A lot of time in the ICU is spent turning patients.  Every two hours we turn our patients to prefect bed soars (pressure ulcers).  Right at shift change yesterday the oncomming nurse calls me into her room to help turn her patient.  I walk in there and say to her “hey are you aware of all this blood under his back” and “did you know that his central line is bleeding like crazy”.  This was her first time into the room and she had not seen either.  We gently turn the patient slightly and notice that his sheets under his back are saturated with blood. He had recently had spinal surgery and had two JP drains.  Both were full of blood, his back dressing was compltetly saturated. We lower his head to look at his back and he becomes extremely anxious, we check his sPO2 to find it in the 50%!!!  Quickly we slap on the non rebreather mask and the nasal cannula slowly his stats come up to the 90’s.

We look at his spinal dressing, its about 12 inches long and saturated.  WHile turning him we notice a foul smell.  Yep, he had soiled his bed at the same time.  So here we are with a patient bleeding from his fresh surgical site, saturated central line dressing, soiled, and desatting.  Both charge nurses run in.  We call the neuro surgeon.  He runs up we quickly drain the JPs and they refill.  The filling begins to slow.  We change the dressing, the site looks ok.  We get the patient clean.  He finally stablizes.

The joys of ICU nursing.

The night was going perfectly.  It was 3:15 am and I was sitting in my pod between my two patients rooms.  Suddenly, one of their pumps starts beeping.  This is not uncommon and happens when an infusion is complete, sometimes when the patient moves, or just because the pump is being stubborn. I glance into my patients dark room to view the pump and see that it reads “occluded – patient side”, so I get up and walk into her room to find her holding her central line in her hand.  She looks at me and says “it’s all wet” . . . !!!

Immediately I grab some sterile gauze and place it over her neck which is bloody.  Her insulin drip and saline are now soaking her bed.  Central lines are run through a large vein, in this case it was the internal jugular vein which drops straight into the heart.  Extreme care is taken when dealing with central lines as they are such large veins so close to the heart.  Patients run the high risk of bleeding or infection with central lines, but for many patients it is the only IV access and is the best access for many ICU patients on several drugs.

This little lady had become confused and agitated and within the 15 minutes from when I last was in her room to this point had managed to pull the 12 inch line clear out of her neck.  Luckily we were able to regain access to a small vein in the hand.  Calling the physician on this was not fun!  The patient is stable and doing well.

withdrew life support on my first brain dead patient tonight.  He came in with an intracerebral hemmorahge.  Yesterday morning he was completly functional and lving alone.  He did not come to the door when his ride came to get him for dialysis in the morning and his sister called him, his speech was jumbled so she called EMS who brought him into the ED.  Midway through the day his BP dropped and His pupils blew at this point it was obvious that he was beginning to herniate in his brain.  The thought was that he would die during my shift last night he survived the night but had a brain death test done in the morning which confimred brain death.  At 730 pm the family decided to withdraw his breathing tube.  At this point his sister who had been the point person became upset and had a very difficult time coping with the decision.  Minor caious eruppted trying to get firm answers on the plan of care for the patient.  Then a nephew of the patient began to have a seizure in the room and had to be evaluated by emergency personel.  Within 20 minutes his heart stopped beating. We brought him to the mourge. Prior to leaving all of the family gave me big hugs and his mother said “I love you!, I was so happy that you were his nurse today, I will always remember you and your smile, you were always smiling, Thank you for taking care of my son.”  It was a nice moment and the family truly appreciate the care we gave their family.  There must have been 10-15 people there in his room.

They arrived at 3am.  I took over their care at 7am.  He complained of some left sided numbness.  A CT scan revealed extensive brain masses.  As the day went on the situation deteriorated as we learned more from additional testing.  This man was previously in “perfect” health,  he and his wife of decades were nearing retirement.  As the day went on we learned that went was in his head were ten or more metastatic lesions as a result of melanoma and similar lesions covered his kidneys and liver.

My job was to care for them as the news continued to come in and a plan of care was developed.  They were both in deep tears as they day went on and the prognosis worsened.  On the second day of their stay and with time it was determined that the lesions were too small and too extensive for neurosurgery to be of any effect and the patient would undergo targeted radiation and chemo.  The patient was moved to the oncology floor.  As they said goodbye to me they both teared up and gave me a big hug and said “thank you so much for all you have done”, (I thought, i haven’t done anything), “you brought such a calm and peace into this room, thank you so much.” They hugged me again we said goodbye.  Patients love their nurse and remember those who bring peace to their room and take command of the situation and advocate for their care.

