to treat OH is required.

Once OH is identified and the cause proposed the role of the nurse is to provide patient education and in collaboration with the patient develop an individualised management plan. Patient education is vital. Information about OH, the symptoms and the strategies to reduce the effects of OH form the foundation of an effective patient education program.

Strategies worth considering by the nurse which have been shown to help patients in minimising OH symptoms fall into 3 categories as previously mentioned 1. increasing blood volume 2. decreasing venous pooling and 3. increasing vasoconstriction. Some of these strategies require very careful consideration of existing co-morbidities.


Increasing Blood Volume

  • aim for 2-2.5 litres fluid a day
  • head of bed raised 20-30 cm at night
  • increase salt diet
  • cold water bolus 500 mls
  • high potassium diet (fruit and vegetables)

Decrease Venous Pooling

  • calf pumps before standing
  • maintain upright activity during the day
  • prevent prolonged recumbency
  • postural changes to be graduated
  • mild physical exercise ideally in a seated position
  • abdominal compression
  • graduated compression stocking to the waist

Increase Vasoconstriction

  • reduce or cease alcohol
  • frequent small meals rather than large high carbohydrate dense meals
  • minimise exposure to heat in the environment including showers and baths

Mild cases of OH may be adequately treated with patient education and non-pharmacological interventions. Moderate to severe cases of OH will additionally require prescribed drugs to assist in treating OH.

Its worthwhile asking the question what place does OH screening by nurses have in caring for older persons particularly in hospitals. What screening tools are available or is it as simple as measuring an early morning lying and standing blood pressure as soon as possible post admission.

 

Customer Service in Healthcare – Focus on The Nurse

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Is there community or organisational expectation that nurses should be adopting a McDonald’s like customer service “would you like fries with that” approach to providing patient care.

Customer service is about the journey experienced from beginning to end. McDonald’s has this down to a fine art with scripted interactions and standardised systems and processes. The difference between hospitality and retail type industries with the health care industry is the customers state of mind prior to accessing the service.

Healthcare customers are sick, stressed, uncomfortable and find themselves in an unfamiliar environment impacting on self-confidence and personal inner strength. When reviewing customer service models for consideration in implementing in health services the state of mind of customers must be taken into consideration.

With any customer service model attitude is one of the foundational stones. Attitude is the enthusiasm and positiveness that individuals have towards their job and their interactions with customers. Excessive workloads and centralised chaotic workplaces drain nurses positive energies negatively influencing nurse:patient interactions.

Historically health care organisations and healthcare professionals  prioritise safety, efficiency and positive outcomes over the patients experience. Consumers are now wanting and expecting a respectful and as pleasant a journey as possible through the health system. Funding agencies in the USA are now also allocating part of hospital funds based on customer service scores.

In Australia care models introduced into healthcare in recent times have included Lean Thinking, Transforming Care at the Bedside, Person Centered Care, Intentional Rounding and Clinical Handover at the Bedside. Underpinning these models is the value and importance of releasing nurses back to the bedside, reducing waste (consumables and time) and providing increased opportunities for patients to be more involved in their own care planning and decision-making.

Customer service training within healthcare is minimal and patchy at best. Care models introduced as above have been in many instances implemented reactively and quickly rather than in a considered and comprehensive manner. Reactive implementation of any change generally results in minimal collaboration with workers and even less training or dissemination of information almost guaranteeing lack of engagement of the worker.

Nurses and the care they deliver are an integral aspect of excellent customer service. Car parking, cleanliness of the facility, ease of access into services, waiting times and quality of food delivered are other important aspects which impact on and influences the customer experience.

The Disney customer service healthcare model which uses “Disney’s chain of excellence” is an interesting model worth considering implementing in the healthcare industry. Disney invests a lot of energy on reducing time-wasting systems, hassles and distractions for workers. Reducing these distractions free the workers time up so their time can be better served focusing on attending to the customer and their experience.

