Discharge Instructions: Trans Urethral Resection of the Prostate (English and Spanish version)

*(Looking for other types of discharge instructions in English or Spanish? Click here).

I Hope You Were Given Some Discharge Instructions . . .

Waste not, want not.  I'm reviewing my collection of patient educational materials which includes brochures and flyers that I've picked up over the last 14 years.  This entry is a transcription of an undated, uncopyrighted, no author given, flyer that we used at Providence Memorial Hospital in El Paso, Texas as discharge instructions for our "TURP" patients (Trans Urethral Resection of the Prostate).  El Paso County is roughly 90% Hispanic with Spanish being the primary language so it was essential to have discharge instructions available in both languages.  I've included the Spanish version here and have linked (at bottom) to another blog post I created with LOTS of Spanish discharge instructions. 

Looking at these TURP discharge instructions now, I'm surprised at what BASIC information our patients were given. 

***TURP Patients:  Be sure to look at the information you were provided at discharge to ensure you are following YOUR physician's post-op recommendations.***


Trans Urethral Resection of the Prostate, “Discharge Instructions”

What do I need to remember when I go home?

1. Eat well-balanced meals.
2. Drink at least eight (8) glasses of liquids per day, preferably water.
3. NO heavy lifting.
4. NO heavy straining.
5. Take a mild laxative if you have difficulty with bowel eliminiation.
6. NO strenuous exercise.
7. Keep all follow-up appointments with your physician.
8. Call your physician if you have:

• Fever (101 degrees F or over) and/or chills
• Persistent, heavy bleeding and/or clots
• Inability to urinate
• Severe Pain

Questions that you need to ask your physician:

1. When can I drive a car?
2. When can I go back to work?
3. When can I engage in sexual activity?

What should I do if I have bleeding?

Blood in the urine is a natural product of the healing process. You should drink ample amounts of fluid to “flush out the system” and prevent clots from forming.
If bleeding persists and clots form, call your physician.

Any Other Specific Instructions?


 ______________________________________________________


Reseccion Trans Uretral De La Prostata, “Instrucciones Para Cuidado En Casa” 

¿Que Debo Recordar Al Irme A Casa?

1. Coma comidas bien balanciadas.

2. Tome por lo menos 8 vasos de liquidos al día, preferiblemente agua.

3. NO levante cosas pesadas.

4. NO se esfuerze en exceso.

5. Tome un laxante suave si Ud. tiene estreñimiento.

6. NO haga ejercicio rigueroso.

7. Asista a las citas con su doctor.

8. Llame a su doctor si Ud. Tiente:

• Calentura (101 F o mas) y/o escalofrios
• Sangrado persistente o coagulos
• Inhabilidad de orinar
• Dolor severo

Preguntas Que UD. Debe Hacarle a Su Doctor:

1. Cuando puedo empezar a manejar el coche?

2. Cuando puedo regresar a mi empleo?

3. Cuando puedo resumir actividades sexuales?

¿Que Debo Hacer Si Hay Sangrado?

La sangre en la orina es un producto natural del proceso de sanamiento. Ud. Debe tomar cantidades amplias de liquidos parea “enjuagar el sistema” y prevenir la formación de coagulos.

Si el sangrado persiste y coagulos se forman, llame a su doctor.

¿Otras Instrucciones Especificas?

*Click here: to link to my blog post with many more links to discharge instructions in Spanish *


. . . . .

Patient Education Brochures and Booklets are Still Essential Despite the Internet: Where to Find Them?

A Small Cost to the Provider, but Invaluable to the Public and the Patient

I mentioned in another blog post that I'm a bag lady when it comes to medical brochures.  I expect to pick up something of interest if I happen to visit a health fair or health-related event.  The vendors are not going to attract my interest by merely displaying a poster or a table-top video display.  I want to pick up something that I can read when I'm ready.  "Readiness to learn," after all, is a basic fundamental in the teaching-learning realm of education.  

While the internet offers vast opportunities to find what we seek in the way of health information, I still have a desire for the traditional illustrated pamphlets that were so long a staple of patient education.  I can attest that even now, in large hospitals that promote themselves as cutting edge, the lack of a patient educational handout means the lack of patient teaching.  Period and end of story.  I have never seen any patient willingly turn the TV to the patient education channel to learn more about their health needs.  A patient sick enough to be bedfast in the hospital is typically not online to search for health-related information.  And many patients can't afford the luxury of a laptop to bring to the hospital--or perhaps they are not internet savvy to begin with. 

There is a real need, in my opinion to preserve the traditional patient education tools. In a pre-op or post-op teaching situation, computer based learning is not conducive to the one-on-one, individualized teaching that needs to take place.  The patient brochures are awesome adjucts to this type of patient education interaction.  Hospitals--start stocking more patient education brochures and making distribution of them a priority--please!! 

