ISSN 2395 - 1982
SRI BALAJI VIDYAPEETH ACADEMY OF HEALTH PROFESSIONS EDUCATION AND ACADEMIC DEVELOPMENT
ANNALS OF SBV Volume 4 - Issue 1 JAN - JUN 2015
Theme
RECENT TRENDS IN SPECIALITY NURSING CARE
Annals of SBV
Annals of SBV
Index
Editorial Advisors Rajaram Pagadala K R. Sethuraman
1.
K.A. Narayan
Core Committee
3.
R. Jagan Mohan
R. Pajanivel
Advanced Nursing Practice in Burns Management
Issue Editor K. Renuka Editorial Assistants A. Kripa Angeline S. Rajeswari Editorial, Technical and Production Consultant A.N. Uma
Sri Balaji Vidyapeeth Editorial correspondence to Editorial and Production Consultant
Annals of SBV Sri Balaji Vidyapeeth
09 17
- Sumathy.P, Rajeswari.S
5.
Wurn Technique in Gynecological Nursing Care
23
28
7. Save Students from Suicide through S.A.V.E
33
- Annie Annal M , Anitha. B
6.
Current Trends in Home Health Care - Suguna Mary.D, Rajalakshmi.R, - Prabavathy.S, Beniya Elizabeth Rani. R
8.
Nurse led ward rounds – A Valuable Contribution to Neurological Patients
37
- Renuka.K, Hemapriya.S , Anbu.M
9.
Postural changes in Hemodynamically Unstable Patients in Critical Care Unit
43
- Kripa Angeline A, Vijayaraj. R, Manopriva V
10. Specially Focused Nursing Care for Preemies - Born Too Soon
49
- Geetha.C, Saranya.S
11. Contemporary Nursing Approaches in Induction of Labour
Published, Produced and Distributed by
05
- Renuka.K, Kripa Angeline. A, Sangeetha.M.A
4. Evidence Based Nursing Interventions in Prevention of Pressure Ulcer among Children
Karthiga Jayakumar
Seetesh Ghose
It is Newfangle! Nexus with Healthcare Profession Required! - Rajaram Pagadala
V.N. Mahalakshmi
M. Ravishankar
04
- Renuka K
2.
Editor-in-Chief N.Ananthakrishnan
From the Editor’s desk Recent Trends in Speciality Nursing Care
55
- Lavanya.S, Poongodi.V, Umamaheswari .R
12. Emerging and Re-Emerging Disease in the community
59
- Elavarasi.R, ArunaDevi.M, Ruma Shanthini.S, Guna.S
13. Community Mental Health Initiatives
67
- Ramaprabhu.Z, Malini Pon Angel.I
(Deemed to be University, Declared Under Section 3 of the UGC Act, 1956) Mahatma Gandhi Medical College & Research Institute Campus Pillaiyarkupam, Puduchery - 607 402 INDIA E.mail:annals@sbvu.ac.in | Phone : +91 413 2615449 to 58 | Fax : +91 413 2615457 Visit Annals of SBV Online at http://www.annals.sbvu.ac.in
Ann. SBV, Jan-June2015;4(1)
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Annals of SBV
From the Editor’s Desk Nursing: What is New? It is Newfangled! Nexus With Healthcare Profession Required!
RECENT TRENDS IN SPECIALITY NURSING CARE Dr. Renuka K *
The driving forces of health care cost containment and nursing responsibility for helping to attain cost containment have escalated the need for speciality nursing care and advanced nursing practice. Patients may need specialized care in certain situations, where specially selected and trained nurses can make a meaningful difference to recovery and well-being. Clinical nurse specialist plays a vital role in specialized care to address specific patient needs and conditions. Advance practice to integrate care across the continuum and through three spheres of influence: Patient, Nurse and System. These three spheres are overlapping and possess a distinctive focus. The primary goal of each sphere is continuous improvement of patient outcomes, standard and competent nursing care. Key elements of speciality nursing practice are to create environments through mentoring, system changes that empower nurses to develop caring process, evidence based practices to alleviate patient distress, facilitate ethical decisionmaking and respond to diversity. Speciality nursing care include category wise - Based on population, includes pediatrics, women’s health, adult health, geriatrics; Setting based – eg. Critical care emergency department, acute care, long term care; Disease wise – eg. Diabetes, oncology, palliative care; Type of care – eg. Psychiatric, rehabilitative care. Role of nurse specialists in rendering speciality care include nursing autonomy, patient advocacy, emergency care, skillful, rapid assessment, holistic nursing care, client teaching, wellness & health promotion, coordination & continuity of care. Sparacino (2005) identified seven core competencies that every clinical nurse specialist should exhibit during • Direct clinical practice - the expertise in advanced assessment, implementing nursing care and evaluating outcomes.
• Expert coaching and guidance encompasses modeling clinical expertise while helping nurses to integrate new helping nurses to integrate new evidence into practice. Also provide education or teaching skills to patients & family. • Collaboration focuses on multidisciplinary team building • Consultation involves reviewing alternative approaches and implementing .planned change. • Research involves interpreting and using research, evaluating practice. • Clinical & professional leadership involves responsibility for innovation and change in the patient care system. • Ethical decision-making involves influence in negotiating moral dilemmas, allocating resources, direction patient care and access to care. Thus, clinical nurse specialists (CNS) in every field or speciality is responsible and accountable for diagnosis and treatment of health / illness states, disease management, health promotion and preventions of illness and risk behaviors among individuals, families, groups and communities. Having speciality nurses and rendering care in a hospital setting will reduce length of stay, costs of care, while improving patient outcomes and standards of health profession. This issue holds variety of articles emphasizing the current concepts in nursing speciality rendering specialized care for different group of patients in different situations. I hope this issue will satisfy the readers / nursing fraternity to update their knowledge with current trends
* Principal, Kasturba Gandhi Nursing College, Sri Balaji Vidyapeeth. Puducherry 607402, India.
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Ann. SBV, Jan-June2015;4(1)
You are a human being first, nurse next. Realize “service to humanity is service to God”. Rajaram Pagadala* Recent changing trends in the nursing and nursing profession require rethinking to find out what is new in the profession. It shows that the nursing profession has become a specialty of medical profession. Nurses see their job as newfangled, novel and challenging, assuming increased leadership in managing the patients, however critical they may be. Nursing profession has emerged to re-emphasize that it has a nexus with medical profession for better patient care. Nurses began undertaking more and more responsibilities in controlling emerging situations and guiding other professionals working with them. This in turn eased the medical profession with routine burden giving an opportunity to spend more time to research. Nursing Profession- Traditions: Historically a review of literature shows that the origin of nursing profession began from the time of Hippocrates (fifth century BCE). At that time nursing profession was mainly taken up by men and therefore nurse was known as “male attendant”. However the foundation for modern nursing was laid down by missionaries and monks. Nurse is generally respected by calling her as ‘sister’ and male nurse as ‘brother’. They are kept in high esteem by the society. In the past, mostly nurses were unmarried until they are “paid pension and asked them to get marry and stay at home”. However there was a setback for the profession for over 200 years until the light was lit by Florence Nightingale who was an ‘influential figure for the birth of modern nursing’. The Nightingale model of nursing professional’s education spread widely in Europe and North America after 1870.
Florence Nightingale (1820-1910)
Today, the Indian scenario for nursing is still primitive, due mostly to non-implementations of policies and various recommendations by the expert committees. India has a severe shortage of human resources for healthcare. Qualified healthcare workforce is concentrated in urban areas. Government though lays down the rules and regulations for the institutions to follow, monitoring has become cursory. However it is acknowledged that the problem is challenging, and the Government is unable to bring the qualified healthcare workers to rural and underserved areas. Thus the rural population mostly depends on their unqualified healthcare workers available in their villages. Nurses Migration and Shortages: The migration of qualified doctors and nurses leading to shortages is enormous that is affecting the healthcare services in India. There is no consistent plan to encourage serving in the underserved areas at least for a period of time by rotation. The worst victims are qualified nurses, who are troubled due to corruption. Lack of incentives leads nurses to migrate to corporate hospitals and other foreign destinations. A workable comprehensive national policy for human resources especially in healthcare sector must be implemented to achieve universal health care. This must include drastic changes in the service conditions that should promote local community members to take up nursing profession and serve in their areas to solve the shortage problems in the area.
* Prof. Rajaram Pagadala, Chancellor, SBV, Puducherry, India.
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Nursing: What is New?
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Nurses Stand: Trained Nurses Association of India (TNAI)
can be a better supervisor in achieving ‘Health for Quality of Life”.
“There is always that one special patient that you will remember forever.” ---------Author unknown
In the United States, United Kingdom and in other developed countries nurses have assumed critical positions and have become Clinical Nurses. In some case the advance training, that they undergo, they are virtually discharging the duties of medical specialists managing independently under a medical specialist who supervises 6-8 Clinical Nurses, virtually wiping off the need for more medical specialist. This not only eased the burden of recruiting physicians but has reduced the operating costs drastically.
The Trained Nurses Association of India (TNAI) wants the voice of nurses must be heard. It claims that, “lack of adequate Nursing input in the existing health care policy of the Government is one of the factors responsible for the disparity that exists between poor and rich”. The TNAI further claims that; “since nursing is predominantly a ‘Caring profession” in promoting the health of an individual and thus the societal health, a nurse has a right to contribute in formulating health related policies.” It further rightly claims that the information provided by nurses must be consumed “for formulating a realistic national health policy”. Thus it implies to draft nurses “to various positions at all levels for a meaningful improvement of overall health care service system of the nation.” However, the TNAI failed to appreciate and mention that nurse being the first line of contact in emergency situations; where the patient may be collapsing, say due to a Cardio-Vascular accident or other life threatening conditions. The nurse having been trained should have the right to manage and try save the life until the physician arrives by prescribing and administering standard medications. The TNAI has also not underlined that the shortage of manpower in some specialties like Anesthesiology, Operating Rooms, Psychiatric, and Geriatric wards nurses must be trained as in the West, and allowed to function as a physician under the supervision of a Physician anesthetist. In some universities, a graduate nurse is allowed to pursue part-time medical course and become a doctor, too. Nursing Profession- Global Scenario: Historically the nursing profession has been playing important role besides taking care of the sick and suffering in hospitals, nurse also takes care of the individual and families. In the developed world the role of nurses is being expanded to administration, education, and research. They also supervise health and hygiene projects to promote preventive medicine. Therefore in India, in view of the changing trends and introducing innovative plans for promoting health, like “Swatch Bharat” programs, a nurse Page 6
A Clinical Nurse earns decent wages equivalent a physician’s beginning salary, having prescribing authority. Even a Nurse Assistant is better trained and equipped to manage patients unlike in India. Nurses are researchers, academicians and even assuming administrative roles at National and International levels. The role of Nurses functioning as counsellors, technicians, dieticians etc. is remarkable. There is nothing like trained birth attendant as it still exists in many developing countries. Another changing trend is that more and more men are entering the nursing profession. Male nurses perhaps better suited for say, outdoor emergencies. A consistent and powerful policy for National Community Health Nursing Services must be evolved. The National Center for Health Workforce Analysis of USA in their data analysis in 2013 brought out interesting points. In USA at least 16 percent of the Registered Nurses (RN) workforce and 24 percent of the Licensed Practitioner Nurse (LPN) workforce are located in rural areas. Growth in the nursing workforce outpaced growth in the U.S. population. The number of RNs and LPNs per capita has increased by about 14 percent and 6 percent respectively. Currently, about 55 percent of the RN workforce holds a bachelor’s or higher degree. This analysis helped formulation of ‘The National Nursing Policy’ that suggested; in order to for providing sustainable for healthcare services, more facilities are offered for Nurses to pursue their academic career and course like Master’s and Doctoral degrees and facilities to do research and obtain MPhil and PhD are provided. There is increased concern about the ethical aspects of global health worker migration. The World Health Organization (WHO) prescribed principles and practices to follow in International Ann. SBV, Jan-June2015;4(1)
recruitment. It directs to follow strict ethical practices and prescribes the norms of wages and working conditions. In order to prevent shortages of nurses, a country should plan and project supply and demand. It further says that it is possible only when ‘the bureaucracy realizes that nursing profession is, indeed, indispensable and is highly technical job’. The Health Resources and Services Administration’s (HRSA) created a ‘Health Workforce Simulation Model’ for the nurse requirements for USA. It concluded that the supply of nurses between 2012 and 2025 will outpace demand, even though there is a 33 percent growth in production. This demand is mainly due “to greater focus on managing health status and preventing acute health issues”
require skills for nurses to take decisions on the spot and advice.
Nursing Specialties and Technology
Nurse and Socio-economic conditions:
It is emphasized that in the changing demographic scenario there is increased need for nurses in managing chronic diseases, cancer, obesity related diseases, trauma, rehabilitation, health and hygiene etc. Therefore, in order to balance the supply and demand of nurses, the Govt. must ensure adequate funds for nursing education and improving the teaching and training. Innovative methods on par, those already in practice for decades must be introduced.
It is also important to discuss the attitude of the nurse towards the patient while attending. Equally, it is important, however sick the patient may be, and having confidence and faith in attending nurse will be beneficial. The service that a nurse provides also depends on her socio-economic conditions both at home and the community she lives in. Any disturbed situation at home reflects the services she provides to the patient and thus quality suffers. Therefore the essence of being psychologically strong will help nurse and the healthcare services provided. Therefore, the service conditions must be tuned to keep the psychological harmony of the nurse.
Saying: “Don’t mess with me — I get paid to poke people with sharp objects.” Nursing students may be granted with adequate scholarships, loans, and easy repayment facilities. Incentives for nurses willing to work in critical units, remote areas, and also research projects related to health and hygiene must be provided. In addition the recent technological developments in creating healthcare industry is challenging for nursing profession. Nurses have to be more skillful and computer literate to handle digital technology. It has become mandatory for nurses to be able to handle the obligatory and compulsory knowledge to manage and maintenance of Electronic Health Records. In order to be an expert in the field of Clinical Nursing one should be well versed with all the advanced technology taking place in instrumentation, minimal invasive surgery, robotics, and advanced technology used in the Neurosurgery, Cardio-Vascular and Thoracic surgery, Transplantations etc. The recent trends in daycare management of surgical cases Ann. SBV, Jan-June2015;4(1)
Therefore it is essential to modify the existing Nursing Policies in teaching and training. The Government should look into its Healthcare Policy and change to keep in pace with the modern healthcare services. Reallocation of budget, therefore, becomes an essential arm to upgrade the nursing profession for achieving “Health for All” providing quality healthcare comparable to that inn existence to advanced countries. The availability of sophisticated services in corporate hospitals is not enough but similar services must be made available from Primary Health Care to tertiary care facilities.
Nurse as a Leader The domain of nursing specialty training should be of forward thinking. Nurse must be trained to handle the cutting-edge technology that is emerging. They must be trained to understand how digitally advanced technology that is vastly being used, works. This also implies training them in clinical and administrative fields also. The clinical training should focus on how to provide the immediate needs of the patients should they land in critical conditions. A nurse should have the ability to identify and monitor the impending complications that may arise. Therefore the nursing professionals should be able to take part in delivering the curative, promotive, preventive, and rehabilitative healthcare services. The aim should be to make the nurse to emerge as on-the-spot leader of the Healthcare practices. A graduate nurse should be able to specialize in the fields like Pediatrics and its sub specialties Page 7
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like Neonatology, Obstetrics, and Gynecology and its sub specialties like High Risk Pregnancy, Labor Rooms, Emergency, and Trauma units, Burns Unit, Intensive Care Units and other areas like hospice facilities, assisted living etc. Nurse also must be able to function as a teacher, researcher, manager, and leader in providing health education and family counseling. In order to improve and maintain the standards in nursing education, the institutions imparting the training and employing the nurses must be brought under strict scrutiny of National Accreditation Boards and other quality and standard controlling authorities. Research and Administration both at micro and macro levels in the Nursing Education must be made mandatory. Nursing Education: Lessons to Learn: Therefore significant and striking changes must be brought in the nursing education and how much and how to deliver for the consumption of nursing student. The emerging global technologically advanced trends should encourage to carve out a model for Healthcare System that and incorporates the advances taking place in teaching and training. Lessons from the failures and successes of British National Health Services and United Sates Private Sector policies and practices must become areas of interest to extract what is good that is needed for its country. ‘Nursing Robot’-“The Pearl”: There is an explosive research taking place to combat the challenge of shortage of nurses. The research in led the innovators to invent “Nursing Robots”. But is it possible? May be one day it is likely in limited areas of nursing like dispensing medicines and making beds etc. Scientists are confident that a Nurse Robot can play a role in assisting the elderly and that might
ease ‘the burden on the overburdened nurse’. The Japanese Scientists researching nicknamed Nurse Robot as “Pearl”. Nursing Model for Healthcare Services: Therefore significant and striking changes must be brought in the nursing education and how much and how to deliver for the consumption of nursing student. The emerging global technologically advanced trends should encourage to carve out a model for Healthcare System that and incorporates the advances taking place in teaching and training. Lessons from the failures and successes of British National Health Services and United Sates Private Sector policies and practices must become areas of interest to extract what is good that is needed for its country. Nursing-A Trustworthy Profession: Finally, it must be stressed that for centuries families and society did not accept Nursing profession as a decent one. Some, however, dared to become a nurse out of frustration in the family or to live in a dignified manner independently. One did choose to become a nurse. But for decades the government and the bureaucracy did not accept the nursing profession as a profession who should be compensated on par with other similar professions, encouraging migration. Country of origin was left to suffer from deficiencies. However the outburst of healthcare needs and the progressive medical and surgical management leading to increased survival rate began to admit nursing in the main stream of medical profession. It is to be noted that the Healthcare industry is a thriving and flourishing ‘industry’. It is a fact that the suffering humanity trusts the nurse most. However it must be noted that the basic objective of becoming a nurse is “Service to Humanity”..