The chain of excellence starts at the top moving through the organisation to the worker and on to the customer. The organisation focuses on taking care of the worker allowing the worker to focus on and take care of the customer. Nurse are at the forefront of care delivery and interactions with customers more so than any other health care worker.

Having a customer service frame of reference all other disciplines and departments within a healthcare organisation must treat nurses as internal customers with a focus on providing a responsive and efficient support service to the nurse. Any opportunity to keep the nurse face to face with the patient providing care must be acted upon and addressed swiftly.

At Disney we have a common purpose and we each have tasks……..job descriptions. Each of those descriptions have tasks associated with them, but we have a singular common purpose, and the common purpose for us will always trump and be more important than our task. So at any point in my day and I’m delivering on my task, I have an opportunity to deliver on the common purpose I do that. And I’m rewarded for that intrinsically because it makes me feel good. The more I do that the more I want to do that. Healthcare institutions can be a better place to work. It can be a better place to be cared for simply by coming back to the purpose.”

                                   Patrick Jordon Healthcare Consultant Disney Institute

If health care organisations are serious in providing excellent customer service than a change in attitude towards nurses is required. Care of nurses need to be the focus of organisations who in turn take care of patients ensuring a positive experience is realised. Increased opportunities for nurses to access “consumer free” time for training, peer and professional supervision as experienced by all other health professionals within the health care industry. Nurses need to be articulate and persistent in raising awareness of organisations on the vital role nurses play in the consumer journey and customer service.

Caring for the Nurse underpins and is vital for customer service of excellence for any healthcare organisation.

Over Invovlment is the Leading Cause for the Crossing of Professional Boundries

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The nurse-client relationship is the foundation of nursing practice across all populations and cultures and in all practice settings.

www.crnbc.ca

The nurse relationship with the patient/client  is one built on trust and respect. Nurses generally have the balance of power in this relationship as the patient is quite often at their most vulnerable. Nurses have access to confidential and private information about the patient and have knowledge and skills which can be used to influence care decisions.

Therapeutic communication and establishment of therapeutic realationships are core elements of nursing practise and nurse training. The intent of the relationship is to help the patient overcome barriers in meeting their unmet needs. Stepping outside this helpful role is where the nurse is most at risk of unprofessional conduct.

Professional boundries are guidelines for maintaining a positive and helpful relationship with our clients or residents. Understanding boundries helps care givers avoid stress and mis conduct, recognise boundary crossings and provide the best possible care.

Professional Boundries for Caregivers Manual

The literature conceptualises professional boundries as the Zone of Helpfulness model and also as a Continuum of Professional Behaviour. Each model includes both ends of the extreme being under involment and over involvement. Most transgressions of professional boundries are said to be due to over involvement.

Signs of over involment can be from the obscure to the very obvious. Below are some signs for nurses to look for in themselves and in their colleagues.

  • spending an inappropriate amount of time with a patient/client
  • visiting the patient when off duty
  • swapping allocations to be with a patient/client
  • thinking you/they are the only ones who truly understands the patients/clients needs
  • having/holding  secrets with the patient/client
  • over sharing of own personal information and circumstances
  • reacting/overacting emotionally to patient behaviour
  • giving or receiving gifts or giving special favours
  • giving advise outside own skills, expertise and scope of practise

Boundry crossings can at times be intentional in an effort to gain engagement of the patient. In these instances a question the nurse needs to ask is “would I feel comfortable if others were  fully aware of what I have done”. Professional boundries are crossed every day mostly unintentionally. In most instances nurses are not  aware that they are in danger of crossing over into unprofessional conduct.

Regular dissemination of information and in-services is one strategy of raising nurses awareness. Interactive education sessions would be most beneficial providing nurses with an opportunity to clarify and explore from own personal and hypothetical incidences.

Whose role is it to ensure, guide, mandate or provide awareness raising education to and for nurses. AHPRA is the governing registering body in Australia for most health professions which includes Nursing. AHPRA does provide fact sheets and standards about professional conduct for nurses.

