After learning about cultural diversity by reading a nursing textbook, five nursing students from Pennsylvania College of Technology got to go out and experience diversity firsthand. Participating in a study abroad course, students traveled to the small town of Nueva Santa Rosa, Guatemala to treat patients in a medical clinic for seven days.
The Penn College students were led by Christine B. Kavanagh, the instructor of nursing programs, and accompanied by a larger volunteer group from Glens Falls Medical Mission. Glens Falls is based in New York and leads weekly trips to the small Guatemala community twice a year to help patients who live two hours away from the nearest hospital.
During their weeklong stint at the medical clinic, the group of volunteers saw over 1,300 patients by communicating through translators. They practiced in five clinical areas including triage, dental, pediatrics, women’s health, and general medicine, providing basic screenings, treatments, medical education, fluoride for dental care, and referrals to outside specialists when needed. Students were amazed by the positivity exuded by their patients who experience a wide variety of issues, not just medical.
Penn College offers a variety of study abroad courses, but this was the first time nursing students participated in a trip. After a successful mission, they hope to offer the course and service trip to nursing students every fall. In addition to the nursing trip, Penn College also offers a course in providing dental hygiene education in the Dominican Republic.
It seems that every day there are new discoveries in the field of Alzheimer’s disease. From new treatments to ways to screen for the disease, the condition is in the news as frequently as some politicians. How reliable are these findings, though? Are they published in reputable journals and are they anything more than snake oil? Here are four of the most recent new pieces about Alzheimer’s disease and a look into how likely they are to make an impact on patients’ lives.
The News: An article published in Forbes points to a research article in the scholarly journal Nature that studies the effect of aducanumab, an antibody that has shown promise in attacking the amyloid plaques that form between nerve cells in Alzheimer’s. In a double-blind, four-year trial, the infusion of the antibody showed marked improvement in the symptoms of Alzheimer’s in those with moderate disease indicators.
The Background: The Nature research paper, though compelling, has several flaws that most Alzheimer’s trials suffer from: the sample size. This study, though well planned, only tested the antibody on 145 patients and all were pooled from the United States. Although the study points to positive responses, the research is far from becoming a treatment for Alzheimer’s.
Implications: The study into aducanumab is certainly intriguing, but it is not convincing. Although it offers hope for those with Alzheimer’s, it is not a cure just yet. A larger study is necessary to even bring this treatment into trials, let alone present it for approval by the FDA. While interesting, the breakthrough may not be the miracle cure patients are looking for.
Indicative Gene Signatures
The News: According to an article published on ScienceDaily, a group of researchers have found that younger people with a particular gene signature can show a risk for Alzheimer’s early in life. This gene signature makes parts of the brain more susceptible to the proteins that form in the condition, causing the plaques that are so devastating to the neurons when Alzheimer’s begins in earnest.
The Background: The research was conducted by the University of Cambridge, and it was published in the journal Science Advances. The researchers studied the brain tissues from 500 healthy individuals and found this gene signature common to those that are found in Alzheimer’s patients. This pattern repeated itself in the healthy brain tissue and the Alzheimer’s identified brain tissue alike, though it does not indicate why the patients with healthy brain tissue had the signature and did not have the condition.
The Implications: As with most studies, more research needs to be done to plug up the holes in this study. Why are normal brains showing the same markings as Alzheimer’s brains? Could this be a coincidence? In any case, gene therapy is in its infancy so finding genes that are indicative of Alzheimer’s, while intriguing, does not actually help cure the disease in the immediate future.
Fast-Tracking BACE Inhibitors
The News: Unfortunately, drugs to treat Alzheimer’s are difficult to come by. One drug, named AZD3293, has shown some promise in treating mild to moderate cases of the condition by reducing the amount of amyloid buildup around the neurons. Although it has been fast-tracked, it is nowhere near ready to become a treatment for Alzheimer’s, as this article in the Wall Street Journal relates.
The Background: This new drug is supported by both Eli Lilly and AstraZeneca. The two companies are rivals in the pharmaceutical industry, but since the search for a drug is so elusive, the two have teamed up. They have even agreed to split profits from the drug, which is nearly unheard of. Unfortunately, other Alzheimer’s test drugs have caused severe liver issues and other problems in humans, and none have been viable as a drug to reverse or inhibit the disease, besides Aricept and Namenda.
