Yesterday I was writing about corneal abrasions and the medications that a physician will likely prescribe after such an injury occurs. It occurred to me today that listing some good links on "how to" administer eye drops (and other prescribed medications) to infants or toddlers would be a good idea.
Based on my past years of working as a pediatric registered nurse, I know how difficult it can be to medicate infants and toddlers. In order to give the medication with the minimum of fuss, it's best to swaddle (wrap) an infant gently but firmly in a receiving blanket so that the baby's arms are fixed at his/her side. For an older toddler, it may very well take two people to give necessary medication.
Here are two websites with rather nice information about how to give medication to infants and toddlers:
Great Ormond Street Hospital for Children: How to Give your Child Eye Drops
From the Ohio State University Medical Center: How to Give Your Baby Medicine by Mouth
Follow the Doctor's Orders
Give your child medication that is prescribed for him or her. Don't borrow or share medication meant for someone else. Store the medication as directed by your pharmacist's instructions. Most antibiotics will need to be refrigerated. Continue to give the prescribed medication for the entire period that the doctor has ordered. Don't stop the medication early because the child "seems better." Doing so can cause lingering infections that become resistant to the medication.
Do Not Give . . .
Never give aspirin to infants or children. Check the lable of any medication you intend to give. If any of the ingredients contain salycilic acids don't give your child the medication. Check the labels on all of your over-the-counter medications. Look for "black box" warning labels and other instructions to parents. Recently many cold and cough medications have been deemed dangerous to young children and the new packaging reflects such information.
Talk to your pharmacist . . .
Pharmacists do more than fill your prescriptions. They will gladly discuss over-the-counter medications with you and help you find appropriate options for your child. In addition, consult your pharmacist to determine whether or not the prescribed medication can be made more palatable for your child--by adding "better" tasting flavors by compounding the medication.
. . . .
Wednesday, December 16, 2009
Corneal Abrasion, Corneal Scratch, Pain and Sensation of Something in the Eye
“It feels like something is in the eye, and it's very painful.”
Why I’m compelled to write about this topic today: Recently one of my patients was expected back from surgery after undergoing a complicated procedure to repair a fracture. Shortly before the young man was due to arrive in his hospital room, the nurse from the surgical recovery care unit called to report that he was experiencing severe pain in one eye along with a sensation of “something in the eye.” The surgeon was aware and had ordered an eye flush. Although the nurses in recovery had copiously irrigated the eye with sterile water, the patient’s extreme discomfort persisted. The pain from his orthopedic surgery was nearly eclipsed by the pain and irritation in his eye. Close examination hadn’t revealed any obvious reason for the persistent eye pain. When he arrived on our floor, the patient’s affected eye was “bloodshot,” very sensitive to light, and he was writhing due to the combination of both eye and surgical incision pain. The surgery resident physician was soon at his bedside. She ordered an application of “Lacrilube” ointment to soothe the eye and diagnosed a corneal abrasion. Having participated in the surgery, she remarked that the affected eye “really wasn’t taped closed well enough” during the lengthy surgical procedure.
Corneal Abrasions
There are a number of reasons why a cornea might be scratched or irritated resulting in an abrasion. Although they are extremely tiny, corneal abrasions, are very painful . . . and why not? After all, even a paper cut to our fingertips can cause startling pain. Often a small corneal abrasion will heal itself within 24 hours. There is treatment that may soothe the affected eye, such as sterile artificial tears (see below for further discussion of additional treatments). Keep in mind, however, not all eye pain is due to a corneal abrasion, and not all corneal abrasions may be treated with home care alone.
Some Structures of the Eye
To understand what the cornea is, it’s useful to think of the eye as a room with the cornea being a window. The eyelids are similar to shutters that can be opened or closed. The space between the shutters and the window glass is the conjunctiva. The cornea functions as the window glass does; that is, the light flows through the cornea to enter the eye. Directly behind the cornea is the round, colored iris which functions in much the same way as curtains; the muscles of the iris expand and contract to allow more or less light inside of the “room.” The pupil is the space through which the light passes between the open curtains. The lens is yet another “window pane” that the light passes through before it enters the room. My suggestion is to think of the lens, for this example, as a large glass “sun catcher” suspended from the ceiling just inside the window. Vitreous humor is the gelatinous substance that fills the center of the eye just as normal atmospheric gasses fill up a room in your home. The retina is the back wall of the room just opposite from the window. As light strikes the “wall” (retina) there is inevitably a particular spot where the sunlight is more concentrated. The macula in the back of the eyeball is similar to that part of the room with the brightest exposure to the light. The fovea is an area of the macula which provides the sharpest vision; similarly the brightest spot in the room is best for reading or performing tasks that require sharp visual acuity.
(See a nice depiction of the eyes' anatomy here: http://www.eyecareamerica.org/eyecare/anatomy /).
A Little More About the Cornea
As mentioned in the preceding paragraph, the cornea functions like the glass of our windows. It’s a protective structure for the more delicate features behind it, and it functions to let light flow into the eyeball. Although the cornea consists of five distinct layers, it is very thin—with a depth of only about 1 mm at its deepest point.
The cornea has an abundance of nerve endings, as a result it’s very sensitive to both touch . . . and pain.. That trait helps protect our vision from trauma as all of our instincts quickly react to try to prevent an injury to the eye. However, corneal abrasion is still one of the most common eye injuries.
How Does a Corneal Abrasion Occur
A person may have no recollection of trauma to the eye and there are numerous scenarios that may result in a corneal abrasion. A poke in the eye (particularly if a fingernail is involved), a branch from a tree, flying glass or metal shards, or a surgical drape or equipment brushing across your eye if it is exposed during a surgical procedure . . . any of these things can cause a corneal abrasion. Debris in the eye can also cause an abrasion, particularly when the eyes are rubbed vigorously or if a contact lens causes friction.
Prevention during Surgery
Taping the eyes closed is a standard preventive measure aimed at protecting the eyes from corneal abrasion. Some surgeries pose a greater risk of a corneal abrasion occurring. Those in which the patient is positioned face down, surgery on the head or neck, and any lengthy procedure carries more risk. Of course in some surgeries taping is contraindicated as the eyes may need to be opened during the procedure. In such cases the anesthesiologist or nurse anesthetist will use their judgment to make the appropriate decisions. Instillation of eye drops, gels or eye ointments may be the decided course of prevention, or special goggles, eye cushions or pads may be used.
Diagnosis
Your doctor may use a combination of fluorescent dye and either a cobalt-blue filtered ophthalmoscope or a “slit-lamp” to make a definite diagnosis of a corneal abrasion. The physician may instill drops to temporarily numb the eye during the exam. If they observe a foreign body present in the eye, it will also be removed during this examination.
Treatment
At one time eye patches were applied when patients suffered a corneal abrasion. This is no longer a standard treatment; however, in some cases your physician may determine that an eye patch is in your best interest. It’s more likely that eye drops or ointment will be prescribed for home use. The drops and/or ointments may include a medication to control the pain, an eye lubricant, a topical antibiotic, or a steroid. Steroid eye drops may be prescribed to reduce inflammation. (Please note, some of the eye drops and ointments may result in temporarily blurred vision). Occasionally, a pain medication to be taken by mouth will be prescribed as well.
If metal shards were responsible for your eye injury, a tetanus booster shot will be needed. If it has been more than 5 years since your last tetanus shot--or if you cannot remember when your last tetanus shot was given--you will should be given a booster shot after the eye examination.
Follow your physician’s orders and use the medications exactly as prescribed. Do not stop the medication sooner than the directions tell you to simply because the eye “feels better.” Continuing the full course of prescribed treatment is important to prevent possible complications later on.
If you have questions about your doctor’s ordered treatment, ask him or her. You have a right to know the reason for the treatment decisions that are made on your behalf.
How long to heal
A small corneal abrasion may heal in a few hours. Often after a night’s sleep the cornea has healed. In the case of a larger abrasion, it may take several days time for complete recovery. It is important to keep from rubbing the affected eye as that may delay healing. If the symptoms suddenly recur after the initial healing phase, consult your physician right away. Inadequate treatment of a corneal abrasion can sometimes lead to complications such as a corneal erosion.
First Aid for Eye Emergencies
Plan to seek treatment at your urgent care center or ER for any bleeding from the eye, chemical splash, visible scratch or penetrating injury, eye pain, double or blurred vision, nausea and headache.
Do not rub the injured or irritated eye. Wash your hands with soapy water. Remove contact lenses if they are in place. Do not attempt to use any tweezers or cotton swabs to try to treat eye emergencies at home.
Chemical splash to the eye: Start flushing the eye with cool clean water from a sink, bottle, hose, etc. Tilt the head back and to the side. Keep the affected eye wide open and pour the clean water gently but directly into the eye. Make sure the head is tilted away from the “good eye” so that chemicals which are rinsed out don’t flow into that eye during the flushing process. (A child might be more comfortable laying down in an empty bath tub to have the eyes irrigated.) Continue to flush chemicals from the eye continuously for at least 15 minutes. Call 911 or have someone drive you to the ER. If the chemical that splashed into the eyes is known, be sure to provide the name to the healthcare providers at the hospital. For more information see:
First aid tips for a chemical splash to the eye from the Mayo Clinis.
Foreign body in the eye: Do not rub the eye. With clean hands, open the eye and allow tears to move the foreign body (such as an eyelash or speck of dirt). Rinse the eyes with cool clear water as explained above if tearing isn’t effective. If an object is embedded in the eye—do not attempt to remove it. Seek medical help in the ER or urgent care center immediately. For more information see: Mayo clinics advice on corneal abrasion and Mayo's first aid advice for a foreign body in the eye.
Bleeding from an eye: Do not put any pressure on the eye, gently cover it with a clean cloth and go directly to the Emergency Room. (The person with the injured eye should not drive).