Advanced Nursing Practice in Burns Management “Pain after burn injury is preventable, and nurses are central to Achieve that goal” Renuka.K, Kripa Angeline. A, Sangeetha.M. A *
Abstract
Burns are the most intensely painful injuries. All patients will experience pain, regardless of the cause, size, or depth of the burn. In spite of advances in topical wound care and pharmacological management and palliative care, wound care is the main source of the pain associated with burn injury. A deeper understanding of the many aspects of treating burns and their associated pain can help nurses to provide more effective analgesia. Nurses play a vital role in understanding the management of burn wound, prevention of infection and pain management . Key Words : Burns, Fluid management, Wound care, Rehabilitation, Skin Grafting
Introduction Recent discoveries and new therapies resulting from clinical and basic research are continually being incorporated into burn care worldwide. As a result, the mortality of burned children and length of the hospital stay have been greatly reduced over the last 25 years. Advances in the last 25 years have not only improved the length of hospital stays and survival rates, but also tremendously improved the long-term outcomes of severely burned patients. These patients have skills and developmental improvements that are truly outstanding, making them effective, productive and thoughtful members of society1.This review will summaries some of the more significant changes that have occurred in the field of burn care. These have resulted in improved survival and functional status. It highlights innovative fields of research which may be responsible for further improvement in outcome.
The emergent phase occurs from the time of injury through the first 72 hours of treatment. Care during this period focuses on stabilization and transport. The first 24 hours are the most critical 2. The acute phase of injury is the majority of the patient’s time in the hospital. The focus during this time is infection control, wound care,
Phases of Burns Management Burn injury can be divided into three phases: emergent, acute and rehabilitative.
Emergency management of Burns
* Prof. Dr. Renuka.K, Kripa Angeline. A, Assoc. Prof, Sangeetha.M. A, Asst Lecturer, Dept of Medical Surgical Nursing, KGNC, Puducherry 607402, India.
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pain control, nutritional support (as much as 10,000 calories a day may be required), surgical intervention, physical and occupational therapy, and psychosocial support2 The rehabilitative phase lasts from complete wound closure through the active scar maturation process and its average is 1-2 years. Complete rehabilitation may be lifelong, involving reconstructive procedures and contracture releases.2
Management of burns patient Emergent Phase During the emergent phase, rapid assessment and intervention are essential, the nursing care is prioritized as follows: Initial assessment by primary survey includes a rapid examination of the ABCs: airway stabilization and C-spine immobilization (if needed), breathing and circulation (check status and start IV lines and fluid). History taking based on AMPLE (Allergies, Medications, Past Medical History, Last Meal and Events Preceding Injury). • Accurate burn size estimation using Rule of nine35. The fluid resuscitation needs within the first 24 hours after burn injury, is calculated using the following formulae • Parkland formula • Modified Brooke formula • Consensus formula
• Eliminate media for bacterial growth; promote healing of partial-thickness wounds ; prevent conversion of burn wounds • Promote patient comfort and • Minimize scarring and contracture5. Wound care procedures such as wound cleansing, debridement, skin grafting (including donor site care and the removal of surgical staples anchoring skin grafts into place), dressing removal, insertion and inflation of tissue expanders, passive range of motion exercises in affected joints, and splint application helps to achieve these goals.4
Recent Advancement in Burns Management Hydrotherapy Hydrotherapy is used to vigorously flush the burn wound, cleaning the wound and removing loose, nonviable tissue. Most often, a shower gurney is used for this purpose. Because this method reduces the risk of infection, it is preferable to another form of hydrotherapy known as Tanking, in which the patient is immersed into a tank of turbulent warm water. An antimicrobial soap such as Dial liquid soap or Hibiclens should be used, with water, to wash the burn wound before the application of any antimicrobial ointment. Followed by hydrotherapy Manual debridement is often done by nurses after wound cleansing. It involves the scraping or pulling off of loose nonviable skin. 34 Deep surgical debridement is also done to remove adherent eschar under general anesthesia within three to five days after injury. Moistening the adherent dressings prior to removal will minimize patient discomfort.5
All pain medications should be given intravenously, tetanus status should be checked and baseline laboratory studies obtained. 2
There are different types of collagen dressing Hydrocolloid: Hydrocolloid dressings are used on burns, light to moderately draining wounds, necrotic wounds, under compression wraps, pressure ulcers and venous ulcers.6 Hydrogel : This type of dressing is for wounds with little to no excess fluid, painful wounds, necrotic wounds, pressure ulcers, donor sites, second degree or higher burns and infected wounds.6
Wound care Wound Cleansing and dressing. Ann. SBV, Jan-June2015;4(1)
The only silver foam dressing that offers the healing benefits is AQUACEL Combining hydrocolloid technology with Hydrofiber Technology and ionic silver, AQUACEL Ag Surgical dressing provides the following benefits: Waterproof: Provides excellent absorption and retention capabilities for moderate to highly exuding wounds.2 Antimicrobial Protection1-3 Comfortable and Flexible: Comforts to the wound surface to form an intimate contact,3 Skin Friendly: Helps reduce wound pain while the dressing is in situ and upon removal.4-7 Supports wound healing by providing a moist wound healing environment. Skin grafting Subsitutes There are various ways to classify the skin substitutes. A classification was proposed based on composition as follows 4
Alginate: Alginate dressings are used for moderate to high amounts of wound drainage, venous ulcers, packing wounds and pressure ulcers in stage III or IV. Collagen: A collagen dressing can be used for chronic or stalled wounds, ulcers, bed sores, transplant sites, surgical wounds, second degree or higher burns and wounds with large surface areas.33,34
It is the less expensive and widely used dressing for burns. Banana leaves are a cheap and effective alternative to traditional medical wound dressings. Wounds treated with banana leaves heal in the same period of time as wounds treated with Vaseline gauze dressings.
Infection control and wound care constitute the primary focus during the acute phase.3
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Collagen dressings are dressings that are derived from animal sources, such as bovine (cattle), equine (horse) or porcine (pig) sources. The collagen helps to promote the growth of new collagen at the wound site, prompting an often speedier recovery period. Collagen dressings can also help with fibroblast production and according to, some dressings may also help maintain the appropriate temperature of the wound site’s microenvironment.6
Banana leaf dressing
Acute Phase
The overall goals of wound care for burn patients are universally accepted and seek to:
Collagen dressing
Aquacel foam dressing
Ann. SBV, Jan-June2015;4(1)
Skin Grafting Class I: Temporary impervious dressing materials a) Single layer materials • Naturally occurring or biological dressing substitute, e.g. amniotic membrane, potato peel • Synthetic dressing substitute, e.g. synthetic polymer sheet (Tegaderm, Opsite), polymer foam or spray b) Bi-layered tissue engineered materials, e.g. TransCyte Page 11
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Class II: Single layer durable skin substitutes a. Epidermal substitutes, e.g. cultured epithelial autograft (CEA), Apligraft b. Dermal substuitutes • • • •
bovine collagen sheet,e.g. Kollagen porcine collagen sheet bovine dermal matrix, e.g. Matriderm human dermal matrix, e.g. Alloderm
Class III: Composite skin substitutes a) Skin graft • Allograft • Xenograft b) Tissue engineered skin • Dermal regeneration template, e.g. Integra • Biobrane From the practical point of view, the skin substitutes are best classified as temporary or permanent and synthetic or biological. Biological Skin substitutes • Amnion The amnion is a thin semi-transparent tissue forming the innermost layer of the foetal membrane. The amnion has been used as biological dressings for burns.19-20As fresh amnion carries risk contaminations and disease transmission, amnion is collected from placentae of selected and screened donors. Various preservation methods have been introduced, including cyopreservation in liquid nitrogen, preservation in silver nitrate, storage in antibiotics solution, glycerol-preserved sheets, dried sheets and gamma-irradiated sheets.6 It has been claimed to be one of the most effective biological skin substitutes used in burn wounds, with efficiency of maintaining low bacteria count. It also has advantages of reducing loss of protein, electrolytes and fluids, decreasing the risk infection, minimising pain, acceleration of wound healing and good handling properties. Amnion is primarily used for covering partial-thickness burns until complete healing. It is particularly useful for superficial partialthickness facial burns6. When used in facial burns, it is noted to be adhesive, conformable and easily removable. It is also used for temporary coverage Page 12
in wound bed preparation and sandwich grafting technique. Cultured epithelial autografts The culture of keratinocytes is an important advance in the burn care. CEA was first reported in the clinical use in 1981 in extensive full thickness burns. A large surface area of keratinocytes can be obtained from the relatively small biopsy of healthy skin from the patient. The autologous keratinocytes are isolated, cultured and expanded into sheets over periods of 3–5 weeks. The technique of suspension in fibrin glue has reduced the time for clinical use to 2 weeks 7. Synthetic skin substitutes Synthetic skin substitutes are constructed out of non-biological molecules and polymers that are not present in normal skin.8 These constructs should be stable, biodegradable and provide an adequate environment for the regeneration of tissue. It should maintain its three-dimensional structure for at least 3 weeks to allow ingrowths of blood vessels, fibroblast and coverage by epithelial cells. Biodegradation should preferably take place after this period. This process should occur without massive foreign body reaction as this process would increase the inflammatory response, which may be associated with profound scarring. It should also be composed of immunocompatible materials to avoid immunoreactive processes. The artificial nature of these skin substitutes has some distinct advantages and disadvantages when compared to natural biological structures. The composition and properties of the product can be much more precisely controlled. Various additives such as growth factors and matrix components can be added to enhance the effect. These products could also avoid complications due to potential disease transmission. However, these synthetic skin substitutes generally lack basement membrane and their architecture do not resemble native skin. The use of non-biological components can be problematic when trying to produce a biologically compatible material.8 There are several synthetic skin substitutes that are available for wound coverage. However, there are also substantial number of synthetic substitutes undergoing in vitro or animal testing.9-11 Amongst Ann. SBV, Jan-June2015;4(1)
the synthetic skin substitutes available in the market are Biobrane, Dermagraft, Integra, Apligraft, Matriderm, Orcel, Hyalomatrix and Renoskin. • Biobrane Biobrane consists of an inner layer of nylon mesh that allows fibrovascular ingrowth and an outer layer of silastic that serves as a vapour and bacterial barrier.12 It has been used to give a good effect in clean superficial burns and in donor sites. When used to cover partial-thickness wounds, the mesh adheres to the wound until healing occurs beneath. Biobrane should be removed from any full-thickness wound prior to skin grafting. Biobrane is an established synthetic dressing for burn wounds, particularly in the paediatric population. Whitaker et al. published a critical evaluation of the evidence base for the varied uses of Biobrane within the field of plastic and reconstructive surgery.13 They concluded that there is good evidence (Grade A) to support the use of Biobrane in the management of burns, particularly in partial-thickness burns in children. When dressed with Biobrane, patients with superficial partialthickness burns experience less pain as compared to gauze and silver sulfadiazine dressing.14 Biobrane also significantly reduces hospital stay, wound healing time and requirements of pain medications.15 There are reported applications in patients with toxic epidermal necrosis, chronic wounds, or following skin resurfacing.13,16 • Dermagraft Dermagraft is a bioabsorbable polyglactin mesh seeded with allogenic neonatal fibroblast.17 Indications for the usage of Dermagraft are in burn wounds, chronic wounds and diabetic ulcers.8 It can be used as a temporary or permanent covering to support the take of meshed split-thickness skin grafts on excised burn wounds.17,18 Dermagraft appears to produce results as good as allograft with regard to wound infection, wound exudate, wound healing time, wound closure and graft take. It was also reported to be removed easier than allograft, with significantly higher level of patient satisfaction.8,19 There has been no adverse reactions to Dermagraft, with no evidence of rejection, early deterioration or separation from wound.18 There has so far been no safety issues regarding Dermagraft.19 Ann. SBV, Jan-June2015;4(1)
• Integra Integra is a dermal regeneration template consisting of bovine collagen, chondroitin-6-sulphate and a silastic membrane. This product has gained widespread use in the clinical treatment of deep partial-thickness and full-thickness burn wounds, full-thickness skin defects of different aetiologies, chronic wounds and in soft tissue defects.8,17,20,21 The bovine collagen dermal analogue integrates with the patient’s own cells and the temporary epidermal silicone is peeled away as the dermis regenerates. A very thin autograft is then grafted onto the neodermis.17,22 Heimbach et al. showed that Integra was superior to autograft, allograft or xenograft in terms of wound healing time.21,23 • Apligraft Apligraft is a bilayered living skin equivalent. It is composed of type I bovine collagen and allogenic keratinocyte and neonatal fibroblast.17,22 It is indicated in partial to full thickness burns, skin graft donor sites, chronic wounds, diabetic ulcers and Epidermolysis Bullosa.8 It has to be applied “fresh” as it has a shelf-life of 5 days at room temperature.17 Apligraft has been shown to accelerate wound closure. Apligraft when combined with autograft has produced more favourable results than autograft only. Scar tissue, pigmentation, pliability and smoothness were significantly closer to normal with Apligraft.24 • Matriderm Matriderm is a structurally intact matrix of bovine type I collagen with elastin. It is utilised for dermal regeneration. Its indications are full thickness or deep dermal burn wounds and chronic wounds. The matrix serves as a support structure for the ingrowth of cells and vessels. Its elastin component improves the stability and elasticity of the regenerating tissue. As the healing process advances, fibroblast lays down the extracellular matrix and the Matriderm reabsorbs.25 Its indications seem to be similar to Integra. Schneider et al. compared the engraftment rate and rate of vascularisation of Matriderm and Integra in a rat model. They revealed no major differences in engraftment rates or vascularisation.26 However, unlike Integra, Matriderm has been shown to be able to accommodate immediate split thickness skin grafting with no diminished take.27 In experimental models, the matrix reduces wound contracture, and histologically collagen bundles in Page 13
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the scar are more randomly orientated. Clinical trials with a long-term clinical evaluation showed no difference in scar elasticity between the described dermal substitute and split thickness grafts alone.27 • OrCel OrCel is a bilayered cellular matrix in which normal human allogeneic skin cells (epidermal keratinocytes and dermal fibroblasts) are cultured in two separate layers into a type I bovine collagen sponge. OrCel is a bilayer dressing resembling normal skin and was developed as a tissue-engineered biological dressing. It is indicated in the treatment of chronic wounds and skin graft donor sites. OrCel has also been used as an overlay dressing on split-thickness skin grafts to improve function and cosmesis.8,28,29 • Hyalomatrix Hyalomatrix is a bilayer hyaluronan base scaffold with autologous fibroblast. It has an outer silicone membrane. The scaffold delivers hyaluronan to the wound bed, and the silicone membrane acts as a temporary epidermal barrier.30 It is indicated in burn wounds and chronic wounds.8 Skin Grafting Surgical debridement under anesthesia can facilitate the removal of nonviable tissue. There are two basic types of skin grafts: split-level thickness and full thickness. Split-Level Thickness Grafts involves removing only the top two levels of the skin the epidermis and the dermis from the donor site. These grafts are used to cover large areas. A full thickness graft involves removing the muscles and blood vessels as well as the top layers of skin from the donor site.
Pain management Pharmacologic therapies • Morphine remains the gold standard in the treatment of moderate-to-severe acute pain. Hospitalized burn patients require three types of pain medication: background, procedural and breakthrough.13 • Severe background pain can be managed with morphine through continuous IV infusion or patient-controlled analgesia (PCA). Mild-toPage 14
moderate background pain can be managed with short-acting, orally administered opioids, such as oxycodone 5 mg - acetaminophen325 mg (Percocet). Regularly scheduled long-acting morphine can be used to treat chronic pain. If used, the dose must be adjusted as needed and should be tapered over time. • Intravenous fentanyl (Sublimaze), another opioid, is more effective in the control of severe burn pain.8 Fentanyl is often combined with the benzodiazepine midazolam (Versed) to induce conscious sedation with analgesia. The success of efforts with fentanyl has led to research on alternative routes of administration. Sharar and colleagues compared the use of oral transmucosal fentanyl citrate delivered in a raspberry-flavored lozenge with oral oxycodone before outpatient pediatric burn wound care and documented similar outcomes in pain and anxiety levels. The patients also preferred the taste of the fentanyl preparation.10 • Ketamine (Ketalar), a dissociative drug used in general anesthesia, has been described as effective in controlling procedural burn pain in children.12 • Procedural pain is more severe than background pain and can be excruciating without adequate analgesia so that Procedural medication is usually ordered before dressing changes. The dose is dependent on the extent and severity of injury. Morphine is the preferred drug and can be administered in an IV, oral instant-release or elixir form. Propofol (Diprivan) is another general anesthetic used for procedural burn wound care. Propofol is preferred over ketamine for procedural burn pain in adults. • Breakthrough pain medications are added as needed. Narcotics should be administered based on objective pain scores. Titrating according to response and weaning when appropriate helps decrease untoward side effects.14] • Gabapentin (Neurontin) and methadone hydrochloride (Methadone) can prove helpful in controlling chronic burn pain. . Methadone can also be used to help wean off patients from opioids after long-term use.
