Features

Improving nurses’ attitudes toward patients with substance use disorders

Editor’s note: The author uses substance use disorder as a diagnostic term. However, some of the research he cites uses a different term, such as drug addiction or drug misuse. In those cases, to ensure an accurate description of the study, he retains the specific terminology of that study.

People with substance use disorders suffer not just from the disorder itself but also from discrimination. In a 2014 survey, more than half of respondents said treatment options for people with drug addiction (the survey’s term) aren’t effective—and nearly half opposed increasing government spending on treatment. What’s more, almost two-thirds believed discrimination toward people with drug addiction isn’t a serious problem and 43% opposed equivalent insurance benefits for drug addiction. The overwhelming majority (78%) said they wouldn’t work closely with someone with a drug addiction.

The survey highlights stigmas and stereotypes related to substance use disorders, as well biased attitudes toward people with these problems. (See Key facts about substance use.) Even many nurses and other healthcare professionals have negative attitudes, which may contribute to suboptimal care or create barriers to care.

Exploring nurses’ attitudes

Nurses see patients with substance use disorders in emergency departments (EDs) and many other settings. In 2009, almost 1 million visits to public nonfederal EDs involved use of an illicit drug; the total number of drug-related ED visits was estimated at 4.6 million.

Like the general public, many nurses think poorly of people with substance use disorder. Substance use can cause not only physical signs and symptoms but also behavioral dysregulation that may be beyond the person’s control.

Nursing literature describes a variety of nurses’ attitudes and feelings toward patients with substance use disorders, including:

• intolerance

• anger

• distrust

• powerlessness

• anxiety

• feelings of being manipulated by these patients

• frustration, futility, and disappointment related to patient relapse and recidivism.

A longitudinal review of the literature on nurses’ attitudes revealed many nurses across three decades believed treatment for substance use disorders was hopeless and “misusers” (the study authors’ term) were irresponsible. However, surveys from recent years showed nurses’ attitudes have improved over three decades, becoming more positive and less condemnatory. Also, younger respondents with more education are likely to be optimistic about the treatment of alcohol use disorders specifically. As the next generation of nurses enters the workforce, this is good news.

A fairly recent review from Australia showed that nurses’ attitudes toward patients with problem alcohol use improved over time. Study authors noted that “on average, the nurses had neutral to positive attitudes regarding alcohol problems, which is encouraging compared to the predominantly negative views uncovered by research from the 1980s and 1990s.”

But nurses’ perspectives on patients with substance use disorders aren’t defined by straightforward improvement. The picture is more complex, with dissonance between what nurses value and how they feel and behave. The authors of the longitudinal review cited above noted that although nurses’ attitudes improved over time, “a significant minority…continued to stereotype alcohol and drug misusers negatively.” Authors of the Australian review found consistent pessimism in a solid minority of nurses, including 14% who didn’t want to work with patients who are “drinkers” and 12.5% who found little reward in working with people with alcohol problems. (See Vicious cycle: Knowledge deficit, poor care, escalating demands.)

Even in the context of negative perceptions of patients with substance use disorders, nurses can simultaneously feel sympathetic concern and an ethical duty to care for them. They may experience their ambivalent feelings as internal struggles, feeling frustrated even as they strive to understand patient suffering and focus on patient strengths and the possibility of a better future.

Why nurses have negative feelings, and what can be done

Nurses consistently say lack of knowledge or competence in caring for patients with substance use disorders contributes to their negative feelings, including powerlessness and anxiety. A 2014 qualitative study found nurses believed they lacked knowledge of substance abuse and dependence, which caused “a disconnect in their ability to care for patients with both physiologic and psychiatric disorders.” This knowledge deficit can perpetuate suboptimal care, and nurses recognize this.

One thing is clear: Nurses must become more knowledgeable about substance use disorders to care for patients effectively. Few have had adequate, if any, educational preparation in substance use disorders. Yet education can lead  not just to more effective care but also to improved attitudes. In one comparative study, undergraduate nurses received 16 hours of substance- use education that included theory, epidemiology, identification of alcohol-related harms, and nursing-care elements (such as patient education, counseling, brief interventions, and motivational interviewing). This education led to greater knowledge and improved attitudes toward working with patientswho had alcohol problems— specifically in students’ ability to help them. It also increased their personal and professional satisfaction in this work. Other studies show that even brief educational programs that focus on treating substance use disorders can improve nurses’ knowledge, confidence, and attitudes.

Beyond education

But education alone isn’t enough. Nurses also need support. A 2014 study of hospital-based medicalsurgical nurses who’d received 10 hours of drug and alcohol education plus role support found they had better therapeutic attitudes when working with patients who had substance use disorders. The strongest factor related to this improvement was having someone to collaborate with in creating the plan of care.

A cross-sectional survey of generalist nurses in Australia found role support was the strongest driver of nurses’ therapeutic attitude and that workplace educationon illicit drug use was useful only when combined with role support. Other studies identify education, training, and support as key factors in improving providers’ attitudes toward patients with substance use disorders.

Of course, other healthcare professionals also need more than just education to improve their attitudes and to reduce patient stigmatization. In the 1990s, all healthcare professions began using a disease model of substance use disorders. Providers generally are knowledgeable and confident when it comes to disease models of illness and care. Yet while the paradigm has shifted to some degree, an attitude shift didn’t follow. Perhaps this shows that personal and institutional stigmas are slow to change, even as care structures evolve.

Resources for change

In nursing, we can identify numerous resources for support in caring for patients with substance use disorders. Unit or system educators, such as clinical nurse specialists, can design specific support programs based on patient and provider needs. Those helping to improve nurses’ attitudes (and care outcomes) toward patients with substance use disorders should investigate available support options to treat patients effectively. Ideally, they should identify local champions who have, or can pursue, addictions certification from the International Nurses Society on Addictions (IntNSA) at the registered nurse (RN) or advanced practice RN level. Also, the Providers’ Clinical Support System for Medication Assisted Treatment, a joint project of numerous substance use treatment organizations, has a mentoring program that includes nurse mentorsIn addition, the American Psychiatric Nurses Association has an addictions council and offers many online resources. (See Resources for support, information, and education.)

Many effective evidence-based treatments for substance use disorders exist and can be applied to excellent effect. The Affordable Care Act and the 2016 federal  budget created additional opportunities to devote public funds toward effective treatments.

Patients with substance use disorders can—and do—get better every day. According to the Kaiser Family Foundation, nurses in the United States (including both RNs and licensed practical nurses) number approximately 3.96 million. We represent the largest healthcare workforce in the country. By pursuing education and support in treating patients with substance use disorders, we can lead the way in reducing stigmas and discrimination.

But we can improve more than just our attitudes. Let’s also improve treatment for patients with substance use disorders. Our patients need and deserve it.

Matthew Tierney is an associate clinical professor in the Department of Community Health Systems of the University of California, San Francisco School of Nursing.

Selected references

Barry CL, McGinty EE, Pescosolido BA, Goldman HH. Stigma, discrimination, treatment effectiveness, and policy: public views about drug addiction and mental illness. Psychiatr Serv. 2014;65(10):1269-72.

Bartlett R, Brown L, Shattell M, Wright T, Lewallen L. Harm reduction: compassionate care of persons with addictions. Medsurg Nurs. 2013;22(6):349-53,358.

Cherpitel CJ, Ye Y. Drug use and problem drinking associated with primary care and emergency room utilization in the US general population: data from the 2005 national alcohol survey. Drug Alcohol Depend2008;97(3):226-30.

Crapanzano K, Vath RJ, Fisher D. Reducing stigma towards substance users through an educational intervention: harder than it looks. Acad Psychiatry. 2014;38(4):420-5.

Crothers CE, Dorrian J. Determinants of nurses’ attitudes toward the care of patients with alcohol problems. ISRN Nurs. 2011;2011:821514

Ford R, Bammer G, Becker N. The determinants of nurses’ therapeutic attitude to patients who use illicit drugs and implications for workforce development. J Clin Nurs. 2008;17(18):2452-62.