The Implications: Drug companies are getting closer to finding a treatment for Alzheimer’s, and this fast track is promising. It shows that the FDA is convinced enough to give the green light and allow the companies to proceed. However, the search for a treatment still remains murky, and even this fast-tracked drug can pose problems. Although it can be a bright light in the darkness of Alzheimer’s, it could be another frustrating dead end.
The News: Instead of trying one method of combating Alzheimer’s, the researchers at Sutter Neuroscience Institute in Sacramento, California, are trying as many as five different methods to treat the disease, according to an article published in the Boston Herald. Among these, the use of the intravenous immunoglobulin antibodies, the effects of vitamin D on memory, and the ethnic implications of Alzheimer’s are all under investigation. All of these research projects are ongoing, but none have yet reached the point of publication.
The Background: Although this may seem like a scattershot method of looking for a cure, it actually makes sense. The current drugs for Alzheimer’s are woefully deficient. At best, they can give the patient an extra year of memory health, but they cannot stop the relentless march of the disease. They are inadequate at best, and the frantic search for some treatment means that this sort of research is the only way the medical profession is going to find something that works.
The Implications: Something in these research studies in Sacramento may end up being the cure for Alzheimer’s, or it may end up being something that slows its progress . . . or it may end up another dead end. The implication of this sort of study is the hope for a cure. It isn’t going to help patients now, and it probably won’t help patients in the near future. Someday, though, this sort of research will help patients. With the dedication of people like the researchers in Sacramento and across the country, a solution will eventually be found. It hasn’t been found yet, but everyone still keeps looking. That’s what counts.
A Day in the Life of a Nephrology Nurse
In honor of Nephrology Nurses Week, we wanted to give readers a peak into the daily life of nephrology nurses. Of course, especially in nursing, days can be quite different depending on the patients you’re serving or what department you’re working in. For the following three nurses, though, they’ve presented a glimpse of a typical day in nephrology.
Cindy Richards, BSN, RN, CNN Immediate Past President, American Nephrology Nurses Association Pediatric Renal Transplant Coordinator, Children’s of Alabama, Birmingham, Alabama
“The day in the life of a nephrology nurse can vary greatly! Nephrology nurses are more than just technical experts. There are many areas of knowledge that nephrology nurses provide to their patients other than just the technical aspects of dialysis care. Some of those may include the roles of caregiver, advocate, educator, facilitator, and mentor. Nephrology nurses may provide care in a hospital, a physician’s office, a dialysis unit, a nursing home, a prison, or a university. In fact, one of the best aspects of the specialty is the diversity of nephrology nursing roles and settings. Nephrology nurses can also help provide care to patients anywhere along the spectrum of renal disease. Chronic kidney disease (CKD) is listed in stages from 1 to 5, so nurses can work with patients anywhere on that continuum. Nephrology nurses’ responsibilities vary based on the setting. In an outpatient dialysis unit, the nurse is responsible for providing the dialysis therapy as ordered by the physician or nurse practitioner, as well as educating patients about their disease, their diet, their medications, and a host of other areas. If the patient chooses a home dialysis therapy, the nurse is responsible for teaching the patient and his or her family members how to perform that therapy in their home. In an inpatient hospital unit, the nurse is responsible for providing the acute care to help the patient recuperate sufficiently to be discharged home. A transplant coordinator is responsible for educating a patient about transplantation, coordinating a team to perform an evaluation to assess for suitability for transplant, and education and support after the transplant.”