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Nonpharmacologic modalities Nonpharmacological therapy includes relaxation techniques (for example, focused deep breathing and hypnosis), cognitive strategies (such as distraction, reappraisal, guided imagery, and visualization), biofeedback, music therapy, therapeutic touch, and the presence of significant others for emotional support, have been studied by researchers. Many of these have proven to be beneficial, but such modalities are adjuncts to, not substitutes for, narcotic analgesia during painful wound care.3, 18 Prensner and colleagues found music to have a distracting benefit when used as an adjunctive therapy to reduce pain and anxiety during burn wound care.19 Transcutaneous electrical nerve stimulation (TENS) has also been used successfully in burn pain management. Topical selection is based on established criteria: These medications can be applied directly. It is messy and may be indicated for more superficial wounds or in areas where pressure from a secondary dressing is contraindicated. The closed method is more common. In this method, topicals are applied directly to a wound and a bandage covers the topical, or the topical agent may be impregnated into the gauze to avoid desiccation. Control of drainage, ease of use and cost are important features. Always wrap digits separately, minimize for function, avoid pressure over the ears and wrap to minimize edema.14 • Silver sulfadiazine (Silvadene) cream is effective against all organisms commonly associated with burn wound infection. • Mafenide acetate (Sulfamylon) is a thick, white cream with antimicrobial properties, is often used on burned ears and noses, (the drug’s nickname, “white lightning”). It is more effective than silver sulfadiazine at penetrating eschar. • PluroGel is a topical antimicrobial agent developed at the University of Virginia Medical Center that has properties similar to those of Silvadene and is effective against all organisms commonly associated with burn wound infection.
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Innovative silver-coated dressings such as Acticoat and Aquacel Ag are the most recent antimicrobial alternatives for topical burn wound care.34 Rehabilitative Phase During the rehabilitative phase, significant lifestyle changes become more evident to patients. Prurities can be problematic, caused by a combination of dry skin and the release of histamine during scar remodeling. The relief strategies include cool or tepid baths, pressure garments, massage, avoidance of caffeine and the application of ice37. Sensitivity to heat and cold is a problem for many patients with a high TBSA. These patients should avoid extremes in temperature, especially in the first year post-injury. They should dress appropriately for the weather, with an emphasis on layers of clothing that can be removed as needed. Grafted areas have decreased sensation and require visual inspection for open areas, Scar and discoloration are topics of great discussion and controversy. Some agents may minimize hypertrophic scarring: pressure garments, silicon gel sheets (Silon, Cica-Care, Avogel), steroid injections and creams (Kenalog, Aristocort, Triderm), and Uvex face masks. Camouflage makeup may help with hypoor hyperpigmentation35. Reintegration into society is difficult due to the disfigurement associated with burn injury. Support is available through various groups typically based at burn centers. School re-entry programs are available to help children with the transition back to school. A peer support counseling network, Survivors Offering Assistance in Recovery, is available throughout many areas of the country.15 A burn injury is challenging and requires specialized care across the continuum. Nurses are ideally suited to facilitate this process.
Conclusion Nurses spend their majority of time in direct patient care that affords them the opportunity to establish meaningful therapeutic relationship with burned patients and their families. Therefore, it is vital that nurses should update their knowledge on advanced practice for burns wound care to establish a standard and quality in nursing practice.
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References 1. Thomas J. The Cocoanut Grove inferno. 50 years ago this week, 492 died in a tragedy for the ages. Boston Globe 1992 Nov 22 2. Cope, O., Laugohr, H., Moore, F.D., Webster, R. Expeditious care of full-thickness burn wounds by surgical excision and grafting. Annals of Surgery 125: 1- 22, 1947. 3. Sheridan R, et al. Management of background pain and anxiety in critically burned children requiring protracted mechanical ventilation. J Burn Care Rehabil 2001;22(2):1503 4. Choiniere M, et al. Patient-controlled analgesia: a doubleblind study in burn patients.Anaesthesia 1992;47(6):467-72. 5. Meyer WJ, 3rd, et al. Acetaminophen in the management of background pain in children post-burn. J Pain Symptom Manage 1997;13(1):50-5. 6. Long TD, et al. Morphine-infused silver sulfadiazine (MISS) cream for burn analgesia: a pilot study. J Burn Care Rehabil 2001;22(2):118-23. 7. Horch RE, Stark GB. Comparison of the effect of a collagen dressing and polyurethane dressing on healing of split thickness skin graft donor sites. Scand J Plast Reconst Surg Hand Surg. 1998;32:407–13. 8. Nataraj C, Ritter G, Dumas S, Helfer FD, Brunelle J, Sander TW. Extra cellular wound matrices: Novel stabilization and sterilization method for collagen-based biologic wound dressings. Wounds. 2007;19:148–56. 9. Gruss JS, Jirsch DW. Human amniotic membrane: A versatile wound dressing. Can Med Assoc J.1978;118:1237– 46. 10. Hadjiiski 0, Anatassov N. Amniotic membranes for temporary burn coverage. Ann Burns Fire Disasters.1996;9:88–92. 11. Linneman PK, et al. The efficacy and safety of fentanyl for the management of severe procedural pain in patients with burn injuries. J Burn Care Rehabil 2000;21(6):519-22. 12. Prakash S, et al. Patient-controlled analgesia with fentanyl for burn dressing changes.Anesth Analg 2004;99(2):552-5. 13. Sharar SR, et al. A comparison of oral transmucosal fentanyl citrate and oral oxycodone for pediatric outpatient wound care. J Burn Care Rehabil 2002;23(1):27-31. 14. Finn J, et al. A randomised crossover trial of patient controlled intranasal fentanyl and oral morphine for procedural wound care in adult patients with burns. Burns2004;30(3):262-8. 15. Groeneveld A, Inkson T. Ketamine. A solution to procedural pain in burned children. Can Nurse 1992;88(8):28-31. 16. Humphries Y, et al. Superiority of oral ketamine as an analgesic and sedative for wound care procedures in the pediatric patient with burns. J Burn Care Rehabil 1997; 18(1 Pt 1):34-6. 17. Powers PS, et al. Safety and efficacy of debridement under anesthesia in patients with burns. J Burn Care Rehabil 1993;14(2 Pt 1):176-80. 18. Raymond I, et al. Sleep disturbances, pain and analgesia in adults hospitalized for burn injuries. Sleep Med 2004;5(6):551-9. 19. Raymond I, et al. Incorporation of pain in dreams of hospitalized burn victims. Sleep2002;25(7):765-70. 20. Raymond I, et al. Quality of sleep and its daily relationship to pain intensity in hospitalized adult burn patients. Pain 2001;92(3):381-8.
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21. Ashburn MA. Burn pain: the management of procedurerelated pain. J Burn Care Rehabil1995;16(3 Pt 2):365-71. 22. Hoffman HG, et al. Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study. Clin J Pain 2000;16(3):244-50. 23. Powers PS, et al. Interrupted debridement. J Burn Care Rehabil 1985;6(5):398-401 24. Elliott CH, Olson RA. The management of children’s distress in response to painful medical treatment for burn injuries. Behav Res Ther 1983;21(6):675-83. 25. Kelley ML, et al. Decreasing burned children’s pain behavior: impacting the trauma of hydrotherapy. J Appl Behav Anal 1984;17(2):147-58. 26. Nover RA. Pain and the burned child. J Am Acad Child Psychiatry 1973;12(3):499-505 27. Ptacek JT, et al. Pain, coping, and adjustment in patients with burns: preliminary findings from a prospective study. J Pain Symptom Manage 1995;10(6):446-55. 28. Perry S, Heidrich G. Management of pain during debridement: a survey of U.S. burn units. Pain 1982;13(3):267-80. 29. Wiechman SA, Patterson DR. ABC of burns. Psychosocial aspects of burn injuries. BMJ2004;329(7462):391-3. 30. Saxe G, et al. Relationship between acute morphine and the course of PTSD in children with burns. J Am Acad Child Adolesc Psychiatry 2001;40(8):915-21. 31. Trop M, et al. Silver-coated dressing Acticoat caused raised liver enzymes and argyria-like symptoms in burn patient. J Trauma 2006;60(3):648-52. 32. By Patricia A. Connor-Ballard, AJN t April 2009 , Vol. 109, No. 4 33. Park SN, Lee HJ, Lee KH, Suh H. Biological characterization of EDC-crosslinked collagen-hyaluronic acid matrix in dermal tissue restoration. Biomaterials. 2003;24:1631–41. 34. Lazovic G, Colic M, Grubor M, Jovanovic M. The application of collagen sheet in open wound healing.Ann Burns Fire Disasters. 2005;18:151–6. 35. Veves A, Sheehan P, Pham HT. A randomized, controlled trial of promogran (a collagen/oxidized regenerated cellulose dressing) vs standard treatment in the management of diabetic foot ulcers. Arch Surg.2002;137:822–7. 36. Nagata H, Ueki H, Moriguchi T. Fibronectin: Localization in normal human skin, granulation tissue, hypertrophic scar, mature scar, progressive systemic sclerotic skin, and other fibrosing dermatoses. Arch Dermatol. 1985;121:995–9. 37. Motta G, Ratto GB, De Barbieri A, Corte G, Zardi L, Sacco A, et al. Can heterologous collagen enhance the granulation tissue growth? An experimental study. Ital J Surg Sci. 1983;13:101–8.
Evidence Based Nursing Interventions In Prevention of Pressure Ulcer Among Children P.Sumathy, S. Rajeswari*
Abstract
Pressure ulcer (PU) has now become a common problem among the Paediatric population. The risk factors can be classified into intrinsic and extrinsic factors. There are several scales for assessment of pressure ulcer for children but the Braden Q scale is found to be more valid and reliable, and for the new born, it is the Neonatal Skin Risk Assessment Scale (NSRAS). All children who are admitted should have a comprehensive assessment and those with pressure injuries are staged as per National Pressure Ulcer Advisory Panel. Nurses have got a pivotal role in prevention of pressure ulcer among children by adopting various preventive strategies. Key Words : Pressure Ulcer, Braden Q scale, Neonatal Skin Risk Assessment Scale
Introduction Excellent skin care is an attribute of quality care. Prevalence of skin breakdown and pressure ulcer has become a standard by which hospitals are evaluated and assessed with pressure ulcers recognized as an international patient safety problem. Most pressure injuries are preventable, if appropriate measures are implemented. Clinical practice guidelines for prevention and treatment of pressure ulcers that specifically address the needs of the pediatric population.1
Pressure Ulcer Prevalence Rates While the problem of Pressure ulcers in adults has received a great deal of attention, far less is known about pressure ulcer in children and neonates. 1 Recent studies have indicated that PUs are also common in the pediatric population, and in the last ten years greater attention has been paid to this problem. There is greater awareness that pediatric patients in certain health care settings are also at high risk of developing Pressure ulcers. Prevalence
rates for PUs in hospitalized pediatric patients range from 3% to 28%. 2 The pressure ulcer prevalence rates are as high as 27% in PICU and 23% in NICU, most of it which occurs within 2 days of admission.1
Risk factors for Pressure Ulcers Pressure ulcers are defined as a localized area of tissue destruction that develops as a result of soft tissue being compressed between a bony prominence and an external surface, causing starvation of oxygen and vital nutrients.3 A pressure ulcer can develop in as short as 30 minutes if there is a high pressure in a small area, increased pressure over short periods of time and slight pressure for long periods of time has shown to cause equal damage. Several factors have been identified to cause skin breakdown in the pediatric population. Although the true risk factors are difficult to determine there are certain suggested risk factors which can be classified into intrinsic and extrinsic factors.4
* Prof. Mrs. P. Sumathy, Mrs. S. Rajeswari, Asso .Prof, Dept. of Child Health Nursing, KGNC, Puducherry 607402, India. .
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Extrinsic Factors - Impact Injury loss, Heat, Moisture, Posture, Infection. Intrinsic Factors – Immobility, Sensory loss, Age Disease, Body type , Incontinence, Poor Nutrition. Both the factors are related to Pressure Ulcer
Who are the Children at Risk: ¾¾ ¾¾ ¾¾ ¾¾ ¾¾ ¾¾ ¾¾ ¾¾ ¾¾ ¾¾ ¾¾
Neonates Length of stay > 4 days Edema Weight loss Sepsis Traction devices Mechanical ventilator Children with spina bifida and cerebral palsy Extra corporeal membrane oxygenator Duration of intubation Medical devices.5
Skin Differences: • The difference in the skin of an infant from that of an adult predisposes the infant to a higher risk of skin injury because of a lack of healthy and mature skin barrier.6 • The infant skin has also has a higher absorption rate as compared with an adult’s skin. This difference in the absorption rate also predisposes infants to a dry, flaky and impaired skin barrier. Moreover the skin cells are smaller and thinner than an adult skin, which results in a weakened barrier to the environment.7 • A preterm infant’s skin is also prone to injury because of the lack of collagen in the skin. Collagen helps to maintain the strength and the elasticity of the dermis and hence if deficient, leads to a higher risk of an injury to the skin.8 Risk Assessment scales for Pressure Ulcer in Pediatric Population: Although there is no agreement on which risk factors contribute to pressure ulcer development in neonates and children. There is an agreement that prevention lies in early identification.9 There are around 10 published pediatric pressure ulcer risk assessment scales, out of which the Braden Q scale for predicting pediatric pressure ulcer risk Page 18
is a widely used valid and reliable pediatric specific pressure ulcer risk assessment tool which is adapted from the adult based Braden scale.10 The sensitivity of the Braden Q scale was found to be 88% and a specificity of 58%.11 The Braden Q scale includes the 6 original Braden subscales (mobility, activity, sensory perception, moisture, friction and shear, and nutrition) and in addition has a 7th component i.e., tissue perfusion /oxygenation.
Stage 1 : Pressure Injury Non-Blanchable Erythema:
Stage 3 Pressure injury: Full Thickness Skin Loss
• Intact skin with non blanchable redness of a localized area usually over a bony prominence • The area may be painful, firm , soft, warmer or cooler compared to adjacent tissue.
Braden Q Scale can be used for children < 5 years , and Adult Braden Scale is used for children > 5 years.12
Scoring the Braden Q Scale
• Subcutaneous fat may be visible but bone, tendon muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include tunneling and undermining.
The total Braden Q scale scores range from 7 (highest risk ) to 28 (lowest risk), with a score of 16 or lower identifying pediatric patients at risk for pressure ulcers.11
• The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and can be shallow, but areas of significant adiposity can develop extreme deep injuries.
The other assessment scales include the Glamorgan scale and the Neonatal Skin Risk Assessment Scale (NSRAS), which has got a sensitivity of 98.4%, and 83% and a specificity of 67.5% & 81% respectively.13
Patient and Wound Assessment: On admission all neonates and children should have a comprehensive assessment that includes skin assessment and risk assessment for pressure ulcers.
• Darkly pigmented skin may not have visible blanching, its colour may be different from the surrounding area. • May indicate at risk persons (heralding sign of risk)
Stage 2 Pressure Injury : Partial Thickness Skin Loss
Skin assessment: Accurate head to toe skin assessment should be carried out which includes visual inspection of the anterior and posterior surface of the skin. Thorough examination of high risk areas such as under splints, braces, traction boots, tracheostomy plates and arm boards is critical.14 The risk assessment is carried out by using the Risk Assessment Scales.(Braden Q Scale, Glamorgan Scale, Neonatal Skin Risk Assessment Scale (NSRAS). If pressure ulcers are noted location, size, undermining , tunneling, drainage, necrotic tissue, epithelisation of any stage and surrounding skin tissue should be documented. Pressure injuries are staged according to the 2009 National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel (NPUAP/EUPAP), Injury classification System.15 Ann. SBV, Jan-June2015;4(1)
Stage 4 Pressure Injury: Full Thickness Tissue Loss
Full thickness full tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. • Presents as a shallow , open wound with a red pink wound bed, without slough. • May also present as an intact or open/ruptured serum filled blister. • Presents as a shiny or dry, shallow ulcer without slough or bruising.
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The depth of a stage 4 pressure injury varies by anatomical location. It can extend into muscles and /or supporting structures, making osteomyelitis possible. Exposed bone or tendon is visible or directly palpable.
Unstageable Pressure Injury : Depth Unknown Full thickness tissue loss in which the base of the pressure injury is covered by slough (yellow, tan, grey, Page 19
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green or brown ) and or eschar (tan, brown or black) in the pressure injury bed. Until enough slough/eschar is removed to expose the base of the pressure injury, the true depth and therefore the stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body’s natural biological cover and should not be removed.
• The risk of developing pressure ulcer in the occipital area can be done by changing the position of the head and repositioning the patients every 2nd hourly. • Protective devices such as Gel Pillow,17 Foam
Device related pressure injury: Device related injuries are common pressure injuries in children. More than 50% of the pressure injuries are due to devices.1 The common device related injuries includes the use of pulse oximeter, naso gastric tube, CPAP, nasal cannula, and tracheostomy plates. 20
Evidence Based Inter ventions for Prevention and Treatment of Pressure Ulcer Key Role of the Skin Champion’s – The Nurses Prevention of pressure ulcer and early detection is the goal of all health care providers. Nurses play an important role in the prevention of pressure ulcers. Hence it is essential to develop strategies to prevent the occurrence.14 The strategies include: 99 Increase awareness of pressure ulcer risk. 99 Identify, assess, and monitor children at moderate and high risk. 99 Initiate pressure ulcer prevention protocol 99 Interdisciplinary education 99 Pressure ulcer data collection (weekly skin audits) 99 Make recommendations for pressure ulcer prevention and treatment.5
Prevention and Treatment of Pressure Ulcer: Interventions should aim at 1. Positioning the child 2. Minimizing or eliminating friction and shear/ minimizing pressure 3. Managing moisture 4. Maintaining adequate nutrition/hydration 5. Educating mothers /caregiver 1.Positioning: Turning and re-positioning schedule every 2 hours. The aim of repositioning is to reduce or eliminate pressure in order to maintain circulation to areas of the body at risk for pressure ulcer development.16 2. Minimize pressure: The occipital area is the most common anatomical site in children for the development of pressure injury, followed by the sacrum, ear lobes and heels.14 Page 20
• Ear protector-donut shaped, convoluted polyurethane foam raises the ear from the bed allowing air passage, drainage and protection from bed sores.