Howard MO, Chung SS. Nurses’ attitudes toward substance misusers. I. Surveys. Subst Use Misuse. 2000;35(3):347-65.

Johansson L, Wiklund-Gustin L. The multifaceted vigilance—nurses’ experiences of caring encounters with patients suffering from substance use disorder. Scand J Caring Sci. 2016;30(2):303-11.

Junqueira MA, Rassool GH, Santos MA, Pillon SC. The impact of an educational program in brief interventions for alcohol problems on undergraduate nursing students: a Brazilian context. J Addict Nurs. 2015;26(3): 129-35.

Kaiser Family Foundation. Total number of professionally active nurses. April 2016.

Monks R, Topping A, Newell R. The dissonant care management of illicit drug users in medical wards, the views of nurses and patients: a grounded theory study. J Adv Nurs. 2013;69(4):935-46.

Neville K, Roan N. Challenges in nursing practice: nurses’ perceptions in caring for hospitalized medical-surgical patients with substance abuse/dependence. J Nurs Adm. 2014;44(6):339-46.

Pescosolido BA, Martin JK, Long JS, et al. “A disease like any other”? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. Am J Psychiatry. 2010;167(11):1321-30.

Rassool GH, Rawaf S. Predictors of educational outcomes of undergraduate nursing students in alcohol and drug education. Nurse Educ Today. 2008;28(6):691-701.

Savage C, Dyehouse J, Marcus M. Alcohol and health content in nursing baccalaureate degree curricula. J Addictions Nurs. 2014;25(1):28-34.

Substance Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality. Results from the 2015 National Survey on Drug Use and Health: Detailed Tables. September 8, 2016.

Substance Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. February 22, 2013.

van Boekel LC, Brouwers EP, van Weeghel J, Garretsen HF. Healthcare professionals’ regard towards working with patients with substance use disorders: comparison of primary care, general psychiatry, and specialist addiction services. Drug Alcohol Depend. 2014;134:92-8.

van Boekel LC, Brouwers EP, van Weeghel J, Garretsen HF. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend. 2013;131(1-2):23-35.

Frailty syndrome: A weakly addressed problem

Fran Covington, age 82, has a history of cardiovascular disease, chronic diastolic heart failure, type 2 diabetes, and chronic obstructive pulmonary disease (COPD). She lives at home with her husband and enjoys gardening and visiting with her grandchildren.

Like Mrs. Covington, Myrna Wilson is age 82 with cardiovascular disease and a history of chronic diastolic heart failure, type 2 diabetes, and COPD. She lives in a skilled nursing facility and requires assistance with all routine daily activities. She complains of progressive physical decline and weakness and has lost 12 lb unintentionally in the past year.

Although these women are the same age with the same major comorbid conditions, one is active and independent while the other shows functional decline. What explains the striking difference between them? Most likely, the answer is frailty syndrome.

Distinctly different from general disability and multimorbidity, frailty syndrome is characterized by signs and symptoms common in patients identified as frail. The condition is linked to various comorbid conditions—specifically, cardiovascular and pulmonary diseases and diabetes.

Frailty syndrome remains underrecognized, even though it’s associated with functional decline and costly adverse health events in older adults, such as disability, hospitalization, falls, fractures, and deaths. It’s strongly linked to lack of resilience and decreased ability to adapt to physical stressors, as well as a higher risk of peri- and postoperative complications, including prolonged mechanical ventilation and longer stays after elective surgeries. Recent literature  describes frailty as causing a domino effect because of the high potential for a cyclic cascade of adverse health-related events once an elderly adult becomes frail.

Epidemiology

Frailty is most common in adults older than age 70. Its prevalence rises substantially after age 80. Research indicates frailty is more common in elderly females, African- Americans, and persons with less education and of lower socioeconomic status.

Know that being frail isn’t synonymous with being thin or cachectic; nor is it as simple as the medical diagnosis of sarcopenia (muscle wasting). While simultaneous weight loss and muscle wasting commonly are correlated with frailty syndrome, obese persons (even, in some cases, the morbidly obese) can be frail. So when evaluating older adults for frailty syndrome, be sure to use a validated questionnaire (such as one of those described in this article).

Assessment

When asked to describe frailty syndrome, some clinicians might answer, “You know it when you see it.” But is this really true? In 2001, Fried, et al pioneered efforts to identify a clear, comprehensive definition of this previously ambiguous syndrome (some times known as failure to thrive). They identified major characteristics of frailty as unintentional weight loss of more than 10 lb within the last year, weakness, poor endurance, exhaustion, slow gait, and a selfreported feeling of exhaustion and low activity level. This landmark study generated an explosion of frailty literature. Since then, more evidence has surfaced suggesting such clinical characteristics as cognitive decline and an increased number of comorbid conditions are possible additional markers for frailty syndrome.

Screening and identification

While more research is needed on frailty syndrome, early identification and management are crucial. Yet no community-wide or population- based frailty screening recommendations exist. Although international consensus statements recommend screening every patient age 70 or older for frailty in every healthcare setting, such screening continues to be largely overlooked as a routine part of risk assessment for elderly adults across all healthcare settings. Consider, for example, the many screening tools in place for hospital admission to a medical-surgical floor: Elderly adults may be screened for physical and emotional abuse, alcohol use, tobacco use, depression, fall risk, and potential for impaired skin integrity. Yet few healthcare settings screen them for frailty.

As a nurse, you can play a leading role in screening and identifying frail patients. This role presents a tremendous opportunity for every nurse who cares for older adults to have a meaningful impact on the quality of care for this vulnerable population. For information on screening tools for frailty syndrome, see Frailty screening tools.

Treatment and recommendations for clinical practice

Although frailty is strongly associated with advancing age, we know elderly adults can enjoy life in their ’80s,’90s, and beyond without becoming frail. Based on emerging evidence, a growing number of experts believe that with early identification, frailty syndrome probably can be treated and even prevented. However, this conclusion hasn’t been firmly substantiated by scientific evidence, highlighting the need for more studies on frailty prevention and treatment, including effective interventions for managing pre-frail and frail states in elderly patients.

Given the known adverse effects of frailty, clinicians should develop treatments and interventions aimed at improving the quality of life, reducing the need for institutionalization, and decreasing overall healthcare costs. In many cases, nonpharmacologic interventions, such as physical therapy and activity programs, are primary treatment strategies to diminish the major manifestations of frailty (such as sarcopenia and falls).

Treatments

In 2012, the majority of an international consensus group agreed that four potential treatments can be used to manage frailty in older adults:

• exercise

• nutritional and protein supplementation

• vitamin D supplements

• elimination of unnecessary medications.

Exercise programs are well supported as a way to reduce adverse health events associated with frailty, including falls and hospitalizations. Because weight loss is common in frail patients, nutritional and protein supplementation is recommended. Frail adults also should receive vitamin D supplements and reduce or eliminate unnecessary medications, as appropriate. We need further research to determine more specific or advanced treatments for frailty.

Improving elders’ outcomes

Frailty in older adults has become an increasingly important topic in the medical literature, and the importance of identifying frailty is well documented. What’s more, frailty has influenced care processes in our leading healthcare delivery systems.

As nurses, we’re well positioned to implement frailty screening in our daily clinical practice to improve the health outcomes of elderly patients and help develop the weight of evidence in favor of early identification of pre-frail and frail older adults. Nurses across all settings should become involved in screening, early identification, and management of this syndrome in elderly adults.

Kristi Phillips-Burkhart is the lead structural heart team coordinator at Mount Carmel Health System in Columbus, Ohio. (Names in the scenario are fictitious.)

Selected references

Dodds R, Sayer AA. Sarcopenia and frailty: new challenges for clinical practice. Clin Med (Lond.). 2015;15(suppl 6):s88-91.

Fried LP, Tangen CM, Walston J, et al; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.