A question that should be asked is what more should AHPRA be doing in this space. Is it more appropriately the role of employers of nurses or is it the responsibility of individual nurses to ensure nurses are aware and responsible for professional behaviour.

Parents Failing To Immunise – A Nursing Influence

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Parents are electing not to vaccinate their children increasing their child’s risk and risk to other children within the community.

What is the role of nurses as a healthcare professional in regards to vaccination. Nursing is one of the most highly regarded and trusted professions in Australia. Each year the Australian Roy Morgan Image of Professions Survey is conducted and in 2014 found

 A very large majority, 91% (up 1% to its highest since 2007) of Australians aged 14 and over rate Nurses as the most ethical and honest profession – the 20th year in a row since Nurses were first included on the survey in 1994.

Parents of children not vaccinated registered with the Australian government are recorded as being vaccine objectors based on grounds of  personal, philosophical, religious or medical.

Parental concern against vaccination is multi factorial. Concerns voiced are regards potential allergic reactions, increased risk for autism, no guarantee vaccination will prevent getting the disease and vaccine safety. Looking for alternative options to vaccination  has led some parents towards homeopathic immunisation or to not vaccinate at all relying on natural immunity.

Utilising the professions credibility within the community nurses should look for opportunities within their clinical environment to check in with parents regards the child’s immunisation record addressing any concerns or queries. Parents reluctance or refusal to vaccinate is generally based on genuine concerns for their child’s safety and well-being.

Information provided needs to be evidence based and delivered with empathy, without judgement and at an appropriate educational level that parents understand the consequences for their child and the community should they decide not to vaccinate.

“All vaccines registered in Australia by the Therapeutic Goods Administration (TGA) are evaluated to ensure they are effective, comply with strict manufacturing and production standards, and have a strong safety record. This includes stringent testing for each vaccine component, including preservatives, additives and vaccine adjuvants. It can take up to 10 years for a vaccine to be approved for use”

“Both the British Homeopathic Association and the Australian Register of Homoeopaths recommend that people should receive conventional immunisation and that homoeopaths preparations should not be recommended as a substitute for conventional vaccination programs”

“Multiple studies have been completed which investigated the measles, mumps and rubella vaccination in relation to autism. Researchers have also studied thimerosal, a mercury-based preservative, to see if it had any relation to autism. The results of studies are very clear; the data show no relationship between vaccines and autism”

“Vaccines are designed to generate an immune response that will protect the vaccinated individual during future exposures to the disease. Individual immune systems, however are different enough resulting in the individual not being effectively protected.  This occur in less than 1% of all cases of most vaccines.”

The Australian Commonwealth government recently announced a “No Jab, No Pay” policy. The intent of the policy is to assist in increasing child vaccination rates within Australia. Those who will be impacted by the new policy are those accessing funding and tax benefits relating to childcare rebates and Family Tax A benefits.

Whether this will be successful or detrimental to vaccination rates is unknown at this stage. Currently it is the parents decision to vaccinate or not to vaccinate. Continued research and sharing of credible information addressing parents concerns remains at the forefront of any vaccination campaign. Nurses clearly  play a significant role in communicating and disseminating the information with parents and the community generally.

My Pain Is What I Say It Is Nurse

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You put down what your doing and head into a Room 23A to answer the buzzer. Patty (patty the patient) is recovering from a fractured left ankle, ribs and right humerus post MVA. Patty wheeled past you in her wheelchair just 5 minutes ago with some friends in tow.

“I need my pain meds nurse.Its 8/10 and driving me crazy”. A friend jokes “I thought you said you weren’t going to be driving anywhere anytime soon”. Patty and her friends continue to joke and muck around as you leave the room.

Seriously you ask yourself how can someone be in soooooo much pain but show very little sign of being in pain. We are all unique and respond to situations including pain in our own way. Not appearing to respond as one would normally expect can at times influence how others judge or perceive the situation.

