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Topics in Clinical Nursing
Patient safety incorporates many core measures as put forth by the Joint Commission. As Dr. Shaunghnessy stated, the population in America will contain more aging adults than any other time in history (Laureate Education, 2009). This will put a burden on monies spent in health-care. Additionally, health-care professionals will be held to higher standards in order to lessen this burden, by performing their duties with a high degree of responsibility and accountability. The Joint Commission and the Centers for Medicare and Medicaid strive to improve the quality of health-care by developing core standards of protocol to be followed. The National Database of Nursing Quality Indicators assists nursing professionals at the unit level in making informed decisions to improve patient outcomes (“NDNQI,” n.d.).
So you just want to pass the Math section on the TEAS or the TEAS A5. How do you do that, if your math background isn’t that substantial. Well there is a way. Practice Practice and more practice. But where and what do you begin to study? At the Nurses Learning Center there are many tests that you can take online. You can choose from many different levels of math practice tests. All tests are online and you can choose to purchase one or more. Learn the steps to answer all of the math questions on the TEAS. Raise your scores so that you can get into the nursing school of your choice. Most nursing schools require a score of 80% on the TEAS or the TEAS A5. The math section is the one part of the exam that most students fail or score poorly. At the Nurses Learning Center students can feel confident that they are getting the correct study materials to pass the TEAS. What really helps students is that each questions has an explanation that goes through the entire problem, so that there is no question at how to arrive at the answer. Since students are not allowed to use a calculator on the test and they only have a short period of time to complete the math section, it is imperative that students can use their critical thinking skills.
The Nurses Learning Center helps students develop their math critical thinking skills by presenting the answer to each question step by step. Even students in school do not get as much help in their math classes. The Math 1 exam covers basic math skills such as adding, subtracting, decimals, long hand division and long hand multiplication. These skills are no longer taught in middle school and in high school. Yet those students seeking entrance into nursing school must do all the problems without calculators using long hand multiplication and division. Quite scary if you do not feel comfortable with these skills. Once you are a nurse you must use these skills to calculate medication dosages. Here a the Mynursingedu.com you can also purchase a hard copy book of the “Pass The NET”. It is the same as the online tests offered at nurseslearningcenter.com. Testing the TEAS can be very challenging. Students feel very intimidated by math. Some students will not go near a math test. Understanding math questions and knowing how to answer them will help students pass their math section. Knowledge is the key. Students should take their time studying for the TEAS. They should set aside time where it is quiet and they have the ability to concentrate. It is suggested that students take up to three months to prepare for the TEAS.
Best Wishes to All,
Nancy Kimmel RN PhD
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Ethics, Biases and Responsibilities of Nursing
October 7, 2014
Ethics, Biases and Responsibilities of Nursing
On any given day, the nurse will be faced with ethical challenges. The consequences of the nurses action in doing the “right thing” creates a dislocation point within their peer and management group.(Huston, 2014, p. 256) From my personal experience I know of one ethical dilemma that I faced. It was the morning shift. I had just made rounds. As I sorted out the medications I was going to pass, I noticed that one of my patient’s medications consisted of Depakote®(“Valproic Acid and Pregnancy,” 2014), Zyprexa®(“What special precautions should I follow?,” 2014) and Tetracycline®(“What special precautions should I follow?,” 2014). This would not have been a problem except the nurses from the midnight shift stated that the patient was only three months pregnant and had stated she was going to have an abortion. I looked through the chart to see if there was a consent signed for a D &C. There was none. I also proceeded to check if the psychiatric medication consent form was signed. This form needed to be signed prior to administering any anti-psychotic medications. The Physician was responsible for explaining to the patient the side effects. Next, I noticed that the attending Physician wrote the order for the Tetracycline and that the Psychiatrist wrote the order for the anti-psychotic meds. After reading this, I went to the patient and explained to her that there could be very teterogenic side effects to her unborn fetus if she were to take these medications either together or individually. She stated that she didn’t care because she was planning to have an abortion. I graciously bowed out and went to my head nurse. I explained to my head nurse that without documentation of a procedure for a D & C or any signature from the patient indicating that they understood the side effects of the combined medications, I could not in good faith pass these meds. In fact, I added that she could change her mind in a few hours. My head nurse just looked at me and asked me if I was defying a Physicians order. I said, “Yes”. She then proceeded to call the nursing supervisor who also asked me if I was refusing to pass the meds. I told her that I would not pass the meds citing documentation via the Micro-Medex®(“Truven Health Analytics,” 2014) drug compatibility table and my nursing code of ethics, to do no harm.(“Code of Ethics for Nurses,” 2010) After a brief discussion with my head nurse, they relieved me of this patient and gave me someone else. The nurse who took over the care of my patient followed the Dr.’s orders and passed the meds. I was told to write an incident report.