Patient Education Publishers of Note

One of my favorite patient education brochures that I've kept is by the Channing Bete publishing company.  Channing Bete has been in this business for decades and now boast a host of patient education products and services.  I've had this booklet so long that I see it's been replaced by an updated version.  The one I have (in two versions, English and Spanish):  "Sooo . . . You're going to have an OPERATION" and "De mondo que . . . le van a OPERAR!"  And the newest versions:  About Having Surgery, About Ambulatory Surgery, and for kids: Same Day Surgery:  A Coloring and Activity Book.  Honestly, these publications are sublime in their simplicity and ability to communicate the need-to-know basics of surgery day to patients and their loved ones.

Krames Education Products and Services is an offshoot of a larger company called Staywell.  My old favorite publication by Krames is called, "Pressure Ulcers, Your Role in Prevention and Treatment" (aimed at nurses.)  Now there is a newer version on their website called,  "Pressure Ulcers Prevention and Treatment." These are great publications for caregivers with wonderfully detailed illustrations and excellent explanations.  Find other worthwhile topics for patient education from their catalog:
Krames Patient Education Print Materials

One thing about physician's offices these days--there are not a lot of actual nurses in these settings.  Nurses are more expensive than medical technicians, so physicians tend to employ more of these unlicensed assistants.  The loss of professional nurses in that setting allows for a gap in patient teaching.  Often in pre-surgery teaching sessions bewildered patients who had already been with their physicians for a previous appointment to determine that surgery was necessary, would admit that they had no real idea what their upcoming surgery entailed.  And for some of the complicated surgeries they didn't know how to spell the procedure correctly in order to search for appropriate information online.  I found that Colen Publishing offers a dozen or so titles to explain surgical procedures (often ones that are in the neurosurgery realm), these titles cover Craniotomy, Laminectomy, Ventricular Shunt, Cervical Fusions and more.  See an example of one of their Tri-Fold Surgery Cards: Anterior Cervical Discectomy and Fusion. I think it would be a great service for a patient anticipating surgery to have one of these nice explanatory tri-folds instead of trying to (alone) search out information online that may or may not pertain to their particular situation and surgery.

Of course the American Cancer Society and National Cancer Institute offer many wonderful publications about cancer, but please don't overlook the three that are available free from the Patient Resource Cancer Guides (3 titles available free to patients & in bulk to hospitals or clinics.) Place your order today:  Patient Resource.Net. 

Some other worthwhile sources of hard-copy patient educational brochures:

• National Institue of Health Publications for Consumers, see also titles in Spanish. 
• American Cancer Society free brochures
• Public Health Foundation Learning Resource Center
• National Cancer Institute, "What you need to know about . . . " (various cancer topics)

. . . . .

ERCP (Endoscopic Retrograde Cholangiopancreatography)

The Society of Gastroenterology Nurses and Associates (SGNA), Inc. distributed this patient education handout back in the mid-1990's and I have always found it to be very useful.  Certainly there are many easily accessed patient education tools about ERCP via the internet, for example this one this one courtesy of the Jackson/Siegelbaum Gastroenterology Group in Camp Hill, PA is especially nice.

Because my copy of the pre-internet ERCP patient information handout distributed by the SGNA is tattered and of poor quality, I'm transcribing this helpful patient education handout below. It's undated, no author listed and lacks a copyright statement. (Today I inquired with Kathleen O'Brien from SGNA via their online support suite chat feature and received no objection to transcribing this information here for the purposes of my blog readers.)

Patient Education:  ERCP (Endoscopic Retrograde CholangioPancreatography)

After careful medical assessment, your doctor has recommended that ERCP be performed for further evaluation and treatment of your condition.  ERCP is a valuable examination of the diagnosis of many diseases of the pancreas, bile ducts, liver and gallbladder.  ERCP allows the doctor to perform necessary treatments such as enlarging a bile duct opening, removing gallstones lodged in the bile duct, inserting a stent (drain) in the duct or taking a biopsy specimen (tiny bit of tissue).

A flexible fiberoptic tube (duodenoscope) is passed through the mouth, esophagus (food tube) and stomach into the duodenum (first part of the small intestine.)  The ampulla (opening where the bile and pancreatic ducts empty into the duodenum) is then identified.  A small plastic tube (cannula) is passed through the duodenoscope into the ampulla. X-ray dye is injected through the cannula into the ducts.  X-rays are then taken to study the ducts.  Any necessary treatments can be performed at this time.

Dentures and eyeglasses must be removed prior to the start of the procedure.  You may prefer to remove contact lenses at this time.

