It’s that time of year: almost everyone is being discharged from hospital visits with an antibiotic. From pneumonia to skin infections to strep throat, there are a myriad of reasons your patients may leave with an antibiotic prescription. With microbial resistance on the rise, and because of the many complications of antibiotic use (C. Diff comes to mind), nurses play a crucial role in ensuring medication compliance and proper home use. Below are some tips for making sure you are teaching your patients correctly about their medications—from penicillin to Cipro and beyond.
1. Make sure your patients know to take their antibiotics with food, preferably at mealtimes.
Many antibiotics can upset the stomach or cause gastritis, so avoid taking them on an empty stomach. (The only antibiotics that should be taken on an empty stomach are ampicillin, dicloxacillin, rifabutin, and rifampin.) A heavy meal is not necessary, but a small snack can prevent indigestion.
2. It is imperative that the patient take the full bottle or dispensed amount, even if they start feeling better before completion.
In fact, it is very likely that the patient will feel better before the prescribed amount is finished. Even so, feeling better is not an indication that the bacteria are all gone. Patients who do not complete their entire prescription help promote antibiotic resistance, because any bacteria not killed yet can go on to reproduce with genes that allow them to avoid destruction by common antibiotics. Sometimes, emphasizing to patients that future antibiotics may not work for them can be an effective way to ensure compliance.
3. If the patient has a reaction to an antibiotic he or she needs to call their doctor immediately.
Several antibiotics can cause rashes or hives, or more seriously, an anaphylactic response. It is important to teach your patients to be on alert if it is a medication they’ve never taken before or if they have had reactions in the past.
For some specific classes of antibiotics, some additional teaching is required.
Fluoroquinolones, such as ciprofloxacin, levofloxacin, or moxifloxacin, can cause tendon injuries. Specifically, patients may experience peripheral neuropathy that can have permanent effects. Caution patients to immediately report any symptoms of pain, burning, pins and needles, or tingling or numbness. Rupture of the Achilles tendon is possible even with short-term use of these drugs.
Antibiotic–associated diarrhea is an overgrowth of usually harmless bacteria that live in the GI tract, most usually Clostridium difficile. In severe cases, C. diff can be life-threatening. The antibiotics most likely to cause a C. diff infection are fluoroquinolones and clindamycin, but diarrhea remains a risk when taking any antibiotic. To help prevent cases of C. diff, patients can take an over-the-counter probiotic or eat yogurt with live and active cultures (but yogurt must be ingested three times a day to be effective).
Certain antibiotics, such as tetracyclines (doxycycline) and fluoroquinolones, need to be separated from divalent cations—found in dairy products, antacids, and vitamins—by at least two hours. These antibiotics can also cause gastritis, so it is important to still eat them with a small meal to decrease this effect.
It’s no wonder our patients can be overwhelmed when taking antibiotics—there is a lot of information to remember! But proper patient education can help nurses play a role in preventing microbial resistance and ensuring safe medication compliance.
I would make a wager that most nurses don’t see themselves as innovators, even though we innovate all the time. In fact, nurses are probably some of the most creative, quick-thinking people in the workforce. Whether it’s determining the best way to move a patient, the best way to decrease the number of steps you’re taking, or working out how to prioritize sixteen different orders on four different patients, nurses are constantly analyzing and problem solving. From scrub designers to app designers, nurses are often the brains behind many of health care and technology’s latest developments.
Nurses are authors, musicians, engineers, podcast writers, and inventors. We are a creative bunch who are always trying to make life easier for our patients—and for ourselves. From innovative wound dressings to re-purposing gloves or hospital socks for off-label uses, we are always thinking outside the box. We just never realize it.
Because nurses work at such an individual level it is sometimes difficult for us to see how we could affect change at the system level. And it’s not our fault, either: The infrastructure to scale our solutions to the system-at-large is very underdeveloped. There aren’t many ways for us to showcase our ideas to help bridge gaps in health care. We need design-thinking workshops that let us develop our creative thinking and empower us to innovate. We need to highlight our diverse backgrounds, our unique work environments, and our drive to improve patient care delivery.