Impact of Legal Responsibilities
My first and foremost responsibility is too my patient. That has and will always be how I practice nursing. However my stance, the actions that I took obviously affected the care of the patient and not for the better. Could I have done it differently? It is important that the nurse has a scope of practice. This is what guides us to know what we can and cannot do. As nurses we must be very careful what lines we cross. Physicians are notorious for asking us to perform skills not within the scope of our practice.
Strategies to Address Conflict
There is no easy answer but as a group voice we can be heard. Which is why being part of the legislative due process of lobbying, helps to have laws passed that protect the nurse and patient.(Mason, Leavitt, & Chaffee, 2014, p. 669) Joining a nursing association also helps bring a unique camaraderie for nurse in their field so specialty, where they can also find peer group support for their cause.
Code of Ethics for Nurses with interpretive statements. (2010). Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf
Huston, C. J. (2014). Legal and Ethical Issues. In Professional Issues in Nursing Challenges & Opportunities (3rd Edition ed., pp. 256-262-262). Baltimore, MD: Lippincott Williams & Wilkins a Wolters Kluwer business.
Mason, D. J., Leavitt, J. K., & Chaffee, M. W. (2014). Policy and Politics in the Community. In M. Iannuzzi (Ed.), Policy & Politics in Nursing and Health Care (6th ed., pp. 668-669-669). St. Louis, MO: Elsevier Saunders.
Micromedex Solutions. (2014). Retrieved from http://micromedex.com/
Olanzapine. (2014). Retrieved from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601213.html
Tetracycline. (2014). Retrieved from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682098.html
Valproic Acid and Pregnanacy. (2014). Retrieved from http://www.mothertobaby.org/files/Valproic_Acid.pdf
Clinical practice guidelines for chronic Pain
October 18, 2014
Clinical practice guidelines for chronic Pain
The purpose of this paper is to identify the current clinical nursing guidelines regarding the treatment of chronic pain and its financial impact on the healthcare system, community, patients and their families. Additionally, this paper will explore the expectations of the BSN in the implementation and documentation of evidenced based practice.
Nursing management of chronic pain
Pain is a symptom that frequently goes unreported and unrecognized in patient care settings. Pain also has negative effects on the patient and their families.(Stenner, Carey, & Courtenay, 2012, p. 3335) “It’s disheartening for frontline nurses and other providers to feel they are not meeting their patients’ needs,” LaFevers said. “Not everyone can go to a pain specialist.”(“Better management needed,” 2014, para. 37)
Chronic pain and its significance in nursing practice
Chronic pain is an individual experience. Nurses face many challenges in helping those who suffer from chronic pain.(Dysvik & Furnes, 2012, p. 187) Pain is the main reason that patients seek healthcare.(Gretarsdottir & Gunnarsdottir, 2011, p. 16) Research shows that over 50% of these patients have suffered pain within 24 hours of seeking medical help.(Gretarsdottir & Gunnarsdottir, 2011, p. 16) An individual nurse may be able to help relieve the patient’s pain during their shift, whereas the next nurse on duty may not be able to provide the needed relief. Nurses working collectively as a team can better manage the effects of chronic pain in patients than a nurse acting alone. The management of pain as a group effort requires nurses’ to have a thorough knowledge of pain theory and the use of the behavioral and cognitive approach.(Dysvik & Furnes, 2012, p. 187)
The expectation of the BSN in chronic pain management
Belonging to a supportive team with clear roles helps in the complex management of chronic pain.(Dysvik & Furnes, 2012, p. 189) The BSN nurse typically assumes the leadership role.(Video Laureate Education, Inc., 2009) The group leader in the management of chronic pain is multifaceted.(Dysvik & Furnes, 2012, p. 189) The BSN must utilize the current research on the management of chronic pain and present this to the group. It is the moral and ethical duty of the BSN to utilize evidenced based practice.(Video Laureate Education, Inc., 2009) They are also the catalyst of change for their group.