Pillow, Air Fluidized Beds, and Viscous Fluid Mattress are found to be useful In removing the Pressure Off from the Occipital Region. A foam overlay with and without a gel pillow provides an effective and cost effective pressure reducing surface in pediatric patients ages infant through 16 years of age.18 Foam mattresses aim to redistribute body weight and the movement of a child is only slightly limited .19 • Pro t e c t i on of the heels can be accomplished by suspending the heels off the bed using pillows, gel foams, positional protective pillows or a foam padded boot. Eg., Prevalon boot – this boot will protect the heel, the lateral ankle and the medial ankle from injury.1 • Protective barrier dressing on the sacral region not only includes foam cushioning for the protection of bony prominences but also should protect the skin from shearing with their removal.
Strategies to prevent pressure ulcer due to devices • Change the location of the pulse oximeter. • Fenestrated contact dressing can be applied underneath devices such as a pulse oximeter. •
Foam protective barrier dressing can cushion and protect the skin from the pressure of the gastrointestinal tube and absorb any drainage or leakage which may occur from or around the gastrointestinal tube site.
• Silicion tape or a thin hydrocolloid can be beneficial in maintaining the skin integrity to secure devices such as nasal cannulae, prongs etc.,1
4. Maintain adequate nutrition and hydration: The systemic and immunologic effects of malnutrition further limit the tissue tolerance to pressure , frictional forces and shear especially as third spacing from hypoalbuminemia develops. 22Hence, a comprehensive assessment and good nutrition can help prevent injury from occurring. If pressure ulcers have occurred additional proteins, calories, vitamins and minerals are required to promote the wound healing process.20 5. The need for Education: Patient education is an important piece of pressure ulcer prevention and treatment. The patient, family and care givers are key to prevention, management and treatment of pressure ulcers. Teaching materials should be given to the patient and family on admission or at the time risk is identified. The areas for education includes causes of pressure ulcers, ways to prevent them, dietary needs, positioning, signs of infection, types of tissue, normal and abnormal colours of tissue, infection control, dressing change technique etc.,21
Treatment of Pressure Ulcers: 1. Wound Cleansing: Only sterile water or normal saline is used and most preferred for neonates is sterile water. Normal saline to be diluted with sterile water in the ratio of 1:1.23 2. Debridement: Necrotic tissue should be debrided , but adequate guidelines for managing heel pressure ulcers in neonatal and pediatric population is lacking. 3. Dressings: Recommendations for non infected wounds include the use of hydrogels, hydrocolloids and film dressings. For infected wounds sheet hydrogels can be combined with topical antibacterial and antifungal ointments but must be changed every 6-8 hours24.
Eg., Mepilex Border Sacrum – this is a silicone based product that is non adherent and is gentle on the skin when removed.20 Ann. SBV, Jan-June2015;4(1)
3.Managing of moisture: A moist environment due to faecal or urinary incontinence can cause skin breakdown in the diaper area. A petroleum based ointment or a zinc oxide paste to the skin with each diaper change can be beneficial. 21
4. Pain management: Researchers have examined the use of topical medications for pressure ulcer pain treatment.25 Ann. SBV, Jan-June2015;4(1)
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Conclusion Pressure ulcer prevention in the pediatric patient is accomplished through pressure ulcer awareness with education to all health care providers and families involved in the care of a child. A thorough skin assessment and utilizing a risk assessment guide is essential to determine the patients who are at risk .The successful implementation of new nursing interventions is the key to a comprehensive pressure ulcer prevention program
References 1. Mona Mylene Baharestani, Catherine R. Ratliff. Pressure ulcers in Neonates and Children .Advances in Skin and Wound Care 2007; 20(4): 208-219. 2. Kottner J, Wilborn D, Dassen T. (2010). Frequency of Pressure ulcers in the Pediatric Population: a Literature Review and new empirical data. International Journal of Nursing Studies; 47: 1330-1340. 3. Bryant R (2006) Acute and Chronic Wounds. Nursing Management. Second edition. Mosby, st louis MO. 4. Willock J, Hughes, Tickle S, Rossiter G, Johnson C, Pye.H. Pressure sores in children- the actual hospital perspective. Journal of Tissue Viability 2000; 10(2):59-62. 5. Rebecca Kraus , Paula Balestrieri, Mary Bolhuis Rebekah Brunoehler, Mary Charter, Wendi Redfern.Pressure Ulcer Prevention Team Wisconson Children’s hospital. 6. Schindler C. A., Mikhailov T. A., Fischern K., Lukasiewicz G., Kuhn E. M., Duncan L. (2007). Skin integrity in critically ill and injured children. American Journal of Critical Care, 16 (6), 568-574 7. Blume-Peytavi U., Hauser M., Stamatas G. N., Pathirana D., Graciana Bartels N. (2012). Skin care practices for newborns and infants: Review of the clinical evidence for best practices. Pediatric Dermatology, 29 (1), 1-14. 8. Turnage Carrier .C, Mc Lane KM, Gregurich MA. Interface Pressure Comparison of Healthy Premature infants with various Neonatal Bed Surfaces. Advances in neonatal Care 2008; 8(3): 176-184. 9. Sims A, McDonald R An overview of pediatric pressure care . Journal of Tissue Viability 2003;13:144-148. 10. Catherine Noonan, Sandy Quigley , Martha A.Q, Curley. Using the Braden Q scale to Predict Presure Ulcer risk in
11. 12. 13. 14. 15. 16.
17. 18.
19. 20. 21. 22. 23. 24. 25.
Paediatric Patients ; Journal of Paediatric Nurisng 2011; 26 :566-575. Curley MA, Quigley. Pressure Ulcers in Paediatric Intensive care , Incidence and Associated factors , Pediatric Critical Care Medicine 2003; 4 : 284-90. Quigley.S &Curley M. Skin integrity in the Pediatric Population -Preventing and Managing Pressure ulcers. Journal of Pediatric Nursing 1996;1: 17-18. Willock J Antony D, Baharestani M. Development of Glamorgan Pediatric Ulcer risk Assessment scale. Nursing Times 2007. Butler C.T. Pediatric skin care: Guidelines for Assessment, Prevention and Treatment. Dermatology Nursing 2007; 19(5):471-485 Black J Baharestani, Cuddigan J .National Pressure Ulcer Advisory Panel Updated Staging System. Advanced Skin Wound care.2009. Hardy , Harrell.D Tran K, Smith S,Zins B et. al., Exploring the effects of wound dressing and patient positioning on skin integrity in a pediatric burn facility Ostomy Wound Management 2007; 53(6): 67. Reddy, M., Gill, S. S., & Rochon, P. A. Preventing pressure ulcers: A systematic review. JAMA: Journal of the American Medical Association2006; 296(8): 974. Mc Lane KM, Krowskop TA, Mc Cord S, Fraley JK. Comparison of interface Pressure in the Pediatric Population among various Support Surfaces. Journal of Wound Ostomy Continence Nurse 2002; 29: 242-51. Parnham A .Pressure ulcer risk assessment and prevention in children. Nursing Children and Young People 2012; 24: 24-29. Schober Flores.C Epidermolysis bullosa-Wound Care Pearls for the Non-infected and Infected Wound. Journal of the Dermatology Nurses Association 2009; (1):21-28. Cakmak S.K. Gul.U, Ozer.S, Yegit Z, Gonu.M Risk factors for Pressure Ulcer. Advances in Skin and Wound Care 2009; 22(9):412-415. Baranoski S, Ayello EA. Wound care Essentials, practice principles, 2nd edition, Philadelphia P.A Lippincott Williams &Wilkins 2007. Samaniego I Developing a Skin Care Pathway for Pediatrics .Dermatology Nursing 2002;14:393-396. Lund C Prevention and Management of Skin Breakdown, Nurse Clinic North America 1999;34:907-920. Prentice WM, Roth LJ, Kelly P. Topical Benzydamine Cream and the relief of Pressure Pain. Palliat Med. 2004;18(6):520– 524
Wurn technique in gynaecological nursing care M. Annie Annal, B.Anitha. *
Abstract
The Wurn technique is a manual physical therapy technique used as a form of alternative medicine gives often dramatic improvements in urogenital, reproductive, sexual function, and to treat endometriosis, pelvic inflammatory disease, pelvic spasms, polyps, and tubal obstruction. The wurn technique focuses on decreasing pain and increasing mobility and function of abdomino-pelvic and reproductive organs by diminishing adhesions. Key Words : Adhesion, Endometriosis, Infertility, Pelvic inflammatory disease, Pelvic spasm, Technique.
Introduction The Wurn technique is a site-specific massage therapy in the form of relaxing technique. It is designed to deform and detach the bond of adhesions and return the body to normal, painfree function of reproductive organs.1 This physical therapy focuses on deforming the adhesive collagen cross-links that comprise adhesions and appear to contribute to treat the underlying causes of infertility, including mechanical blockages and some hormonal imbalances2. By decreasing adhesions that bind the organs appears to help the body to function and
Wurn technique
to promote the function of abdomino-pelvic and reproductive functions. Wurn technique is a unique therapy, developed by physical therapist Belinda Wurn & Larry Wurn. The nurses must require training courses from physical therapist and must be licensed to treat the gynaecological problems with wurn technique.3
Purposes: The principle intent of the Wurn Technique is to find adhered tissues and structures wherever they exist in the body and detach the chemical bond of adhesions, thereby it helps, ¾¾ To improve fertility and improve pregnancy rates ¾¾ To help in opening Blocked Fallopian Tubes ¾¾ To increase Orgasm and treat inhibited Orgasm, dyspareunia and other sexual dysfunctions ¾¾ To treat Endometriosis ¾¾ To decrease pain and restore mobility after surgical procedure by improving soft tissue mobility, elasticity and distensibility ¾¾ To improve circulation and restore balance, functional ability of reproductive organs
* Prof. M. Annie Annal, HOD, Ms .Anitha,B, Lecturer, Dept. of OBG Nursing, KGNC, Puducherry 607402, India.
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¾¾ To correct Postural asymmetries or deviations ¾¾ To alleviate stress and induce overall relaxation1.
and inhibited or absence of orgasms.This reduction in adhesion makes it easier for an embryo to implant by improving the surface of the uterus. It reduces spasms in the uterus and cervical stenosis.
Adhesion
Infertility
Adhesions are scar tissue resulting from infection, inflammation, trauma, or sugery occurring anywhere in the body.They are tiny but very strong collagen fibres that form naturally as the firststep in healing.It is the body’s response to surgery and the healing process in the presence of increased levels of inflammatory cytokines that promotes the formation of adhesions4. They are bands of scar tissue with the potential to bind organs to other structures, which leads to multiple symptoms including organ dysfunction and pain. It reduces the function and movement of affected organs. In addition to being a common outcome of pelvic or abdominal surgery, adhesions are known to accompany related conditions such as bowel obstruction, chronic abdomino pelvic pain, endometriosis, pelvic inflammatory disease, pelvic spasms, polyps, and tubal obstruction. Dyspareunia and orgasmic problems may be due to the formation of pelvic adhesions.
Infertility is defined as the inability to conceive after 12 months of unprotected sexual intercourse. Internationally, the time frame is generally longer than 24 months. Approximately 5 million infertile women in the United States, it is estimated that 2 million (40%) have medical or hormonal infertility; 1 million (20%) have idiopathic infertility; and 2 million (40%) have mechanical infertility.
Adhesions can restrict the mobility and function of the organs, ligaments, muscles and nerves of reproductive organs. Thus, they affect the biomechanics of the entire abdomino pelvic region, limiting the ability to conceive even with In vitro fertilization (IVF) and other assisted reproductive technologies (ART) 5. Effect of Wurn Technique in Adhesion: The therapy used various site-specific pressures across the restrictive bands of adhered tissues and structures, working progressively deeper from the most superficial tissues, to restore mobility of structures. The wurn technique operates by peeling apart adhesions .The Nurse should apply site-specific pressure over the adhered part .in the abdominal region over the courses of 20 hours in five days It improves the movement and elastic nature of the targeted reproductive organs and various support structures that hold them in place. The soft tissue pressure application decreases the amount of adhesions and micro adhesions in the uterus and uterine wall. Mobilization of the soft tissue may break down collagenous cross-links and adhesions that can cause pain and dysfunction including dyspareunia Page 24
Pelvic adhesions are the primary causes of mechanical infertility. In addition to being a common outcome of pelvic surgery, the formation of pelvic adhesions is known to accompany related conditions such as endometriosis, pelvic inflammatory disease (PID), tubal obstruction, polyps, pelvic spasms, bowel obstruction, and chronic abdominopelvic pain.[6-8] Infertility-causing adhesions may form in the following locations, • on uterine walls and ligaments, increasing the possibility of uterine spasm, implantation problems, and miscarriage and decreasing the ability to conceive; • at and within the tissues of the cervix, creating stenosis, affecting the relaxed midline position, contributing to uterine spasms, and complicating sperm transfer to the uterus; • on the surface of the ovaries, preventing exposure of the ovum and making transfer to the fallopian tube difficult; • at the distal aspect of the fallopian tube, restricting the tentacle-like grasping of the egg by the fimbria, hence increasing its risk of being wasted in the abdominal cavity; and • anywhere on the inside or outside of the fallopian tube, causing partial or total tubal occlusion, decreasing the probability of conception, and increasing the chance of an ectopic pregnancy. • Ann. SBV, Jan-June2015;4(1)
Effect of Wurn Technique in Infertility: This manual therapy appears to be beneficial for women diagnosed with adhesions, potentially improving conception rates for women using this technique. Among women with the above-listed causes of infertility, the adhesions tend to block organs that are critical for the reproductive process. This includes the fallopian tubes and ovaries. In Wurn Technique Nurse practioner applied pressure to the specific identified site for the courses of 20 hours in five days programme. This approaches reduce the incidence of infertility through treating adhesions. This technique uses as a natural infertility treatment, this therapy functions as an adjunct to regular gynecologic care when applied before intrauterine insemination (IUI) and IVF. It helps to improve mobility and motility of the reproductive organs by decreasing the following: • adhesions and microadhesions on and within the uterine walls, helping to create a more hospitable surface for implantation; • uterine and cervical hypertonicity and spasm, thus creating a more relaxed environment for implantation; • cervical stenosis, adhesions, and tensions within the cervix and its attachments, thus improving cervical mobility and facilitating transfer to the preferred implantation site. • Thus, In wurn technique, the adhesions are resolved, the infertility can also be cured and reproductive health can be restored.
Endometriosis Endometriosis often accompanied by adhesions. Adhesions from endometriosis can join structures with strong glue-like bonds. Adhesions, endometriosis, pain and dysfunction are intimately related. Advvhesions from endometriosis can cause pain anywhere in the body (abdomen, pelvis, lower back). Dysfunctions such as poor digestion, irritable bowel and infertility may also result from the adhesions and endometriosis. Ann. SBV, Jan-June2015;4(1)
Endometriosis with Adhesions
Adhesion may form as a result of endometrial implants bleeding into the area which cause inflammation, leads to to the formation of scar tissue as a part of the healing process. Patients may develop adhesions after laproscopic excision of endometriosis.The glue-like bonding of adhesions has potential to cause decreased mobility and motility of abdominal, pelvic organs, pain, and dysfunction of adhered structures.
Effect of Wurn Technique in Endometriosis The Site-specific manual Wurn Technique can improve soft tissue elasticity, mobility and distensibility and rendering improvement in reproductive rates. This massaging technique resolves the adhesion which around the structures and associated symptoms of endometriosis7.
Blocked Fallopian Tube Blocked Fallopian tube is a major cause for female infertility. Blocked fallopian tubes are unable to let the ovum and the sperm coverage, thus making fertilization impossible.
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Wurn technique in gynaecological nursing care
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Effect of Wurn Technique in Blocked Fallopian Tube
Extensive Patient History Review • Nurse should receive the patien t’s historyincluding , gynecologic, surgical history • Collect and note thorough past history of trauma , surgery, infection and inflammation. Motivate for Patient Participation • Nurse should motivate the client for therapy. Ensure that the wurn technique is a nonsurgical technique without adverse effect for the client. Thorough Palpatory Evaluation
When adhesions block the tube by the uterus, nothing can pass. Eg .sperm, egg
• Nurse must do the palpatory assessment of the patient’s abdomen and pelvis, specific areas of visceral and myofascial cross-linking are determined the adhesion sites due to their restricted mobility9. Manual Treatment Focusing on these adhered areas, the therapist engages the uterine fundus and sidewalls and tractions them to the left. To assist and improve the mobility of the soft tissues, the therapist may release the tension of the traction either suddenly or gradually, depending on the desired effect to decrease spasm and adhesions between the uterus and the bladder. This was evidenced by increased mobility at the precise sites of visceral and myofascial restrictions after each therapy session. The changes were further demonstrated by improved alignment, biomechanics, and increased range of motion of osseous and soft-tissue structures (eg, improved pelvic floor
The therapy also cleared tubes blocked by adhesions in the tube and function returns to normal
musculature tone, decreased pelvic floor spasms) (10-12).
This site-specific manual soft-tissue therapy improves soft-tissue mobility, elasticity, and distensibility. Mobilization of the soft tissue may break collagenous cross-links and adhesions that cause pain and dysfunction, including physiciandiagnosed mechanical infertility 14.
Conclusion The primary goals of manual therapy are to decrease pain and restore mobility by improving soft-tissue mobility, elasticity, and distensibility. The intent of the manual physical therapy protocol used to create microfailure of collagenous cross-links, the “building blocks” of adhesions13. These unique softtissue techniques were developed after extensive study of current, innovative, manual physical therapy methods. The Wurn method of massage helps in softening and stretching the adhesions. The idea is to address any kind of adhesion-related problem, including overstretched, adhered or restricted connective tissue. The massage attempts to restore proper circulation among the affected areas. The Wurn philosophy believes that the adhesions are composed of tensile, collagen fibers that form layers of scar tissue. Thus, this therapy treats adhesion related conditions and promotes reproductive health and increase conception rates through massaging15-16.