2009 All rights reserved for content and photos, Carolyn Cooper, MPH, RN
References:
WebMD: http://www.webmd.com/eye-health/tc/objects-in-the-eye-home-treatment and http://firstaid.webmd.com/corneal-abrasion-treatment
Eye Safety for Emergency Response and Disaster Recovery from the CDC: www.cdc.gov/niosh/topics/eye/eyesafe.html
Wilson, S.A. and Last, A. (2004). Management of Corneal Abrasions. American Family Physician. Retrieved 12/16/2009 from: http://www.aafp.org/afp/2004/0701/p123.html
Verma, A. (2009). Corneal Abrasion. Emedicine from WebMD. Retrieved 12/15/2009 from: http://emedicine.medscape.com/article/1195402-overview
First Aid for Eye Emergencies from Prevent Blindness: http://preventblindness.org/safety/firstaid.html
Tarmey, N. & White, L.A. (2009). Chapter 5, Damage to the Eye. Risks associated with your anaesthetic, Information for patients: the Royal College of Anaesthetists. Retrieved 12/16/2009 from:
http://www.rcoa.ac.uk/docs/Risk_5Eye-damage.pdf
.
Tuesday, December 01, 2009
A patient with Down's Syndrome and ARDS; Carol was not "my" patient
Not My Patient . . .
“Your patient is being discharged,” my nursing instructor informed me as we started our clinical rotation on a medical/surgical floor in my first year of nursing school.
"Oh, just great," I thought to myself. I had spent hours learning about and planning the proper care for "my patient" who had recently suffered a basilar skull fracture. My sheaf of clinical documents, medication lists, and a large pathophysiology flow sheet, were now suddenly made obsolete by my patient's imminent departure to a rehabilitation facility.
“He’ll still be here for a couple of hours. We’ll find you another patient later,” she assured me.
I was relieved that my painstakingly-crafted flow sheet, care plan, and medication cards wouldn’t go to waste. Although I only had one patient, the preparation required for the clinical day was nevertheless tedious and often proved exhausting in addition to other demands of family, school, and life in general. Still, as a new nursing student with little experience in the healthcare setting, the advance preparation gave me confidence that I would know what to do for my assigned patient. I decided not to fret about it, and simply hoped I'd be able to cope with whatever came my way in the shift ahead.
Our group of 10 nursing students and our instructor assembled at the nursing desk waiting for the nurses going off duty to give change of shift report to the group coming on. We were working second shift, 3 pm to 11 pm that day. Each week we spent three days attending lectures at our nursing college and two days working in the hospital to practice the hands-on-nursing skills and put into practice what we learned in class. There was always a sense of heightened anxiety on our hospital days, particularly in the chaotic environment of our very large county hospital. This was a trauma center and the busiest hospital on the U.S. side of the Mexican border. It was also a teaching hospital, with a slew of resident doctors and interns managing most of the patient care.
“The patient in 410 has a fever of 101.5!” a nursing assistant called out as she passed the nurses’ station where the harried day-shift nurse was “reporting off” to the oncoming "real" evening nurse and our huddle of nursing students.
The nurse going off shift sighed, “I’ll call the doctor—the girl in 410 just transferred here from the pediatric floor a half-hour ago. She’s supposed to go to the OR for surgery, an ORIF of the femur, as soon as her mom gets here to sign the consent.” The RN turned to our instructor, “It would help me out if one of your students could give her an acetaminophen suppository for the fever.”
Although none of our group was assigned to care for this new arrival to the surgical floor, we were always ready to perform a clinical skill to check off our list. Therefore, an entourage of three students and our instructor entered room 410 where 18-year-old Carol, afflicted with Down's Syndrome and a fractured femur, would prove to teach me more than any other patient that day.
Carol had been struck by a car as she crossed a busy street the day before. The fractured leg was her only known injury. She appeared to be sleeping deeply, with regular, but deep and fast respirations. Her eyelids fluttered as I explained that we needed to give her a suppository. Working together, we students gently repositioned her, mindful of the Buck's traction supporting her injured leg. A slight groan was Carol’s only acknowledgement as we cleaned her bottom (she had been incontinent with a bowel movement), before I inserted the suppository. Our instructor pointed out scattered petechiae on Carol's chest as we snapped a fresh gown across her hot skin and turned her to replace the soiled linen on her bed with clean sheets.
“These petechiae are probably the result of the trauma from her car accident,” our instructor explained, as she gestured towards the splash of flat pink spots that looked to me like tiny red freckles.
Back at the nurses' station our little group reassembled to continue shift report. We told the nurse about our interventions and reported Carol's limited response to our actions.
“They gave her an injection of Demerol before she was transferred from the pediatric unit," the nurse mused, "And we don’t know her baseline mental status, she has Down's, and for all we know she could be profoundly retarded.”
I was absorbed in my clinical experience for a few hours. The care for my basilar skull fracture patient proved to be very minimal. One of our nursing students needed a helping hand with a very complicated dressing change for a young man who had lost a leg in while trying to jump aboard a moving train. And I was pleased to learn that another patient needed a new intravenous needle placed. I was lucky enough to get the chance to do the venipuncture. I suspect that I caused that patient a great deal of pain with my novice attempt, but with a seasoned nurse over my shoulder talking me through it, the result was satisfactory. I kept busy in this way helping the staff nurses and other nursing students with their tasks until my patient was officially discharged. My instructor disappointed me then by suggesting that I return to Carol and follow up on her care. It seemed a puzzling assignment to me, I knew there were no meds to pass, IV's to start or dressings to change in that room--and I was here to learn nursing . . .
In Carol’s room I found that her mother had arrived from out-of-state. She was regarding her daughter pensively.
“She won’t wake up,” she complained.
I repeated the explanation that the nurse had given us in report earlier, that Carol had been medicated with Demerol.
“When did they give that? And how long will it last? Something’s just not right,” she continued.
Her questions were good ones. I set out to find the "real" nurse to explain the mother's concerns, but the nurse arrived at that moment with a syringe in hand to give Carol another intramuscular injection of Demerol for her pain. The busy nurse briefly attempted to reassure Carol's mother before rushing back to care for her other nine patients.
As I continued to converse with Carol’s worried mother, I became uneasy. She described a high-functioning independent young woman who lived in a group home while attending a vocational educational program in the city. Demerol or not, the Carol we were observing didn't fit the girl her mother described.
Carol occasionally writhed and moaned, seeming to struggle to wake as her mother tried to arouse her. Her breathing was audibly harsh with a frequent moist cough. The family doctor was alarmed at her appearance when he made informal rounds to check on Carol. He wasn't in charge of her hospital care which was in the hands of the attending physicians who were on staff at this hospital, but he asked that the chief trauma resident be called to see her right away.
Before the staff nurse could return to Carol's room, the senior trauma resident appeared at the bedside and started questioning me. He examined Carol while I slipped out to get her nurse who told me she would "be there as soon as she could."
Awkwardly, I waited with Carol's mother as the resident considered Carol. He wondered aloud why she hadn't gone down to the OR earlier as scheduled. I reminded him of the fever and as he listened to her lungs, I casually pointed out the petechiae, which was more diffuse across her chest now.
The resident was suddenly abrupt and to the point, it seemed he'd slapped the last piece into a puzzle. “She’s thrown a fat embolus from her fractured femur--get her to ICU stat.” Then he turned on his heel and was gone before I could say a word.
I had enough of the classroom experience in nursing to fear a pulmonary embolism (a tiny blood clot that lodges in the lungs), but I didn't have a great deal of insight into the prognosis and treatment for a fat embolus. The hours that Carol's condition had progressed undetected were haunting me. Right away I knew that Carol needed her nurse, and I needed my instructor.
It took some time to find Carol’s nurse and convince her that the resident wanted her patient transferred to ICU. She made the requisite phone calls to confirm the orders and set the wheels in motion so that the ICU would assign Carol a bed. Meanwhile, Carol's chart was nowhere to be found. It was misplaced somewhere on the surgical floor. I nervously looked for the chart while the nurse arranged for Carol's transfer.
My instructor, aware of the unfolding drama, gave me a brief suggestion, "Just help where you can with the transfer."
Carol's mother, numb with worry, was making phone calls to advise her family members of this turn of events. A sense of urgency was consuming me as I returned to Carol’s room. Carol's nurse was still on the phone making arrangements for the transfer. Suddenly the resident reappeared and scolded me. “This patient should have been in ICU already! Get her there now!!”
But no such luck . . . The nursing unit had their own procedures to follow. They set about taking a complete set of vital signs, "It's required that we do so before transferring a patient."
The nurse's aide who was trying to check Carol's blood pressure was having a hard time because, "This machine can't be right, her pressure's way too low." She went to search for a manual blood pressure cuff that affirmed the hypotensive state of the patient.
Carol’s nurse returned with a respiratory therapist who placed a pulse oximeter on Carol's cool, pale finger and advised, “She needs oxygen, her oxygen saturation is only 65%!” Her saturation should have been at least 92. The oxygen set-up for transport through the hospital to the ICU floor would have to wait for a few minutes while someone went looking for the missing key to the metal portable oxygen cylinder. The precious moments SLOWLY passed as these tasks to make Carol ready for transfer were completed.
I felt useless as the evening nurse and an aide prepared the bed for transport. “What can I do to help?” I pleaded.
“You can carry the patient’s bag of belongings and make sure not to bring her flowers, she can't have them in ICU,” the staff involved in this whole situation seemed snappy and angry. I thought it was a waste of brain cells for the nurse in charge to even think about the flowers under the circumstances. In retrospect, I'm sure I was sensing the staff's anxiety and concern, and I have to believe they all shared my frustration with the obstacles that slowed the transfer to what seemed like a crawl.