You will be asked to sign a consent form authorizing the doctor to perform the procedure.

Be sure to tell the doctor and the GI nurse if you are allergic to any medicines, x-ray dyes or iodine products.

A needle for intravenous (IV) medicines and fluids will be placed in your arm vein.  Medicine will be injected through the IV needle that will make you sleepy and relaxed.  Your doctor may also spray your throat or ask you to gargle with a numbing medicine.

You will lie on an x-ray table on your left side and  a small plastic mouthpiece will be placed between your teeth.  You will be able to breathe normally.  The doctor will help you to swallow the lubricated flexible duodenoscope tube.  When the tube is present in the duodenum, you will be helped to turn onto your abdomen with your head turned to the right.

During the procedure you may feel some abdominal fullness or bloating due to the air which the doctor puts into the duodenum.  As the X-ray dye is injected into the ducts, you may feel some mild discomfort.  These feelings should be completely tolerable and not painful.

After the duodenoscope is removed, you may be asked to move into various positions so that more X-rays can be taken.

Many people do not recall any of the procedure because of the effect of the medicine. After the procedure you will probably feel drowsy and may sleep for a short time.  After you have rested, the doctor will discuss the findings with you.

If you have any questions please feel free to ask the doctor, the GI nurse, or the technician.

More ERCP factsheets for patients:

"A+" link:  http://www.gastro.org/wmspage.cfm?parm1=860 from the American Gastroenterologic Association
National Institues of Health Factsheet on ERCP

GI Care Endoscopy Center, ERCP
PDF format with excellent format and info for patient teaching


. . . . . . . .

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:

• 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)  .. . .

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.

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 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.

• 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. 

Links to Reputable Websites with Instructions on JP Drain Care (including log sheets to record drainage).  Most of these include log sheets you can copy to record your drain output . . . or you can just write it on a piece of notebook paper--that would be just fine, too, as long as you include the date/time/amount (and drain number if you have more than one.)

• 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 Videos

 

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) . .

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

• 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.

. . . and even More, More, More about Menstruation!

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!


. .. .

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.

In case you were wondering . . . abbreviations for medical titles and degrees

"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.

. . .

Bloody nose: Stop a nosebleed and prevent recurrent bleeding

Why do nosebleeds occur?

In medical terminology, a nosebleed is properly called "epistaxis." Trauma from an injury is probably the most common way to develop a nosebleed. Dry weather and irritation from fingers in the nose are also commonly associated with nosebleeds. Anyone who takes blood thinning medication (such as Coumadin) or even some vitamins and supplements(such as fish oil, vitamin E, etc.) are more susceptible. Cancer patients undergoing chemotherapy may have nosebleeds due to loss of clotting factors called platelets that are destroyed by the chemo. Patients who receive oxygen therapy by means of a nasal cannula (also called "nasal prongs") may suffer nosebleeds because of the dry stream of air against the nasal tissue unless some humidity is added to the oxygen set-up. Uncommon reasons such as inherited problems of the blood vessels are disorders such as Osler-Weber-Rendu Syndrome (Hereditary Hemorrhagic Telangiectasia) or an inherited blood clotting disorders such as a type of hemophilia.

How to Stop a Nosebleed:

1. Sit or stand the person with the bleeding nose UPRIGHT with their head tilted FORWARD. This keeps the blood from going down the back of the throat and into the stomach which will cause irritation and often results in vomiting. Allow the blood to flow into a basin or onto a cloth if available. Stopping a bloody nose is the priority--you can worry about cleaning a mess later.

2. Have the person with the bleeding nose breathe through their mouth as they (or you) pinch the nose together to apply pressure. You'll know that you are doing this correctly if there is no longer visible blood coming out while you are applying the pressure. Make sure to pinch the soft part of the nose to apply pressure--the lower third of the nose, just above where the nose flares outward. Obviously if you try to pinch against the bony part of the nose you won't really be applying any pressure to the blood vessels underneath. Remember to encourage them to sit upright with their head tilted forward. In addition to applying pressure, you can also put an ice pack over the bony bridge of the nose to constrict the blood vessels even more.

3. Don't let up the pressure for at least 5 minutes--not even to take "a peek." Time this by the clock, don't wing it. You are trying to establish a clot in the bleeding vessels--steady, constant pressure is important in doing this. After 5 minutes of direct pressure, check for bleeding. If the nose is still bleeding, repeat step 2, only this time keep the steady continuous pressure going for at least 10 minutes.

4. Have you done all this with no improvement? In that case, it's time to visit the doctor or ER. Don't forget to continue pressure during transport and in the waiting room. Depending on the circumstances the ER doctor may have to resort to nasal cautery to stop the bleeding, by packing the nose with a gauze "nasal tampon," or by some other means to apply compression to the bleeding vessels.