Denise Delos Santos, RN, BSN Hemodialysis Nurse, Morristown Medical Center for Renal Ventures, Morristown, New Jersey
“Hemodialysis nurses provide care to patients with chronic kidney disease requiring hemodialysis. Hemodialysis involves teamwork, in which nurses work with certified hemodialysis technicians in giving direct patient care and coordinate their care with the health care team (nephrologists, dietitian, social worker, etc.). Hemodialysis nursing skills involve not only teamwork, but good assessment skills, technical skills, therapeutic communication, collaborative skills, documentation skills, good attention to detail, and leadership qualities. Patients receive dialysis three times a week; patients receive their treatment on a Monday-Wednesday-Friday schedule or Tuesday-Thursday-Saturday schedule. My day begins with arriving to the unit upon opening at 6 a.m. and ensuring all safety checks with the water treatment and dialysis machines/equipment were completed by the certified hemodialysis technicians. First shift patients are assessed upon arrival at their scheduled times. In our unit, one nurse is assigned to work with one technician to care for our ‘chair side’ stations, and the other nurse is assigned with another technician to the ‘bed side’ stations. After I perform the patient assessment and document accordingly in our computer system, we weigh the patient and calculate the goal of fluid removal for the treatment. We then proceed to initiate dialysis treatment. We monitor the patients during treatment, obtaining vital signs every half hour, and discontinue treatment when completed. Post-dialysis, we assure that the patients’ vital signs are stable, patients have been weighed, and they are safely escorted out of the unit. We then clean and disinfect each station before the next shift’s patient arrives. Hemodialysis nurses must monitor patients during treatment, assure dialysis prescription is followed per MD order, administer prescribed medications, ensure vital signs are stable before treatment and before discharging from the unit, coordinate with MDs as needed, refer patients to MDs, dietitian, or social worker as needed, refer patients to vascular access center to implement ‘fistula first,’ provide patient education, monitor patients’ monthly lab results, adjust dialysis medications per company protocol, etc. At the end of the work day, we make sure that the unit is tidied up and that all equipment was disinfected and ready for use for the following day.”
Joana Rengstorf, RN-BC, CMSRN, ONC Charge Nurse, Regions Hospital, St. Paul, Minnesota
“As a charge nurse in an acute care setting, I begin my shift getting report from the previous charge nurse. We discuss each patient’s needs and plan of care. We review staff assignments for the shift and discuss which staff may need more support based on their patients’ needs as well as the level of experience and proficiency of the staff working. After charge report, I complete chart reviews on all patients on my unit. I review lab results, nursing and provider notes, orders, and their daily schedule (peritoneal dialysis vs hemodialysis vs diagnostic procedures). I then round on each patient on the unit with the staff nurse to review the plan of care and discuss any questions I may have with the staff nurse. If there are urgent needs or questions, I assist the nurses with patient cares or by contacting providers. I then participate in multidisciplinary rounds and discuss treatment plans, help address any difficulty with patient compliance, and review discharge plans. Throughout the shift I provide support and education to staff nurses as needed.”
Because nephrology nurses often work with their patients for months or years, Richards says the biggest challenge is making sure not to cross professional boundaries and maintaining appropriate relationships with people they may see as extended family. For Delos Santos, the challenge is to work with patient compliance. “Patients are expected to comply with their fluid, dietary, and medication regimens,” she says. Despite this, many remain noncompliant, which leads to hospitalization and even death. Rengstorf agrees that noncompliance is an issue. For nurses, it’s also tough to maintain a healthy work-life balance, as working with patients with chronic illness can be difficult. Patients can feel frustrated and have expectations that can take a toll on their mental health and coping skills. This can lead to caregiver fatigue.
“My favorite part of being a nephrology nurse is getting to know the patients and working with my team,” says Delos Santos. “We are a big part of their lives as we are their ‘lifeline’ in providing dialysis. I believe that creating an environment of comfort and feeling at home is an important part of what we do.” “I love working with patients and their families over many months and years. As nephrology nurses, we get to assist the patient with attempting to achieve the highest quality of life they can attain,” explains Richards. “It’s also rewarding to help patients to stay healthy on dialysis in an attempt to receive a kidney transplant and transition from chronic dialysis therapy to a more normal lifestyle with a transplant or to help a patient stay as healthy as possible in order to delay the start of dialysis therapy.” Rengstorf loves her job as well. “It’s rewarding to know the care you provide is literally life-saving. When patients share stories about milestones and celebrations they were able to participate in, it is rewarding to know they are alive for those moments because of the dedication of those in my profession.”
Bill Warner, a concrete mixer driver in North Carolina, had always been a “strong” and “innovative” man, according to his wife, Carla. But after undergoing a routine endoscopic procedure at a local hospital in early 2013, the once robust 55-year-old developed a raging infection—a superbug—that rendered him “unable to do even the simplest tasks for himself,” his widow recounted last year in testimony before the U.S. Food and Drug Administration.