I arrived to work and found that my assignment had remained the same from the night before.  I had four step down patients all post spinal or brain surgery.  As I went to assess my patients I walked into the room of a burly Hispanic gentleman room.  He had recently had extensive lumbar surgery but was thrashing in bed, sweating, grimacing, clearly something wasn’t right.  He was in severe pain.  I quickly treated the pain via IV and PO medication.

Within minutes he was calm and resting again.  Later in the day he told me that he was so happy to see me first thing in the morning as I opened the door to see him.  He went on to say that he was in terrible pain all night long and that his pain had not been treated all night.  I reviewed his medication administration record to find that in fact he had not received any pain medication.  He was not sure how to tell the nurse and she had not asked if he had pain.  He was never assessed for pain throughout the night and was never offered alleviation from his severe pain.
Patients truly see nurses as their saviors when we walk into their rooms and offer our sincere concern and poor our hearts into our work to alleviate their suffering and bring the relief.  This man will always remember the care I brought him and the difference in his night and his day.

We took our son up to Childrens Hospital here in Dallas TX to look at the Trainscape and see his Aunt who works at the hospital.  We stopped in the gift shop and found that they had adorable scrubs for young children.

The gift shop carried green and pink scrubs.  On the back of the green scrubs were the letters “MD” and on the back of the pink scrubs . . . you guessed it “RN”.  Should I laugh or take offense.  I just laughed.  Slowly society will catch up with reality.  My wife didn’t even catch it when I pointed it out she just said, “Oh well, that’s okay girls can wear the green scrubs too”.  Indicating of course that girls can be doctors completely missing the bright pink RN scrubs clearly designed for little girls.

My parents teach a Sunday school class with kids ages 12-14.  When they told their students that their adult son was a nurse they responded . . . “there needs to be a male word for nurse”.  I said, “there is, its NURSE”.

So, I work in a level 1 neuro ICU in a large city.  Today one of my patients said to another nurse as I was leaving to go home from my overnight shift that, I am “so good, such a great nurse, knows what he is doing, so good . . . . he should be a doctor”.
While this poor elderly woman meant this as a compliment I had a hard time not taking offense to this!  My only response to her was, “I chose to become a nurse so that I could actually take CARE of patients”.  I wasn’t really sure what to say.  I think that the misconception that nurses are simply doctors hand maidens is a fading one, but still is out there among many individuals.

As nurses we truly are on the front lines keeping patients alive.  As a night shift nurse in a busy surgical, trauma, medical – – – neuro ICU I am often all alone with critical patients left to make life altering decisions on my own.  The docs are home asleep, the patients are hanging on for dear life, and there I am left to keep them alive for 12 more hours.  I am proud of my role in the medical field . . . as a nurse we are in the trenches WITH our patients.  Physicians have separated themselves so far from actual patient care that some will only see their patient every other day or so from the door way and make changes to care plans on a 5 second head to toe view while we as nurses are in the room every 2 minutes suctioning, pushing meds, adjusting drips, cleaning, feeding, turning, assessing, etc. . .

I am proud of my role as a nurse where I can actually change peoples lives and be there for those critical acute changes.  I didn’t become a nurse because I couldn’t get into medical school . . . I became a nurse because I CHOSE to be a nurse.

Patients very seldom recall their doctors name . . . but they will ALWAYS remember the nurse who stayed up all night long with them to see them through a crisis, the nurse who explained what the hell the doctor was even talking about after they leave the room, the nurse who with love is firm in carrying out medical orders for the patients benefit. In my short time as a nurse I know that I have impacted peoples lives, I know that there are families who will always remember me and the care I brought to them.

In fact, this same patients husband left me a kind Christmas card expressing his deep gratitude for the love and compassion  showed his wife . . . He will always remember nurse Jon, yet he does not recall the physicians name.  If you want to change lives and impact families there is no better calling than nursing.