Heuberger RA. The frailty syndrome: a comprehensive review. J Nutr Gerontol Geriatr. 2011;30(4):315-68.

Kim H, Higgins PA, Canaday DH, Burant CJ, Hornick TR. Frailty assessment in the geriatric outpatient clinic. Geriatr Gerontol Int. 2014;14(1):78-83.

Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392-7.

Woo J, Leung J, Morley JE. Comparison of frailty indicators based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation. J Am Geriatr Soc. 2012;60(8):1478-86.

Xue QL. The frailty syndrome: definition and natural history. Clin Geriatr Med. 2011; 27(1):1-15.

Caring for patients with lumbar drains

A LUMBAR DRAIN is a small, flexible tube placed in the arachnoid space to drain cerebrospinal fluid (CSF). Indications for lumbar drains include:

• to drain CSF leakage secondary to a traumatic or postoperative dural fistula

• to treat a shunt infection

• to reduce intracranial pressure (ICP) during a craniotomy

• to evaluate idiopathic normal-pressure hydrocephalus.

This article explains what you need to know to provide safe, effective care for a patient with a lumbar drain.

Drain placement

Before the procedure begins, obtain informed consent according to your employer’s policies and procedures. Perform a baseline neurologic assessment and review the patient’s laboratory test results—particularly coagulation results, as bleeding is a potential complication. If ordered, administer antibiotics and sedatives. To ensure proper catheter placement, the patient must be placed in a rounded-back position to widen the intervertebral space. Help the patient into a side-lying position, with knees to chest and chin tucked to chest. (If needed, assist with holding the patient in this position during the procedure.) Alternatively, the patient may sit up and lean over a bedside table.

The physician determines the appropriate level of drain placement in the lumbar subarachnoid space (L2-L3, L3-L4, or L4-L5). Before placement, a local anesthetic is injected into the marked area and a spinal needle is inserted into the subarachnoid space. The physician advances the lumbar-drainage catheter through this needle until it reaches the T12-L1 space. Once the needle is in place, the physician withdraws it, attaches the catheter to the sterile closed collection system, and sutures the catheter to the skin in one or two places. An occlusive sterile dressing is placed over the site.

Management

One of three protocols can be used to manage a lumbar drain—draining at a specific level, draining to a specific volume, or draining at a specific pressure. (See Lumbar drain management protocols.)

Nursing care

On a regular basis, document drainage volume, color, and clarity. Assess the drain insertion site for signs of infection and check patency of the drainage system. Monitor the patient for systemic signs and symptoms of infection, such as an elevated temperature. Perform a neurologic assessment per hospital protocol, noting changes from baseline and level of consciousness. Be sure to maintain the drain at the proper level, keeping the patient’s head, neck, and back in a neutral position.

Keep the drain insertion site clean and dry; cover it with an occlusive dressing. A transparent dressing allows better assessment of the insertion site. Observe for kinks in the tubing; if you note kinks or other problems with the drainage system, take appropriate steps. (See Troubleshooting a lumbar drainage system.)

As needed and ordered, obtain CSF specimens from a stopcock using aseptic technique; be sure to wear sterile gloves and a mask. Maintain aseptic technique when changing the drainage bag.

Complications

A lumbar drain can lead to various complications, including intracranial venous thrombosis and infection. (For critical complications, see Life-threatening complications.)

Intracranial venous thrombosis secondary to dural injury

Venous dilation can cause venous stasis, which may result in a thrombus.

Suspect this complication if the patient complains of headache lasting more than a week, accompanied by confusion, disorientation, nausea, and vomiting. Treatment may include anticoagulation or an inferior vena cava filter.

Infection

A 2016 study found that the high incidence of infection associated with lumbar drainage systems may stem from lack of strict hospital protocols for placement and maintenance of these systems, as well as lack of strict tracking of drainagesystem infections. Infection risk may increase with obstruction of the system, leakage, and longer duration of the lumbar drain. Infections of lumbar drainage catheters can lead to bacterial meningitis. Infection risk rises 5 days after drain placement if the system has been opened or irrigated.

A positive CSF culture identifies bacterial infection. Be sure to document signs and symptoms of meningeal irritation or infection, including fever, swelling or redness at the drainage site, and increased drainage. Promptly report decreased level of consciousness headache, nausea or vomiting, stiff neck, or photophobia. Infection may warrant antibiotics or drain removal.

Nerve root irritation

Drain positioning may lead to nerve root irritation, resulting in numbness, tingling, radicular pain, and changes in deep tendon reflexes. Nursing interventions include making slight changes in patient positioning and providing pain medication. If pain persists, the drain may have to be removed.

Catheter tip remaining in the patient after catheter removal

Failure to remove the catheter tip can result in infection. The physician may be able to retrieve the tip, depending on where it has become lodged.

Providing patient and family education

To maintain safety of the lumbar drainage system, patients and family members require education. Teach them about the purpose of the lumbar drain and the expected outcome. Advise patients not to cough, sneeze, or strain because these actions increase ICP. Instruct them to ask for help if they want to change position, to ensure adequate assistance with this activity. Emphasize that bed controls need to be locked.

Tell patients they may feel discomfort at the drain insertion site or a mild headache just after drain insertion; reassure them pain medication can be ordered for relief. Inform them which signs and symptoms to report. Stress the need to notify you immediately if they experience worsening headache, leg numbness, and disorientation. With astute assessment, thorough documentation, and patient education, you can detect important changes in the patient’s condition and take quick actions to prevent a poor outcome.

Shari J. Lynn is an instructor at the Johns Hopkins University School of Nursing in Baltimore, Maryland. 

Selected references

American Association of Neuroscience Nurses. Care of the patient undergoing intracranial pressure monitoring/external ventricular drainage or lumbar drainage. Glenview, IL: American Association of Neuroscience Nurses; 2011.

Hepburn-Smith M, Dynkevich I, Spektor M, et al. Establishment of an external ventricular drain best practice guideline: the quest for a comprehensive, universal standard for external ventricular drain care. J Neurosci Nurs. 2016;48(1):54-65.

Johns Hopkins Medicine. Neurology and Neurosurgery: Extended CSF drainage trial via lumbar drain.

Turner, LW. Care of the patient with an EVD or lumbar drain.

Human trafficking

Human trafficking: Preparing for a unique patient population

In most ways, human trafficking (modern slavery) is no different from slavery of ancient times: It’s a brutal, highly profitable business with no regard for its victims. As nurses, to grasp the impact we can have on the lives of trafficking victims, we need to understand the nature of the crime, its prevalence, how to recognize victims, and how to help.

Human trafficking falls into two broad categories.

  • Labor trafficking typically is either forced hard labor, usually in agriculture or textile sweatshops; or domestic labor, such as working as a nanny or house servant.
  • Sex trafficking involves forced work in strip clubs, massage parlors, pornography production, or prostitution. It also may involve mail-order brides.

This article focuses on sex trafficking—the most prevalent form of slavery in the United States. An estimated 14,500 to 17,500 people are trafficked into the United States annually and 100,000 to 200,000 American minors are exploited in the sex industry. Worldwide, 2 million children and young women are trapped in sex slavery.

Consequences for victims

Human trafficking victims face grave physical and emotional danger every day. Research suggests initial gang rape is a common method of recruitment into slavery. Threats of repeated rape if the victim doesn’t comply with demands are common. Some victims rescued from the sex trade report customers who didn’t like condoms and paid extra to avoid using them. This puts victims at great risk for sexually transmitted infections, unplanned pregnancy, and physical trauma from rape.

Physical abuse, rampant in the trafficking business, is a primary means of forcing victims to comply. A study of European trafficking victims found about 75% had been kicked, punched in the face, burned with cigarettes, hit with objects, dragged by their hair, or struck in the head. More than half had posttraumatic stress disorder. Also, many victims abuse or become addicted to the drugs or alcohol their traffickers give them (sometimes by force) to control them. What’s more, many victims suffer from chronic untreated disease, such as tuberculosis, diabetes, or asthma, as well as infestations, poor dentition, dehydration, and malnutrition.