Warner, it turns out, had contracted Carbapenem-resistant Enterobacteriaceae, or CRE, a highly resistant bacteria that kills up to half of patients infected with it. The superbug ravaged Warner’s body. He lost more than 60 pounds, required tube feedings and was racked with excruciating pain. In November of 2013, after eight months of battling the infection, he died.
Drug-resistant organisms like the one that killed Warner are on the rise—and health officials warn that lethal infections will become more widespread unless the health care community takes aggressive action. Fueled in part by the overuse and misuse of antibiotics, drug-resistant germs cause more than 2 million illnesses and kill at least 23,000 Americans every year, according to the Centers for Disease Control and Prevention (CDC). Cases of Klebsiella pneumoniae carbapenemase (KPC), the most common type of CRE, have increased sevenfold over the past decade.
With a shrinking arsenal of antibiotics to combat these virulent infections, and a scarcity of new drugs in the development pipeline, health care officials warn that superbugs could lead to a global crisis. At the rate things are going, superbugs could kill 10 million people a year worldwide by 2050, according to one recent report on antimicrobial resistance backed by the British government.
The good news is that infection control experts say there is still time to act. Edward Septimus, MD, the medical director of infection prevention and epidemiology at HCA and a professor at Texas A&M Medical School, told attendees of last year’s international Infection Prevention Society (IPS) conference that the world is at a “tipping point.” With proper infection prevention strategies and better antimicrobial stewardship, he says, it’s still possible to slow the spread of supergerms, but “if we don’t take these warning signs seriously, we are going to be headed into a full-blown crisis.”
With that in mind, here’s a look at the three antibiotic-resistant pathogens that the CDC has classified as the most “urgent threats” and information on what nurses can do to help combat the problem.
Carbapenem-resistant Enterobacteriaceae (CRE)
The Threat: This so-called “nightmare” bug is not just one germ, but actually several different strains of bacteria within the Enterobacteriaceae family, which live in the gut. What all CREs have in common—and what makes them different from “normal” species of Enterobacteriaceae—is that they are resistant to carbapenems, powerful antibiotics generally reserved as “last-line” agents for the gravely ill. This leaves clinicians with few options in treating such infections. Symptoms vary, but CRE can cause sepsis, pneumonia, meningitis, and urinary tract and wound infections. Immunocompromised patients, and those being treated with invasive devices, such as central lines, urinary catheters, and mechanical ventilation, are more susceptible to illness.
Danger Zones: While CRE has been reported in most states, the pathogen—at least for now—is mostly confined to acute care hospital settings. Long-term acute care facilities are especially good at incubating the microbe. During the first half of 2012, 4% of short stay-hospitals reported a CRE infection, compared to 18% of long-term facilities, according to a 2013 CDC Morbidity and Mortality Weekly Report. Several CRE outbreaks around the country have been traced to a contaminated duodenoscope used in an endoscopic retrograde cholangiopancreatography (ERCP) procedure, which is used to diagnose and treat problems in the pancreas and bile ducts. Rooms of infected patients are also a breeding ground for CRE. The most contaminated areas include bedside tables, infusion pumps, and sheet surfaces that surround a patient’s pillow, legs and “crotch,” according to a 2013 study in the Journal of Clinical Microbiology.
What You Can Do: Hand hygiene is the number one way to prevent CRE infections and personal protective equipment should be used when caring for patients. Identifying infected patients early is also key. Hospitals should take pre-emptive precautions for patients transferred from high-risk facilities—and once a patient is found to have CRE, contact precautions should be initiated. Ideally, patients should be isolated in a single room. If that’s not possible, patients and staff should be “cohorted” to reduce the risk of transmission. There’s also growing evidence that bathing CRE-positive patients with antiseptic washes like Chlorhexidine can reduce contamination.
Clostridium difficile (C. difficile)
The Threat: This aggressive intestinal bug causes half a million infections in the United States each year and is responsible for one-third of all health care infections, according to the CDC. Toxins produced by C. difficile damage the lining of the intestine and lead to explosive and watery diarrhea. Older age, recent antibiotic use, and immune system dysfunction are all risk factors for developing C. difficile. The infection can be stubbornly difficult to eradicate and relapses are common.