5. All fixed? What now? After the nosebleed ask the patient to rest in a reclining position with the head elevated above the heart, limit strenuous activity for the rest of the day, and avoid bending and heavy lifting. It's okay to gently sniff, but avoid blowing the nose and if the patient must sneeze--encourage them to do so with an open mouth to minimize pressure through the nose.

6. What if the nosebleed starts up again?

• Follow steps 1-3 again.
• If unsuccessful in stopping the bleeding, or if the patient is experiencing any associated symptoms such as severe headache, body sweats, weakness, or shortness of breath--it's time to go to the ER. Remember to ensure that pressure is maintained in an effort to control the bleeding during the ride to the ER.
• If the patient has already seen the doctor--review the discharge instructions and follow the written advice the physician gave--phone the doctor's office for any questions or concerns. Proceed to the ER if indicated.
• On their website, the Ear, Nose, and Throat Associates of Corpus Christi suggest this additional advice for recurrent nosebleed: "Clear nose of all blood clots by sniffing in forcefully," and "Spray nose four times on both sides with decongestant spray (such as Afrin,® Duration,® Neo-Synephrine,® etc.)"

Quick sources for additional reading:
Ask Dr. Sears: About Nosebleeds
The Children's Hospital, Aurora, Colorado



Below: Jay Dolitsky, MD, Clinical Professor and Director of Pediatric Otolaryngolgy at the NY Eye and Ear Infirmary offers his expert opinion about nosebleeds in this YouTube video.

Tracheostomy Care and Suctioning

A link to a very remarkable video series crossed my path today: "Breath of Life: a caregiver's guide to pediatric tracheostomy care." When their infant daughter Elizabeth needed a tracheostomy due to severe laryngomalacia and tracheal stenosis, Matt and Melanie Dragovits used their professional backgrounds in video production and education, respectively, to produce this video which also features expert advice from respiratory therapist Ron Barrows. The caliber of tracheostomy care training Matt and Melanie received in the hospital after Elizabeth's surgery inspired this educational video, because they were left with the feeling that "more could have been done to help them take Elizabeth home." After watching this well-produced, professional video, I'm convinced that adult tracheostomy patients would also benefit greatly by watching this video.

Breath of Life is available free online, but can also be purchased as a DVD for those without internet access.

Among the patients assigned to my care in the hospital recently have been two adults with new tracheostomies. Both of these tracheostomies were intended for long-term (probably permanent) treatment of the underlying condition. In one case, a cancerous tumor was encroaching on the airway, while the other "trach" was necessary because severe injury damaged tissue in the upper airway.

Once upon a time . . . it was commonplace for an RN to provide comprehensive health teaching on a regular, shift-to-shift basis in the hospital . . . this education and evaluation of the patient's/family member's understanding was an emphatic component of the care provided to patients who were about to leave the hospital and embark on a life-altering course of complicated self-care . . . It was with shame and remorse that these recollections crossed my mind regarding these two patients--meanwhile, the obligations of the patient load as a whole whirled me away from contributing to reinforcement of the essential teaching points.

The consequences of poor tracheostomy care and suctioning can mean the difference between life and death. In Echo Heron's nursing anthology, Tending Lives, Diane C., a home health nurse, wrote a chilling account of poor trach care that haunts me to this day. A few years ago while working in an outpatient care center, a foster mother brought her toddler with a trach in to provide a mucus sample to determine the nature of the child's chronic lung infections. I was glad that I decided to observe the mother suctioning the trach to obtain the specimen. Her technique was so utterly wrong that she grossly contamintated the child's lungs with each suctioning that she'd performed during the months that the child was in her care. I remember literally feeling faint with the shock of what I was seeing. This foster mother meant no harm--but she was truly misinformed to a degree that could have certainly resulted in fatal harm to the child had it continued.

Most of us are visual learners who retain new information best when we can watch a demonstration--often more than one time. As inhabitants of the modern Western hemisphere, we've been influenced by many, many years of television viewing which have reinforced our visual learning preferences. It's also possible to find YouTube videos about tracheostomy care. Granted, they are not the same quality as professionally produced videos, but these amateur videos can definitely provide some helpful, additional visual images of trach care.

Once we have the visual image of the procedure clear in our mind, it's much easier to process the excellent written instruction instructions provided by Cincinnati Children's Tracheotomy Care Handbook and at tracheostomy.com. (These are just two of the many excellent resources for trach information that I selected based on my online trach patient information search.)

It's imperative that you follow the advice of your physician, home health nurse and respiratory therapist and immediately consult them with any questions or problems about your loved ones tracheostomy.