In your own nursing unit or department, you could start by thinking of a problem. What irritates you every day? Is there a flow issue in your unit? Do you see any glaring areas for improvement? For example, think about how many steps you take per shift. Could resources be shifted or moved so that you and your colleagues can take fewer steps? Imagine what you need to be more efficient. After all, necessity is the mother of invention—and innovation, too. All ideas are potentially valuable: trust yourself and feel empowered to share your thoughts and innovations with others. The future of health care depends on it.
If you are interested in learning more about health care innovations, the Smithsonian’s Lemelson Center for the Study of Invention and Innovation is hosting a free program on March 16th with a panel of innovative problem solvers. If you are in the DC area, you can attend the event (and find more details here). If you aren’t a DC local, you may visit the Lemelson Center online to find program highlights or to explore multimedia content.
Opioid addiction is an epidemic in every US state. A new study in the New England Journal of Medicine has linked opioid-addicted patients to the very first provider who prescribed the medication. The researchers found a correlation between the pain-prescription habits of emergency room physicians and the frequency of their patients becoming opioid-addicted. (You can read an article in the New York Times about the research here.) The bottom line? The risk of opioid addiction begins with a single exposure to narcotic pain medications—which frequently occurs during an emergency room (ER) visit.
Naturally, prescribers are in the most control: They can limit the quantity of pills prescribed after an incident, or change their prescription habits to restrict the instances warranting their use. For example, instead of patients leaving the ER with a prescription for 30 oxycodone tablets after a sprained ankle, they can prescribe 5 pills. Better still, they can prescribe ibuprofen, ice, and rest; if that becomes insufficient for pain control at home, pharmacologic methods can then be addressed.
Although physicians and advanced practice providers write the prescriptions, it is the nurses who most often provide medication education to patients at the time of discharge. It is therefore the nurse’s responsibility to ensure adequate patient education and to stress the dangers of taking opioids to their patients—even before they ever start taking the medication. Now more than ever researchers are discovering that a single exposure to these dangerous medications is enough to put opioid-naive patients at risk for addiction.
Set expectations. Patients may have a right to pain control, but they also have a right to know just how many risks opioids bring. After an injury, many patients seem to think they will be instantly pain free. It is important to manage expectations that some degree of pain after an injury or illness is normal, as their body heals and recuperates. It is when the pain become unbearable that they should turn to pharmacological relief.
Discuss alternatives. After a musculoskeletal injury, other methods of pain control can be useful. Consider teaching patients to RICE (rest, ice, compress, and elevate) their injuries, and offer other methods of pain control such as distraction, positioning, massage, heat, and ice.
Lay out the risk of addiction. Narcotic drugs are very risky medications. Teach your patients that they are dangerous and may cause addiction even in small uses. Tell your patients to take the medications very sparingly, and be firm with your language. Patients trust nurses, and their cautious attitudes can affect patient perceptions and behaviors.
Review the unpleasant side effects. Opioid pain medications have a number of serious side effects and complications. Emphasize that your patient may experience sedation, constipation, dry mouth, tolerance or dependence, confusion, nausea, dizziness, or itching as a result of using the drug. Remind them that they cannot drive while taking the medication. Teach also that they may experience withdrawal symptoms after use.
Teach the symptoms of overdose and addiction. If the patient feels like they need more of the pills to feel normal or relief, this is a sign of increasing dependence and tolerance on the drug, and they should seek medical advice. If the patient has slurred speech; feels lethargic, foggy, or confused; is difficult to arouse or has loss of consciousness; or experiences a decreased respiratory rate, small pupils, or cold clammy skin, they may be experiencing an overdose and need immediate medical attention.
Nurses may think that since they do not prescribe the medications, they have no contribution to the opioid epidemic in this country. However, as some of the most trusted professionals in health care, it is the nurse’s role to properly educate, set realistic pain management expectations, and relay the serious risks of taking these medications.
Evidence-based practice. Those three words seem to be all the buzz in health care in recent years, and there is a good reason why. Evidence-based practice (EBP) is the science of our nursing care: It keeps us current, up-to-date, and providing the best care to our patients for the best reasons.