Clinical practice guidelines in the management of chronic pain
According to the National Guideline Clearing House, chronic pain management should begin with assessment of the pain, the duration, intensity, description in the patient’s own words, location, onset, quality and duration.(Institute for clinical systems improvement , 2013) The nurse should also take into consideration the psycho-social factors the chronic pain may influence, such as depression and drug abuse.(ICSI, 2013) The treatment of chronic pain is a mulifactorial group approach led by the physician and nurse leader.(ICSI, 2013) Treatment should be addressed in levels with medications not being the sole focus.(ICSI, 2013) Comprehensive patient assessment algorithms for chronic pain begin with addressing the psycho-social factors. These factors include the patient’s reaction to their pain, their scioeconic status, their support or lack of support system, family history of pain therapies and their cultural and ethnic beliefs on the management of pain. The nurses understanding of the biopsychosocial model helps with the implementation of a pain treatment protocol that will benefit the patient’s long term goals.(ICSI, 2013)
The impact of chronic pain on the patient and the community
The under treatment of pain is a global problem.(Gretarsdottir & Gunnarsdottir, 2011, p. 16) Unresolved treatment of pain can have negative impact on the quality of life, economic productivity and healthcare utilization.(Gretarsdottir & Gunnarsdottir, 2011, p. 16) In 2011 at least 100 million American adults have common chronic pain conditions.(“Relieving pain in America,” 2014, para. 12) Pain is a significant public health problem that costs society at least $560- $635 billion annually,( an amount equal to about $2000 dollars for everyone living in the U.S.).(“Relieving pain in America,” 2014, para. 12)
The cost of pain to the healthcare system
In 2008 the cost of pain to the federal and state government for medical expenditures was $99 billion dollars.(“Relieving pain in America,” 2014, para. 13) Analysis from the CDC showed that nearly half a million emergency department visits in 2009 were from people abusing or misusing prescription pain killers.(“Relieving pain in America,” 2014, para. 13)
Dysvik, E., & Furnes, B. (2012). Nursing leadership in a chronic pain management group approach [Chronic pain management group approach]. Journal of nursing management, 187-195. http://dx.doi.org/http://dx.doi.org.ezp.waldenulibrary.org/10.1111/j.1365-2834.2011.01377.x
Facts on pain. (2014). Retrieved from http://www.painmed.org/PatientCenter/Facts_on_Pain.aspx#highlights
Gretarsdottir, S., & Gunnarsdottir, E. (2011). Systematic review aimed at nurses to improve pain management [Magazine]. Nordic journal of nursing research and clinical studies, 31(4), 16-21. Retrieved from http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/resultsadvanced?sid=fe778475-dd1f-42b0-9f12-420e94669cc5%40sessionmgr113&vid=9&hid=125&bquery=nurses+to+improve+pain+management&bdata=JmRiPXJ6aCZ0eXBlPTEmc2NvcGU9c2l0ZQ%3d%3d
Institute for clinical systems improvement. (2013). Assessment and management of chronic pain. Retrieved from http://www.guideline.gov/content.aspx?id=47646&search=chronic+pain
Stenner, K., Carey, N., & Courtenay, M. ( 2012, February 9th). Prescribing for pain – how do nurses contribute? A national questionnaire survey [Prescribing for pain]. Journal of Clinical Nursing, 21(23/24), 3335-3345. http://dx.doi.org/doi:10.1111/j.1365-2702.2012.04136.x
The state of pain-better management needed. (2014). Retrieved from http://www.theamericannurse.org/index.php/2014/01/02/the-state-of-pain/
Video Laureate Education, Inc. (2009, ). Research and scholarship for evidence-based practice: Introduction to evidence-based practice and research [Video file]. Retrieved from
Change in practice assignment
November 16, 2014
Change in practice assignment
The purpose of this assignment is to address the problem of the development of pressure ulcers occurring in susceptible individuals during short terms stays in the hospital. Identifying those factors that put patients at risk and critically evaluate current nursing practices used on the floor, such as documentation, identification and current methods of prevention.