These facts underscore the immediate and imperative need for healthcare advocacy for victims. Unfortunately, nurses may have limited knowledge about human trafficking and how to identify victims in healthcare settings.

Implications for nurses

In 2014, Katherine Chon, senior advisor on Trafficking in Persons for the U.S. Department of Health and Human Services, testified before Congress that roughly 75% of trafficked women saw a healthcare provider while in captivity. In most cases, this provider was in an emergency department (ED).

However, many victims can be identified in other settings where nurses are present, such as schools, health clinics, acute-care hospital units, dental offices, and jails. This encounter may be a victim’s only possible entry point into the social safety net—yet many trafficking
victims aren’t identified as such in healthcare settings. Once this opportunity is lost, it may never arise again, because traffickers typically don’t allow visits to care providers unless a victim’s health is so precarious that she or he can’t work.

Even victims who seek care may go unrecognized or be mistaken for domestic violence victims, drug addicts, or prostitutes. Failure to identify a trafficking victim in a healthcare facility can lead to tragic consequences or even death for that person. Because nurses are frontline caregivers for this population, they need to know how to identify victims and refer them to appropriate resources.

Recognizing trafficking victims

How can nurses recognize the unique characteristics of trafficking victims? While human trafficking and domestic violence victims share some common presentations, important differences exist. For instance, domestic violence victims usually fear one abuser, whereas trafficking victims may fear many people because they may have multiple abusers.

Victims who are immigrants probably have been told that authority figures are the enemy and will seek to arrest or deport them. Consequently, they may fear and mistrust anyone in a uniform, including a nurse’s uniform. Also, trafficking victims tend to be more isolated than domestic violence victims, to suffer disease or malnutrition, and to have little or no family contact. They’re also more likely to abuse substances.

Some victims, although cognitively intact, may be unable to verbalize their current location if asked. This is especially true of those trafficked into the United States from other countries. Not only are they in unfamiliar surroundings, but they also may see little of the outside world and may not even know where they are.

Be aware that adults and children who’ve been coerced into prostitution in the United States aren’t considered criminals. On the contrary, they’re victims of human trafficking and protected under the federal Trafficking Victims Protection Act. Persons younger than age 18 who are involved in commercial sex exploitation fall into the legal criteria for minor sex trafficking; their traffickers are prosecutable under the law. Nurses are considered mandatory reporters for suspected minor human trafficking victims.

Approaching a suspected victim

If you suspect your patient is a trafficking victim, consider how best to approach him or her. Never ask outright if she or he is a trafficking victim, especially if a companion is present. Most victims probably don’t know what the term trafficking means. What’s more, few people—no matter how dire their circumstances—want to be called a victim because they’re trying to retain as much dignity as possible.

The most important thing to do is separate the suspected victim from the companion, because typically victims won’t speak openly in a companion’s presence. Sometimes, simply referring to hospital policy and the need to assess the patient’s physical status in private may persuade the companion to leave the room. If necessary, call for security to separate victim from companion.
If the victim doesn’t speak English, call for a medical interpreter. Be prepared for the companion to insist that he or she can interpret—but decline this offer, explaining that facility policy allows only for certified medical interpreters. Also consider cultural factors. For instance, female victims from patriarchal cultures typically are unwilling to speak up for themselves; the same is true of minors.

Anticipate that the victim will resist help. Feelings of intense fear, shame, and helplessness may even compel some to try to leave the facility without treatment. In some cases, a companion who senses that authorities suspect the true nature of the situation may force the victim to leave. So if you suspect trafficking, make sure a staff member stays with the victim at all times.

Assessing suspected victims

Human trafficking victims don’t receive preventive health care, so by the time ED or clinic providers encounter them, many health conditions may have become serious and victims may be in dire health circumstances. With this in mind, conduct a head-to-toe nursing assessment, providing as much privacy and comfort as possible.

Asking certain questions can help you determine if the patient is a trafficking victim without causing fear or alienation. (See Screening suspected trafficking victims.)

Screening suspected trafficking victims

Be aware that repeated violent penetration may cause vaginal or anal fistulas. Even young women may have bowel or bladder incontinence, or both. Many trafficking victims also have positive drug screens, infectious diseases, lice or scabies infestations, and tattoos or brands of gang symbols, trafficker initials, or barcodes.

Psychosocial issues are prevalent among this population. Although victims may have pronounced anxiety or panic, some may be stoic almost to the point of complete withdrawal. (See Common assessment findings.)

Common assessment findings

Finally, lack of trust may lead victims to suspect you’re trying to trap them into revealing information as a test of loyalty to the trafficker, putting the victim or the victim’s family in danger. Establishing trust is difficult but crucial, because the trafficker most likely has established himself as the only person the victim can trust and rely on.

Helping to rescue victims

A nurse may be a victim’s only point of contact with the environment outside captivity. To help rescue victims from a horrific life they didn’t choose, healthcare providers need to become knowledgeable about this crime against humanity. An excellent resource is the National Human Trafficking Resource Center. Consider posting the center’s toll-free number (1-888-373-7888) where patients can see it.

The more you know about trafficking and its victims, the more adept you’ll be at identifying them—and helping to rescue them. An in-depth grasp of how this population presents to healthcare facilities can help nurses identify and approach these vulnerable patients, create an effective plan of care, and advocate for them successfully.

Cheryl Green is a cardiac/medical-surgical nurse at Cone Health Alamance Regional Medical Center in Burlington, North Carolina.

Human Trafficking Characteristics

Human Trafficking Facts

Human Trafficking Resources

References

Chisolm-Straker M, Richardson LD, Cossio T. Combating slavery in the 21st century: the role of emergency medicine. J Health Care Poor Underserved. 2012;23(3):980-7.

Chon K. Trafficking Awareness Training for Health Care Act. Testimony before Committee on Energy and Commerce, U.S. House of Representatives. September 11, 2014. hhs.gov/asl/testify/2014/09/t20140911a.html

Dean E. Rescuing the vulnerable. Nurs Stand. 2013;27(43):16-7.

de Chesnay M. Psychiatric-mental health nurses and the sex trafficking pandemic. Issues Ment Health Nurs. 2013;34(12):901-7.

de Chesnay M. (2012). Sex Trafficking: A Clinical Guide for Nurses. New York: Springer Publishing; 2012.

Deshpande NA, Nour NM. Sex trafficking of women and girls. Rev Obstet Gynecol. 2013;6(1):e22-7.

McClain NM, Garrity SE. Sex trafficking and the exploitation of adolescents. J Obstet Gynecol Neonatal Nurs. 2011;40(2):243-22.

Peters K. The growing business of human trafficking and the power of emergency nurses to stop it. J Emerg Nurs. 2013;39(3):280-8.

Polaris Project. Recognizing the signs. polarisproject.org/human-trafficking/recognizing-the-sign.

Sabella D. The role of the nurse in combating human trafficking. Am J Nurs. 2011;111(2):28-37.

Trout KK. Human trafficking: the role of nurses in identifying and helping victims. Pa Nurse. 2010;65(4):18-20.

U.S. Department of State. Office to Monitor and Combat Trafficking in Persons. Human trafficking awareness training: “TIP 101.” state.gov/j/tip/training/index.htm

U.S. Department of State. Office to Monitor and Combat Trafficking in Persons. Identify and assist a trafficking victim. state.gov/j/tip/id/index.htm

radiation dermatitis

Understanding radiation dermatitis

According to the National Cancer Institute, an estimated 1.6 million new cases of cancer will have been diagnosed in the United States in 2015. During the course of their disease, most cancer patients receive radiation therapy.

Delivering high energy in the form of waves or particles, radiation therapy alters the DNA of cancer cells, causing their death. Radiation can be administered either externally or internally (through materials placed into the body). It’s given in fraction doses, with the total recommended dose divided into daily amounts. Treatment, including the total dose, is determined on an individual basis.