References 1. Wurn BF, Wurn LJ, King CR, Heuer MA, Roscow AS, Scharf ES, Shuster JJ. Treating Female Infertility and Improving IVF Pregnancy Rates with a Manual Physical Therapy Technique. Med. Gen. Med. 2004 Jun 18; 6(2): 51. PMID 15266276 2. Burnette, A. Physical Therapy to Improve IVF Pregnancy
Rates. Achieving Families. 2005, Sept: 30. 3. Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL. Peritoneal Adhesions: Etiology, Pathophysiology, and Clinical Significance. Dig Surg. 2001; 18: 260-273. PMID 11528133. 4. Ellis H, Moran BJ, Thompson JN, Parker MC. Adhesionrelated hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet Br J Med. 1999; 353: 1476-80. PMID 10232313 5. Mosher W, Pratt W. Fecundity and Infertility in the United States. 1990.(Dec 4) 2-6. Available from: http:// www.clearpassage.com/what-we-treat/infertility/blockedfallopian-tubes/ 6. Meldrum DR, Hacker NF, Moore JG. Essentials of Obstetrics and Gynaecology.Philadelphia.W.B.Saunde rs.1992:444. 7. Stickler RC.Factors influencing fertility-Evaluation and Treatment. Philadelphia. W.B saunders.1995:8-18.http:// www.livingwithendometriosis.org/category/alternativemedicine/ 8. Stone K. Adhesions in Gynaecologic surgery. Curr opin obstet Gynaecolo. 1993:5:322 Available from: https:// diaryofamiracle.wordpress.com/2009/06/21/what-is-thewurn-technique/ 9. Stege JF, Stout Al. Resolution of chronic pelvic pain after laproscopic lysis of adhesions. AM J crynecol.1991: 165: 278-283. Available from: https://www.linkedin.com/pub/ belinda-wurn/9/a41/9a1 10. Pt Belinda Wurn,Lmt Larry Wurn, MD Richard King . 2009 - Health & Fitness 11. Valiani, M. The effects of massage therapy on dysmenorrheal caused by endometriosis. Iran J Nurs Midwifery Res: 2010;167–71. Available from: http://www.clearpassage.com/ who-we-are/about-the-wurn-technique/. 12. Juliafracegiaslmt. 2015.(April) Available from: https:// diaryofamiracle.wordpress.com/2009/.../what-is-the-wurntechnique... 13. Lawrence J Wurn, LMT, Belinda F Wurn, PT, and Amanda S Roscow, MPT. Increasing Orgasm and Decreasing Dyspareunia by a Manual Physical Therapy Technique: Available from: http://www.wisegeek.com/what-is-thewurn-technique.htm#didyouknowout. 14. Holtz G. Prevention and management of peritoneal adhesions. 1984: 41: 497-507. 15. Wiechmann G. Wurn L. Manual soft tissue therapy to decrease Abdomino pelvic adhesions.Gianservicle. http:// infertilityhandbook.com.au/?p=568 16. Drollette CM, Badawy SZ. Pathophysiology of pelvic adhesions.Modern trends in preventing infertility. J Reprod med. 1992. 37: 107-122.
Nurses Role in Wurn Technique: • • • •
Extensive Patient History Review Motivate for Patient Participation Thorough Palpatory Evaluation Manual Treatment
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Current Trends In Home Health Care
Current Trends In Home Health Care
& emotional health. Its purpose is to maximize the clients level of independence & to minimize the effects of existing disabilities through non institutional services. [15]
Suguna Mary.D, Rajalakshmi.R*,
The Standards of home health care are:
## We’re leaving the hospital earlier and thus need more intensive care. ## Sophisticated medical technology has moved into our homes. Devices are now in our living rooms and bedrooms.[3]
Abstract India has the second largest geriatric population in the world. Of the 300 million over-60s, 200 million are likely to be suffering from chronic ailments, and so it is essential to concentrate on Home healthcare includes supportive, preventive, promotive and rehabilitative services with the facilities available at the patient’s home. Home health care helps them get better, regain independence, and become as self-sufficient as possible. It also helps to ensure a “good quality of life.”This article focuses on the Current Trends in Home health Care and the Standards, Challenges and the future plans in Home health Care nursing.. Key words: Home health care, Caregiver, Agencies, Nursing Standards & Practice.
Introduction India has the second largest geriatric population in the world. Of the 300 million over-60s, 200 million are likely to be suffering from chronic ailments. Already, non-communicable diseases including cardiovascular diseases, diabetes, chronic obstructive pulmonary disease and cancer cause around 50% of all deaths in India, and so it is essential to concentrate on Home healthcare that includes supportive, preventive, promotive and rehabilitative services with the facilities available at the patient’s home. Devices needed for patient are provided at home itself. These care services include Respiratory Therapy, Home Infusion Therapy, Rehabilitation Services, and Palliative Care. The most significant healthcare trend witnessed recently is the shift of treatment from hospitals to home in order to gain a cost advantage and reduce hospital expenditure. The move from treatment to proactive monitoring is also opening up new opportunities for this market. Patients prefer home healthcare over hospitals mainly for the convenience and cost-effectiveness it offers. [1] “Home care”, “home health care” and “In-home care” are phrases that are used interchangeably to mean any type of care given to a person in their
own home. These phrases have been used in the past interchangeably regardless of whether the person required skilled care or not. More recently, there is a growing movement to distinguish between “home health care” meaning skilled nursing care and “home care” meaning non-medical care. Home care aims to make it possible for people to remain at home rather than use residential, longterm, or institutional-based nursing care. Home care providers deliver services in the client’s own home. These services may include some combination of professional health care services and life assistance services. Professional home health services could include medical or psychological assessment, wound care, medication teaching, pain management, disease education and management, physical therapy, speech therapy, or occupational therapy. Home care is often an integral component of the post-hospitalization recovery process, especially during the initial weeks after discharge when the patient still requires some level of regular physical assistance. [1]
Definition Home health care refers to all of the services & products provided to clients in their homes to maintain, restore, or promote their physical, mental,
Mrs. Suguna Mary.D, Asst..Prof, Mrs. Rajalakshmi.R, Lecturer, Dept. of Community Health Nursing, KGNC, Puducherry 607402, India. Page 28
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Aspects of Home Health Care Most of the home care is informal, with families and friends providing a substantial amount of care. For formal care, the health care professionals most often involved are nurses followed by physical therapists and home care aides. Other health care providers include respiratory and occupational therapists, medical social workers and mental health workers. Home health care is generally paid for by Medicaid, Medicare, long term insurance, or paid with the patient’s own resources. The goal of home health care is to treat an illness or injury. Home health care helps you get better, regain your independence, and become as self-sufficient as possible. It also helps to ensure a “good quality of life.”A number of interacting factors directly affect home health care the capabilities of patients and caregivers, the tasks and medical therapies undertaken, the devices and technologies used, and the physical as well as community environment in which all this occurs.[2]
Need for Home Health care ## We’re living longer and more of us want to “age in place with dignity.” ## We have more chronic, complex conditions. Ann. SBV, Jan-June2015;4(1)
Standards of Professional Practice: • Quality of care: systematically evaluates the quality & effectiveness of nursing practice. • Performance appraisal: evaluates the nursing practice standards, scientific evidences & regulations. • Education: should update and maintain current knowledge and competency in nursing practice. • Collegiality: contributes to the professional development of peers & other health care providers as colleagues. • Ethics: home health nurse’s decisions & actions on behalf of clients are determined in an ethical manner. • Collaboration: essential in providing home health care. • Research: Home health Nurse uses research findings in practice. • Resource utilisation: Home Health Nurse assists the client or family in becoming informed consumers about the risks, benefits & cost of planning & delivering client care. [14]
Types of Home Care Personnel Most people receiving home care receive care from to or more caregivers, either formal or informal. Page 29
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Informal Caregivers: Are family members & friends who provide care in the home. They provide routine custodial care such as bathing & feeding to sophisticated skilled care, including tracheostomy care, IV medication administration. Formal caregivers: Are professionals & paraprofessionals who are compensated for the In – home care they provide.
Types of Home Care Agencies: Voluntary agencies: Financed with non tax funds such as donations, endowments and third party provider payments. Proprietary agencies: Are expected to turn a profit on the services they provide, either for the individual owners or stock holders. Hospital based agencies: Governed by the sponsoring hospital board of directors or trustees. Official Agencies: Created and empowered through statutes enacted by legislations. Services are frequently provided by the nursing divisions of state or local health departments. Hospices: Promotes a care perspective that recognizes that death is inevitable and cure is not at present a possibility. Services are comprehensive and are delivered by an interprofessional team, including volunteers, that focuses on“Care” rather than “Cure”. [6] [12] [15]
Trends in home health care: Chronic Care, Everywhere: Home healthcare can provide management of chronic illnesses more cost effectively than hospitals or nursing homes. Since each chronic condition increases costs by a factor of three, Page 30
managing this population is the sweet spot for the ACO (accountable care organizations), and the deepest pool from which to pull savings. To do it, an increasing number of providers will deploy Ambulatory Intensive Care Units (A-ICUs) or patient centered medical homes as part of their ACO, which will be charged with better managing chronic conditions exclusively within a clinically integrated, financially accountable primary care practice. As part of the approach, providers will develop care pathways for better managing chronic conditions and behavioral health needs, with an eye toward lowering hospital utilization, including inpatient bed days, length of stay, admissions, readmissions, and emergency department visits. [14]
Physical, emotional, social, cultural, educational, developmental, and spiritual dimensions are considered when team members establish goals for the client.[7] [9]
Hospital at Home.
Practitioner
Also driving the growth is the need to make care more convenient, particularly for those with chronic conditions, so patients can be monitored and coached to health anytime, anywhere. And there’s a cost component to the trend as well. “Hospital at Home,” a program designed by Johns Hopkins that provides acute care services in the homes of patients who might otherwise be hospitalized, has been demonstrated to increase the quality of care patients receive, improve their satisfaction, and reduce costs by at least 30 percent. [1]
• Acts as a resourceful caregiver during a crisis that is aggravated by a chronic illness or a disabling condition. • Implements nursing care based on scientific knowledge, home care standards, and principles that are appropriate to the home care environment • Collaborates with the interdisciplinary team in the management of the team function in the home environment; is responsible for ensuring that the client is involved as a significant member of the team. • Helps the client and the client’s family adapt to changes in lifestyle necessitated by the disabling condition. • Assesses the appropriateness of a client’s admission to, and the delivery of rehabilitation services in, the home environment.[13] Care coordinator
Virtual Care at Home Technology-enabled at-home health care is increasingly solving an access issue for patients. According to a recent survey, almost half of rural hospitals use virtual care or telemedicine to connect with patients who may be too far away for an inperson visit, allowing them to close the gaps in care that arise due to geography. [2]
Rehabilitation Nurses Rehabilitation nursing is a specialty practice that is committed to improve the quality of life for individuals with a disability or a chronic illness. The rehabilitation nurses mission is to improve the optimal level of functioning of individuals with a disability or a chronic illness at home and in the community. The goal of the rehabilitation process is to provide, in collaboration with an interdisciplinary healthcare team that includes the client, a holistic approach to nursing care that maximizes the clients independence and mastery of self-care activities. Ann. SBV, Jan-June2015;4(1)
Examples of skilled home health services ¾¾ Wound care for pressure sores or a surgical wound ¾¾ Patient and caregiver education ¾¾ Intravenous or nutrition therapy ¾¾ InjectionsMonitoring serious illness and unstable health status [12]
Roles of the home health nurse
• Acts as a member of the interdisciplinary healthcare team and promotes the coordination of client care, the activities of other professionals. Integrates the knowledge and skills of various professional and non-professional disciplines into a comprehensive continuum of care & Facilitates the design and implementation of the plan of care for clients who are chronically ill or who have disabling conditions. [5] Advocate • Advocates for clients and their families or caregivers & Teaches clients and their families or caregivers to advocate for themselves. Ann. SBV, Jan-June2015;4(1)
• Facilitates the client’s transition from the hospital to the home and the community. • Furthers an understanding of home care-based rehabilitation issues among people in the community and among those in government who are in a position to deal with issues related to this patient population. Educator • Provides education for clients and their families • Provides staff orientation and guides staff development, both at the professional and the paraprofessional levels, in the area of rehabilitation home care & Provides rehabilitation-focused continuing education programs. • Develops policies and procedures that are specific to rehabilitation home care & Develops educational materials designed to help clients and their family members become knowledgeable consumers in the healthcare arena.[10] Consultant • Identifies clients and families who could benefit from home care services. • Provides case management expertise within the home care environment. • Serves as a liaison with third-party payers and justifies the use of funds for home care. • Promotes nursing services to community health professionals and to the community at large. Researcher • Participates in research involving home care clients and their families. • Participates in the analysis and dissemination of evaluative data that may have an impact on clients and their families. • Incorporates evaluative data into nursing practice.[8]
Challenging Factors In Home Health Care Increased demands. Care providers: licensed nurses, certified care providers Client care tracking and service recording Long-term healthcare coverage Fixed-rate increase by Medicare and Medicaid Page 31
Annals of SBV
Types of home care: respite, long-term, hospice, and elderly Supplies: equipment, transportation, medical, and special needs Rise in travel costs for care providers Home healthcare agency franchises (increase in profits) Seniors choosing to live at home and receive care Hospice care training for care providers.[7] [4] Working as a Home Care Nurse has drawbacks, such as having fewer opportunities to consult with colleagues about challenges than in other settings such as a hospital. The median annual salary of Home Care Nurse is below the median hospital nurse’s salary. The rewards of being a Home Care Nurse far outweigh any disadvantages. Having one-to-one client interaction fosters an authentic and personal nurse/client relationship. Those CHNs working with community groups can affect the health of many and have input about how scarce resources are used. On the practical side, Home Care Nurse have a more flexible work schedule than hospital-based nurses and more independence. Home Care Nurse is challenging, rewarding, and filled with professional and personal satisfaction.[11]
Building for Tomorrow With life expectancy increasing significantly in India, home health care is becoming mandatory. As a result of advances in communication and medical technology, a lot of interventions that could earlier take place only in hospital settings are now becoming possible in the home environment. Specialty home health care will be a key element of patient-centric care in the coming years. The task of understanding the complexities of the home health care environment so that high quality and safe care can occur.” As the demand increases for home healthcare a care tracking solution is needed. “The Indian educational system currently does not have a structured training program for home health care. Inorder to render specialised, evidence based care a clear, evidence-based treatment protocols that cover the range of protocols should be delivered by the experts team. Government has to offer some special courses for the Community Health Nurses to overcome the bottleneck factors so that a personalised care will be rendered by a qualified Home Health Care Provider. [7]
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References 1. “Hospital to Homecare”. Hospital to Homecare. Retrieved 10 March 2012. 2. Emerging Trends: Indian Healthcare Industry December-2013 Hospital Services Industry: Riding on the back of growing healthcare demand; available at; http:// www.onicra.com/images/pdf/Healthcare-industry-reportTransparent.pdf 3. Human factors challenges in home health care: Research Activities, December 2011, No. 376. December 2011. 4. Christensen, L.R.; E. Grönvall (2011). “Challenges and Opportunities for Collaborative Technologies for Home Care Work”. Aarhus, Denmark (Springer): 61–80. DOI :10.1007/978-0-85729-913-0_4. Retrieved 24 July 2013. 5. Patrick A. Cunningham, Home Healthcare Nurse: The Role of the Psychiatric Nurse in Home CareNovember/December 2007 - Volume 25 - Issue 10 - p 645–652 DOI: 10.1097/01. NHH.0000298935.76211.07 6. “Home Health services” - BAYADA Home Health Care retrieved 2013-07-19 7. Susan D, The Changing Health Care World: Trends To Watch In 2014.DOI:feb,10 2014; available at: http://healthaffairs. org/blog/2014/02/10/the-changing-health-care-worldtrends-to-watch-in-2014/ 8. Rising Trends In Health Care: Body and Mind staff ; Avilable at http://www.pennlive.com/bodyandmind/index. ssf/2011/02/5_rising_trends_in_health_care.html: 2011. 9. The Home Care Rehabilitation Nurse: association of rehabilitation nurses;DOI:feb,02 2015, available at: http:// www.rehabnurse.org/pubs/role/Role-The-Home-CareRehab-Nurse.html 10. Kulbok, P.A., Thatcher, E., Park, E., Meszaros, P.S. (May 31, 2012) “Evolving Public Health Nursing Roles: Focus on Community Participatory Health Promotion and Prevention” OJIN: The Online Journal of Issues in Nursing Vol. 17, No. 2, Manuscript 1.DOI: 10.3912/OJIN. Vol17No02Man01 11. Ricco,Patricia.A (2001) “ Quality Evaluation of Home Nursing Care: Perceptions of Patients, Physicians and Nurses”. Journal of Nursing Care Quality 15 (2):58 – 67. DOI: 27 July 2008. 12. Lotus Shyu, Yea-Ing; Hsiao-Chin Lee (2002). “Predictors of nursing home placement and home nursing services utilization by elderly patients after hospital discharge in Taiwan”. Journal of Advanced Nursing 38(4): 398–406. DOI:10.1046/j.13652648.2002.02193.x.PMID 1198561. 13. Modin, S.; A. K. Furhoff (2002). “Care by general practitioners and district nurses of patients receiving home nursing: a study from suburban. Scandinavian Journal of Primary Health Care 20 (4): 208-212(5). DOI:10. 1080/ 0281343 02321 0 0 48 54. Retrieved 27 July 2008. 14. Scope and Standards of Home healthnursing practice. Washington, D C; American Nurses Publishing, American NursesAssociation (1999) 15. Judithann Allender, Promoting andProtecting the Public’s Health Community Health Nursing,6th edition, Lippincott Williams & Wilkins, pg: 886 – 890.