The Development of Pressure Ulcers during Short Term Stays
According to the National Guideline Clearing House, people of all ages are at risk of developing pressure sores based on the vulnerability of their current health status (“Target population,” 2011, para. 4). In the current work setting, almost all patients with limited mobility who cannot get out of bed by themselves and need to wear briefs or use the bedpan begin to develop a stage I pressure ulcer prior to discharge within 1 -2 days after hospitalization or short term emergency room stay. The hallmark of quality nursing care is excellent skin care (Wurster, 2007, p. 267). It is up to the nurse to lead the role in pressure ulcer prevention. The importance of this problem extends beyond the hospitalization stage. Those individuals who are discharged with stage 1 pressure ulcers do not always have properly trained family members to care for them thereby preventing the stage 1 from getting worse. For many of the elderly patients, pressure sores are a common health problem particularly among the physically limited or bedridden and without proper treatment can remain for the duration of the persons life (Jaul, 2010).
The incidence of pressure sores has increased by 63% between the years of 1993 to 2003 in hospitalized patients(Wurster, 2007). The nurse is responsible for targeting the care that these patients need to receive to prevent pressure ulcer development. Coordinating staff to work as a team is currently lagging in the work place. The charge nurse does not follow up on the staff nurse notes, nor does the staff nurse follow up on the nurse aide tasks of turning the patients and providing nutritional supplements provided by their dietary orders. The assessment and management of pressure ulcers require a comprehensive multidisciplinary approach (Jaul, 2010, p. 313).
The proposed evidenced based practice change would begin by the identification of gaps in knowledge and practice of the treatment of pressure sores (Schmidt & Brown, 2012). This process would begin with a survey on current patients with pressure sores, identifying their dietary intake of protein, vitamin C and other nutritious intake such as flavored protein shakes and healthy snacks(Wurster, 2007). The survey would include verifying linen change frequency and adherence to turning schedules. Identification of vulnerable patients who have limited mobility, incontinence, dementia or are over the age of 65 (Jaul, 2010).
Staff RN’s current knowledge base on pressure sore prevention should be evaluated. This could be done by asking the RN’s to fill out a pressure sore prevention questionnaire. The nurse aides would also be asked to fill out a questionnaire on pressure sores, identifying patient’s comfort levels and the importance of a turning schedule. The questionnaires would also evaluate the level of communication between staff members and shift team members thus identifying communication gaps (Banning, 2005).
RN’s would be assigned to collect quantitative articles from credible databases such as CINAHL or the National Guideline Clearninghouse for best practices documentation literature review. A proposed meeting time and place would be agreed upon to review article research, wherein the credibility of the articles obtained would be determined. The articles requested would be those that meet the quantitative standards(Schmidt & Brown, 2012).
