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.

http://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.

Use of Cranberries in Urinary Tract Infections – What’s the Evidence

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It’s estimated that as many as 50% of women suffer from an episode of urinary tract infection at least once in their lifetime with as many as 10% -15% experiencing an episode of urinary tract infection (UTI) in the past

12 months. 30% of women experiencing a UTI in their lifetime will suffer from recurrent urinary tract infections.

For many years alternative therapists have recommended to their patients the regular use of cranberries for prevention of urinary tract infections. At the time there were few scientific studies which fully supported their claims. Originally the benefits of cranberries in regards to urinary tract health was thought to be due to its acidic properties similar to Vitamin C which was also recommended at the time for urinary tract health.

A United States study comparing the effectiveness of 5 prevention and management strategies in women with recurrent urinary tract infections published late 2013 concluded daily doses of cranberry were found to be as effective as daily oestrogen in post menopausal women in reducing reoccurrence of UTI in those women at high risk for recurrent UTIs. In this particular study high risk was described as those women experiencing 3 or more urinary infections in the previous 12 months. In the same study daily doses of an antibiotic as a prophylaxis was found to be much more effective.

In high risk premenopausal women low dose prophylactic antibiotic therapy is generally recommended. In 2014, World Health Organisation (WHO) published its first global report on surveillance of antimicrobial resistance. Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it. Widespread prescribing and use of antimicrobials is putting at risk the ability to treat common infections in the community and hospitals. WHO recommend health professionals across the globe  “prescribe and dispense antibiotics only when they are truly needed”.

The active ingredient in cranberries is A-type proanthocyanidins (PACs) which can affect the ability of bacteria from adhering to the bladder wall. Due to the minimal regulation of dietary supplements the amount of A-type proanthocyanidins (PACs) in cranberry juices, extracts and tablets is wildly variable. This makes it difficult in prescribing an appropriate dose of cranberry with any certainty.

Taking into account the World Health Organisations’ strong recommendation regards antimicrobial stewardship it’s important that alternative approaches be considered in treating infections. Scientific research does seem to support the use of cranberries in high risk women experiencing recurrent urinary tract infections.

 

Intentional Rounding – Branding an Old Concept

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Have you ever heard the saying ‘what is old is new again’? Some 30 years ago nurses did frequent back rounds. Despite its title it wasn’t just limited to back care – it included making sure patients were comfortable and had everything they needed.

Sweeping across the US, UK and Australia is a nursing concept branded Intentional Rounding. Its being promoted by governments and organisations alike in an effort to release nurses back to the bedside as part of transforming care at the bedside. The promoted benefits are happier patients, less falls, less incidences of incontinence episodes and pressure areas, less call bell usage and increased satisfaction of nurses.

Implementing intentional rounding does not bring with it additional nursing labour  resources. It’s what government and health executive management call cost neutral. Intentional Rounding is about changing nursing practise from reactive (responding to calls for assistance/clinical incidents which are unplanned) to proactive (checking in and providing assistance which is planned).

Falls, episodes of incontinence and pressure areas are costly not only for the patient but also for health organisations. Nursing labour resources associated with each can be significant in terms of time and cost of care. The assumption is that if there is  decreased falls, pressure areas and episodes of incontinence due to intentional rounding this will provide additional time more than sufficient for nurses to attend (and document)  hourly rounding.

An add-on value to intentional rounding has been shown to be  happy patients. Happy patients make less demands and are less likely to complain even if things don’t go 100% well. Patients and their families/carers are more likely to be forgiving of minor mistakes and miscommunication.

The literature out there in the health care domain does not necessarily fully support all the promotional aspects of intentional rounding. There have been several studies done primarily since 2006 which was very positive about the benefits of intentional rounding. In recent years however the literature has identified issues with the original US research studies methodologies and also highlighting the differences in nursing roles across USA and UK where the bulk of the research has originated.

Anecdotally  surely all agree that if a patient is checked each hour and all their care needs are met at the time that it is highly beneficial and worth any cost. There can be no disagreement with this as the studies do show real benefits in reduced falls and pressure area rates etc.

Dissension within the literature is related to the implementation of intentional rounding. As stated in several studies in recent years it needs to be flexible enough for nurses to have a voice in what Intentional Rounding looks like within their individual workplace based on their patient unique needs. This will facilitate nurses engagement and most assuredly provide sustainability of Intentional Rounding.

Interestingly what has not been discussed in the literature is potentially the legal fraternity using hourly rounding ie lack of full compliance or documentation as  grounds for allegations of negligence against the individual nurse. This would certainly make for  an interesting qualitative study involving nurses and lawyers.