Save students from suicide through S.A.V.E “Take any suicidal talk or behavior seriously. It’s not just a warning sign that the person is thinking about suicide—it’s a cry for help.” - International Association for Suicide Prevention Prabavathy. S, Beniya Elizabeth Rani. R *
Abstract
According to the most recently available data presented in the Statistical Abstract of India, 17,100 young Indians (15 to 44 years old) died in 2011 due to suicide. At no other time during the life span were suicide rates so high. Suicide among college and university students is estimated to be 50% higher than for other age group. Not only suicide is considered by many researchers to be the number one health problem on the nation’s campuses but the suicide rate for this population has tripled over the past 25 years. Professional nursing students could perhaps be at an even higher risk for suicide than other college students. “Nursing students are more doubtful than other college students about their academic performance. They encounter stress in adjusting to a rigorous program of theory and practice. The reality is often far different from a prospective student’s image of it”. Because of the longevity of contact hours spent with nursing students in both lecture and clinical milieus, nursing faculty are in a uniquely favorable position to identify and assess those students who appear to be at risk for suicide. In addition, as most nurse educators provide supportive relationships, rich with caring and trust for their students, distressed students are usually open to talking to a faculty member. If a suicidal risk is found during the assessment interview, the faculty member should then provide an immediate referral for further psychiatric evaluation and intervention. To assist faculty in the quick recall of the essential components of this helping process the acronym S.A.V.E. is used: S - Signs of suicidal thinking. A - Ask questions. V - Validate the student’s experience. E- Encourage treatment and Expedite care /getting help. Key words: S.A.V.E, Student, Suicide.
Introduction: Suicide is the 10th leading cause of death.Suicide is the third leading cause of death for 15to24 years, second leading cause of death for 25-34 yearsand the second leading cause of death for 5to14years. Teenagers experience strong feelings of stress, confusion, self-doubt, pressure to succeed, financial uncertainty, and other fears while growing up. One suicide death occurs for every 4 suicide attempts.1 “Suicide is a desperate attempt to escape suffering that has become unbearable. Blinded by feelings of self-loathing, hopelessness, and isolation, a suicidal
person can’t see any way of finding relief except through death.”2
Epidemiology: According to WHO, 258,075 people committed suicide in India in 2012, with 99,977 women and 158,098 men taking their own lives. India’s suicide rate was 21.1 per 100,000 people, according to the report.12The number of suicides in the country duringthe decade (2003–2013) has recorded an increase of 21.6% (1,34,799 in 2013 from 1,10,851 in 2003). The increase in incidence ofsuicides was reported each year till 2011 thereafter a declining
* Mrs. Prabavathy.S, Asso.Prof, Ms.Beniya Elizabeth Rani. R, Lecturer Dept. of Mental Health Nursing, Puducherry 607402, India.
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trend was noticed.13Thepopulation has increased by 15.0% during the decade while the rate of suicides has increasedby 5.7% in 2013 over 2003(from 10.4 in 2003 to 11.0 in 2013), hence showing a mixed trend in incidents of rate of suicides during the decade (2003-2013).14 In India, about 46,000 suicides occurred each in 15-29 and 30-44 age groups in 2012 - or about 34% each of all suicides.13Poisoning (33%), hanging (31%) and self-immolation (9%) were the primary methods used to commit suicide in 2012.The high rate of suicides was seen among students admitted to professional courses under management quota in Puducherry, Death of 41 students in three years has taken place and the fact that theUnion territory’s suicide rate is three times greater than that of the national average.Puducherry recorded 35.6 suicide deaths per lakh population against the national average of 11 in 2013.15
Common Risk Factors among Adolescents: A personal or family history of suicide attempts A family history of suicide attempts or completed suicide A personal or family history of severe anxiety, depression, or other mental health problem, such as bipolar disorder (manic-depressive illness) or schizophrenia An alcohol or drug problem (substance abuse problem), such as alcoholism Previous suicide attempts.3 Alcohol and substance abuse in family. History of mental illness. Poor self-control Hopelessness Recent loss (loved one, job, relationship) Family history of suicide History of abuse Serious health problems.4, 16
Suicide prevention through S.A.V.E: Operation S.A.V.E. will help you act with care and compassion if you encounter a Veteran who is suicidal.7,18 S - Signs of suicidal thinking A - Ask questions V - Validate the Student’s experience E- Encourage treatment and Expedite care /getting help Page 34
1. Signs of Suicidal Thinking: Acute Warning Signs and Symptoms: Threatening to hurt or kill self Looking for ways to kill self Seeking access to pills, weapons or other means Talking or writing about death, dying or suicide8 Additional Important Warning Signs:
Hopelessness o Rage, anger, seeking revenge o Acting reckless or engaging in risky activities ¾¾ Feeling trapped ¾¾ Increasing drug or alcohol use ¾¾ Withdrawing from family, friends, society ¾¾ Anxiety, agitation ¾¾ Dramatic changes in mood ¾¾ Feeling there is no reason for living, no sense of purpose in life ¾¾ Difficulty sleeping or sleeping all the time.5 ¾¾ Giving away possessions ¾¾ Dramatic changes in mood ¾¾ No reason for living, no sense of purpose in life ¾¾ Difficulty sleeping or sleeping all the time ¾¾ Giving away possessions ¾¾ Increase or decrease in spirituality.17
2. Ask Questions: DO ask the question in such a way that is natural and flows with the conversation. DON’T ask the question that gives “no” answer.18 Things to consider when you talk with the person 99 99 99 99 99 99 99
Remain calm Listen more than you speak Maintain eye contact Act with confidence Do not argue Use open body language Limit questions to gathering information casually 99 Use supportive and encouraging comments 99 Be as honest and “up front” as possible19 3. Validate the Student’s experience: Validation Means: • Showing the person that his/her problems are listened to. • Accepting their situation for what it is. Ann. SBV, Jan-June2015;4(1)
• Not passing judgments. • Let them know that their situation is serious and deserves attention. • Acknowledge their feelings • Let him or her should know that there are people to help.20 4. Encourage treatment and Expedite care/ getting help: 1.Explain that there are trained professionals availableto help them. 2.Explain that treatment works. 3.Explain that getting help for this kind of problem is nodifferent than seeing a specialist for other medicalproblems. 4.Tell them that getting treatment is his or herright. 5. If they tell that they have had treatmentbefore and it has not worked, try asking.9 • Any time a person has a weapon or object that can be used as a weapon – “call for help”. • If a person tells that they have overdosed on pills or other drugs or there are signs of physical injury – “call for help”. • In addition to “calling for help”, if confronted with a hostile or armed person, leave the area and attempt to isolate the person. If the person leaves the area, attempt to observe his or her direction of movement from a safe distance and report the observations as soon as authorities arrive on scene.21
Role of Mentors in Suicide Prevention: • Promote awareness that suicide is a public health problem that is preventable. • Develop broad-based support for suicide prevention. • Develop and implement strategies to reduce the stigma associated with being a consumer of mental health, substance abuse and suicide prevention services. • Develop and implement community-based suicide prevention programs. • Promote efforts to reduce access to lethal means and methods of self-harm.10 • Implement training for recognition of at-risk behavior and delivery of effective treatment.
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• Develop and promote effective clinical and professional practices. • Increase access to and community linkages with mental health and substance abuse services.6 • Improve reporting and portrayals of suicidal behavior, mental illness and substance abuse in the entertainment and news media. • Promote and support research on suicide and suicide prevention. • Improve and expand surveillance systems.11,22
Suggestions: Periodic counseling sessions to be hosted. Good healthy- professional relationship with the mentor-mentee. Early Identification of student’s with behavioral change. Every three months once parents meet with mentor to be conducted. Students should be encouraged to participate in Co-Curricular and Extra- Curricular Activities. Problems of the student’s should be identified then and there.
Conclusion: The growth of nation is determined by the knowledge and development of the students. Students are the pillars of our nation. They are in the hands of teachers like clay, who are to be molded Physically, Psychologically and Socially. Prevention of suicide among students is a major role which is to be done by the teachers to save our younger generation and our nation from destruction. They should save students from suicide through S.A.V.E.
References Book References 1. 1. Kaplan &Sadock. (2005). Comprehensive Text Book of Psychiatry. Philadelphia: Lippincott Williams and Wilkins Publication. 2. Mary Ann Boyd. (2005). Psychiatric Nursing, Contemporary Practice. Philadelphia: Lippincott Publications. 3. Morreen Frisch, C. (2006).Principles and Practice of Psychiatry Nursing. New York: Delmar Publishers. 4. Rawlins, W. (2007). Mental Health Psychiatric Nursing.A Holistic Life Cycle Approach. Philadelphia: Mosby Publication. 5. Townsend MC. Psychiatric Mental Health Nursing: Concepts of Care in Evidence- Based Practice. 5th ed. New Delhi: Jaypee Publishers; 2007.
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Annals of SBV 6. Lousie. (2008). Basic concepts of Psychiatric-Mental Health Nursing. New Delhi: Wilkins & Williams Publishers. 7. Johnson. V, Singh, Sivaraj. P, Journal of Nursing Education (Impact Factor: 0.76). 02/2012; 37(2):92-5. 8. Patel, V.; Ramasundarahettige, C.; Vijayakumar, L.; Thakur, J. S.; Gajalakshmi, V.; Gururaj, G.; Suraweera, W.; Jha, P. (2012). “Suicide mortality in India: A nationally representative survey”. The Lancet 379 (9834): 2343. doi:10.1016/S01406736(12)60606-0. 9. Singh A.R., Singh S.A. (2003), Towards a suicide free society: identify suicide prevention as public health policy, Mens Sana Monographs, II:2, pg: 3-16. [cited 2011 Mar 7] 10. Gururaj G, Isaac M, Subhakrishna DK, Ranjani R., (2004), Risk factors for completed suicides: A case-control study from Bangalore, India, Inj Control SafPromot, 11:183-91. 11. Vijaykumar L. (2007), Suicide and its prevention: The urgent need in India, Indian Journal of Psychiatry;49:81-84, 12. http://en.wikipedia.org/wiki/Suicide_in_India 13. http://ncrb.gov.in/adsi2013/suicides%25202013.pdf
14. Suicides in India The Registrar General of India, Government of India (2012) 15. “Government decides to repeal Section 309 from IPC; attempt to suicide no longer a crime”. Zee News. December 10, 2014. Retrieved December 10, 2014. 16. India has highest number of suicides in the world: WHO PTI | Sep 4, 2014, 06.33PM IS 17. Tackle suicides among Pondy students, says HCTNN | Oct 26, 2014, 05.28 AM IST, Times of India 18. Suicide Prevention Initiatives http://www. suicidepreventioninitiatives.org 19. Suicide Prevention Center of New York State http://www. preventsuicideny.org/ 20. Office of Mental Health: Suicide Prevention http://www. omh.ny.gov/omhweb/suicide_prevention/ 21. New York Suicide Hotlines http://www.suicidehotlines. com/newyork.html 22. American Foundation for Suicide Prevention http://www. afsp.org
Nurse led ward rounds – a valuable contribution to neurological patients Renuka.K Hemapriya.S , Anbu.M *
Abstract Nurses are integral part of the multidisciplinary team, providing care from planning, implementing and evaluating patient’s condition. Neurological patients which includes stroke, head injury, paralyzed patients, post operative craniotomy patients , seizure and coma patients are totally dependent on the care giver.. Therefore it is imperative for the nurses to have keen rounds and care for these patients towards recovery. The nurse led ward rounds delineates three phases which depicts the activities that, a nurse should carry out before, during and after nurse led ward rounds. The nurse takes up multiple roles such as Advocate, Chaperone, Transitor, Informator, Organizer and Nurse centered. Although it is important to have interprofessional staff collaboration for successful patient management, nurse-physician collaboration during rounds occur infrequently. To improve the way nurses manage neurological patients in an acute setting, a nurse-led ward round helps to ensure patient care and safety. Key words: Nurse led Ward Rounds, Neurological Patients, Communication, Advocacy
Introduction: Ward round has been a historical clinical method of inter-professional collaboration to support inpatient care by exchanging information and discussing plan of care, treatment goals, and discharge plans for the patient2.Although traditional ward rounds offer the opportunity for doctors to spend quality time with patients, reports indicate the experience to be brief for patients, with little opportunity to ask questions, etc. For example, nurses generally spend more time at the bedside of patients and their families, and therefore observe behaviors that doctors do not see at first hand during their brief rounds.17 Therefore, we believe that improvements in the conduct of ward rounds may lead to better patientcentered care. Hence, the inclusion of nurses in ward rounds can align professional priorities and facilitate a shared understanding of the patient’s needs18. Nurses have a crucial role on ward rounds, not only sharing key information between the patient and the healthcare team, but also supporting patients
in articulating their views and preferences. Absence of a nurse at the bedside has clear consequences for communications, ward-round efficiency and patient safety9.
Scope of Nurse Led Ward Rounds: • Nurses have a vital role in ward rounds and should make it a priority to attend. • Nurse led Ward rounds provide a link between patients’ admission to hospital and their discharge or transfer elsewhere. • Ensure the continuity of care provided to the patients. • It eliminates many misconceptions between physician and the nurse. • It enables the nurse to rectify the doubts of the patients and give them assurance. • It ensures the involvement of patient and care takers in clinical decisions. • It helps the new comers in the ward such as the nursing students to know about the patients and their conditions4
* Prof. Dr. Renuka.K, Principal. Ms.Hemapriya.S, Lecturer. Ms. Anbu.M, Lecturer Dept. of Medical Surgical Nursing, KGNC, Puducherry 607402, India
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Process of nurse led ward rounds in neurological units.
Table 1. Nurse Led Ward Rounds Proforma
The nurse led team consists of clinical nurse specialist, nurse manager, ward supervisor and staff nurse. The rounds will be carried out every Monday of the week. The time spend with each patient varies according to the condition of the patient. It usually ranges from ten to fifteen minutes per patient21. The rounds provide an opportunity for the multidisciplinary team to listen to each patient’s narrative and jointly interpret the concerns. From this the nurse unfolds diagnosis, management plans, prognosis formation and the opportunity to explore social, psychological, rehabilitation and placement issues20. During the rounds the team addresses patient needs and makes appropriate nursing diagnosis and goals. Elma J and Julia S suggested the use of a proforma for patient assessment in nurse led ward rounds among neurological patient14(Table 1). After each patients rounds the nursing team places the completed proforma in the medical notes6.
ESSENTIAL STROKE CARE Review of skin integrity 1
Any skin breakdown: Yes No Type of wound:………………………………………. Location: …………………………………………...... Current treatment:……………………………...……. On pressure relieving mattress:……………….……… Nursing plan:…………………………………….…....
Review of Continence
2
3
4
a.Bladder Continent : Yes No With catheter: Yes No NA Does patient need a catheter Yes No Consider a “trial without catheter” Yes No b.Bowel Last bowel movements documented:………………………….. Bowel not open in the past 2 days …………………………….. Any laxative Yes No
Three distinct stages to nurse led ward rounds, each of which has equal importance.
Antecedents (Before) Key activities before a nurse led ward round are
Oral care
Is patient mouth moist? Yes No Any signs of oral candidiasis? Yes No Any treatment? Yes No
Review of medications
Need drugs chart rewritten Yes Any issues on prescribing? Yes
No No
Stroke outcome measures 5
Current Barthel Index ………………………………………….......….. Current Mood Assessment Score ……………………………………… Current Modified Ranking Score ……………………………………… Current weight …………………………………………………….....… Previous weight …………………………………………………......…..
Others 6
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Peripheral line site checked: Yes No NA Nasogastric tube / PEG checked: Yes No NA Venflon checked: Yes No NA Any signs of infection in the sites Yes No NA Venous Thrombo Embolism(VTE) checked Yes No Wrist band checked Yes No
• Orienting to patient profile, demographic data and history of the patient. • Establishing results of investigations such as blood and electrolytes, coagulation profile, Renal Profile, CSF analysis report, CT & MRI, X ray, ECG, EEG. • If the patient is conscious, the patients will be informed that nurse led ward rounds will be taking place, in case of unconscious patients it will be informed to the patient care giver to address the patient’s problems and needs5.
Critical attributes (During) This refers to the key activities, that is integral to nurse led ward rounds • Obtain a complete neurological and pertinent general history from an adult taking into account age and mental state.
NA Ann. SBV, Jan-June2015;4(1)
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• Distinguish between signs and symptoms that are physiological and those that are the result of a psychological disorder22. • Review of patient’s medication management. E.g. culture and sensitivity report in case of antibiotics, therapeutic levels of medications, managing the adverse affects of medications administered and inspects the drug chart to see if the prescribed medications is administered following eight rights22. • The nursing team inspects major pressure areas, start bladder strategies, ensuring pressure relieving bed mattress, ensuring patient’s bowel movements, inspecting for any oral thrush etc23. • The nurse also inspects the neurological patient’s outcome measures on a weekly basis to evaluate whether neurological patients are improving through provision of rehabilitation therapy, nursing care and treatment23. • The team also inspects the peripheral line/NG tube/ percutaneous gastrostomy tube for any signs of infection around the insertion site and ensures the need for change. • Decision making and documentation of care. E.g. oral care, back care, perineal care, skin care. • Outline a plan of investigation including laboratory tests, neuro imaging, and other investigations. Judgment should be exercised taking into account the patient’s age, general health risk, cost of investigations, and epidemiology of the disease. • Formulate an appropriate nursing diagnosis with respect to common signs or symptoms involving the nervous system. • Review of patients going home (pre-discharge); Pre-discharge occupational therapy home assessments, falls-prevention strategies and functional independence in neurological patients4.