• Blood analysis required to diagnose TB
• COPD clients with acute exacerbation will have impaired memory
• Monitor for unilateral breath sounds post thoracentesis – indicates pneumothorax
• Proteinuria will be found with glomerulonephritis
• Continue passing suctioning catheter for trach patient if coughing
• Do not suction more than three times
• TMP/SMZ can lead to Stevens-Johnsons syndrome
• Tensilon Test used for myasthenia gravis
• Fluid overload – shortness of breath
• Effect on ADLs will have the greatest influence on pain perception
• Fluid volume deficit – orthostatic hypotension
• Feedings should not exceed 10 mL/min
• Assess the mouth of a client with neutropenia q8h
• Confusion and petechiae – signs of fat embolism
• Beta blocker side effects include heart failure demonstrated with coughing
• Cardiac tamponade – pulsus paradoxus
• Crohn’s diet – low fiber – not to eat fruit and veggies
• Memory loss indicative of increasing ICP in bacterial meningitis
• Risperidone side effects – wt gain, orthostatic hypotension, insomnia
• Osteoporosis – sedentary life style
• Mannitol – pulmonary edema side effect
• V-fib – administer shock switch defib to asynchronous
• Hypermagnesemia – cardiac monitoring

Introduction

There is a shortage of primary care physicians in the United States.  The Patient Protection and Affordable Care Act (PPAC) is expected to increase access to primary care services for 32 million Americans.  The current shortage of physicians who care for adults is projected to reach up to 44,000 by 2025.  This problem can be alleviated by allowing advanced practice registered nurses (APRNs) to practice primary care with greater autonomy.  Advanced Practice Registered Nurses have been shown to be able to deliver the same outcomes as a physician with lower costs.  Using APRNs as a source of primary care is a resource that needs to be used if affordable healthcare is to be provided to the growing population in the United States.

Literature Review

The largest group of health care providers in the United States are nurses with close to around 2.9 million registered nurses (RNs) (Naylor & Kurtzman, 2012).  Of the RN population, around eight percent are APRNs.  According to Stokowski (2010), “each year, 8,000 new NPs graduate, and 7,000 of these new graduates are prepared as primary care NPs.”  The U.S. Department of Health and Human Services (HRSA) has begun supporting the creation of nurse managed clinics (“HRSA Electronic,” ND). States which have implemented these recommendations and taken advantage of this system have seen positive economic and health benefits according to Naylor and Kurtzman (2010). The literature is abounding with examples of the need for greater access to health care and the enormous gap that exists between need and availability.  Physicians are no longer able to meet the ever increasing demand of primary care patients simply based on the sheer volume of patients in need.  Illinois alone is facing nearly 1000 medically underserved areas including several communities in almost every county in the state (“Medically underserved areas,” 1995). It is clear from the literature that we can no longer limit patients access to healthcare by limiting the scope of practice and billing privileges of primary care APRNs who are qualified and experienced in providing care to families and individuals in a primary setting. Nurse managed clinics with increased autonomy and billing rights  headed by these APRNs is the solution to the widening health care disparity gap.  Coddington and Sands (2008) found that “nurse-managed clinics (NMCs) can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations”.  This finding illustrates the need for more nurse managed clinics which are able to reach the highly underserved populations unable to obtain insurance and thus appropriate health care. Their findings show that not only are nurse managed clinics able to meet the growing concern of a shortage of primary care providers but that they are also able to provide cost effective care to bridge the gap for uninsured individuals unable to seek health care otherwise. In 2010 the Institute of Medicine declared that “current laws in some states were hampering the ability of advanced practice nurses to contribute to innovative health care delivery solutions” (Frellick, 2011). These findings indicate the need for innovative solutions in health care provision.  Limiting the ability of advanced practice providers will only increase the health disparities currently affecting the country. It becomes vital that cost effective and productive solutions to the increasing number of patients, decreasing number of primary care physicians, and increasing costs of health care be examined in order to appropriately treat patients.

Policy Analysis

For a policy recommendation to be implemented, it must go through a rigorous process.  In order for the policy to be effective, this process must follow certain steps.  In Milstead’s Health Policy and Politics, this process is laid out into four stages: agenda setting, legislation and regulation, implementation, and evaluation (Milstead, 2008).

Agenda setting requires getting the attention of government that there is a need for a new policy or for a change in an existing policy.  Currently in the State of Illinois there is no official policy requiring an insurance company to reimburse APRNs acting as primary care the same was as a physician.  The Illinois Society for Advanced Practice Nursing is an example of an organization that uses advocacy to bring forth the issue to the attention to the State.