My neck flushed as we awkwardly maneuvered the Carol's bulky hospital bed into the hall and then, after all the delays, ironically took off running for the elevator leading to the intensive care unit. There wasn't enough room for all of us on the elevator. Carol's mother and I rode together on an adjacent elevator.
The small ICU waiting room was overflowing with visitors waiting to be allowed in to see other patients. I said farewell to Carol's mother and urged her to call her ex-husband to let him know what was happening.
I'd never before been through the sliding doors that isolated the large intensive care unit from the rest of the hospital. No matter, I found Carol’s room easily. Nearly every nurse in the ICU was at her bedside, hooking up monitors, taking vital signs, putting in an additional IV, preparing suction, and hanging fluids. I could see the resident doctor with his interns assembling supplies. In a few minutes time Carol would have a tube in her trachea that allowed a mechanical ventilator to breathe for her.
I layed down Carol's bag of belongings lingered in the background for a few minutes. Clearly Carol was in good hands, these nurses were calm and in control of the situation.
Suddenly my shift was over--it was time to meet my instructor and the rest of the clinical group before going home. But I was sad and miserable. I went beyond my required textbook reading that night. Fat emboli and acute respiratory distress syndrome (ARDS) consumed my thoughts. I grieved for Carol's mother and lamented that I hadn't known enough to help expedite her care that evening.
Two days later as I skimmed the morning paper, I was shocked--but not surprised--to see Carol’s photograph smiling brightly from the obituary column. I cut that little clipping out of the newspaper and pasted it into my tiny notebook of nursing tips. To this day I still carry that notebook in my nursing work bag. I guess Carol's legacy has been with me every day that I've worked as a nurse, now that I think of it.
Technically, Carol was never "really" my patient. No medication cards, flow sheets, or care plan followed me to her room that evening and my education and experience to that point certainly didn't prepare me for the gravity of her situation. Of course, ironically, it was the deepest and most vivid clinical situation I experienced as a student. I always recognized that I contributed little, but benefited much from this experience. Many of the lessons learned are so obvious that they don't bear repeating.
An obvious lesson that does bear repeating, on the other hand: never assume nor underestimate any patient's baseline mental capacity. Good communication with a responsible party who can provide definite information on a patient's usual abilities is absolutely vital so that care is not compromised or delayed in the event of important neurological changes. That's Carol's legacy to me.
All rights reserved 2009 Carolyn Cooper MPH RN
. . . . ,
“Your patient is being discharged,” my nursing instructor informed me as we started our clinical rotation on a medical/surgical floor in my first year of nursing school.
"Oh, just great," I thought to myself. I had spent hours learning about and planning the proper care for "my patient" who had recently suffered a basilar skull fracture. My sheaf of clinical documents, medication lists, and a large pathophysiology flow sheet, were now suddenly made obsolete by my patient's imminent departure to a rehabilitation facility.
“He’ll still be here for a couple of hours. We’ll find you another patient later,” she assured me.
I was relieved that my painstakingly-crafted flow sheet, care plan, and medication cards wouldn’t go to waste. Although I only had one patient, the preparation required for the clinical day was nevertheless tedious and often proved exhausting in addition to other demands of family, school, and life in general. Still, as a new nursing student with little experience in the healthcare setting, the advance preparation gave me confidence that I would know what to do for my assigned patient. I decided not to fret about it, and simply hoped I'd be able to cope with whatever came my way in the shift ahead.
Our group of 10 nursing students and our instructor assembled at the nursing desk waiting for the nurses going off duty to give change of shift report to the group coming on. We were working second shift, 3 pm to 11 pm that day. Each week we spent three days attending lectures at our nursing college and two days working in the hospital to practice the hands-on-nursing skills and put into practice what we learned in class. There was always a sense of heightened anxiety on our hospital days, particularly in the chaotic environment of our very large county hospital. This was a trauma center and the busiest hospital on the U.S. side of the Mexican border. It was also a teaching hospital, with a slew of resident doctors and interns managing most of the patient care.
“The patient in 410 has a fever of 101.5!” a nursing assistant called out as she passed the nurses’ station where the harried day-shift nurse was “reporting off” to the oncoming "real" evening nurse and our huddle of nursing students.
The nurse going off shift sighed, “I’ll call the doctor—the girl in 410 just transferred here from the pediatric floor a half-hour ago. She’s supposed to go to the OR for surgery, an ORIF of the femur, as soon as her mom gets here to sign the consent.” The RN turned to our instructor, “It would help me out if one of your students could give her an acetaminophen suppository for the fever.”
Although none of our group was assigned to care for this new arrival to the surgical floor, we were always ready to perform a clinical skill to check off our list. Therefore, an entourage of three students and our instructor entered room 410 where 18-year-old Carol, afflicted with Down's Syndrome and a fractured femur, would prove to teach me more than any other patient that day.
Carol had been struck by a car as she crossed a busy street the day before. The fractured leg was her only known injury. She appeared to be sleeping deeply, with regular, but deep and fast respirations. Her eyelids fluttered as I explained that we needed to give her a suppository. Working together, we students gently repositioned her, mindful of the Buck's traction supporting her injured leg. A slight groan was Carol’s only acknowledgement as we cleaned her bottom (she had been incontinent with a bowel movement), before I inserted the suppository. Our instructor pointed out scattered petechiae on Carol's chest as we snapped a fresh gown across her hot skin and turned her to replace the soiled linen on her bed with clean sheets.
“These petechiae are probably the result of the trauma from her car accident,” our instructor explained, as she gestured towards the splash of flat pink spots that looked to me like tiny red freckles.
Back at the nurses' station our little group reassembled to continue shift report. We told the nurse about our interventions and reported Carol's limited response to our actions.
“They gave her an injection of Demerol before she was transferred from the pediatric unit," the nurse mused, "And we don’t know her baseline mental status, she has Down's, and for all we know she could be profoundly retarded.”
I was absorbed in my clinical experience for a few hours. The care for my basilar skull fracture patient proved to be very minimal. One of our nursing students needed a helping hand with a very complicated dressing change for a young man who had lost a leg in while trying to jump aboard a moving train. And I was pleased to learn that another patient needed a new intravenous needle placed. I was lucky enough to get the chance to do the venipuncture. I suspect that I caused that patient a great deal of pain with my novice attempt, but with a seasoned nurse over my shoulder talking me through it, the result was satisfactory. I kept busy in this way helping the staff nurses and other nursing students with their tasks until my patient was officially discharged. My instructor disappointed me then by suggesting that I return to Carol and follow up on her care. It seemed a puzzling assignment to me, I knew there were no meds to pass, IV's to start or dressings to change in that room--and I was here to learn nursing . . .
In Carol’s room I found that her mother had arrived from out-of-state. She was regarding her daughter pensively.
“She won’t wake up,” she complained.
I repeated the explanation that the nurse had given us in report earlier, that Carol had been medicated with Demerol.
“When did they give that? And how long will it last? Something’s just not right,” she continued.
Her questions were good ones. I set out to find the "real" nurse to explain the mother's concerns, but the nurse arrived at that moment with a syringe in hand to give Carol another intramuscular injection of Demerol for her pain. The busy nurse briefly attempted to reassure Carol's mother before rushing back to care for her other nine patients.
As I continued to converse with Carol’s worried mother, I became uneasy. She described a high-functioning independent young woman who lived in a group home while attending a vocational educational program in the city. Demerol or not, the Carol we were observing didn't fit the girl her mother described.
Carol occasionally writhed and moaned, seeming to struggle to wake as her mother tried to arouse her. Her breathing was audibly harsh with a frequent moist cough. The family doctor was alarmed at her appearance when he made informal rounds to check on Carol. He wasn't in charge of her hospital care which was in the hands of the attending physicians who were on staff at this hospital, but he asked that the chief trauma resident be called to see her right away.
Before the staff nurse could return to Carol's room, the senior trauma resident appeared at the bedside and started questioning me. He examined Carol while I slipped out to get her nurse who told me she would "be there as soon as she could."
Awkwardly, I waited with Carol's mother as the resident considered Carol. He wondered aloud why she hadn't gone down to the OR earlier as scheduled. I reminded him of the fever and as he listened to her lungs, I casually pointed out the petechiae, which was more diffuse across her chest now.
The resident was suddenly abrupt and to the point, it seemed he'd slapped the last piece into a puzzle. “She’s thrown a fat embolus from her fractured femur--get her to ICU stat.” Then he turned on his heel and was gone before I could say a word.
I had enough of the classroom experience in nursing to fear a pulmonary embolism (a tiny blood clot that lodges in the lungs), but I didn't have a great deal of insight into the prognosis and treatment for a fat embolus. The hours that Carol's condition had progressed undetected were haunting me. Right away I knew that Carol needed her nurse, and I needed my instructor.
It took some time to find Carol’s nurse and convince her that the resident wanted her patient transferred to ICU. She made the requisite phone calls to confirm the orders and set the wheels in motion so that the ICU would assign Carol a bed. Meanwhile, Carol's chart was nowhere to be found. It was misplaced somewhere on the surgical floor. I nervously looked for the chart while the nurse arranged for Carol's transfer.
My instructor, aware of the unfolding drama, gave me a brief suggestion, "Just help where you can with the transfer."
Carol's mother, numb with worry, was making phone calls to advise her family members of this turn of events. A sense of urgency was consuming me as I returned to Carol’s room. Carol's nurse was still on the phone making arrangements for the transfer. Suddenly the resident reappeared and scolded me. “This patient should have been in ICU already! Get her there now!!”
But no such luck . . . The nursing unit had their own procedures to follow. They set about taking a complete set of vital signs, "It's required that we do so before transferring a patient."
The nurse's aide who was trying to check Carol's blood pressure was having a hard time because, "This machine can't be right, her pressure's way too low." She went to search for a manual blood pressure cuff that affirmed the hypotensive state of the patient.