Consequences (After) Once the ward round is over, a number of activities will be necessary: • The progress of the patient will be discussed. • The senior nurse will be presenting the findings of nurse led ward rounds in weekly multidisciplinary meeting. • Clarifying the doubts of the patients and attenders. Page 39
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• The nurse team uses it as a platform for discussion patient care issues and making a team decision about patient care. • Motivation of the ward team7 Reshma A, Aisha L, Dale A conducted an ethnographic prospective observational study comparing nurse-led and physician-led rounds in General Medicine ward at the National University Hospital in Singapore. The study was conducted among 57 patients. The objective of the study was to determine the average time spend with patients at the bedside for a nurse-led rounds and physicianled rounds. The result suggested that quality time spent with patients at the bedside during morning rounds may be improved by nurse-led rounds when compared to physician led ward rounds8.
Importance of nurse led ward rounds for neurological patients. The neurological patients are at risk to develop complications, because their sensory and motor reflexes are diminished. The neurological patients are wholly or partially dependent on the nurse. The patient is difficult to arouse and needs constant stimulation in order to follow a simple command. The patient may respond verbally with one or two words, but will drift back to sleep. So the patient needs constant stimulation24. The common problems faced by them are unable to mobilize independently, loss of control over bowel and bladder, Poor oral hygiene linked with the development of aspiration pneumonia due to bacterial colonization, Dry mouth, oral ulcers and stomatitis. Falls are also most common among these patients and hence they require continuous and meticulous care and observation9. The physician led ward rounds are very brief and nursing care aspects are often overlooked by them and therefore it is important to have nurse led ward rounds to vulnerable patients of all ages who have neurological disorders. In a nurse led ward rounds, accurate and consistent documentation helps to ensure subtle changes in neuro status which is essential to compare the findings with the previous examinations and it also helps to spot changes and intervene any necessary interventions quickly and appropriately19.
Role of Nurse in Nurse Led Wards Rounds The key aspects of the nurse’s role on nurse led ward rounds can be defined using the acronym. Page 40
“ACTION” • • • • • •
Advocate; Chaperone; Transitions; Informative; Organiser; Nurse-centred.
Advocate: The nurse will be a resourceful person for neurological patients, family and community groups. She will assist with the provision of health promotion activities , she will provide psychological support for the patients who are conscious and also for the care givers of unconscious patients who are wholly dependent10. Chaperone: The role of nurse as chaperone includes preparing and assisting in any invasive and non invasive procedures like lumbar puncture, CT, MRI , neurological examination etc. The nurse will also help the patient in communicating and positioning, giving privacy, minimizing anxiety & potential embarrassment and respecting their cultural issues25. Transitions: As a transitor the nurse functions will include noting any ongoing investigation and communicating to the patient and team, documenting any incomplete investigation, referrals and for patient discharge. Informative: The nurse plays a vital role as an informative seeker and giver. The function includes. Communicate effectively and regularly with patients, parents, and families of wholly and partially dependent patients about the medical status and establish therapeutic relationships. The nurse will also provide appropriate information about the progress, major procedures, prognosis and clinical decision to the patients/family members26. The nurse also Communicates effectively with the health care providers including neurology nurses, ward nurses, consulting physicians, residents, medical and nursing students and discuss appropriate information11.
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Organizer:
Conclusion:
The role of a nurse as an organizer encompasses, to be informed of the management plans proposed by the referring physician or other consultants for every inpatient to effectively coordinate the neurological aspects of the patients care. The nurse will Contribute effectively in discharge planning for every inpatient with emphasis on the neurological aspects of the patients’ ongoing care (e.g. long-term care facility, homecare, parent education, rehabilitation of neurological patients).The nurse will discuss the Discharge planning with the referring physician and other consultants12.
A nurse-led ward round has addressed nursing issues in a timely proactive fashion. The initiative has been successful in improving clinical communication between nurses and patient involvement in their care planning. It has enabled the nurses to make decisions within their professional arena, and its contribution has had an impact on patient care and safety through early detection and prevention of neurological complications.15
Nurse centered: The nurse centered role includes Utilizing resources effectively to balance patient care, learning needs, allocating finite health care resources wisely. The nurse will provide appropriate judgment in triaging patients for access to resources which are limited and also establish routines for carrying out regular activities and adhere to them. The role also extends in maintaining complete and accurate medical records. In a nutshell the nurse in-charge of a ward or unit who is clinically overseeing all areas of the ward will provide feedback to the staff nurses and other multidisciplinary team after the ward rounds13. Catangui EJ conducted a study in imperial college health care trust among 108 stroke patients on nurse led ward rounds a valuable contribution to acute stroke care. The objective of the study was to evaluate the stroke related outcomes by initiating nurse led ward rounds. The study concluded that the initiative has been successful in improving clinical communication between nurses and patient involvement in their care planning. It has also empowered nurses to make decisions within their professional arena, and its contribution had an impact on patient care and safety through early detection and prevention of stroke complications. The authors have designed a profoma for nurse led ward rounds to assess the outcomes of stroke patients. It is also used to evaluate whether stoke patients are improving through the provision of nursing care and treatment. The proforma for nurse led ward rounds for stroke patients, includes various dimensions and caring aspect from which the progress of the patient can be identified provide early nursing intervention14.
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Reference: 1. Stickrath C, Noble M, Prochazka A, Anderson M, Griffiths M, Manhein J, Sillau S, Aagaard E. Attending rounds in the current era: what is and is not happening. JAMA Intern Med. 2013;173:1084-1989. 2. Weber H, Stockli M, Nubling M, Langewitz WA. Communication during ward rounds in Internal Medicine: an analysis of patient-nurse-physician interactions using RIAS. Patient Educ Couns. 2007;67:343-348. 3. Cohn A. Restore the prominence of the medical ward round. BMJ. 2013;347:f6451. 4. Lees L. The nurse’s role in hospital ward rounds. The Nursing Times. 2013.109:12,12-14. 5. Coleman, S., Henneman, E.A. Comprehensive patient care and documentation through unit-based nursing rounds. Clin Nurse Spec. 1991;5:117–120. 6. Catangui EJ, Slark J. Nurse-led ward rounds: a valuable contribution to acute stroke care. Br J Nurs. 2012 Jul 1225;21(13):801-5. 7. Aitken, L.M., Burmeister, E., Clayton, S., Dalais, C., and Gardner, G. The impact of nursing rounds on the practice environment and nurse satisfaction in intensive care: pre-test post-test comparative study. International Journal of Nursing Studies. 2011; 48 8. Reshma A, Aisha L, Dale A. A pilot study on nurse-led rounds: Preliminary data on patient contact. International Journal of Technical Research and Applications.2014. Nov, PP. 68-71. 9. Katherine DS. APN-led nursing rounds: An emphasis on evidence-based nursing care. Journal of the British Association of Critical Care Nurses .2013.May. 10. Bourgault, A.M., King, M.M., Hart, P., Campbell, M.J., Swartz, S., and Lou, M. Circle of excellence. Does regular rounding by nursing associates boost patient satisfaction?. Nursing Management. 2008; 39: 18–24 11. Davies, K.E. Hourly patient rounding. An effective program can decrease call bell usage and patient falls, and increase patient and staff satisfaction. ; 2010 (Advance healthcare network for nurses. Retrieved August 17, 2010. 12. Kalman, M., Olrich, T., and Nigolian, C. Hourly nursing rounds: shaping nursing culture to achieve nursing quality outcomes. Clinical Nurse Specialist. 2008; 22 13. Meade, C.M., Bursell, A.L., and Ketelsen, L. Effects of nursing rounds: on patients’ call light use, satisfaction, and safety. American Journal of Nursing. 2006; 106: 58– 70 (Retrieved September, 2006 ).
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Annals of SBV 14. Catangui EJ, Slark J. Nurse-led ward rounds: a valuable contribution to acute stroke care. Br J Nurs. 2012 Jul 1225;21(13):801-5. 15. Desai T, Caldwell G, Herring R. Initiative to change ward culture results in better patient care. Nurs Manag (Harrow). 2011 Jul;18(4):32-5. 16. Kohn LT, Corrigan JM, Donaldson MS (eds). To Err is Human: building a Safer Health System. Washington, DC: National Academic Press. 2000 17. Zwarenstein M, Rice K, Gotlib-Conn L, Kenaszchuk C, Reeves S. Disengaged: a qualitative study of communication and collaboration between physicians and other professions on general internal medicine wards. BMC Health Services Research. 2013;13:494. 18. Launer J. What’s wrong with ward rounds? Postgrad Med J. 2013;89:733-734. 19. Marshall, R. S., & Mayer, S. A. (2001). On call neurology (2nd ed.). New York: W. B. Saunders. 20. Vos, H. (2002). The neurologic assessment. In E. Barker (Ed.), Neuroscience nursing: Spectrum of care (2nd ed.). St. Louis: Mosby.
21. Hickey, J. V. (2003). The clinical practice of neurological and neurosurgical nursing (5th ed). Philadelphia: Lippincott 22. Bader, M. K., & Littlejohns, L. R. (2004). AANN core curriculum for neuroscience nursing (4th ed.). Philadelphia: Saunders. 23. Messner, R., & Wolfe, S. (1997). RN’s pocket assessment guide. Montvale, NJ: Medical Economics. 24. Kerr, M. E. (2000). Intracranial problems. In S. M. Lewis, M. M. Heitkemper, & S. R. Dirksen (Eds.), Medical surgical nursing (5th ed). St. Louis: Mosby. 25. Neville, K., Lake, K., LeMunyon, D., Paul, D., and Whitmore, K. Nurses’ perceptions of patient rounding. Journal of Nursing Administration. 2012; 42: 83–88. 26. Sobaski, T., Abraham, M., Fillmore, R., McFall, D.E., and Davidhizar, R. The effect of routine rounding by nursing staff on patient satisfaction on a cardiac telemetry unit. Health Care Management (Frederick). 2008; 27: 332– 27. Woodard, J.L. Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clinical Nurse Specialist. 2009; 23: 200–206 (Retrieved August, 2009
Postural changes in Hemodynamically Unstable Patients in Critical Care Unit Kripa Angeline A , R. Vijayaraj, Manopriya V *
Abstract In the critical care population, heart rate and rhythm, blood pressure, respiratory rate, and oxygen saturation are monitored continuously, providing immediate feedback regarding any changes in patient status. Hemodynamic instability is a term commonly used by clinicians to describe labile changes in cardiopulmonary status. The clinician’s perception of hemodynamic instability may cause a delay or omission in turning, repositioning, and other interventions to advance patient mobility and may contribute to pressure ulcer formation. The intensive care unit’s practice culture and individual clinician perceptions regarding hemodynamic instability may lead to staff not turning patients out of fear that they are “too unstable to turn.”Critical care personnel determine the quality of patient care and patient outcomes. Interdisciplinary care is based on a comprehensive approach that includes standards and guidelines consistent with high quality evidenced based care. Key words: Hemodynamic instability,Progressive mobility, Repositioning.
Introduction
Defining Hemodynamic Instability
Caring for the critically ill patient allows the bedside nurse to see the extent to which excellent nursing care can be a major factor in reducing morbidity and mortality.(1-3) Clinical assessment provides a number of advantages over the use of invasive methods to assess severity of illness and adequacy of the initial resuscitation of the hemodynamically unstable patient.Assessing hemodynamically unstable patients provide timely, low risk and potentially useful diagnostic and prognostic information.(4-5) The Nurse rapidly monitors for the development of complications, consults with appropriate personnel for additional interventions and generally ensures that care is provided according to accepted practice guidelines and protocols. (6,7 )Routine care of mechanically ventilated patients typically involves a regimen of body position changes to aid in the prevention of skin breakdown, to enhance secretion clearance, and to improve ventilation/ perfusion relationships.(8)
Hemodynamic instability is typically characterized by blood pressure lability, bradycardia, tachycardia, systemic hypotension, hypoxemia, and/or hypoperfusion, and may be affected by blood loss, decreased systemic vascular resistance from sepsis, decreased cardiac output, as well as supportive measures such as extracorporeal circulation.(10-11)
Clinical Assessment of Hemodynamically Unstable Patients Clinical assessment methods are readily available and can be performed without the use of additional specialized equipment. Several types of clinical assessment including change in temperature and mean arterial pressure have been validated to predict mortality in patients with critical illness in different patient populations. In addition, there is evidence that response to therapy in hemodynamically unstable patients may predicted by changes in clinical exam.
* Ms. Kripa Angeline A ,Assoc.Prof., Mr. R. Vijayaraj, Ms. Manopriya V , Asst Professors, KGNC, Puducherry 607402, India.
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Further, clinical assessment is low risk and can be repeated as often as necessary.(12-14)
Need for postural changes 1. Critically ill patients who are older, with comorbid conditions such as diabetes and preexisting cardiac disease and or the presence of vasoactive agents, will be at greater risk for not tolerating in-bed mobilization. It is critical that the nurse assess the risk factors and plan when activity will occur to allow sufficient physiological rest to meet the oxygen demand that positioning will place on the body. 2. When positioning the high-risk patientswho need preoxygenation before position change to increase the oxygen supply side, the right lateral position should be used initially to prevent the hemodynamic challenges. 3. Prevent prolonged gravitational equilibrium by initiating a turning schedule within hours of admission to the ICU. Prolonged periods in a stationary position result in greater hemodynamic instability when the patient is turned. 4. If the patient does not tolerate manual turning using the just-stated recommendations, as evidenced by a sustained decrease in blood pressure and oxygen saturation and/or an increase in heart rate, the patient should be returned to the supine position and the nurse should consider the use of continuous lateral rotational therapy in an effort to train the patient’s body to tolerate side-to-side movement. 5. Continuous lateral rotation therapy should be managed. Significant problems are created for ICU patients when they are not mobilized effectively. Mobilization enables the prevention of complications and faster healing and recovery.(9-10)
Positions andHemodynamics Effect of Supine Position 1. In the supine position, ventilation and perfusionare greater in dependent areas of the lungs than in the anterior areas. In healthy lungs,adequate matching of ventilation and perfusion(V/Q match) can be achieved in the supine position. Page 44
2. In diseased lungs, prolonged placement in the supine position can alter the V/Qmatch. For example, excess fluid associated with pulmonary edema accumulates in the dependent areas of the lungs and interferes with diffusion of gases across the alveolar capillary membranes Perfusion, however,remains constant in the dependent areas. 3. Therefore, there is a V/Q mismatch that results in an intrapulmonary shunt.The supine position results in anatomical changes that alter ventilation and perfusion,especially in patients with enlarged hearts. In the supine position, the major part of the left lower lobe and a significant part of the right lower lobe are located beneath the heart. 4. Enlarged heart produce an increased pleural pressure in the dependent areas and contribute to alveolar collapse. Studies using isotope ventilation-perfusion scans in patients with cardiomegaly and no evidence of pulmonary pathology have shown a 40% to 50% reduction in left lower lobe ventilation in a prolonged supine position with no concomitant reduction in regional perfusion. 5. Patients with acute respiratory distress syndrome (ARDS) who are mechanically ventilated while in the supine position develop atelectasis in the dependent areas of the lungs. 6. Ventilation is impaired by airway, lung edema, and cardiac and abdominal compression of the lungs while perfusion is secretions maintained, and this results in intrapulmonary shunt and severe hypoxemia(31). Effect of Prone Position 1. Increases intra abdominal pressure, decreases VR to the heart, and increases systemic and pulmonary vascular resistance however, may improve as Perfusion of the entire lungs improves Increase in intra abdominal pressure decreases chest wall compliance,which under PPV, improves ventilation of the dependent zones of the lung, and Previously atelectatic dorsal zones of lungs may open(29).t 2. Research demonstrates that prone positioning in critically ill patients with acute lung injury and/or ARDS improves pulmonary gas exchange and reduces the rate of VAP. The physiological mechanisms responsible for improvement in pulmonary gas exchange have not been fully elucidated. Ann. SBV, Jan-June2015;4(1)
3. Possible mechanisms may include better drainage of pulmonary secretions, reopening of atelectactic units inthe dorsal regions of the lungs, and minimizing ventilator-induced lung injury. 4. Despitein pulmonary gas exchange, recent studies reported no survival benefit for the use of the prone position in ARDS. Alsaghir and Martin recently conducted asystematic review and meta-analysis to assess the effect of the prone position, as compared to the supine position, on improvement in oxygenation,number of days on the ventilator, VAP, and mortality. 5. Prone positioning showed significant and persistent improvement in PaO2/FIO2 in all phases of ARDS Although no significant difference in short-term or long-term mortality was reported, a couple of studies showed that prone position significantly reduced mortality in patients with higher illness severity. 6. Adverse consequences include dislodgement ofthe artificial airway and enteral feeding tubes,loss of venous access, development of facial edema and pressure ulcers, and difficulties with cardiopulmonary resuscitation. 7. For critical care units that use prone positioning,evidence-based guidelines for bedside nurses should be in place. These guidelines should include indications and contraindications,preprone assessment and safety practices,strategies for placing the patient in the prone position, assessment guidelines for monitoring patient response to the prone position,and limb positioning while in the prone position(27,28,29).