“I am in pain you just don’t know it cause I smile through the rain and refuse to show it

image“The dingo took my baby” is a prime example of this. Some Australians judged Lindy Chamberlain negatively and with suspicion purely based on how she responded to the situation and appeared in the media. Her response was not considered normal by many at the time. Lindy was viewed with suspicion and labelled by many.

Pain is by its very nature subjective. Yes when pain is severe there are physical changes i.e. vital signs which are an objective measure. Irrespective of our thoughts of how much pain Patty is experiencing in this instance it is all about the patient. What the patient says the pain is what the nurse needs to treat.

Analgesia is one strategy to minimise pain however there are other alternatives that can by considered in collaboration with or as stand alone treatments. Resting, positioning, activity, stretching, thermal (ice or heat) and diversion such as listening to music and meditation are non pharmacological strategies for pain management.

Educating patients regards pain is also an important aspect of a nurses role in pain management. Not understanding why they have or still have pain increases anxiety. Anxiety exacerbates or heightens the pain. Having a good understanding of why the pain exists and knowing the plan for relieving that pain can reduce some of that anxiety.

Working with Patty in developing a plan of care around her pain management assists in giving her a much needed feeling of control over her pain. Patty is the expert when it comes to what has worked best for her in the past which must be respected in developing the plan.

Increasing medication is not always the answer. With each new medication or increase in dose the risk increases for drug interactions and unwelcome side effects. Getting the right management plan in place though is always the answer.

Research Findings – Statistically Insignificant Might Be Clinically Important

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How many times have you read a research article that concluded with – the study findings are “statistically insignificant” or “not statistically significant”. What does this really mean from a clinicians perspective. Can research findings of statistical insignificance still be of clinical significance and or importance that can lead clinicians to change their management of patient care.

This is a difficult question and is quite complex with many layers however it does require answering. Nurses need to have a good understanding of what the term statistically significant actually means. Research and an understanding of research is very important if nurses are to ensure our individual and our collective nursing practise is evidenced based.

Primarily the purpose of research is to generate and answer questions and to provide a framework for researchers to work within in an effort to establish a level playing field. The research question (hypothesis) is identified and the researcher generates the evidence for and against a hypothesis.

Statistical significance basically means that from a statistical point of view, the study result was not due to chance. The two most common measures for statistical significance is probability value (p-value) and confidence interval (CI).

P-value is measured as a value from 0-1 with the lower the measure the lesser the result being attributed to chance. A p-value (p < 0.05) is often considered significant, but the lower this figure, the stronger the evidence.

CI estimates the range within which the real results would fall if the trial is conducted many times. Hence, a 95% CI would indicate the range between the two treatments would fall on 95% of the occasions, if the trial is carried out many times

The research paper provides a summary of the research method, results and provides information around the statistical significance. In making a decision as a clinician (individually or as a group) other aspects should be taken into consideration.

Clinical significance (clinical importance), can be viewed as a difference between two therapy results that is large enough to justify the changing of management of a patients care. Caution is required though because whilst the research outcome is statistically significant the real difference may be too small to support a move to change a current practice. It’s important for clinicians to understand that statistical significance doesn’t necessarily equate to clinical importance.

Ultimately, in order to choose among different

treatments, clinical physicians have to consider

not only the P-value of the latest published paper,

but also the magnitude of benefit of each

treatment, side-effect profiles, direct and possibly 

indirect costs, patients’ preferences and even

their own comfort with prescribing a new therapy.

Regular reading of research papers and being involved in professional discussions regards the research outcomes facilitates greater understanding of the clinical importance and implications for management of care.

Journal Clubs are a well established strategy for this and are well entrenched in many professions especially within medicine.The nature of nursing does present barriers to nurse participation. More effort is required by nurse leaders in breaking down the barriers to optimise nurses regular participation in research reading and discussion.

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