Carol’s nurse returned with a respiratory therapist who placed a pulse oximeter on Carol's cool, pale finger and advised, “She needs oxygen, her oxygen saturation is only 65%!” Her saturation should have been at least 92. The oxygen set-up for transport through the hospital to the ICU floor would have to wait for a few minutes while someone went looking for the missing key to the metal portable oxygen cylinder. The precious moments SLOWLY passed as these tasks to make Carol ready for transfer were completed.
I felt useless as the evening nurse and an aide prepared the bed for transport. “What can I do to help?” I pleaded.
“You can carry the patient’s bag of belongings and make sure not to bring her flowers, she can't have them in ICU,” the staff involved in this whole situation seemed snappy and angry. I thought it was a waste of brain cells for the nurse in charge to even think about the flowers under the circumstances. In retrospect, I'm sure I was sensing the staff's anxiety and concern, and I have to believe they all shared my frustration with the obstacles that slowed the transfer to what seemed like a crawl.
My neck flushed as we awkwardly maneuvered the Carol's bulky hospital bed into the hall and then, after all the delays, ironically took off running for the elevator leading to the intensive care unit. There wasn't enough room for all of us on the elevator. Carol's mother and I rode together on an adjacent elevator.
The small ICU waiting room was overflowing with visitors waiting to be allowed in to see other patients. I said farewell to Carol's mother and urged her to call her ex-husband to let him know what was happening.
I'd never before been through the sliding doors that isolated the large intensive care unit from the rest of the hospital. No matter, I found Carol’s room easily. Nearly every nurse in the ICU was at her bedside, hooking up monitors, taking vital signs, putting in an additional IV, preparing suction, and hanging fluids. I could see the resident doctor with his interns assembling supplies. In a few minutes time Carol would have a tube in her trachea that allowed a mechanical ventilator to breathe for her.
I layed down Carol's bag of belongings lingered in the background for a few minutes. Clearly Carol was in good hands, these nurses were calm and in control of the situation.
Suddenly my shift was over--it was time to meet my instructor and the rest of the clinical group before going home. But I was sad and miserable. I went beyond my required textbook reading that night. Fat emboli and acute respiratory distress syndrome (ARDS) consumed my thoughts. I grieved for Carol's mother and lamented that I hadn't known enough to help expedite her care that evening.
Two days later as I skimmed the morning paper, I was shocked--but not surprised--to see Carol’s photograph smiling brightly from the obituary column. I cut that little clipping out of the newspaper and pasted it into my tiny notebook of nursing tips. To this day I still carry that notebook in my nursing work bag. I guess Carol's legacy has been with me every day that I've worked as a nurse, now that I think of it.
Technically, Carol was never "really" my patient. No medication cards, flow sheets, or care plan followed me to her room that evening and my education and experience to that point certainly didn't prepare me for the gravity of her situation. Of course, ironically, it was the deepest and most vivid clinical situation I experienced as a student. I always recognized that I contributed little, but benefited much from this experience. Many of the lessons learned are so obvious that they don't bear repeating.
An obvious lesson that does bear repeating, on the other hand: never assume nor underestimate any patient's baseline mental capacity. Good communication with a responsible party who can provide definite information on a patient's usual abilities is absolutely vital so that care is not compromised or delayed in the event of important neurological changes. That's Carol's legacy to me.
All rights reserved 2009 Carolyn Cooper MPH RN
. . . . ,
DVT, Blood Clot, Deep Vein Thrombosis
Preventing a DVT is certainly much easier than curing the condition. In hospitalized patients several methods are used to enhance the flow of blood to the lower legs. First and foremost, being up and around as soon as possible, and as much as possible after surgery or while recovering from an illness is a major advantage in increasing venous flow and decreasing the chance of clots forming. Tight white compression stockings (TED hose) may be prescribed depending on the level of risk for the specific patient (see below). Mechanical "pumps" squeeze the lower legs at regular intervals in another means of prevention. For patients at the highest risk of DVT, blood thinning medication is injected daily under the skin of the abdomen.
Greater Risk of Clots for Some Patients
DVT (Deep Vein Thrombosis) can occur in almost anyone. However, certain individuals may be at increased risk for developing a DVT. Risk factors include but are not limited to:
- Recent surgical procedure (and greater chance of a DVT with a long, intense surgery and joint replacement surgeries)
- Restricted mobility from bedrest, paralysis, traveling for many hours without taking a break to walk around
- Active Cancer
- Congestive Heart Failure (CHF)--if you take "water pills" and are not sure why--ask your doctor if you have CHF
- Age greater than 40 years old
- Pregnancy and the postpartum period (6-8 weeks after delivery)
- Injury to the leg or the deep veins of the leg
- Smoking
- Use of certain medications such as birth control pills and estrogen
- Dehydration
- Polycythemia
- Obesity
- Current smoker
- Past history of having a blood clot or an inherited family tendency to develop blood clots
Check out their website to learn more about DVT and related conditions such as:
- Post Thrombotic Syndrome (PTS) After a DVT is treated and resolved, this chronic condition may result in up to 40% of all individuals. It's the result of damage done by the clot to the valves that move blood through the vein.
- Pulmonary Embolis (PE) Blood clots in the smallest vessels of the lungs.
- Thrombophila Blood that clots too easily. Hypercoagulability is another word used to describe this condition which can be inherited.
- Chronic Venous Insufficiency results when the valves in the veins that move blood don't function properly, often occurs from injury to veins caused by a DVT, from varicose veins, or as the result of an inherited condition.
The Vascular Disease Foundation has a variety of full-color brochures available for download including a great pamphlet called "Focus on Clots." (This publication was previously called "Spot a Clot," but otherwise it's the exact same informational card.)
You may also request a copy of these brochures by calling toll free: 1-888-833-4463.
- Vitamin K and Warfarin (Coumadin): http://www.nattinfo.org/documents/KandWarfarin(Web).pdf
- Family Testing for Clotting Disorders http://www.nattinfo.org/fam-test.pdf
- Sanofi-Aventis (makers of the blood thinner Lovenox) provides tips about DVT's, Risk Factors for DVTs, and includes a risk assessment tool.
A plus: Deep vein thrombosis article from eMEDtv.com
eMedTV.com has many wonderful patient education videos.
Here's a two-minute presentation that explains how unwanted blood clots occur in the vein and why they are dangerous from the: Heart Disease Health Channel on eMedTV.com
Provided by the
. . .
Tuesday, November 24, 2009
Another Black Box: Aranesp, Epogen, Procrit, What you should know about drugs that tell your body to make more red blood cells
Erythropoiesis Stimulating Agents (ESAs) tell your body to make more red blood cells. Drugs in this class include:
• Aranesp (darbopoetin alfa)
• Epogen (epoetin alfa)
• Procrit (epoetin alfa)
• There are other brand names & epoetin variants marketed worldwide
The Good News First . . .
Twenty years ago we didn’t have synthetic medications to treat anemia. Depending on the cause anemia was often treated through diet, by administering supplementary iron or vitamin B12, and frequently, by blood transfusions. The 1980's was a decade of concern over the safety of our blood supply due to blood borne pathogens such as Hepatitis B and C and the HIV virus. New technologies in recombinant DNA allowed science to explore and develop innovative alternative therapies.
In 1989, Epogen (epoetin alfa), the first of a class of drugs called erythropoiesis stimulating agents (abbreviated as “ESAs”), was approved by the FDA in the United States to treat patients suffering from anemia due to chronic kidney disease. Epogen was eventually joined by similar ESAs called Aranesp and Procrit and treatment was eventually broadened to include patients suffering from anemia related to chemotherapy.
The benefit to both groups was that they no longer needed to rely on frequent blood transfusions to treat their anemia. ESAs directly influence the body to speed up the production of its own red blood cells by introducing a synthetic version of the hormone erythropoietin. Erythropoietin is a chemical messenger of sorts with the specific mission of instructing our bone marrow to produce more red blood cells. Epogen, Aransep, and Procrit are easily given by a simple injection under the skin from one to three times per week.
So what exactly is anemia? Anemia results when we don’t have enough healthy red blood cells called erythrocytes circulating in our bloodstream. Healthy red blood cells are vital; they carry a protein called hemoglobin which picks up molecules of oxygen from our lungs and delivers it to the tissues throughout our body. We don’t store oxygen in our body but we use it continuously, and our body’s demand for oxygen is constant as oxygen molecules literally fuel every basic function that each cell in our body must perform.
Symptoms of Anemia. Moderate to severe anemia can cause symptoms of weakness, fatigue, shortness of breath, rapid/irregular heartbeat and pale skin. Milder or chronic anemia may cause subtle symptoms or no symptoms at all.
Erythropoietin. This hormone is a chemical messenger with several functions relating to the manufacture of red blood cells, preserving their lifespan in the body, and enhancing the growth of blood vessels. As we develop before birth, erythropoietin is active within our livers. After we are born, erythropoietin is manufactured and released by cells in the kidney.
Kidneys and Anemia. People often don’t think of a relationship between the kidneys and anemia, but when you carefully consider it, it makes sense for the kidney to have this function. Like a waste-water treatment plant adds chemicals based on the scientific observations of the plant technicians, the kidneys have specialized cells that detect decreased oxygen levels in the blood circulating through them, and as a result, these specialized cells release erythropoietin to enhance red blood cell formation and longevity. If the kidneys become diseased and fail, this system of checks and balances is impaired or lost. When ESAs, or synthetic erythropoietin, was first introduced in 1989, the drug was intended specifically for the benefit of patients in kidney failure.