Danger Zones: While some infections are occurring in the community, the vast majority of cases are contracted in health care facilities. Studies have shown that the hearty C. difficile spores can persist for up to five months on hard surfaces in hospital rooms. Hot spots for contamination include floors and bedrails—but windowsills, toilets, call buttons, telephones, and other objects also harbor the germ. C. difficile spores are often spread to other patients on the hands of nurses and other health care providers.
What You Can Do: Frequent handwashing with soap and water is the number one way to reduce the spread of C. difficile, as alcohol-based hand sanitizers DO NOT kill the bug. Patients should also be placed on contact precautions in single rooms. All visitors and caretakers should wear disposable gloves and gowns when entering a patient’s room, according to the CDC, and rooms should be cleaned daily with bleach or another EPA-approved spore-killing disinfectant.
Neisseria gonorrhoeae (N. gonorrhoeae)
The Threat: In 2006, there were five different treatment options for this common sexually transmitted disease. Today, the CDC warns, there is only one effective class of antibiotics left to treat gonorrhea—the cephalosporins—and new strains emerging in Japan, England, and other countries have proved to be impervious even to those treatments. Currently, the CDC recommends dual therapy for patients—an oral dose of azithromycin and single shot of ceftriaxone—and it is still “highly effective” here in the United States. Gonorrhea can be insidious, though, and women, in particular, may be asymptomatic. When symptoms do occur, they may experience vaginal discharge, abdominal pain, and painful urination. Men frequently present with burning pain upon urination and a purulent urethral discharge. Infection can also occur in throat and rectum.
Danger Zones: Unlike the other two pathogens mentioned in this article, drug-resistant gonorrhea is flourishing in the community—not the hospital. While anyone sexually active is at risk, gonorrhea is common among younger people, between 15 and 24 years of age, and disproportionately affects racial and ethnic minorities as well as men who have sex with men (MSM).
What You Can Do: Candy Hadsall, RN, MA, an STD nurse specialist with the Minnesota Department of Health, says the most important thing nurses can do is stay up to date on the latest CDC treatment guidelines and share the information with their colleagues. Infections should be treated right away with the two medications listed above—and treatment of sexual partners is also a top priority. More than three dozen states, including Minnesota, also provide “expedited partner therapy,” which allows providers to send patients home with a prescription to treat their sexual partners, though it’s still best for individuals to see a clinician so they can receive the IM injection that is most effective in curing the infection. Be sure to instruct patients to complete the entire prescription and to return for retesting by culture and antibiotic susceptibility testing if symptoms persist. Treatment failures should be reported to the health department. Sexually active MSM and women with new and/or multiple partners, or a partner with an STD, should be tested at least once a year for gonorrhea.
Nurse practitioners applaud recent enactment of legislation that empowers them to better address the nation’s opioid crisis.
The Comprehensive Addiction and Recovery Act (CARA) of 2016 gives nurse practitioners the ability to prescribe buprenorphine, a medication for the treatment of addiction to opioids, such as heroin or prescription painkillers. It can quell withdrawal symptoms, reduce cravings, and lower the risk of relapse.
The Act also seeks to increase the access of naloxone to first responders and law enforcement in order to reverse the effects of opioids.
Federal officials have called opioid addiction a national crisis.
Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids, according to the Centers for Disease Control and Prevention.
“[The American Association of Nurse Practitioners] has been very supportive of this legislation to increase access to care for these patients,” says Anne Norman, DNP, APRN, FNP-BC, FAANP, vice president of education at the AANP.
“We are pleased that appropriately trained and educated NPs will be allowed to prescribe the necessary medications for these patients according to their state prescribing regulations and…contribute to the reduction of drug overdose deaths,” Norman says.
Allowing NPs to “treat addiction is a novel solution to bridge the gap in medication-assisted treatment for addiction,” says Peggie Powell, MSN, APRN, FNP-BC, a family nurse practitioner at VCU Health Community Memorial Hospital Pain Management Services in South Hill, Virginia, an affiliate of Virginia Commonwealth University.
“Educating patients about their addiction and the need for self-care are very much within the scope of practice for nurse practitioners. The Act empowers NPs to practice to their full extent, but it also increases access to medication-assisted treatment for those in need,” says Powell, a nurse for 23 years, the last 13 working as a NP.