Articles that meet quantitative and or qualitative standards would be decided at journal club meetings. Best practices would include statistically significant data based upon population parameters, level of significance and positive outcomes. Identification of the RN’s role in delegation of duties to the nurse aide’s job of providing patient safety, comfort and importance of prioritizing the patient’s needs would be reviewed. Determining the importance of the lead RN and their responsibility to subsequent shift team leaders would be identified and discussed at team meetings.
Rewards, praise and recognition of the importance of team members plays a large role in facilitating change (Schmidt & Brown, 2012). The lead RN initiating the change in practice should be responsible for coordinating meetings and dissemination of data.
Evidence Supporting Proposed Change
Icek Ajzen’s theory of planned behavior states that behavior is influenced directly by intention to perform the behavior (Ajzen, 2011, p. 1113). The nurse in charge of the change process begins by creating a sense of urgency (Schmidt & Brown, 2012). Several studies done on nurses’ attitudes toward pressure ulcer prevention revealed that there were barriers and gap knowledge present within staff members.
The first study identified (Athlin, Idvall, Jernfalt, & Johansson, 2009) 30 RN’s as the sample. The setting included two hospitals and one community care facility. The instrument used to evaluate the RN’s attitude toward pressure ulcer prevention was a questionnaire. Variables that were identified included patient health status and vulnerability to the development of pressure sores, the health care structure variable that affect pressure ulcers and prevention. Findings of the research indicated that the knowledge of pressure ulcer prevention was present. However the ability to follow through with collaborative treatment was lacking. This knowledge gap was due to lack of staff, time and consistent prevention routines.
A descriptive cross-sectional study involving 77 RN’s and 77 Nurse Aides traversed six hospitals and six clinics (Kallman & Suserud, 2009, p. 336). The researchers used a 47 item questionnaire which included an 11 item attitude scale (Moore & Price, 2004). The research concluded that all RN’s and Nurse Aides had a positive attitude toward the prevention of pressure ulcers. Their inability to provide collaborative care stemmed from environmental factors such as lack of time and communication between staff members. Performance in the prevention of pressure ulcers was inadequate due to lack of teamwork, access to necessary preventative equipment and supplies and current work routines.
The necessity for increased knowledge regarding the prevention of pressure ulcers is evident across both studies as is the necessity for more staff, time and open lines of communication regarding the worsening status of the patients’ current condition.
Evaluating the Change
To identify whether or not a change is evident begins with the patient population and identification of a positive outcome. In this case it would be a decrease in the amount of stage 1 pressure sores not present at the time of discharge. In short term admissions the first step would be to do a thorough assessment of the patient and their risk for pressure ulcer development. Having collected relevant research data from articles and questionnaires, the lead RN would initiate the plan of action. Identifying team leader RN’s for each shift would ensure that the tasks for prevention of pressure ulcers are being followed through by the staff RN and the nurse aide. Having access to and providing the patient with adequate nutrition would be a priority for all staff (Jaul, 2010) Making sure that their over bed table is always within reach and that assistive feeding be followed through until the patient has finished eating. Frequent turning schedules are to be implemented on patients who are alert and oriented but do not ask for anything or turn on their call light (“Target population,” 2011) Nurse aides and nurses should always ask to reposition for comfort and explain why they are doing so for the patient’s own knowledge. Daily shift meeting should address those interventions taken on the patient’s that are vulnerable for pressure ulcers. Linen change each shift should be mandatory for patients at risk (“Target population,” 2011). Moisture frequency should be evaluated every hour for those who are incontinent of bladder or bowel. This can be done by assistive turning and inspection of the area per patient’s approval. Keeping patients’ involved in their own care is an important aspect of nursing. Self care helps the patient develop confidence and hope in their treatment.
Assuming that all criteria is evaluated with attention to where the knowledge gaps are evident and corrected and the RN’s and nurse aides are able to perform their required tasks, the outcome should be positive. Determining the where the problem with pressure ulcer prevention exists would in the responses from the RN’s and nurse aides. Once the problem is identified then the development of the plan of action would be developed as described above. Putting the plan of action into place requires that the change agent or the lead RN verify that everyone is staying on task. The lead RN can do this through a daily shift evaluation of the patients’ condition and through nurse charting notes. Communication between shifts is a common problem as is the continuum of care. Quality care is the key. Prevention of pressure sores is not that difficult when it becomes a common goal for all who are working on the floor. With the implementation of the described changes the resulting outcome should be positive.