Chemotherapy and Anemia. Cancer cells are bizarre mutant cells that divide rapidly. therefore, malignant tumors can grow large very quickly. The goal of chemotherapy is to target those rapidly-dividing bizarre cells and kill them. Other “good” rapidly-dividing cells in our body get caught in the cross-fire and are also damaged by chemo drugs. Hair is lost when rapidly-dividing cells in the roots are targeted by the chemo drugs. Other fast-growing cells affected by chemotherapy are in the digestive tract; that’s why mouth sores, nausea, and vomiting are a common consequence of chemo. The body’s rapidly dividing blood cells (red cells, white cells, and platelets) are also among the good cells that fall prey to chemotherapy. The anemia that results from chemotherapy is not caused by a lack of erythropoietin, but ESAs were approved by the FDA in 1993 to treat anemia to reduce the amount of blood transfusions necessary for patients suffering from chemotherapy-induced anemia.
Sobering News about ESAs . . .
All medications have both benefits and risks. In the U.S. the FDA places "black box warnings" on the medication labels and inserts of drugs when research suggests there is a risk of serious adverse effects. The first black box warning for ESAs appeared in March of 2007. Eight months later in November 2007, the black box warning was emphatically strengthened by the FDA.
Both the chronic renal failure and chemotherapy patients were found to have some increased risks when using ESAs. Patients with certain types of cancer were found to be at risks of tumor progression and decreased survival when taking ESAs to increase red blood cell production. Chronic renal failure patients were found to be at increased risk of developing heart attack, stroke, blood clots, heart failure and death if their ESA dose was high enough to cause them to make more than recommended number of red blood cells.
The FDA’s guidance to physicians was very specific on the recommended dosage to achieve good results without increasing patients’ risks for a bad outcome. Further, their guidance suggested that physicians specifically discuss the risks and benefits of these medications with their patients.
What’s Inside the Black Box . . . guidance for physicians about prescribing:
For patients with cancer: ESAs should only be used to treat anemia caused by chemotherapy—not to treat anemia from any other cause. After chemotherapy is finished, ESAs should no longer be used. Risks of tumor progression and decreased survival were noted in some clinical trials. The FDA strongly recommends that healthcare professionals discuss these risks with their patients before this therapy is started.
For anemic patients with chronic renal failure: Treat with the lowest level of the drug which will maintain hemoglobin levels within the target range of less than 12 g/dL. The established goal for this group is to maintain hemoglobin between 10-12 g/dL, because the risk for death and serious cardiovascular events increases when higher hemoglobin levels are achieved on ESA therapy. Further, it’s recommended that ESA therapy be discontinued if the patient’s hemoglobin levels remain so low that blood transfusions are still required.
What the FDA recommends for physicians and other healthcare professionals to discuss with their patients:
1. The primary goal of treatment with erythropoiesis stimulating agents (ESA) is to increase the number of red blood cells in order to avoid receiving blood transfusions.
2. These medications require at least two weeks of treatment before there is an increase in the number of red blood cells, and the dose may be adjusted periodically, but not more often than every four weeks.
3. ESAs increase the patient’s chance of blood clots and the risk of dying may be greater in certain circumstances.
4. Patients should keep appointments for blood tests so hemoglobin levels can be monitored.
5. Patients should monitor their blood pressure and call their healthcare provider for changes outside of the range that has been established for them.
6. Call the healthcare provider if they experience any of the following symptoms:
What the FDA wants patients to know about treatment with Aranesp, Epogen and Procrit . . .
Patients with cancer who are currently using or considering the use of an ESA should know the following:
• ESAs may shorten your survival time or may cause your tumors to grow faster.
• ESAs should only be used to treat anemia caused by chemotherapy and not other anemia from other causes in patients with cancer
• ESAs should not be used to treat the symptoms of anemia, such as fatigue or improve the quality of life in patients with cancer. The goal of treatment with ESAs is to avoid blood transfusions
• Treatment with an ESA should be stopped after you complete your course of chemotherapy.
Patients with chronic kidney failure (this includes both patients on dialysis and those not on dialysis) who are currently using an ESA should know the following:
• Your hemoglobin level should be checked regularly to make sure it stays between 10 and 12 g/dL.
• ESAs can increase your chance of heart attack, stroke, blood clots, heart failure, and death when they are given to maintain higher hemoglobin levels.
• If you are not responding to treatment with an ESA (your hemoglobin levels are not increasing) ask your doctor if you need to be checked for other causes of anemia.
Report Adverse Reactions to the FDA: Healthcare professionals are to report adverse and unexpected reactions with these meds to the FDA MedWatch reporting program online or by phone: 1-800-332-1088.
Links to more information about ESAs:
• Comprehensive information about ESAs from the U.S. Centers for Medicaid and Medicare Services: www.cms.hhs.gov/determinationprocess/downloads/id203d.pdf
• Kidney Disease and Anemia: http://kidney.niddk.nih.gov/kudiseases/pubs/anemia/
• Anemia and Kidney Disease: http://www.aakp.org/aakp-library/Anemia-in-Chronic-Kidney-Disease/
• A plus: Anemia and Kidney Disease from Anemia.org: http://www.anemia.org/patients/information-handouts/kidney-disease/
• ESA use for anemia in cancer patients: http://www.medscape.com/viewarticle/571464
.(All rights reserved, Carolyn Cooper, MPH, RN, 2009) .. . .
• Aranesp (darbopoetin alfa)
• Epogen (epoetin alfa)
• Procrit (epoetin alfa)
• There are other brand names & epoetin variants marketed worldwide
The Good News First . . .
Twenty years ago we didn’t have synthetic medications to treat anemia. Depending on the cause anemia was often treated through diet, by administering supplementary iron or vitamin B12, and frequently, by blood transfusions. The 1980's was a decade of concern over the safety of our blood supply due to blood borne pathogens such as Hepatitis B and C and the HIV virus. New technologies in recombinant DNA allowed science to explore and develop innovative alternative therapies.
In 1989, Epogen (epoetin alfa), the first of a class of drugs called erythropoiesis stimulating agents (abbreviated as “ESAs”), was approved by the FDA in the United States to treat patients suffering from anemia due to chronic kidney disease. Epogen was eventually joined by similar ESAs called Aranesp and Procrit and treatment was eventually broadened to include patients suffering from anemia related to chemotherapy.
The benefit to both groups was that they no longer needed to rely on frequent blood transfusions to treat their anemia. ESAs directly influence the body to speed up the production of its own red blood cells by introducing a synthetic version of the hormone erythropoietin. Erythropoietin is a chemical messenger of sorts with the specific mission of instructing our bone marrow to produce more red blood cells. Epogen, Aransep, and Procrit are easily given by a simple injection under the skin from one to three times per week.
So what exactly is anemia? Anemia results when we don’t have enough healthy red blood cells called erythrocytes circulating in our bloodstream. Healthy red blood cells are vital; they carry a protein called hemoglobin which picks up molecules of oxygen from our lungs and delivers it to the tissues throughout our body. We don’t store oxygen in our body but we use it continuously, and our body’s demand for oxygen is constant as oxygen molecules literally fuel every basic function that each cell in our body must perform.
Symptoms of Anemia. Moderate to severe anemia can cause symptoms of weakness, fatigue, shortness of breath, rapid/irregular heartbeat and pale skin. Milder or chronic anemia may cause subtle symptoms or no symptoms at all.
Erythropoietin. This hormone is a chemical messenger with several functions relating to the manufacture of red blood cells, preserving their lifespan in the body, and enhancing the growth of blood vessels. As we develop before birth, erythropoietin is active within our livers. After we are born, erythropoietin is manufactured and released by cells in the kidney.
Kidneys and Anemia. People often don’t think of a relationship between the kidneys and anemia, but when you carefully consider it, it makes sense for the kidney to have this function. Like a waste-water treatment plant adds chemicals based on the scientific observations of the plant technicians, the kidneys have specialized cells that detect decreased oxygen levels in the blood circulating through them, and as a result, these specialized cells release erythropoietin to enhance red blood cell formation and longevity. If the kidneys become diseased and fail, this system of checks and balances is impaired or lost. When ESAs, or synthetic erythropoietin, was first introduced in 1989, the drug was intended specifically for the benefit of patients in kidney failure.
Chemotherapy and Anemia. Cancer cells are bizarre mutant cells that divide rapidly. therefore, malignant tumors can grow large very quickly. The goal of chemotherapy is to target those rapidly-dividing bizarre cells and kill them. Other “good” rapidly-dividing cells in our body get caught in the cross-fire and are also damaged by chemo drugs. Hair is lost when rapidly-dividing cells in the roots are targeted by the chemo drugs. Other fast-growing cells affected by chemotherapy are in the digestive tract; that’s why mouth sores, nausea, and vomiting are a common consequence of chemo. The body’s rapidly dividing blood cells (red cells, white cells, and platelets) are also among the good cells that fall prey to chemotherapy. The anemia that results from chemotherapy is not caused by a lack of erythropoietin, but ESAs were approved by the FDA in 1993 to treat anemia to reduce the amount of blood transfusions necessary for patients suffering from chemotherapy-induced anemia.
Sobering News about ESAs . . .
All medications have both benefits and risks. In the U.S. the FDA places "black box warnings" on the medication labels and inserts of drugs when research suggests there is a risk of serious adverse effects. The first black box warning for ESAs appeared in March of 2007. Eight months later in November 2007, the black box warning was emphatically strengthened by the FDA.
Both the chronic renal failure and chemotherapy patients were found to have some increased risks when using ESAs. Patients with certain types of cancer were found to be at risks of tumor progression and decreased survival when taking ESAs to increase red blood cell production. Chronic renal failure patients were found to be at increased risk of developing heart attack, stroke, blood clots, heart failure and death if their ESA dose was high enough to cause them to make more than recommended number of red blood cells.
The FDA’s guidance to physicians was very specific on the recommended dosage to achieve good results without increasing patients’ risks for a bad outcome. Further, their guidance suggested that physicians specifically discuss the risks and benefits of these medications with their patients.