CARA’s enactment extends prescriptive authority to advanced practice registered nurses such as women’s health nurse practitioners. “This is particularly significant as opioid use in pregnancy can have profound implications for both maternal and infant death,” says Susan Kendig, JD, MSN, WHNP-BC, FAANP, director of policy of the National Association of Nurse Practitioners in Women’s Health (NANPWH).
“When buprenorphine is utilized under careful supervision, pregnant women who are affected by substance abuse disorders have a mechanism to address their addiction while working to achieve a healthy pregnancy outcome. WHNPs often work side by side with our colleagues in OB/GYN and maternal fetal medicine in co-managing these conditions,” Kendig says. “Extension of prescriptive authority for buprenorphine to WHNPs can help to improve access to important care for women.”
Studies show that buprenorphine, a form of medication-assisted treatment, cut the risk of death in half from all causes—from overdoses to car accidents.
Educating the Public
Nurses are in a good position to help educate the public about opioid abuse since they practice in a variety of settings, from schools and clinics to home visiting agencies and community-based settings where “they are the face of health care and may indeed be the only health care provider interacting with an individual at any given time,” says Kendig. “This provides opportunity for assessment, education, and referral for opioid use and misuse.”
Nurses help the public learn the signs and symptoms of opioid abuse, which include sedation, slurred speech, itching, euphoria, constricted pupils, mood changes, and difficulty meeting work or school obligations. Signs of withdrawal include anxiety, nausea, and inability to sleep.
Nurses also teach the public how to safely store opioid pain medication and properly dispose unused opioids. “Never give or sell [it] to others as this is a felony, but also unsafe,” explains Powell.
“Educating the public about the signs and symptoms of opioid abuse is one of the best things we can do as nurses,” says Lorraine Byrnes, PhD, RN, FNP-BC, PMHNP-BC, FAANP, CNM, an associate professor and director of the undergraduate nursing program at Hunter-Bellevue School of Nursing.
“We must also advocate for access to treatment programs that use an evidence-based approach to treatment, which is essential in addressing this public health crisis. Community access and education about naloxone to reverse the effects of a drug overdose and save lives is a critical element in treating opioid abuse. We must also avoid stigmatizing opioid addiction by providing patient-centered care that meets the long-term and short-term needs of our patients and their families,” says Byrnes, who serves on the board of NANPWH.
To help reduce the opioid epidemic, patients treated with opioids must use the medication for a limited time to prevent dependence, opioid addiction must be treated as a chronic condition, and the stigma of addiction must be eliminated, nurse practitioners say.
“Although everyone who uses pain medication will not become addicted, we do know enough about how genetics, temperament, environment, and personal situation to develop individualized, tailored treatment plans for those who may become addicted,” says Byrnes. “Education in the proper use of opioids to manage pain must occur among prescribers and alternatives must be part of every pain management plan.”
Counseling is another crucial recovery component as well as the availability of naloxone without a prescription to families and communities dealing with addiction, says Byrnes.
Powell agrees that “Increasing access to naloxone and providing training on its proper use can save lives. Nurses, pharmacists, and nurse practitioners can be instrumental in educating the public on all these aspects.”
Other changes to address the epidemic include policy changes in insurance and medication drug coverage to reduce the opioid load in the public arena, says Powell. Insurance companies need to include abuse-resistant opioid formulations on their formulary and provide coverage for abuse-resistant opioids for chronic pain.
A Doctorate of Nursing Practice (DNP) student at VCU School of Nursing, Powell’s DNP project focuses on opioid safety in patients on chronic opioid therapy. She recently published an article on opioid safety on the Physician-Patient Alliance for Health & Safety blog.
Prescription opioid related deaths have quadrupled since 1999 in the United States and approximately 80% of deaths are due to unintentional overdose, according to Powell.
“In 2014, opioid overdose death from prescription opioids increased to approximately 19,000 deaths in the United States; this is more than three times the number reported in 2001,” she wrote. “Such statistics are staggering and indicate a need for action to help curb this epidemic. Utilization of risk assessment tools and mitigation strategies to detect and reduce the risk of opioid overdose are needed in clinical practice.”