The second phase in the policy process, legislation and regulation, is the government response to a public problem and often starts in the legislative branch; the response takes its form in laws, rules and regulations, and programs (Milstead, 2008).  Since 2006, Illinois’ Medicaid Department, the Department of Health and Family Services, began reimbursing APRNs at 100% of the physician rate (Illinois Society for Advanced Practice Nursing, n.d.).  The current Illinois Nurse Practice Act states that, “If an advanced practice nurse engages in clinical practice outside of a hospital or ambulatory surgical treatment center in which he or she is authorized to practice, the advanced practice nurse must have a written collaborative agreement” (Illinois Nurse Practice Act, 2007).  The collaborative agreement must be with a physician.  Having a collaborative agreement can place limitations on an APNs ability to act as a patient’s primary care provider, thereby having adverse effects on the patient’s well being and overall health status.  This also limits the amount of time physicians and nurses are able to spend with patients.

The implementation phase is when legislation takes effect and is put into place.  Once a policy has been put into place, the evaluation process should be implemented. Milstead (2008) notes that, “evaluation must be started early and continued throughout a program” (p. 25).

Recommendations

Nurse managed clinics are the solution to the shortage of healthcare providers, the number of underserved populations, and redirect primary care services to disease prevention and health education in addition to treatment, if the appropriate policies are put into place. In order to facilitate the establishment of nurse managed clinics in primary health care, preliminary actions need to be taken.  A revision to the scope of practice guidelines in the Illinois Nurse Practice Act will allow APRNs more autonomy in practice.  APRNs need to be able to practice without the legal ‘supervision’ of a physician and qualify for healthcare provider reimbursement from federal and private insurance companies.  Currently, APRNs need to file for reimbursement under a physician and are only given a percentage of what physicians would receive.  Insurance companies will need to develop a policy that will incorporate APRN’s into reimbursement policies at the same rate as a primary care physician.  As a result, APRN’s will be able to practice in an appropriately funded primary care setting.  Research has indicated the use of APRN’s improve the cost and patient satisfaction in primary healthcare.  Modifying the scope of practice guidelines and ensuring adequate reimbursement will bring the United States closer to an overall effective healthcare system.

Conclusions

The United States Department of Health and Human Services (HRSA) has identified 942 medically underserved communities (MUA) within Illinois (“Medically underserved areas,” 1995).  Communities are designated as an MUA based on the number of primary care physicians per 1,000 people, infant mortality, and the number of the population over the age of 65 among other things. Illinois is not the only state threatened by MUA, aging populations, and limited access to health care.  Nationally, 15% of the U.S. population is underinsured. Fully autonomous nurse managed clinics can provide a cost effective solution for improving access to health care for underinsured individuals and create a solution for treating those individuals living in MUA. By more fully incorporating APRNs into general practice through greater autonomy and billing privledges will ease the strain currently effecting practicing physicians by diverting some of their patient load and lessening the need for them to oversee and sign off on all care provided by APRNs.   Allowing greater autonomy and billing privileges will ease the health care burden, save money, and allow access to health care for underserved populations. According to Naylor and Kurtzman (2010), a study in Massachusetts, after the implementation of universal coverage legislation, revealed “cumulative statewide savings of $4.2-$8.4 billion for the period of 2010-2020” by substituting physician visits with nurse practitioner visits in primary care.  Providing APRNs with  advanced education and clinical experience prepares them to assume the role of primary provider and creates a positive solution to health care disparities currently affecting our nation and community.

References

Illinois Society for Advanced Practice Nursing.  (n.d.)  Reimbursement issues.  Retrieved from http://www.isapn.org/?page=ReimbursementIssues

Medically underserved areas & populations (mua/ps). (1995, June). Retrieved from http://bhpr.hrsa.gov/shortage/muaps/

hrsa electronic handbooks for applicants/grantee. (ND). Retrieved from https://grants.hrsa.gov/webExternal/FundingOppDetails.asp?FundingCycleId=610C1741-CBE5-4EB2-9695-70FB02891AC4&ViewMode=EU&GoBack=&PrintMode=&OnlineAvailabilityFlag=&pageNumber=&version=&NC=&Popup

Milstead, J.  (2008).  Health policy and politics: A nurse’s guide (3rd ed.).  Sundbury, MA: Jones and Bartlett

Naylor, M. D., & Kurtzman, E. T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29(5), 893-899.

Stokowski, L.  (2010).  The nurse practitioner will see you now.  Retrieved from http://www.medscape.com/viewarticle/723986_print

Coddington, J., & Sands, L. (2008). Cost of health care and quality outcomes of patients at nurse-managed clinics. Nursing Economic$, 26(2), 75-83.

Frellick, M. (2011). The nurse practitioner will see you now: Advanced practice providers fill the physician gap . H&HN: Hospitals & Health Networks,, 85(7), 44-49.