What’s Inside the Black Box . . . guidance for physicians about prescribing:
For patients with cancer: ESAs should only be used to treat anemia caused by chemotherapy—not to treat anemia from any other cause. After chemotherapy is finished, ESAs should no longer be used. Risks of tumor progression and decreased survival were noted in some clinical trials. The FDA strongly recommends that healthcare professionals discuss these risks with their patients before this therapy is started.
For anemic patients with chronic renal failure: Treat with the lowest level of the drug which will maintain hemoglobin levels within the target range of less than 12 g/dL. The established goal for this group is to maintain hemoglobin between 10-12 g/dL, because the risk for death and serious cardiovascular events increases when higher hemoglobin levels are achieved on ESA therapy. Further, it’s recommended that ESA therapy be discontinued if the patient’s hemoglobin levels remain so low that blood transfusions are still required.
What the FDA recommends for physicians and other healthcare professionals to discuss with their patients:
1. The primary goal of treatment with erythropoiesis stimulating agents (ESA) is to increase the number of red blood cells in order to avoid receiving blood transfusions.
2. These medications require at least two weeks of treatment before there is an increase in the number of red blood cells, and the dose may be adjusted periodically, but not more often than every four weeks.
3. ESAs increase the patient’s chance of blood clots and the risk of dying may be greater in certain circumstances.
4. Patients should keep appointments for blood tests so hemoglobin levels can be monitored.
5. Patients should monitor their blood pressure and call their healthcare provider for changes outside of the range that has been established for them.
6. Call the healthcare provider if they experience any of the following symptoms:
- Pain and/or swelling in the legs
- Worsening in shortness of breath
- Increases in blood pressure
- Dizziness or loss of consciousness
- Extreme tiredness
- Blood clots in hemodialysis vascular access ports
What the FDA wants patients to know about treatment with Aranesp, Epogen and Procrit . . .
Patients with cancer who are currently using or considering the use of an ESA should know the following:
• ESAs may shorten your survival time or may cause your tumors to grow faster.
• ESAs should only be used to treat anemia caused by chemotherapy and not other anemia from other causes in patients with cancer
• ESAs should not be used to treat the symptoms of anemia, such as fatigue or improve the quality of life in patients with cancer. The goal of treatment with ESAs is to avoid blood transfusions
• Treatment with an ESA should be stopped after you complete your course of chemotherapy.
Patients with chronic kidney failure (this includes both patients on dialysis and those not on dialysis) who are currently using an ESA should know the following:
• Your hemoglobin level should be checked regularly to make sure it stays between 10 and 12 g/dL.
• ESAs can increase your chance of heart attack, stroke, blood clots, heart failure, and death when they are given to maintain higher hemoglobin levels.
• If you are not responding to treatment with an ESA (your hemoglobin levels are not increasing) ask your doctor if you need to be checked for other causes of anemia.
Report Adverse Reactions to the FDA: Healthcare professionals are to report adverse and unexpected reactions with these meds to the FDA MedWatch reporting program online or by phone: 1-800-332-1088.
Links to more information about ESAs:
• Comprehensive information about ESAs from the U.S. Centers for Medicaid and Medicare Services: www.cms.hhs.gov/determinationprocess/downloads/id203d.pdf
• Kidney Disease and Anemia: http://kidney.niddk.nih.gov/kudiseases/pubs/anemia/
• Anemia and Kidney Disease: http://www.aakp.org/aakp-library/Anemia-in-Chronic-Kidney-Disease/
• A plus: Anemia and Kidney Disease from Anemia.org: http://www.anemia.org/patients/information-handouts/kidney-disease/
• ESA use for anemia in cancer patients: http://www.medscape.com/viewarticle/571464
.(All rights reserved, Carolyn Cooper, MPH, RN, 2009) .. . .
Thursday, November 12, 2009
How to Take Care of Your JP Drain at Home (Jackson-Pratt Surgical Drain)
It's not unusual to be sent home from the hospital after surgery with a surgical drain still in place. Typically a nurse will have taught you (or your loved one, if you’re squeamish) how to take care of the drain at home and they probably gave you some paperwork with instructions. Sometimes, however, such teaching is given after surgery when the patient is groggy or in pain and family members are tired and ready to just get on the road towards home. The instructions may get lost in the shuffle of paperwork you were handed at discharge. For this reason I wanted to make a blog entry that includes some basic information about the JP drain and includes links to patient education sheets from reputable physicians and hospitals.
The JP drain is a soft, pliable bulb drain that is either tunneled directly into a surgical incision, or more often into another smaller "stab" incision right next to the main incision. The purpose of the JP drain is to allow the large surgical incision to heal well by draining blood and thin serous material that can build up behind fresh incisions.
The bulb part of the JP drain is connected to the surgical incision by means of a long plastic tube that’s sutured in place on the skin where it enters the body. When the bulb is compressed (squeezed together), it provides constant suction that draws any accumulating fluids such as blood, pus, or other thin drainage from the incision, through the tube and into the bulb. On a regular basis (at least once a day), the fluid that is collected in the bulb is emptied by opening the small plug in the top and squeezing the fluid into a measuring cup. While the empty drain is still unplugged, the drain is squeezed together to remove as much air as possible so it is mostly “flattened.” Then the plug is recapped. The flattened bulb gently expands as it again slowly suctions fluid from the incision.
Keep Track of the Amount of Fluid . . .
The amount of fluid, date and time, and any ususual details about the fluid (color, thickness, clots, smell) is written on a paper for the doctor to review at your appointment, then the drainage is emptied into the toilet and flushed away. Keeping track of the amount of fluid emptied from the bulb is important. This information allows the physician to know if the wound is healing according to schedule . . . or if there are complications that require further attention such as an unusual amount of blood coming from the wound, a foul smell to the discharge, or an unusually large volume of fluid. When the drainage falls to a certain level, usually a few days after surgery, the drain is easily removed by a physician or nurse at the doctor's office.
I’m by no means an artist, but I’m including a couple of my own sketches here. The websites (at bottom) often include great drawings or photos of the drains and their care, but of course they have copyrights to their art and photos so I’ll give you just a basic idea.
Parts of the JP Drain
Drain reservoir bulb—about the size and shape of a large lemon or (in my mind) a hand-grenade. Made of soft flexible semi-transparent silicone with an attached drainage tube that is sutured into a slit on the body near the surgical incision. In order to collect drainage from the tubing, the bulb plug must be opened, air is squeezed out until the bulb appears mostly flat. While still squeezing the bulb flat, the plug is replaced. As the bulb fills with fluid, it may expand. The bulb is emptied at least daily or when full and the drainage is measured and recorded and reported to the physician.
Drain aperture—the hole with a plug, this is where you empty the drainage that is collected. It reminds me of a beach-ball plug and works exactly the same way.
Drain tubing—hollow tubing made of a soft semi-transparent silicone. It’s connected to the drain reservoir bulb. Sometimes the tubing may accumulate drainage that becomes a clot which blocks the drainage. This can be cleared by a gentle pinching motion of the tubing just above the clot, away from the body and towards the bulb, it is usually recommended to “milk” the tubing in this way when needed to keep it draining freely.
Surgeries that result in a drain . . .
. . . includes just about any that may result in a large incision, for example, breast surgery, thyroid operations, weight loss surgery, abdominal surgeries, and operations on the kidneys or bladder. There are other types of surgical drains as well, but the JP is one of the most common.
Keep the JP Drain from Pulling on the Incision
To keep the weight of the drain from pulling on the incision, a flap of tape is applied near the bulb. A safety pin is pinned through this tape flap and then pinned to the patients clothing in such a way as to take up the slack of the tubing. (If you have more than one drain, they will each be numbered for easy reference on the tape flap.) Be careful not to poke a hole through the tubing of your drain!
I don't seek advertising or any funding for my blogging, but I do point out commercial products that may be helpful to my readers. Here are two products that I came across created by patients in order to more comfortably manage their JP drains post-operatively.
About the Jackson-Pratt (JP) Drain . . .
The JP drain is a soft, pliable bulb drain that is either tunneled directly into a surgical incision, or more often into another smaller "stab" incision right next to the main incision. The purpose of the JP drain is to allow the large surgical incision to heal well by draining blood and thin serous material that can build up behind fresh incisions.
The bulb part of the JP drain is connected to the surgical incision by means of a long plastic tube that’s sutured in place on the skin where it enters the body. When the bulb is compressed (squeezed together), it provides constant suction that draws any accumulating fluids such as blood, pus, or other thin drainage from the incision, through the tube and into the bulb. On a regular basis (at least once a day), the fluid that is collected in the bulb is emptied by opening the small plug in the top and squeezing the fluid into a measuring cup. While the empty drain is still unplugged, the drain is squeezed together to remove as much air as possible so it is mostly “flattened.” Then the plug is recapped. The flattened bulb gently expands as it again slowly suctions fluid from the incision.
Keep Track of the Amount of Fluid . . .
The amount of fluid, date and time, and any ususual details about the fluid (color, thickness, clots, smell) is written on a paper for the doctor to review at your appointment, then the drainage is emptied into the toilet and flushed away. Keeping track of the amount of fluid emptied from the bulb is important. This information allows the physician to know if the wound is healing according to schedule . . . or if there are complications that require further attention such as an unusual amount of blood coming from the wound, a foul smell to the discharge, or an unusually large volume of fluid. When the drainage falls to a certain level, usually a few days after surgery, the drain is easily removed by a physician or nurse at the doctor's office.
I’m by no means an artist, but I’m including a couple of my own sketches here. The websites (at bottom) often include great drawings or photos of the drains and their care, but of course they have copyrights to their art and photos so I’ll give you just a basic idea.
Parts of the JP Drain
Drain aperture—the hole with a plug, this is where you empty the drainage that is collected. It reminds me of a beach-ball plug and works exactly the same way.