The only tool that provides an actual quantitative score of opioid overdose risk is the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD).
“I plan to utilize the RIOSORD to determine each patient’s risk of possible accidental overdose or serious opioid induced respiratory depression,” Powell says. “Patients determined to be ‘high risk’ will be given a prescription for naloxone that can be used in an opioid-related emergency to prevent death. The aim is to increase naloxone-prescribing practices among the providers at my clinic.
“Use of this tool will provide a quantitative risk stratification that is based on the patient’s medical history, opioid formulation, morphine equivalent dose, and the presence of concurrent prescriptions for benzodiazepines or antidepressants.”
“Every day, 78 Americans die from opioid overdoses,” President Obama said when he signed the CARA legislation into law this summer.
Among those ages 12 to 25, illegal opioid use more than doubled between 1991 and 2012. Yet nine out of 10 of drug-addicted youth ages 12 to 17 receive no treatment at all, according to the 2012 National Survey on Drug Use and Health.
Nora Volkow, MD, director of the National Institute on Drug Abuse, has called prescriptions such as buprenorphine “an essential component of an ongoing treatment plan” that allow people to “regain control of their health and lives,” according to USA Today.
Nurses are in a unique position to help patients reap the analgesic benefit of opioids without encountering the dangers since they are experts in non-pharmacological interventions to manage pain, including the use of mental imagery and relation therapy, nurse practitioners say.
Nurse practitioners, Powell says, are among the best qualified health professionals to help patients dealing with pain and addiction. “We are vigilant in our monitoring; we are able to demonstrate empathy, but also ensure compliance with safe use; and we focus on educating the patient on the risks as well as possible benefits of opioid use,” she adds.
The patient who watches the clock and requests their pain medication at the top of hour. The patient who always rates their pain a “10” out of 10. The patient who requests a specific narcotic like Dilaudid. Some nurses might view such behavior as red flags and will label those patients as potential “drug seekers”—but pain management experts like Bobbie Norris, BSN, RN, CNRN, BC-RN, a pain resource nurse at Johns Hopkins Department of Neurology and Neurosurgery in Maryland, says nurses who jump to those conclusions are often wrong and do a disservice to their patients.
The patient specifically asking for Dilaudid, for instance, isn’t necessarily an addict. In fact, a patient returning to the hospital for his umpteenth surgery most likely is an expert on what medications work best for him. “Just because a patient knows what works for them, that doesn’t mean they’re drug-seeking,” says Norris.
Susan McMillan, PhD, ARNP, FAAN, a nursing professor at the University of South Florida who has researched pain in oncology patients, echoes Norris’ concerns. “Nurses today are very concerned about drug-seeking,” she says, recalling a study in which nurses were asked what made them decide if a patient was “drug-seeking,” as opposed to suffering. “Their answers were: ‘If their pain was unrelieved, if it’s overwhelming, or if they ask too frequently,’” says McMillan, though in reality, each of those behaviors is an indicator that a patient’s pain is not being well managed.
Indeed, if Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are an effective measurement, patients are not getting enough pain relief during their hospital stays. According to HCAHPS patient survey data, only 71% of those surveyed said their pain was “always” well controlled in 2014-2015. Other studies, meanwhile, show that pain is often undertreated in pediatric patients, in older adults in long-term care, and among certain minority populations.
Experts believe the highly publicized global epidemic of opiod abuse is likely contributing to the conundrum. Nurses and other members of the health care team may worry about patient addiction and tolerance. Patients, too, often worry about addiction and side effects. As a consequence, some are reluctant to take pain medications or even report their pain.
Unrelieved pain, however, can cause serious problems and ultimately jeopardize an individual’s recovery from surgery or illness. Patients with poorly controlled pain are less likely to walk around and breath deeply, increasing their risk for atelectasis and other complications of immobility. Not addressing a patient’s pain also opens a nurse up to legal liability.