Although improvements have been made in delivery of radiation therapy, approximately 95% of patients who receive it experience a skin reaction. What’s more, radiation therapy commonly is given concurrently with chemotherapy or targeted therapy to improve survival, which increases the toxicity risk.

Physiologic effects

Radiation can injure rapidly dividing cells both directly and indirectly by damaging structures and chemicals within the cell. External beam radiation (the most common form of radiation therapy) commonly affects rapidly dividing cells of the epidermis, sebaceous glands, and hair follicles. The initial radiation dose begins to destroy the skin’s basal layer, causing the remaining cells to shed more quickly. Basal cells in the resting phase of mitosis are stimulated into proliferating more quickly and the balance of normal cell production is disrupted. An inflammatory response arises, with histamine production, capillary dilation, edema, and increased vascularity.

Patients may experience both early and late effects of radiation therapy, as well as skin pigmentation changes from melanin migration to the superficial skin layers. Hair growth within the radiation field is interrupted as hair follicles enter a resting phase, with complete hair loss occurring at doses above 55 Gy.

Doses of 30 Gy permanently damage the sweat and sebaceous glands, causing such symptoms as dry skin and pruritus. (See Risk factors.)

Risk factors

Various patient- and treatment-related factors influence whether a patient will develop radiation dermatitis and how severe it might be.

Patient-related factors include older age, poor nutritional status, smoking, overlapping skinfolds, poor skin integrity before radiation therapy, obesity, concurrent chemotherapy (such as with cetuximab), chronic sun exposure, genetic factors, and certain underlying comorbidities (including diabetes and renal failure).

Treatment-related factors include treatment field location; larger treatment volume, field, or total dose; larger fraction size; type of energy used (for instance, X-ray, gamma rays, electrons, protons, or neutrons); and therapy duration. Radiation to the head, neck, breast, chest wall, perineum, or vulva are more likely to cause radiation dermatitis.

Assessment

Signs and symptoms of radiation dermatitis include pain, discomfort, pruritus, burning, and general irritation. In some patients, these problems may restrict movement of an affected limb, impeding activities of daily living (ADLs) and lead to loss of independence and self-care ability. Some patients have difficulty wearing clothing on the affected area.

Clinicians can use various grading scales to define the skin reactions of radiation dermatitis. These scales include:

  • National Cancer Institute (NCI) Common Toxicity Criteria for Adverse Events (CTCAE)
  • Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer toxicity criteria
  • Radiation-induced Skin Reaction Assessment Scale
  • Skindex-16 scale.

In the United States, the CTCAE scale is most commonly used in clinical trials. It defines acute skin reactions to radiation as those occurring within the first 90 days after therapy. The scale encompasses five grades of reactions.

  • Grade 1: faint erythema or dry desquamation. Arising within the first 2 to 4 weeks of treatment, these reactions cause skin redness and warmth and a rashlike appearance. The patient may complain that the skin feels tight or sensitive.
  • Grade 2: moderate to brisk erythema; patchy, moist desquamation usually confined to skinfolds or creases. Moderate edema, dryness, pruritus, and flaking of skin layers (dry desquamation) also may occur.
  • Grade 3: moist desquamation in areas other than creases and skinfolds. Bleeding may arise from minor trauma, such as abrasion.
  • Grade 4: life-threatening consequences, such as full-thickness skin ulcers, necrosis, and spontaneous bleeding
  • Grade 5: death.

Prevention

Although many products have been tested, prevention of radiation dermatitis remains elusive. In 2010, Gosselin et al. tested Aquaphor®, Biafine®, RadiaCare®, and a placebo of sterile water mist. In the study (n=208), none of these skin care products made a statistically significant difference in minimizing the incidence of grade 2 to 4 skin reactions, compared to placebo. A recent pilot study by Fenton-Kerimian (n=30) also reported no statistically significant difference in the effects of calendula cream, RadiaPlex®, and mometasone plus Aquaphor®.

Wong et al. (2013) developed an international clinical practice guideline for prevention and treatment of acute and late radiation reactions. It recommends prophylactic topical steroids, such as mometasone, to reduce discomfort from radiation dermatitis. It gives all other agents, including sucralfate, hyaluronic acid, and silver sulfadiazine cream, only a weak or insufficient evidence recommendation. The panel strongly recommends against use of trolamine (Biafine®) and aloe vera. Similarly, Chan et al. (2014) found no strong evidence for any products in preventing or treating radiation dermatitis.

General skin care during radiation therapy also has been investigated as a way to prevent radiation dermatitis. Some experts recommend washing the skin with a pH-balanced soap, wearing loose-fitting clothing, avoiding scratching or rubbing the skin, and avoiding sun exposure on the treatment area.

Treatment

Like prevention, treatment of radiation dermatitis poses a challenge. For many therapeutic agents, effectiveness hasn’t been established. (See Recommended interventions for radiation dermatitis.) Generally, though, principles of moist wound therapy apply. For grade 1 skin reactions, apply bland emollients to keep the skin moisturized and follow standard hygiene principles.

Recommended interventions dermatitis

Both Chan et al. and Wong et al. found insufficient evidence to support recommending for or against any specific treatment. Generally, topical corticosteroids can ease itching. If the patient develops signs or symptoms of infection, cultures should be obtained from the affected area and antibiotics prescribed based on culture results.

No specific dressing is better than any other; each case should be evaluated individually. Dressing choices include hydrocolloid, hydrogel, hydrofiber, alginates, and polyurethane and silicone foam dressings.

Late skin effects of radiation therapy include chronic ulceration, telangiectasia, and fibrosis. Chronic ulcers should be evaluated for biofilm and subclinical infection and treated according to moist wound principles. These wounds may require debridement or hyperbaric oxygen therapy. Telangiectasia may improve with vascular laser therapy. Chronic fibrosis is hard to treat; refer the patient to a dermatologist with experience treating this complex problem.

Take a cautious approach

Caring for patients undergoing radiation therapy calls for special attention to topical skin care. Yet high-quality studies haven’t shown that specific agents prevent radiation dermatitis, and the literature on treating the condition fails to identify which skin care treatments are most effective. As more and more products reach the marketplace, clinicians needs to be cautious about blanket recommendations until these agents have undergone further testing to determine their effectiveness.

Carole Bauer is a wound and ostomy nurse practitioner at Beaumont Health System in Troy, Michigan.

Selected references

Bauer C, Laszewski P, Magnan M. Promoting adherence to skin care practices among patients receiving radiation therapy. Clin J Oncol Nurs. 2015;19(2):196-203.

Chan RJ, Webster J, Chung B, et al. Prevention and treatment of acute radiation-induced skin reactions: a systematic review and meta-analysis of randomized controlled trials. BMC Cancer. 2014;14:53.

Chen AP, Setser A, Anadkat MJ, et al. Grading dermatologic adverse events of cancer treatments: the Common Terminology Criteria for Adverse Events Version 4.0. J Am Acad Dermatol. 2012;67(5):1025-39.

Dendaas N. Toward evidence and theory-based skin care in radiation oncology. Clin J Oncol Nurs. 2012;16(5):520-5.

Feight D, Baney T, Bruce S, McQuestion M. Putting evidence into practice. Clin J Oncol Nurs. 2011;15(5):481-92.

Fenton-Kerimian M, Cartwright F, Peat E, et al. Optimal topical agent for radiation dermatitis during breast radiotherapy: a pilot study. Clin J Oncol Nurs. 2015;19(4):451-5.

Fogh S, Yom SS. Symptom management during the radiation oncology treatment course: a practical guide for the oncology clinician. Semin Oncol. 2014;41(6):764-75.

Gosselin TK, Schneider SM, Plambeck MA, Rowe K. A prospective randomized, placebo-controlled skin care study in women diagnosed with breast cancer undergoing radiation therapy. Oncol Nurs Forum. 2010;37(5):619-26.