Research has documented that there are knowledge gaps between staff members in the flow of care in the prevention of pressure ulcers. While pressure ulcers continue to be a problem in most healthcare institutions, there is hope in lessening their prevalence. This paper focused on the development of evidenced based practice to reduce the incidence of stage 1 pressure ulcers that develop with a few days after admission in short stay patients’. Evidence from research on the attitudes of nurses and nurse aides in regards to the prevention of pressure ulcers shed light on a common theme, that of a lack of communication and the consistency of care (Kallman & Suserud, 2009). Those interviewed stated that lack of knowledge, time and or access to necessary preventative equipment also exacerbated the patient’s condition. The proposed evidenced based change practice initiates a sense of urgency and provides a plan of action to help reduce the frequency of stage 1 pressure ulcers. The EBP change details how to begin the study and the methods to evaluate the study. Ensuring that the standard of care continues across all shifts requires communication between all shifts. A nurse leader can ensure that this takes place with proper team leadership on each shift. Rewarding and recognizing those who are following the plan of care and going above and beyond ensures that the plan will continue to have positive outcomes for the patient.
Ajzen, I. (2011). The theory of planned behaviour: Reactions and reflections [Magazine]. Psychology and Health, 26, 1113-1127. http://dx.doi.org/110.1080/08870446.2011.613995
Athlin, E., Idvall, E., Jernfalt, M., & Johansson, I. (2009). Factors of importance to the development of pressure ulcers in the care trajectory: Prectptions of hospital and communcity care nurses [Magazine]. Jouranl of Clinical Nursing, 19, 2252-2258. http://dx.doi.org/10.1111/j.1365-2702.2009.02886.x
Banning, M. (2005, April). Conceptions of evidence, evidence-based medicine, evidence-based practice and their use in nursing: independent nurse precribers’ views. [Magazine]. Journal of Clinical Nursing, 14(4), 411-417. http://dx.doi.org/10.1111./j.1365-2702.2004.01086.x
Jaul, E. (2010). Assessment and mnagement of Pressure ulcers in the elderly [Supplemental material]. Drugs & Aging, 27(4), 311-325. Retrieved from http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=19&sid=fcecb593-84bd-4598-81db-b92f5a4f8e60%40sessionmgr198&hid=102
Kallman, U., & Suserud, B. (2009). Knowledge, attitudes and practice among nursing staff concering pressure ulcer prevention and treatment-A survey in a Swedish healthcare setting [Magazine]. Scandinavian Journal of Caring Sciences, 23, 334-341. http://dx.doi.org/10.1111/j.1471-6712.2008.00627.x
Moore, Z., & Price, P. (2004). Nurses’ attitudes, behaviours and preceived barriers towards pressure ulcer prevetnion [Magazine]. Journal of Clinical Nursing, 13, 942-951. http://dx.doi.org/10.1111/j.1365-2702.2004.00972.x
Pressure ulcer prevention and treatment guidelines. (2011). Retrieved from http://www.guideline.gov/content.aspx?id=25139&search=pressure+ulcers+during+short+term+stay+and+pressure+sores
Schmidt, N. A., & Brown, J. M. (2012). Evidence-based practice for Nurses appraisal and application of research (2nd ed.). Sudbury, MA: Jones & Bartlett Learning .
Wurster, J. (2007, September 1). What role can nurse leaders play in reducing the incidence of pressure sores? [Magazine]. Nursing Economic$, 25(5), 267. Retrieved from http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?sid=fcecb593-84bd-4598-81db-b92f5a4f8e60%40sessionmgr198&vid=11&hid=102