Experts say that nurses can better serve their patients by following these five strategies:
1. Believe Your Patient
Margo McCaffrey transformed the nursing profession’s approach to pain management when she declared in 1968 that pain is “whatever the experiencing person says it is, existing whenever he says it does.” While that’s the prevailing philosophy nurses learn in school, it doesn’t always carry over into clinical practice. “Nurses will say to me, ‘They can’t be in this much pain. Their blood pressure’s not up. They’re not tachycardic, they’re not tachypneic,’” says Norris. In fact, patients who’ve suffered from chronic pain for many years often show no objective systemic signs of distress because their central nervous system has “autoregulated.” While the risk of addiction is a valid concern, it does not negate the RN’s responsibility to accept the patient’s report of pain and respond to it with compassion and prompt intervention.
2. Better Monitoring
Measuring pain is an integral part of managing it. That’s why the VA developed an initiative in the 1990s to promote pain as the “fifth vital sign.” The concept of measuring pain as a vital sign—along with heart rate and blood pressure—was intended to get health care professionals in the habit of routinely screening, assessing, and documenting pain levels. One area where nurses continue to struggle, though, is with pain reassessment post-intervention. While every hospital has its own policies about when to reassess pain, ideally pain should be reevaluated at around the time it takes for a drug to reach its peak effect: that’s about 15 to 20 minutes after an IV bolus of morphine, and 60 to 90 minutes after an oral narcotic. Close monitoring also allows the RN to keep an eye on a patient’s sedation level and respiratory status and make any necessary adjustments to the patient’s treatment plan—and that should ease the anxiety of the RN who is worried about overmedicating their patient.
3. Expanding Therapies
Multimodal pharmacology is the optimal approach to managing pain. This means patients do better if they receive a combination of pain medications targeting different pain pathways, such as a narcotic pain reliever that directly decreases transmission of pain signals to the brain—and an NSAID to reduce swelling and inflammation at the site of injury. Drugs aren’t the only way to combat pain. Sandra Siedlecki, PhD, RN, CNS, a senior nurse scientist at Cleveland Clinic, has found that music therapy can be an effective tool to reduce chronic pain, which is notoriously difficult to treat. In fact, when patients suffering from chronic neck, back, and arm pain listened to an hour of music each day, their pain dropped by about 21% according to Siedlecki’s study published in the Journal of Advanced Nursing. A number of hospitals, including Johns Hopkins, have also introduced “Pain Control and Comfort” menus offering patients ‘a la carte’ therapies, ranging from warm packs and icepacks, to handheld fans, repositioning, stress balls, and handheld massagers. While many of the items on the menu have always been available, presenting them in this format gives the patients a feeling of “empowerment,” says Suzanne Nesbit, PharmD, CPE, a clinical pharmacy specialist and pain management research associate at Johns Hopkins.
4. A Tailored Approach
Patients don’t just differ in how they feel pain—they also differ in their response to pain medications. For example, studies have shown that approximately one-third of patients with cancer-related pain don’t respond well to morphine and develop intolerable adverse effects or fail to get any significant pain relief. Researchers, however, are beginning to unravel some of the mysteries of pain and providing scientific explanations for idiosyncrasies in drug response. Genetic variability in the cytochrome P450 (CYP450) system, the enzyme system in the liver that breaks down medications, can dramatically influence how well a drug works. If a CYP450 enzyme metabolizes a medication too quickly, for instance, the patient might require a higher dose for effective pain relief. If the patient’s CYP450 system is sluggish, they might require a smaller dose, otherwise toxicity can occur. Age, gender, and lifestyle can also impact drug response. In the future, hospitals will use genetic testing to help personally tailor pain treatment regimens for patients. Until then, nurses will have to rely on their assessment skills and clinical judgment to implement pain interventions adapted to each patient’s needs.
5. Examine Bias
Research has shown that ethnic minorities are routinely and systemically undertreated for pain when compared to white patients. One study by researchers at Emory University found that 43% of African American patients presenting at an Atlanta emergency department with long bone fractures received no pain medications. By contrast, only 26% of white patients with the same injuries “went untreated for pain.” A 2015 study published in JAMA Pediatrics found that black children with appendicitis were 20% less likely than white children to receive painkillers in the ED. A 2016 study by the University of Virginia on the topic attributed the disparate treatment to erroneous beliefs about biological differences among the two races. Awareness and acknowledgment that such bias exists is a first step to rooting out unconscious bias. The Joint Commission also recommends health care providers perform “teach back,” utilize educational and training techniques to “de-bias” care, and “assiduously” practice evidence-based medicine.