Hymes SR, Strom EA, Fife C. Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006. J Am Acad Dermatol. 2006;54(1):28-46.

McQuestion M. Evidence-based skin care management in radiation therapy: clinical update. Semin Oncol Nurs. 2011;27(2):e1-e17.

Morgan K. Radiotherapy-induced skin reactions: prevention and cure. Br J Nurs. 2014;
23(4):S24, S26-S32.

National Cancer Institute. Cancer Statistics. 2015. http://www.cancer.gov/about-cancer/
what-is-cancer/statistics

Oncology Nursing Society. Radiodermatitis. Updated July 29, 2015. ons.org/practice-r
esources/pep/radiodermatitis

Russi EG, Moretto F, Rampino M, et al. Acute skin toxicity management in head and neck cancer patients treated with radiotherapy and chemotherapy or EGFR inhibitors: literature review and consensus. Crit Rev Oncol Hematol. 2015;96(1):167-82.

Wong RK, Bensadoun RJ, Boers-Doets CB, et al. Clinical practice guidelines for the prevention and treatment of acute and late radiation reactions from the MASCC Skin Toxicity Study Group. Support Care Cancer. 2013;21(10):2933-48.

Research

How to evaluate qualitative research

Editor’s note: This article is a follow-up to “Understanding qualitative research,” published in the July issue of American Nurse Today.

Have you ever told someone a story and then later heard the listener retell it in a way that made you say, “That’s not what I meant!” This happens because as listeners, we filter what we hear through our own experience, knowledge, or preconceptions, which can make us misinterpret the intended meaning.

Similarly, researchers who conduct qualitative studies listen to people’s stories about their experiences. These stories form the foundation for the themes that will serve as the basis of the study results. Obviously, researchers need to capture study participants’ intended meaning so their results don’t merely reflect their own experiences. In other words, the findings must be trustworthy.

How can you evaluate the trustworthiness of a qualitative study? As you read it, ask yourself, “How did the researcher address the issue of potential bias?” Researchers can incorporate strategies into the study design to reduce bias; the published report of the study should describe these strategies.

This article discusses strategies researchers use to make their study findings more trustworthy. They’re based on criteria developed by Lincoln and Guba in 1985 (considered the gold standard for evaluating the quality and trustworthiness of qualitative research). The strategies fall into the broad categories of confirmability, credibility, dependability, and transferability.

Confirmability

Confirmability refers to the objectivity of study findings. To achieve objectivity, researchers commonly use reflexivity and an audit trail. (See Following the researcher’s audit trail.)

 

Research

Reflexivity

Through reflexivity, researchers examine their own thoughts, feelings, and opinions on the study topic and remain constantly aware of their preconceptions throughout data collection and analysis. Keeping a reflexive journal can help them identify their preconceptions and see study participants’ meanings more clearly.

For example, Pearson (2013) studied cancer nurses’ experiences of providing palliative care to children in an acute-care setting. Acknowledging that she came to the study with preconceived notions, she used a reflexive journal to decrease bias potential. In her article, she stated, “The researcher used a reflexive diary [that] provided a consistent and systematic documented account of the participants’ interviews…

The use of reflexivity was important to consider as the researcher came to the phenomenon with a set of preconceptions and experiences that could have influenced the way the experience was described by the participant and the way the data was collected, interpreted, and analyzed.”

Credibility

Credibility refers to how well the study findings represent the data. The most common ways to establish credibility are peer debriefing and member checking.

Peer debriefing

Peer debriefing occurs when two or more researchers analyze the study data and compare results until they reach a common understanding. This step is important because a researcher may be aware of having preconceived ideas on the topic but unaware of when and how these notions might be influencing data interpretation. This is more likely when the researcher is closely involved with the study topic.

For example, Cameron and Waterworth (2014) conducted a study of patients’ experiences with palliative chemotherapy for colorectal cancer. In the data analysis section of the published report, they explained how they addressed the possible bias of one of the researchers, a nurse who worked on the unit where patients were treated: “Transcripts were read by SW following initial analysis by JC, and codes and themes were discussed to consider different interpretations and enhance rigor and trustworthiness. This also enabled JC as a nurse with clinical experience working in the day unit to reflect on her experience and how it could influence the interpretation of the data.”

Member checking

In member checking, the research­er presents findings to the study participants and asks them if the interpretations he or she made are consistent with their experiences. The researcher incorporates participants’ feedback into the findings. Thus, member checking ensures that the data are true to the participants’ experience.

Bowen, MacLehose, and Beaumont (2011) studied family relationship and support needs of patients with advanced multiple sclerosis, interviewing 25 family members in a multisite study. Here’s how they describe their member-checking process: “For the interviewees, this involved two-member checking meetings when participants were asked to read a lay summary of the findings and to comment on the accuracy of the summary, and to give any further reflections. For those who could not attend, a copy of the findings was sent…with contact details should they wish to comment.”

Dependability

Dependability refers to consisten-cy of the findings; it’s achieved through an external audit of the study. In the audit, another researcher who is not connected to the study but has qualitative research experience examines the audit trail, including study findings and conclusions. The auditor looks for a logical progression from the raw data (participants’ descriptions) to the interpretations, findings, and conclusions of the study.

When an external audit is done, details of the auditor’s response usually aren’t given in the published study. But as the reader, you can look at portions of the study to evaluate whether a logical progression exists between raw data and interpretations. In the findings section, the researcher presents the themes, with verbatim quotes from one or more participants that support the themes. You might ask yourself, “Can I easily grasp the connection between the theme and the quotes that support it?” If not, the interpretations may not reflect the participants’ intended meaning.

Here’s an example of a theme with a supporting quote from a study on the experiences of obstetric nurses who were present during a perinatal loss.

• Study theme: responses to the loss; shaken to the core
• Participant quote (from a nurse who discovered the loss): “I could not locate the baby’s heart rate. I started to feel numb. I felt hot and cold at the same time. I literally heard my own heartbeat slowing down. It was loud and pounding ever so slowly; I could hear it. We got a STAT ultrasound, which showed no cardiac activity…I could not work for the rest of the day.”

In this example, you can see a clear connection between the theme and the verbatim quote (the supporting data).

Another way to judge dependability is to evaluate the study’s conclusion section to determine if conclusions flow from the findings or if the researcher has made a leap, drawing conclusions beyond what the findings suggest.

Transferability

When reading a research study, you may want to know if the findings can be applied to the patients you care for; in other words, can they be transferred to another setting and another population? The researcher is responsible for providing “thick descriptions”—rich, vivid descriptions of participants, their experiences, and the setting. The quote from the obstetrics nurse above exemplifies a thick description of her experience. Artwork, photographs, and documents can augment patients’ verbal descriptions and enhance data richness. A study that contains thick descriptions can contribute to the body of evidence that helps you make judgments about implementing practice changes in your setting.

Evaluating qualitative research presents unique challenges not encountered with quantitative research. However, thoughtful examination of qualitative studies can help ensure such research is useful to nursing practice.

Barbara Williams is a nurse scientist at Meridian Health in the Ann May Center for Nursing and Allied Health in Neptune, New Jersey, and an instructor in the nursing program at William Patterson University in Wayne, New Jersey. She is coauthor of Anatomy of Research for Nurses.

Selected references
Bowen C, MacLehose A, Beaumont JG. Advanced multiple sclerosis and the psychosocial impact on families. Psychol Health. 2011;26(1):113-27.

Bruner BG, Chad KE. Dietary practices and influences on diet intake among women in a Woodland Cree community. J Hum Nutr Diet. 2014;27 Suppl 2:220-9.

Cameron J, Waterworth S. Patients’ experiences of ongoing palliative chemotherapy for metastatic colorectal cancer: a qualitative study. Int J Palliat Nurs. 2014;20(5):218-24.

Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park, CA: Sage Publications; 1985.