When you break EBP down to its core, it’s an approach to making decisions and providing nursing care not just on the most current research, but also on the basis of personal clinical experience. It’s the why for your nursing care, validating your decision-making for certain tasks on the basis of outcomes and research. It incorporates the most relevant studies, literature reviews, and clinical cases, but it also emphasizes observations made in your own care over the tenure of your own practice. It aims to incorporate what you and others have found to be the most effective treatments, practices, and ideas. EBP improves patient outcomes and patient safety.
How can you bring EBP to your unit?
Use the Internet
It can be as simple as a Google Scholar search, checking Up-to-Date, or reviewing some of the recent articles from your nursing specialty’s society journal. Changes are easy to implement on the unit, whether you’re a staff nurse or a manager. Do you feel that shift report is rushed or could be improved for better patient safety? Take a look at what the literature says about the topic and what the evidence supports to increase patient satisfaction, outcomes, and safety. It’s often surprising just how much information is already published on a topic you may be interested it. Would your unit benefit from a subscription to the Annual Review of Nursing Research, the Journal of Perinatal Education, or Neonatal Network? Ask your manager to subscribe, or whether your hospital system can provide physical copies for unit reference.
Start a Unit Council
Evidence-based practice is best incorporated into nursing units with a dedicated safety nurse, educator, or EBP leader. In units without such a position, clinical practice councils can be formed by any nurse on a unit to bring together a core team of individuals to tackle unit-based issues and find literature-supported solutions. It is difficult to imagine a unit leader or manager who wouldn’t welcome this type of employee engagement in both patient safety and unit success.
It is easy to be discouraged when one considers the breadth of nursing research about a given topic. But the root of evidence-based care is in the real-world, at the bedside, and on the unit. It starts with the observation of a problem, and the drive to find the best way to fix it. You don’t have to fix the problems plaguing nursing as a profession; you are just aiming to fix issues on your own unit and in your own practice.
The PICO model can help you define a clinical question you’re attempting to address. It stands for problem, intervention, comparison, and outcome. Well-built questions identify all four components when reviewing the literature on a certain topic. It can help format your study, research, and plan of attack.
Involve New Graduate Nurses
Oftentimes, the nurses most familiar with research and clinical questions are the new graduates. New graduates today are given the tools to conduct EBP research, and have been taught the most cutting-edge and up-to-date recommendations for practice available.
Below, I talk with Lisa Shine, BSN, RN, a lab and simulations instructor at a nursing school in Virginia.
What is your background in nursing?
I got my bachelor of science in nursing from Marymount University in Virginia, and then started working in an urban DC emergency department.
How did you hear about your current position as a clinical instructor?
When I was in nursing school, I told my old lab director that I would be back someday. She told me if I had one year of nursing experience she would take me to run simulations and teach labs. After a year, I walked into her office and she gave me the job.
I teach the lab portion of a course in the fundamentals of nursing, which focuses on clinical skills and development, and I run nursing simulations for medical-surgical nursing, mother-child nursing, mental health nursing, and community health.
What is challenging about the role?
It depends. I hear ” I have kids” or “I work full time to support my family” a lot. It can be difficult to teach people who have a lot going on in their personal lives.
What is rewarding?
I love that I am able to teach our future nurses how to manage various kinds of diseases, acute and chronic. Watching the “ah-ha!” moments and recognizing the growth in my students is why I continue to do this in conjunction with a full-time night shift nursing gig in one of the craziest emergency departments in the city. It is my privilege to mentor and “raise up” the next generation of nurses. I try to build good relationships with my students. I currently have a stack of recommendations I need to write—I guess that means they like me!
Who would you recommend for this position?
I think this role would be good for anyone who wants to take a more active role in the development of the new nursing workforce, or who might eventually want to become a professor. It’s great experience. You definitely must have patience and a passion for knowledge. The baby nurses need a lot of support, so you kind of need to be nurturing and warm.
What are your future plans with your career?
Eventually, I plan to go back to school to get my master’s degree. With a master’s I will be able to teach the lecture portion of the undergraduate nursing classes. Right now, though, I enjoy teaching baby nurses clinical skills, like how to drop a good IV line and put a foley catheter in a mannequin.