 Mental illness is an area of practice that is hard for many to understand and cope with. Postpartum depression and psychosis is one area that is not understood by many and still holds a negative stigma for woman. Both of these conditions can have devastating outcomes for the mother and her children if they are not addressed.

Mental illness has always been a difficult subject for many people to discuss. As it refers to postpartum women there are often social stigmas and mores that prevent many people from openly discussing post partum depression (PPD) and postpartum psychosis (PP) despite the fact that PPD and PP affect about 15% of all postpartum women collectively (Doucet et al, 2009). In recent years these disorders have gained in popularity due to events where mothers have killed their children.  The question is should these mothers be tried as murderers?

I believe that there is evidence to support that these women should be tried for manslaughter in such an instance.  According to the website “Life Love and Bipolar” , a support website for individuals suffering from bipolar:

“The law considers bipolar disorder as an EXCUSE, not the reason for the crimes committed by bipolar offenders. The only consideration offered by the legal system in case of this disorder, is a leniency in the charges and the punishment meted out. That means if a bipolar individual commits murder, he may be charged with manslaughter, which is a comparatively lesser charge.”

In their research Doucet et al discovered that PP “represents a variant of bipolar disorder triggered by childbirth” (Doucet et al, 2009).  Bipolar is often triggered by traumatic life event and in the case of PP the onset is often sudden within the first 48 hours to 2 weeks following childbirth.  Issues like family history or mental illness, little social support, low income, advanced birth age, and delivery complications tend to contribute to the incidence of PP and PPD.  I feel that we have an indepth understanding of what contributes to the onset of PPD and PP as well as a strong grasp of treatments for the disorders.  With this understanding I believe that if a mother suffering from PPD of PP murders their child they should be tried for manslaughter as would any individual suffering from a mental illness.  We cannot excuse wrongful death via murder and I feel that trying these people is the appropriate course of action.

The best intervention is always prevention!  As mentioned above we have a good grasp of contributing factors to PPD and PP.  With this knowledge the appropriate action would be to discuss the risk factors with expecting mothers and work trough coping strategies prior to birth.  In women with a family history of bipolar it has been found that prophylactic lithium treatments has reduced the incidence of PP (Doucet et al, 2009).  Many expecting parents, including myself, participate in birthing classes that teach you relaxation and breathing techniques to aid in the birthing process.  These sorts of classes should incorporate discussions of similar techniques to implement in the post partum time to prevent or combat PPD and PP.  Nurses should question mothers and fathers about possible risk factors for PPD and PP and intervene by teaching relaxation techniques, referring to mental health professionals, or providing brief counseling sessions while the mothers are still in the hospital.  Many people have never experience severe depression and are not sure where to go for help.  They need to be made aware of resources and tested to insure they understand that mental health problems do not make you crazy and proper help can improve overall health.

 Many times when a woman becomes pregnant the emphasis and attention is focused on her and the baby and the father is left on the side lines. This can decrease his feelings of being a part and understanding his importance to the family unit. This is especially true in teen pregnancies. As nurses we can sometimes contribute to this problem in the way we interact with the family.

As a stay at home father I can attest to the fact that there are certainly some stigmas in our society regarding parenting.  Although we are a progressing society there are still many expectations for parenting, including a more machoistic approach from men.  Society can influence a male to be more standoffish during the postpartum period and perhaps delay their ability to bond with the child. According to our textbook “culture influences the interactions with the baby, as well as the parents’ . . . caregiving style” (Lowdermilk & Perry, 2006, p 509).  I think the most important role that we can play as nurses would be to let go of our assumptions and attempt to fully include the father. Invite the father to participate in all activities, make eye contact with him, insure that he and the mother feel a part of the teachings, and care of the baby.  As an example of how our society may be overlooking the father there is only one column about the paternal adjustment phase in our book versus 4.5 pages talking about the woman.  I think as we progress as a society and realize that men can be loving and thoughtful caregivers we will aid families in having a more positive adjustment to parenthood.

Resources

Bipolar disorder – relation to criminal offenses. (2009). Retrieved from http://www.lifeloveandbipolar.com/bipolar-crime.html

Lowdermilk, D., & Perry, S. (2006). Maternity nursing. Philadelphia: Elsevier.

Doucet, J., Dennis, C., Letourneau, N., & Blackmore, E. (2009). Differentiation and clinical implications of postpartum depression and postpartum psychosis.JOGNN, 38, 269-279.