Pearson HN. “You’ve only got one chance to get it right”: children’s cancer nurses’ experiences of providing palliative care in the acute care setting. Issues Compr Pediatr Nurs. 2013;36(3):188-211.

Puia DM, Lewis L, Beck CT. Experiences of obstetric nurses who are present for a perinatal loss. J Obstet Gynocol Neonatal Nurs. 2013;42(3):321-31.

SIDS

Good night, baby…sleep safely

For more than 20 years, the American Academy of Pediatrics (AAP) has encouraged everyone to place infants on their backs to sleep to help prevent sudden infant death syndrome (SIDS). The National Institute of Child Health and Human Development’s “Safe to Sleep®” campaign (launched as the “Back to Sleep” campaign in 1994) has had dramatic results: The number of infant deaths from SIDS and sudden unexpected infant death (SUID) has fallen a staggering 53% in 20 years.

In 2011, AAP expanded its 2005 recommendations to encompass the infant’s entire sleep environment. First Candle, a not-for-profit organization dedicated to safe pregnancies and infant survival, took this message to the public as “Safe Sleep Saves Lives.”

But despite decades of guidance from various organizations on what’s best for infants, as well as campaigns to promote safe sleep, as a pediatric nurse practitioner I find that safe sleep guidelines aren’t followed consistently. This article revisits the AAP recommendations on safe sleep and debunks myths, with a special focus on implications for practicing nurses.

Expanding the scope of recommendations

1. Here are the 18 recommendations issued by the AAP in 2011. Place infants to sleep on their back (supine). The slogan “Back to sleep” applies to all infants from 32 weeks postconceptual age in the neonatal intensive care unit to 12 months. When putting an infant down to sleep, place him or her on the back. Side sleeping isn’t recommended. However, if the infant independently rolls onto the abdomen, don’t roll him or her onto the back again; instead, allow the infant to stay in that position.

2. Use a firm sleep surface to decrease the risks of SIDS and suffocation. Use a crib, bassinette, or portable sleep environment that meets the safety standards of the U.S. Consumer Product Safety Commission and ASTM International (an organization that develops and delivers voluntary consensus standards). Make sure fitted sheets fit snugly on the mattress and the mattress fits snugly in the crib. Don’t let an infant sleep in a car seat or a swing.

3. Caution parents not to share a bed with their infant while sleeping, but encourage them to share a room with the infant. Bed sharing isn’t recommended with siblings, either (even with the infant’s twin). If a breastfeeding mother chooses to bring her infant to bed for feeding, she should return the infant to the crib (or bassinette or portable crib) once feeding is complete, before she goes to sleep. Any other person in the bed with the infant increases the SIDS risk. On the other hand, studies show SIDS risk decreases by nearly half when the infant shares a room (not a bed) with parents.

4. Keep soft objects and loose items out of the crib. These include bumper pads, wedges, sleep positioners, blankets, and pillows. Even a sleep positioner designed to reduce SIDS is unsafe. Avoid putting anything in the crib except a mattress, fitted sheet, and the infant. To provide warmth, blanket sleepers and sleep sacks are permitted.

5. Give the infant a pacifier at nap time and bedtime. Studies show this provides a protective effect. For breastfeeding infants, delay pacifier initiation until breastfeeding is well-established (around age 3 to 4 weeks).

6. Avoid overheating the infant. I usually advise parents to dress the infant in one layer more than what the parent is comfortable wearing. For example, a parent who dresses in shorts and a top should dress the infant in a “onesie” and add a knit or cotton sleep sack.

7. Teach women that breastfeeding helps reduce SIDS risk.

8. Encourage supervised “tummy time” while the infant is awake and alert, to promote optimal growth and development. Recommended duration and frequency haven’t been established. However, in my practice environment, the standard of care is to give the infant tummy time (when supervised and awake) with every diaper change for 5 to 10 minutes during the day. Tummy time promotes motor development and helps prevent positional plagiocephaly (head flattening).

9. Don’t use sleep positioners, wedges, special mattresses or sleep surfaces, or other commercial devices marketed to decrease SIDS risk. No evidence suggests these products offer protection, reduce suffocation risk, or are safe.

10. Encourage pregnant patients to get regular prenatal care to decrease SIDS and SUID risk.

11. Instruct women to avoid smoke exposure during pregnancy and after
delivery.

12. Caution women to avoid alcohol and illicit drug use during pregnancy and after delivery.

13. Advise parents not to use home cardiorespiratory monitors. These monitors haven’t been found effective in reducing SIDS risk. If parents ask your advice on buying an apnea monitor, inform them that although these monitors have value for some infants, no evidence supports the claim that they decrease SIDS incidence.

14. Urge parents to immunize the infant according to AAP recommendations and to take him or her for regular well-child checks.

15. Healthcare professionals, parents, and childcare providers should follow SIDS risk-reduction recommendations from the time of the infant’s birth.

16. Media and product manufacturers should follow safe sleep guidelines in their messaging and marketing materials. All media outlets and manufacturers should promote a safe infant sleep environment. Through a cooperative effort, safe sleep for infants can be modeled not just in the hospital and healthcare environment but also in print, television, and media messages.

17. The national campaign to reduce SIDS risk should be expanded to focus on the infant’s entire sleep environment—not just on sleep position. Family physicians and other primary care clinicians are encouraged to participate.

18. Ongoing SIDS research and surveillance are needed.

Implications for nurses

Safe infant sleep is a national priority. Healthy People 2020, a national health promotion and disease-prevention initiative, addresses safe infant sleep as a component of reducing SIDS and SUID incidence.

All healthcare professionals—especially those who provide direct patient care—must promote a safe infant sleep environment. We need to model safe, effective infant care; educate parents and caregivers; and promote components of a safe sleep environment. As nurses, we also need to educate each other. (See Survey reveals need for better education on infant sleep.)

Survey reveals need

What’s more, we need to provide consistent modeling and messages across all healthcare professions. Inconsistent caregiver modeling and messages causes confusion for parents, new nurses, and nursing students. As members of the most trusted profession, nurses are sought out by our communities for advice on health-related topics. We have a responsibility to give them evidence-based, consistent information. (See Using consistent, accurate messaging.)

Using consistent

Finally, nurses should contribute to standardized protocols and surveillance of SIDS and SUID and advocate for adequate funding of these efforts. Some researchers consider SIDS a completely preventable phenomenon. The urgency for action can’t be overstated.

Angela Lane is an assistant professor of nursing at Belmont University in Nashville, Tennessee. She worked as a pediatric nurse practitioner in Nashville for 8 years before transitioning to nursing faculty member.

Selected references
Hitchcock S. Endorsing safe infant sleep: a call to action. Nurs Womens Health. 2012;
16(5):386-96.

Mason B, Ahlers-Schmidt CR, Schunn C. Improving safe sleep environments for well newborns in the hospital setting. Clin Pediatr (Phila). 2013;52(10):969-75.

Murphy SL, Xu JQ, Kochanek KD. Deaths: Final data for 2010. Natl Vital Stat Rep. 2013;61(4):1-117.

National Institute of Child Health and Human Development. Safe to Sleep® Public Education Campaign. Last reviewed and updated January 2, 2015. nichd.nih.gov/sts/Pages/
default.aspx

Schnitzer PG, Covington TM, Dykstra HK. Sudden unexpected infant deaths: sleep environment and circumstances. Am J Public Health. 2012;102(6):1204-12.

Task Force on Sudden Infant Death Syndrome, Moon RY. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011;128(5):1030-9.

Asthma

Understanding asthma pathophysiology, diagnosis, and management

A chronic inflammatory airway disorder, asthma is marked by airway hyperresponsiveness with recurrent episodes of wheezing, coughing, tightness of the chest, and shortness of breath. Typically, these episodes are associated with airflow obstruction that may be reversed spontaneously or with treatment.

Asthma affects approximately 300 million people around the world. In children, males have a higher asthma risk; in adults, females have a higher prevalence.