Drain tubing—hollow tubing made of a soft semi-transparent silicone. It’s connected to the drain reservoir bulb. Sometimes the tubing may accumulate drainage that becomes a clot which blocks the drainage. This can be cleared by a gentle pinching motion of the tubing just above the clot, away from the body and towards the bulb, it is usually recommended to “milk” the tubing in this way when needed to keep it draining freely.
Surgeries that result in a drain . . .
. . . includes just about any that may result in a large incision, for example, breast surgery, thyroid operations, weight loss surgery, abdominal surgeries, and operations on the kidneys or bladder. There are other types of surgical drains as well, but the JP is one of the most common.
Keep the JP Drain from Pulling on the Incision
To keep the weight of the drain from pulling on the incision, a flap of tape is applied near the bulb. A safety pin is pinned through this tape flap and then pinned to the patients clothing in such a way as to take up the slack of the tubing. (If you have more than one drain, they will each be numbered for easy reference on the tape flap.) Be careful not to poke a hole through the tubing of your drain!
I don't seek advertising or any funding for my blogging, but I do point out commercial products that may be helpful to my readers. Here are two products that I came across created by patients in order to more comfortably manage their JP drains post-operatively.
- Surgishorts is a unisex garment that has pockets specifically for the JP bulbs: http://www.surgishorts.com/.
- The drain pouch management gown is a unique hospital gown created with the post-op breast surgery patient in mind: Sage Solutions Drain Pouch Gown.
- National Institute of Health Patient Education: JP Drain (English) and in Spanish
- Breast Reconstructive Surgery.
- UCS Breast Center: JP Drains
- Jackson-Pratt Drain Care
- Health AtoZ: JP Drain pdf
- Carolina Breast Cancer Information
- Dr. Holmes MD Patient Resources
- Cheboygan Surgical
- UCS Drain Record Sheet
Youtube doesn't have many videos about care of the JP drain. I'm surprised. I did find two amateur videos posted there by breast cancer patients who are demonstrating emptying their JP drains at home. These brave ladies are doing a service by posting their experiences to help others. I applaud their willingness to do so and want to include links to their videos here. These are not professional videos, but they give you a glimpse of other people at home with their JP drains in real life:
- An amateur video in which Deborah demonstrates emptying and measuring the contents of her four surgical drains. Note: Deborah is wearing a brassiere, but does have some skin of her upper torso (not breasts) exposed. I know my blog readers come from all walks of life, so if exposed female flesh is offensive to you, this is not a video for you. I think it is interesting to see how the output of each of Deborah's drains varies slightly in amount, color, and consistency.
- Sylvia Soo demonstrates emptying of her two JP drains. This amateur video starts out SLOW and very playful, but if you hang in there for a few seconds, Sylvia comes on camera to show how she cares for her two drains. She does a good job of demonstrating “milking” the drain to remove clots and measuring the drain “output.” Sylvia is completely covered by clothing in this video, so not to worry if bare skin offends you.
. . . ..(All rights reserved, Carolyn Cooper, MPH, RN, 2009) . .
Monday, September 21, 2009
Menstruation Education and other Puberty Resources for Parents
Learning about Menstruation
In 1970 I was in the 5th grade. I vividly remember an afternoon in which all the girls in the class were given a mimeographed note for our mothers to sign and return giving permission for us to stay after school on a certain day to view a film about "menstruation." This was a term that I had never heard of. My classmates didn't have an explanation either, although one boy teased that HE knew what it was all about! We scoured our school dictionary to no avail.
At home, my mother signed the note without comment. She encouraged me to "look it up in the encyclopedia" when I tried to probe further into this mystery. The encyclopedia explanation baffled me, and the sketch of female reproductive organs was as abstract to my 10-year-old mind as a Rorschach inkblot.
Back at school some of the girls asserted that since "menstruation" started with the word "men-," we were going to learn something about boys. One dear little friend then confided some secrets she knew about sex which seemed impossible (but turned out to be true.)
The thirty (or so) 5th grade girls of Willitts Elementary gathered at the end of the day, sitting cross-legged on the cement basement floor of our dear old school. The classroom teachers were joined by the school nurse. Our principal disappeared after he had ensured that any lingering boys were absolutely gone from the campus.
Our film called, "It's Wonderful Being a Girl," featured Libby, a preteen who was learning about menstruation. (Watch it here if you like.) The film featured the Modess brand of menstrual sanitary napkins, understandable as they were products of the sponsor, Personal Products Corp. a division of Johnson & Johnson. It's common for makers of "feminine hygiene" products to offer such educational fare--offering an educational service as they advertise and make babysteps towards influencing brand loyalty. (It was obvously effective, in my case anyway, because I've vividly remembered this film for all of these 35-plus years.) After the film we were given the companion booklet with the (somewhat threatening?) title of, "Growing up and Liking it."
After the film the school nurse gamely lectured the assembled bewildered little girls. As it turned out, a few girls in the other class admitted some knowledge of this subject. Meanwhile, I was still confused and now rather frightened. Sometime later while visiting my friend Sandy, we raided her older sister's room and examined her sanitary napkins and belt--she would have killed us if she'd known. The subject of menstruation never came up again for perhaps a year or so. My mother one day showed me a "starter kit" she had purchased for me for the day I would need it. Ugh! When that day eventually came, I was scared and upset. Mom was at work and the box was in the closet of her room. I did cry a little bit while telling her about "what had happened" to me that afternoon. She gave me the box and a bit of reassurance and that was that.
Menstruation Resources . . .
Menstruation was never much of a topic of conversation in my life. I don't have a daughter and didn't anticipate having to explain menstruation to my son. But he was inquisitive when a 1999 episode of the animated series, "King of the Hill" featured Hank, the main character, awkwardly coping as his neighbor's daughter started her first menstrual period while her parents and his wife were away. Of course, an 8-year-old boy was satisfied with minimal information. I was surprised at the time to notice in myself the urge to be forthcoming coupled with a reluctance to be specific. I attributed it to the lack of discussion on such issues in my own life.
I decided I needed to prepare for more puberty talk to come so I did a bit of research and found a great book to help me explain the "need to know" issues in what was then the pre-internet era for my family. Now days there are all kinds of resources online to help educate girls and boys about menstruation and puberty. Again, many of these informational websites are sponsored by personal product manufacturers, but the approaches are subtle and not off-putting.
. . . from the Feminine Products Industry
Kimberly-Clark, the maker of Kotex, offers "My Daughter's Period," an informational web-based brochure that offers advice on when and what to discuss when talking with your girl about puberty. The Kotex website also includes "Girlspace," a sort of social networking application targeting puberty issues. For the girl or woman who really needs to plan ahead, check out this Kotex Period Planner so that you'll always be prepared.
Johnson & Johnson manufactures a number of different feminine “protection” products including O.B. tampons, Carefree panty shields, and Stayfree sanitary napkins. Their website is worth checking out and includes these notable educational offerings: an interactive website, "Teens for Teens" and for parents "A Guide to Handling Your Child's First Period."
Proctor & Gamble is the parent company of Tampax and Always. Not to be outdone by the competition, their website also boasts a Period Predictor. Most importantly their educational features include, "A Page for Mom" and Beinggirl.com, a website which provides age-appropriate information for pre-teens. The site includes an explanatory section called, "Your Period," which is good information, but I honestly feel it is written over the heads of girls at an age to learn about their first period. Fortunately there are better publications from P&G available for download, namely: "Always Changing" for boys concerning puberty and "Always Changing," for girls to explain menstruation. These booklets also serve as companion literature to Proctor & Gamble's, Always Changing school-based program.
Grade A Plus!!! For any inexperienced young girl, I truly feel this publication is the most exceptional: "Always Changing," Special Ed Version for Girls. Although this is aimed at special ed students, I think that the clear, basic explanations in this publication are very appropriate for tender young girls of age 9 and 10. I would also consider this a good choice in cases where English is a second language. Kudos to P&G on this publication.
. . . from Professional and Governmental Entities
Grade A Plus!!! Find a treasure-trove of vintage Feminine Products Company Booklets about Menstruation (some from as early as the 1920’s.) These booklets are available in their entirety on the Museum of Menstruation website.
My Little Red Book is a recently published anthology of women's stories from around the world discussing the circumstances surrounding their first menstrual periods.
See comments left below from Elizabeth Kissling of the Society for Menstrual Research. I look forward to checking out their website. Thank you Elizabeth!
. .. .
In 1970 I was in the 5th grade. I vividly remember an afternoon in which all the girls in the class were given a mimeographed note for our mothers to sign and return giving permission for us to stay after school on a certain day to view a film about "menstruation." This was a term that I had never heard of. My classmates didn't have an explanation either, although one boy teased that HE knew what it was all about! We scoured our school dictionary to no avail.
At home, my mother signed the note without comment. She encouraged me to "look it up in the encyclopedia" when I tried to probe further into this mystery. The encyclopedia explanation baffled me, and the sketch of female reproductive organs was as abstract to my 10-year-old mind as a Rorschach inkblot.
Back at school some of the girls asserted that since "menstruation" started with the word "men-," we were going to learn something about boys. One dear little friend then confided some secrets she knew about sex which seemed impossible (but turned out to be true.)
The thirty (or so) 5th grade girls of Willitts Elementary gathered at the end of the day, sitting cross-legged on the cement basement floor of our dear old school. The classroom teachers were joined by the school nurse. Our principal disappeared after he had ensured that any lingering boys were absolutely gone from the campus.
Our film called, "It's Wonderful Being a Girl," featured Libby, a preteen who was learning about menstruation. (Watch it here if you like.) The film featured the Modess brand of menstrual sanitary napkins, understandable as they were products of the sponsor, Personal Products Corp. a division of Johnson & Johnson. It's common for makers of "feminine hygiene" products to offer such educational fare--offering an educational service as they advertise and make babysteps towards influencing brand loyalty. (It was obvously effective, in my case anyway, because I've vividly remembered this film for all of these 35-plus years.) After the film we were given the companion booklet with the (somewhat threatening?) title of, "Growing up and Liking it."