Experts believe asthma results from various host factors, environmental factors, or a combination. Host factors include gender, obesity, and genetics. Genetic factors include atopy. Defined as a genetic tendency to develop allergic diseases, such as asthma and allergic rhinitis, atopy commonly is linked to an immunoglobulin E (IgE)–mediated response to allergens.

Pathophysiology

Understanding asthma pathophysiology helps you understand how the condition is diagnosed and treated. Our knowledge of asthma pathogenesis has changed dramatically in the last 25 years, as researchers have found various asthma phenotypes.

Asthma involves many pathophysiologic factors, including bronchiolar inflammation with airway constriction and resistance that manifests as epi­sodes of coughing, shortness of breath, and wheezing. Asthma can affect the trachea, bronchi, and bronchioles. Inflammation can exist even though obvious signs and symptoms of asthma may not always occur.

Bronchospasms, edema, excessive mucus, and epithelial and muscle damage can lead to bronchoconstriction with broncho­spasm. Defined as sharp contractions of bronchial smooth muscle, bronchospasm causes the airways to narrow; edema from microvascular leakage contributes to airway narrowing. Airway capillaries may dilate and leak, increasing secretions, which in turn causes edema and impairs mucus clearance. (See How bronchospasm constricts the airway.)

How bronchospasm constricts the airway

Asthma also may lead to an increase in mucus-secreting cells with expansion of mucus-secreting glands. Increased mucus secretion can cause thick mucus plugs that block the airway. Injury to the epithelium may cause epithelial peeling, which may result in extreme airway impairment. Loss of the epithelium’s barrier function allows allergens to penetrate, causing the airways to become hyperresponsive—a major feature of asthma. The degree of hyperresponsiveness depends largely on the extent of inflammation and the individual’s immunologic response.

Asthma also causes loss of enzymes that normally break down inflammatory mediators, with ensuing reflexive neural effects from sensory nerve exposure. Without proper treatment and control, asthma may cause airway remodeling leading to changes to cells and tissues in the lower respiratory tract; these changes cause permanent fibrotic damage. Such remodeling may be irreversible, resulting in progressive loss of lung function and decreased response to therapy.

Classifying asthma

Asthma may be atopic, nonatopic, or a combination.

  • Atopic asthma begins in childhood and is linked to triggers that initiate wheezing. It may arise after exposure and response to a specific allergen, such as dust mites, grass or tree pollen, pet dander, smoke, or certain drugs or foods. On exposure to a trigger, excessive release of IgE occurs, which initiates B-lymphocyte activation. IgE binds to cells related to inflammation. This action causes release of inflammatory mediators (such as chemokines, nitric oxide, prostaglandin D2, cyto­kines, histamine, and leuko­trienes), in turn triggering
    airway inflammation and bronchoconstriction. Women who smoke during pregnancy may predispose their unborn children to higher IgE levels, causing hyperresponsiveness and asthma development. Exposure to pollution may have the same effect.
  • Nonatopic asthma doesn’t involve an IgE response. It may have fewer obvious triggers and usually occurs in adults, possibly secondary to a viral infection.

Diagnosis

Asthma diagnosis goes beyond symptoms, such as coughing, chest tightness, wheezing, and dyspnea—and even beyond signs and symptoms that worsen at night and improve after treatment. Diagnosis may require pulmonary function tests (PFTs) and peak expiratory flow (PEF) measurements. With asthma, the ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC, also called FEV1%) typically declines.

Asthma symptoms can be reversed by a rapid-acting beta2-agonist, such as albuterol, as measured by spirometry. The generally acceptable response to beta2-agonists is a 12% or 200-mL increase in FEV1 or FVC. PEF measurements not only aid diagnosis but also help clinicians monitor the disease.

Some patients with asthma signs and symptoms may have normal PFT results. They may need further diagnostic testing, such as airway response testing using a bron­chial challenge. (See Bronchial challenge.)

Bronchial challenge

Clinicians must rule out other conditions that may decrease FEV1 and cause signs and symptoms that mimic asthma. These conditions include vocal cord dysfunction, gastroesophageal reflux disease, ischemic cardiac pain, chronic obstructive pulmonary disease, heart failure, upper-airway obstruction, cystic fibrosis, hyperventilation, and foreign-body aspiration. Viral respiratory infections may lead to asthma exacerbations or contribute to eventual development of the disorder.

Management

Asthma management involves both acute and long-term treatment. Medication selection hinges on the patient’s age, disease severity, and comorbidities.

Be sure to obtain a complete medication history before the patient starts taking asthma medications. Some drugs, including beta-blockers, angiotensin-converting enzyme inhibitors, cholinergics, and nonpotassium-sparing diuretics, may be contraindicated for
patients receiving certain asthma agents.

Rescue (quick-relief) drugs

Meant for short-term symptom relief, rescue drugs cause bronchodilation and are used mainly to prevent or treat an asthma attack. They begin working within minutes and may remain effective for up to 6 hours. Potential side effects include jitteriness and palpitations. Rescue drugs include ipratropium bromide inhaler (Atrovent), short-acting beta2-agonists, and oral corticosteroids.

  • Ipratropium bromide, an anticholinergic, may be given in combination with short-acting beta2-agonists in some cases.
  • Beta2-agonists used for quick relief include albuterol, levalbuterol, metaproterenol, and terbutaline.
  • Oral corticosteroids, such as prednisone and methylprednisolone, sometimes are used for brief periods during acute asthma attacks that don’t respond to usual treatments. Long-term use can lead to high blood pressure, muscle weakness, cataracts, osteoporosis,
    decreased ability to resist infection, and reduced growth in children.

Long-term control agents

Used to prevent asthma attacks and control chronic symptoms, these agents include inhaled corticosteroids, leukotriene modifiers, long-acting beta-agonists (LABAs), theophylline, and combination inhalers that contain both a corticosteroid and an LABA. These drugs may take days or weeks to reach maximal effect.

Leukotriene modifiers help prevent symptoms for up to 24 hours. LABAs, which may last up to 12 hours, usually are given in combination with an inhaled corticosteroid, because when used alone they may lead to a severe asthma attack. LABAs also are prescribed to prevent nocturnal asthma symptoms, such as coughing. Theoph­ylline, given orally, acts as a bronchodilator and also is used to treat nocturnal symptoms.

Patient education

Patient education is crucial in asthma management. Teach patients and their families how to use a peak flow meter, optimize environmental controls, and recognize asthma signs and symptoms. Stress the importance of smoking cessation. Urge patients to receive annual vaccinations, as asthma increases the risk of complications from respiratory diseases, such as pneumonia and influenza.

Selected references
Asthma overview. American Academy of Allergy Asthma and Immunology. http://www.aaaai.org/conditions-and-treatments/asthma

Corbridge S, Corbridge TC. Asthma in adolescents and adults. Am J Nurs. 2010;
110(5):28-38.

Fanta CH. Treatment of acute exacerbation of asthma in adults. Last updated February 5, 2015. www.uptodate.com/contents/treatment-of-acute-exacerbations-of-asthma-in-adults

Global Initiative for Asthma. Pocket Guide for Asthma Management and Prevention (for Adults and Children Older than 5 Years). Updated 2015. www.ginasthma.org/local/uploads/files/GINA_Pocket_2015.pdf

Johnson J. Asthma assessment tips. J Nurse Pract. 2010;6(5):383-4.

Kaufman G. Asthma: pathophysiology, diagnosis and management. Nurs Stand. 2011;
26(5):48-56.

Martinez FD, Vercelli D. Asthma. Lancet Sem. 2013;382(9901):1360-72.

National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Section 2: Definition, pathophysiology and pathogenesis of asthma and natural history of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute; 2007; 1-24.

Pruitt B, Lawson R. Assessing and managing asthma: a Global Initiative for Asthma update. Nursing. 2011;41(5):46-52.

Shari J. Lynn and Kathryn Kushto-Reese are instructors at the Johns Hopkins University School of Nursing in Baltimore, Maryland.

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