After the film the school nurse gamely lectured the assembled bewildered little girls. As it turned out, a few girls in the other class admitted some knowledge of this subject. Meanwhile, I was still confused and now rather frightened. Sometime later while visiting my friend Sandy, we raided her older sister's room and examined her sanitary napkins and belt--she would have killed us if she'd known. The subject of menstruation never came up again for perhaps a year or so. My mother one day showed me a "starter kit" she had purchased for me for the day I would need it. Ugh! When that day eventually came, I was scared and upset. Mom was at work and the box was in the closet of her room. I did cry a little bit while telling her about "what had happened" to me that afternoon. She gave me the box and a bit of reassurance and that was that.
Menstruation Resources . . .
Menstruation was never much of a topic of conversation in my life. I don't have a daughter and didn't anticipate having to explain menstruation to my son. But he was inquisitive when a 1999 episode of the animated series, "King of the Hill" featured Hank, the main character, awkwardly coping as his neighbor's daughter started her first menstrual period while her parents and his wife were away. Of course, an 8-year-old boy was satisfied with minimal information. I was surprised at the time to notice in myself the urge to be forthcoming coupled with a reluctance to be specific. I attributed it to the lack of discussion on such issues in my own life.
I decided I needed to prepare for more puberty talk to come so I did a bit of research and found a great book to help me explain the "need to know" issues in what was then the pre-internet era for my family. Now days there are all kinds of resources online to help educate girls and boys about menstruation and puberty. Again, many of these informational websites are sponsored by personal product manufacturers, but the approaches are subtle and not off-putting.
. . . from the Feminine Products Industry
Kimberly-Clark, the maker of Kotex, offers "My Daughter's Period," an informational web-based brochure that offers advice on when and what to discuss when talking with your girl about puberty. The Kotex website also includes "Girlspace," a sort of social networking application targeting puberty issues. For the girl or woman who really needs to plan ahead, check out this Kotex Period Planner so that you'll always be prepared.
Johnson & Johnson manufactures a number of different feminine “protection” products including O.B. tampons, Carefree panty shields, and Stayfree sanitary napkins. Their website is worth checking out and includes these notable educational offerings: an interactive website, "Teens for Teens" and for parents "A Guide to Handling Your Child's First Period."
Proctor & Gamble is the parent company of Tampax and Always. Not to be outdone by the competition, their website also boasts a Period Predictor. Most importantly their educational features include, "A Page for Mom" and Beinggirl.com, a website which provides age-appropriate information for pre-teens. The site includes an explanatory section called, "Your Period," which is good information, but I honestly feel it is written over the heads of girls at an age to learn about their first period. Fortunately there are better publications from P&G available for download, namely: "Always Changing" for boys concerning puberty and "Always Changing," for girls to explain menstruation. These booklets also serve as companion literature to Proctor & Gamble's, Always Changing school-based program.
Grade A Plus!!! For any inexperienced young girl, I truly feel this publication is the most exceptional: "Always Changing," Special Ed Version for Girls. Although this is aimed at special ed students, I think that the clear, basic explanations in this publication are very appropriate for tender young girls of age 9 and 10. I would also consider this a good choice in cases where English is a second language. Kudos to P&G on this publication.
. . . from Professional and Governmental Entities
- The American College of Gynecologists Educational Pamphlet about Menstruation: Patient Education (Menstruation)
- Talking to your child about menstruation,. from KidsHealth.org: Talk about Menstruation
- (And a Spanish Version): Menstruation Education in Spanish
- Mayo Clinic, Menstruation: Preparing your preteen for her period: Preparing Your Preteen for her Period
- Girlshealth.gov
- 4parents.gov: Download brochures to help you explain sexual development to boys and girls.
Grade A Plus!!! Find a treasure-trove of vintage Feminine Products Company Booklets about Menstruation (some from as early as the 1920’s.) These booklets are available in their entirety on the Museum of Menstruation website.
My Little Red Book is a recently published anthology of women's stories from around the world discussing the circumstances surrounding their first menstrual periods.
See comments left below from Elizabeth Kissling of the Society for Menstrual Research. I look forward to checking out their website. Thank you Elizabeth!
. .. .
Sunday, September 06, 2009
Understanding Medical Terms, Lingo, and Abbreviations
Medspeak, Medical Lingo . . . Need Help in Understanding the Language of the Medical World?
Right now I'm going through a stack of patient information brochures that I've been holding on to for awhile. A standout brochure in my collection is called, "Deciphering Medspeak," published by the Medical Library Association (MLA). This publication provides a quick A-to-Z plain-language guide which helps explain the meanings behind common medical terms and abbreviations.
In addition to the original version of Deciphering Medspeak, the plain language (low literacy) version (pdf) is also available online along with French and Spanish versions: Décryptage du Langage Médical and in Descifrando el Lenguaje Medico.
Other Resources with Medical Abbreviations and Terms:
This online medical dictionary can also help you find answers: Medlineplus encyclopedia.
If you have ever wondered what the abbreviations on doctor's prescriptons mean, you'll find this to be a useful guide: RX Riddles Solved, A Prescription Shorthand Guide.
For Very Basic Explanations of Health Terms . . .
MLAnet's "plain-language brochures" are written for health consumers with a 5th grade or lower reading level. These publications are ideal for consumers struggling with limited health literacy. Here is an example of the same health term definition from the original Deciphering Medspeak publication (1) and the plain-language version of the brochure (2):
- (1) DIFFERENTIAL DIAGNOSIS - is a list of the different diseases that can cause these symptoms
- (2) DIFFERENTIAL DIAGNOSIS - a list of diseases with symptoms that are alike. A fever and a runny nose are symptoms. The flu or the common cold are possible causes.
"MPH" is my highest professional degree. It stands for "Master of Public Health" (not miles per hour, as one friend suggested.) I earned my MPH from the University of Texas Health Science Center at Houston. The MPH program requires study in five specific areas important to public health: epidemiology, health education, biostatistics, environmental health, and health services management. My MPH course also required completion of a thesis. (Mine was a qualitative study of lost opportunities in umbilical cord blood banking.) Often, you'll find individuals with an MPH degree working in health departments, for the CDC, or as key personnel in non-profit health organizations. Physicians, dentists, veterinarians, attorneys, and nurses are among the professionals who pursue this degree.
" D.O.": In the U.S. we have two types of medical doctors, those with the M.D. behind their names and those with the less familiar "D.O." or Doctor of Osteopathy. Both types of physicians receive the same basic medical education and pass similar licensing exams. Osteopaths receive training that is holistic in nature--looking at the whole person rather than one aspect of an individual's symptoms.
"P.A.": Physician's Assistant. Many physicians employ P.A.s to serve as mid-level health providers. P.A.s are licensed to practice medicine under the supervision of a licensed physician. Their highest educational level is either at the bachelor or master's degree level. In the clinical setting you'll find P.A.s treating and diagnosing illness, ordering lab tests, performing physical exams and even assisting in surgery.
"N.P.": Nurse Practitioners are another type of mid-level health provider. Like P.A.s, they work under the supervision of a licensed physcian. In addition to a bachelor's degree in nursing, they hold a master's degree and licensure as an advanced practice nurse. You'll find N.P.s providing individualized patient care, performing physicals, ordering lab tests, prescribing medications, etc. in physician's offices, clinics, and hospitals.
"BSN": Bachelor of Science in Nursing. This degree is earned by successful completion of a 4-year-university program. However, the degree does not guarantee licensure as a registered nurse. All graduates are required to complete licensing exams before entering practice. (Personal Note: I earned my BSN from the University of El Paso at Texas. This is my highest nursing degree, although I do have a master's degree in public health.)
"MSN": Master of Science in Nursing. After completing a bachelor's in nursing, the MSN degree is the next educational step towards career advancement for the registered nurse. Nurses with the MSN may be teaching in nursing schools or practicing as certified nurse midwives, nurse practitioners, certified nurse anesthetists, or clinical nurse specialists.
"ADN": Associate Degree Nurse. This degree provides fundamental education for registered nurses. Most RN's practicing today have either the ADN degree or the BSN degree which is a longer program. Most community colleges offer 2-3 year ADN programs in nursing which prepare the graduate for the role of registered nurse. Graduates must successfully pass state licensure exams before entering practice.
"RN": Registered Nurse. At one time, RN's were educated chiefly in hospital schools of nursing. Instead of a degree, upon completion, they were awarded a diploma which entitled them to sit for the RN licensing exams. Today there are still some "diploma" nurses in the workplace, but RN's are also educated in ADN and BSN programs (see above.) In addition, advanced practice nurses such as nurse practitioners, midwives, and nurse anesthesists are RNs, but with an expanded scope of practice. Licensing requirements may vary slightly by state, but the NCLEX exam is the standardized test required for licensure within the U.S.. Even though an individual may hold a degree or diploma in nursing, if they have never passed a licensing exam, or if they lose or surrender their license to practice, it is illegal for them to use the title of "RN."
"LPN or LVN": Licensed Practical Nurse or Licensed Vocational Nurse. LPN and LVN's practice basic nursing, often under the supervision of an RN. I know of LPN programs that can be completed in as little as 9 months; however, at least one year of study is the norm. Instruction may occur in a community college or vocational school. An LPN (or LVN, depending on the state in which one lives) is educated in the basics of nursing care. LPN/LVN's must pass state licensing exams before entering practice in this field. You will ususally find LPNs working as nurses in doctor's offices, nursing homes, hospitals, and home health agencies.
Not finding what you are looking for? Leave me a comment and I'll soon get back with an answer for you.
. . .
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