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Contraindications The following are relative contraindications to prone positioning. Although it might be reasonable to commence proning patients with some of these conditions, they should be considered carefully at consultant and senior nurse level before proceeding. • • • • • • • • • • • •
Increased intracranial pressure Severe Haemodynamic instability Uncontrolled bleeding Recent airway surgery including tracheostomy Cardiac arrhythmias likely to require pacing or defibrillation Significant likelihood of requiring CPR Chest drainage with persistent air leak Spinal instability Unstable fractures Recent abdominal or thoracic surgery Raised intra-abdominal pressure Active intra-abdominal pathology(23)
Stationary Lateral Positions 1. The decision to place critically ill patients inthe left or right lateral decubitus position is based on relevant lung pathology and hemodynamic stability. Studies have shown that when patients with unilateral lung disease(pneumonia, atelectasis) are placed with the consolidated lung in the dependent position,there is a mismatch of ventilation to perfusion that results in hypoxemia. 2. Placement of the diseased lung in the dependent lateral position results in greater perfusion to a diseased poorly ventilated lung and impairs gas exchange. 3. Therefore, patients with unilateral lung pathology should be placed in a lateral positionwith the “good” lung down. 4. Even though this is the golden rule for patients with unilateral disease, there are contraindications to this position in certain lung pathologies. For example,in patients with pulmonary abscesses or pulmonary hemorrhage, it is important to keep the affected lung in the dependent position so that drainage will not migrate toward the healthy lung. 5. At 10 to 30 minutes after a lateral position change, cardiac output and heart rate may not be the same as in the supine position, but Page 45
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these changes in most mechanically ventilated patients are not clinically significant. 6. Early evidence demonstrated that cardiovascular changes can be highly individualized and may be most prominent in patients with low cardiac output and in patients who are hypothermic and/or receiving vasoactive medications. 7. More recent evidence suggests that lateral positioning of critically illpatients who are hypoxemic or have low car cardiac output does not further endanger tissue oxygenation.
Beach Chair Position 1. The beach chair position was conceptualized as a method of early mobilization to help reduce the incidence of VAP in ICU patients who, because of pathological reason(s) or physiological instability, are unable to get out of bed.
(25)
Effect of Semirecumbent Position with Head of Bed Elevation 1. Head of bed (HOB) elevation is an importantcomponent of the semirecumbent position t hat must be considered for patients who are receiving enteral nutrition to prevent aspiration of gastric contents and ventilatorassociated pneumonia (VAP). 2. Several studies using radiolabeled enteral feeding solutions in mechanically ventilated patients have reported that aspiration of gastric contents occurs to agreater degree when patients are in the supineposition than when they are in the semi-recumbent position with the HOB elevated to 30 to45 degree.(24)
Contraindications to HOB Elevation • • • • • • • • • • • • • • •
Pulmonary Atelectasis Pneumonia Hypoxemia Cardiovascular Venous thromboembolism Syncope because of diminished baroreceptoractivity Skin integrity Pressure ulcers Low cardiac index Hypotension Neurological Ischemic stroke Traumatic brain injury Procedure in progress in which HOB elevationis in appropriate Prone position Medical order for no HOB elevation
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2. The BCP is defined as having the patient’s head of bed elevated to 70° and the foot of bed at a −75° angle, as if the patient is sitting in a chair. By using the bed frame to place the patient in the BCP, patients who might not be able to get out of bed are able safely to attain a sitting position. BCP candidates include patients who require sedation or who are hemodynamically unstable.(22,23)
Common Nursing Interventions for positioning Unstable Patient • Turning technique is also very important for success. Moving the patient from the supine position to a full lateral turn during a bed bath, for example, is not an appropriate gauge of the patient’s ability to turn. Rather, we advocate that slow, incremental turns are essential to allow the patient to adjust to the change in gravity versus the body alignment. • The patient should be turned slowly, with adequate staff, to 15° for 15 seconds, then 30° for 15 seconds, 45°for 15 seconds, and then completion of the turn to allow for needed care (eg, linen changes, hygiene, and skin care). The patient should then be brought back down on wedges and pillows to the 30°position, using the same incremental 15-second technique. • Changes in hemodynamic status should be monitored for 10 minutes.(16) Ann. SBV, Jan-June2015;4(1)
• Braden pressure ulcer risk assessment. • Continued in heart rate, for instance, should not invoke a knee-jerk reaction to stop the turning intervention. • These patient-specific responses should be individualized to the patient. If patients are noted to have no concerning changes in vital signs at 15°but show hemodynamic instability without recovery at 30°, then they will be provided a miniturn for the time being at the 15°level. With the next turning attempt, patients will again be turned incrementally, but with the goal to achieve a 30°turn(20-21) • Patients who tolerate repositioning are considered to be “stable”; in these patients, turning frequency should be individualized dependent upon their condition and the support surface that is in use and should generally range from 1 to 4 hours.(16-17) • Provide mini turns • Weight shift patient at least every 30 minutes • Elevate heels from surface of bed • Reposition patients head, arms and legs at least every hour, consider passive ROM • Consider use of continuous lateral rotation therapy to prevent development of gravitational equilibrium. Begin: SLOW and LOW angles of turning to guage patient response • When turning patient: Go SLOW provide serial small turns from supine to lateral position to achieve linen changes, hygiene checks and reposition with wedges and pillows.(15)
Clinical findings which prevent patient turning 1.Development of life threatening arrhythmia with symptomatic response (Ventricular Fibrillation/ Ventricular tachycardia / Systemic Ventricular Tachycardia). This does not include asymptomatic Atrial Fibrillation. 2.Active Fluid resuscitation (ie. no volume going in = no systemic blood pressure). 3.Active Hemorrhaging • Following cardiac surgery / Active Tamponade • Massive G.I bleeding with use of Blakemore tube. • Active hemorrhage following trauma Ann. SBV, Jan-June2015;4(1)
4.Changes in baseline haemodynamic parameters (BP, HR, Oxygen Saturation, RR, etc) does not recover within 10 minutes of position change and is not an expected result faced on diagnosis.(15) • Interdisciplinary Collaboration The task of turning, repositioning, and mobilizing the intensive care patient requires a true multidisciplinary collaboration. For pressure ulcer prevention, the nurse should support the principles of progressive mobility and should join forces with the nursing staff and physical therapists. Increasing patient mobility in the ICU population is likely to contribute to reduction in pressure ulcer incidence. • Even the most critically ill patients can usually be turned; for example, most cardiac surgery patients and neurosurgery patients with intracranial pressure monitoring can be turned safely beginning in the immediate postoperative period.(18)
The Role of Critical Care Nurses Skilled nursing management of a critically ill patient operates on many levels. Critical care nurses’ skill level is dependent upon their knowledge, experience of, and exposure to, critically ill patients. Improving patient outcomes Wards and units can benefit greatly from using the full potential of their critical care nurses(30). Nurses can improve patient recovery by using patient-centred care, pro-active management and vigilance, coping with unpredictable events, and providing emotional support Patients are helped by skilled and timely reduction of sedation, weaning from ventilation, physical rehabilitation, and psychological support. Effective nursing care also includes pro-active prediction and prevention of complications, and prompt and skilled intervention in the event of sudden deterioration. Skilled critical care nursing will reduce the risk of complications, the number of critical care bed days and improve patient outcomes. Observation will reduce a patient’s risk of precipitous deterioration, monitor their total dependence on support equipment and prevent their agitation or confusion leading to harm. Observation involves assimilation, interpretation and evaluation of information, including the patient’s physical and psychological response to interventions, changes in condition, the significance of monitored physiological parameters and the safe functioning Page 47
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of equipment. Only appropriately trained and experienced nurses can provide this comprehensive level of observation.(19-20)
Conclusion Every patient, nurse and care facility is different. So providing the right nursing care for critically ill patients is not simply a matter of applying standard nurse-to patient ratios. The skill of the nurse, the complexity of the patient’s needs and the physical environment of care will all influence nursing requirements.
Reference 1. Joanne V. Hickey (2009) The clinical practice of Neurological and Neurosurgical Nursing, 6th edition Wolters Kluwer publications: Philadelphia. 2. McGee S, Abernethy WB, 3rd, Simel DL. The rational clinical examination. is this patient hypovolemic JAMA. 1999;281:1022–1029 3. Jonathan SevranskyClinical Assessment of Hemodynamically Unstable Patients CurrOpinCrit Care 2009. June :15 (3)234238. 4. PorkornyM,KoldjeskiD , Swanson M . Skin care intervention for patients having cardiac surgery. Am J CritCare. 2003 ; 12 : 535-544 . 5. Solis L,Gyawali S, Seres P, et al. Effects of intermittent electrical stimulation on superficial pressure, tissue oxygenation and discomfort levels for the prevention of deep tissue injury . Ann Biomed Eng. 2011 ; 39 ( 2 ): 649-663 . 6. Kathleen M. Vollman Hemodynamic Instability: Is It Really a Barrier to Turning Critically Ill Patients?2012;32:70-75 doi: 10.4037/ccn2012765Crit Care Nurse Published online http://www.cconline.org © 2012 American Association of Critical-Care Nurses 7. De Laat EH , Pickkers P , Schoonhoven L , Verbeek AL , Feuth T , van Achterberg T . Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients .Crit Care Med.2007 ; 35 ( 3 ): 815-820 . 8. Offner PJ,HaenelJB , Moore EE , Biff WL, Franciose RJ , Burch JM . Complications of prone ventilation in patients with multisystem trauma with fulminant acute respiratory distress syndrome . J Trauma. 2000 ; 49 ( 4 ): 791-792 . Crit Care. 2009 ; 20 ( 3 ): 254-266 . 9. De Jonghe B, Lacherade JC, Shashar T, OutinH . Intensive care unit–acquired weakness: risk factors and prevention.Crit Care Med. 2009 ; 37 ( 10 ): s309-s315 . 10. Bailey P, Thomsen GE, SpuhlerVJ , et al. Early activity is feasible and safe in respiratory failure patients .Crit Care Med. 2007 ; 35 ( 1 ): 139-145 . 11. LingrenM ,Unosson M , Fredrikson M , Ek AC . Immobility a major risk factor for development of pressure ulcers among adult hospitalized patients: a prospective study .Scand J Caring Sci. 2004 ; 18 : 57-64 . 12. Gattinono L, Brazzi L, Pelosi P, Latini R, Togoni G, Pesenti A: A trial of goal-oriented hemodynamic therapy in critically ill patients NEngl J Med 1995 13. Ledwith MB, Bloom S, Maloney-Wilensky E, Coyle
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B, Polomano RC, Le Roux PD Effect of body position on cerebral oxygenation and physiologic parameters in patients with acute neurological conditions Neuro Intensive Care Unit, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. 14. Department of Health (202) Available adult critical care beds at 16 july 2002. Department of Health Forum KH03. 15. Department of Health, Social Services and Public Safety, Northern Ireland (2000) Facing the future: building on the lessons of winter 1999/2000. 16. Pronovost P, Dang G, Dorman T, Garrett E, Jenckes M, Bass E (2001) Intensive Care Unit nurse staffing and the risk of complication abdominal aortic surgery, Effective clinical practice 199-206. 17. Peerless JR, DaviesA, Kelin D, Yu D Skin complications in the Intensive Care Unit. Clin Chest Med. 1999;20(2):453467. 18. Offner PJ, Haenel JB, Moore EE, Biff WL, Franciose RJ, Burch JM. Complications of prone ventilation in patients with multi system trauma with fulminant acute respiratory distress syndrome. J Trauma 2000:49(4):791-792. 19. National Pressure Ulcer Advisory panel. Position statement: not all pressure ulcers are avoidable. march, 2010. 20. Griffiths RD, Hall JB Intensive Care Unit Acquired Weakness. Crit Care Med. 2010;38(3):779-787. 21. Rochester C Rehabilitation in the Intensive Care Unit. SeminRespirCrit Care Med.2009;30:656-669. 22. Zack MB, Pontoppidan H, Kazemi H. The effects of lateral positions on gas exchange in pulmonary disease.Am Rev Respir Dis. 1974;110:49–55. 23. Katz JK, Barash PG. Positional hypoxemia followingposttraumatic pulmonaryinsufficiency. Can Anaesth, Soc J. 1977;24:346–352. 24. AICU Consultant Jonathan Chantler, Senior Sister Carolyn SoanesAICU/CICUguidelines for Prone Ventilation in Severe Hypoxic ARDS Version2 Issue Date:- March2014 25. SreenandhKrishnagopalan, MD; E. William Johnson, MPH etalBody positioning of intensive care patients: Clinical practice versus standards* Critical Care Medicine 2002 Vol. 30, No. 11pp2588-259 26. Karen L. Johnson ,Tim Meyenburg, Physiological Rationale andCurrent Evidence for Therapeutic Positioning of Critically Ill Patients,AACN Advanced Critical CareVolume 20, Number 3, pp.228–240 27. Defloor T. The effect of position and mattress on interface pressure. ApplNurs Res. 2000;13:2–11. 28. Ratliff CR, Bryant DE. Guidelines for the Prevention and Management of Pressure Ulcers. Glenview, IL: Wound, Ostomy, and Continence Nursing Society; 2003. WOCNClinical Practice Guideline 2. 29. Chatte G, Sab JM, Dubois JM, Sirodot M, Gaussorgues P, Robert D. Prone position in mechanically ventilated patients with severe respiratory failure. Am J RespirCrit Care Med. 1997;155:473–478. 30. Theaker C. Pressure sore prevention in the critically illwhat you don’t know, what you should know and whyit’s important. Intensive Crit Care Nurs. 2003;19:163–168. 31. Ibanez J, Penafiel A, Raurich JM, Marse P, Jorda R, Nata F.Gastroesophageal reflux in intubated patients receivingenteral nutrition: effect of supine and semirecumbentpositions. JPEN J Parenter Enteral Nutr. 1992;16:419–422. Ann. SBV, Jan-June2015;4(1)
Specially focused nursing care for preemies - born too soon Geetha.C ,.S Saranya*
Abstract
The little body of a preterm baby still have underdeveloped parts that include the lungs, digestive system, immune system and skin. At birth, neonates undergo physiological adaptations, especially those related to breathing and few minutes of severe oxygen deprivation can cause irreversible brain damage. Thankfully, medical technology has made it possible for preemies to survive the first few days, weeks or months of life until they are strong enough to make it on their own. A specially focused nursing care is very essential to care the babies that are born too soon. It includes the total care of the preterm like thermal regulation, feeding, respiratory support and infection prevention. This article serves on the nursing care that is essential for the preterm baby to prevent the risk and is a brief description of what to expect in the care for a newborn preemie. Key words: Preterm, Thermal care, Breastfeeding, Infection prevention, Breathing Issues
Introduction:
Do Preemies Need Special Care?
Babies born before the 37th week of gestation are considered premature and are sometimes referred to as “Preemies”. World Health Organization definition of prematurity is a baby born before 37 weeks of gestation, counting from the first day of the Last Menstrual Period (LMP).Each year 15 million babies are born preterm and their survival chances vary dramatically around the world. Premature newborns have increased risk of complications. The risks increase the earlier the child is born5. Any complications of a premature newborn will be addressed in the neonatal intensive care unit (NICU). Improvements in the quality of antenatal care, from care during labor until the delivery room and neonatal care have reflected in the survival of premature in different regions and countries of the world .Special care is sometimes provided on the ordinary postnatal ward and sometimes in a specialist newborn (neonatal) area. Having a baby in neonatal care is naturally worrying for parents and every effort should be made to ensure that you receive the information, communication and support that you need
Premature babies are not fully equipped to deal with life in our world as they are born early – one baby in 13 (8 out of 100) is born early in our country, and those babies born before 34 weeks may need extra help with breathing, feeding keeping warm. • Feeding difficulties since the coordinated suck and swallow process only starts at 34 weeks gestation. Preterm babies need help to feed and are more likely to aspirate. • Severe infections are more common, and premature babies are at higher risk of dying once they get an infection. • The majority of babies who die from neonatal sepsis are preterm. • Respiratory Distress Syndrome(RDS) due to lung immaturity and lack of surfactant in the alveoli, resulting in collapsing lungs that take extra pressure to inflate. Below 32 weeks gestation, the majority of babies develop RDS, although this risk can be reduced by antenatal corticosteroids injections to women at risk or in preterm labor.
* Geetha.C , Assoc.Prof., S Saranya., Lecturer,Dept of Child Health Nursing, KGNC, Puducherry 607402, India.
Ann. SBV, Jan-June2015;4(1)
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• Jaundice is more common in premature babies since the immature liver cannot easily metabolize Bilirubin, and once jaundiced, the preterm baby’s brain is at higher risk since their blood-brain barrier is less well developed to protect the brain. • Brain injury in preterm babies is most commonly cause intra ventricular hemorrhage, occurring in the first few days after birth in about 1 in 5 babies under 2,000 g and is often linked to severity of RDS and hypotension. Less commonly, preterm babies may have hypoxic brain injury with white matter loss which differs from that seen in the brain of term babies (Volpe, 2009). • Necrotizing Enterocolitis is a rare condition affecting the intestinal wall of very premature babies, with a typical X-ray image of gas in the bowel wall. Formula feeding increases the risk tenfold compared to babies who are fed with breast milk alone. • Retinopathy of prematurity due to abnormal proliferation of the blood vessels around the retina of the eye, which is more severe if the baby is given too high levels of oxygen. • Anemia of prematurity, which often becomes apparent at a few weeks of age due to delay in producing red blood cells as the bone marrow is immature.
Specially Focused Nursing Care 1. Breathing Issues/Problems In Premature Babies Improvements in the quality of antenatal care, from care during labor until the delivery room and neonatal care have reflected in the survival of premature and very low birth weight babies in different regions and countries of the world3. At birth, neonates undergo physiological adaptations, especially those related to breathing and few minutes of severe oxygen deprivation can cause irreversible brain damage 4 Challenges a premature baby may face when taking in oxygen12: Apnoea Pronounced ‘ap-nee-ya’, this is the term for episodes when a baby stops breathing. Premature babies will often stop breathing, or breathe very shallowly, for 5–10 seconds, before resuming normal breathing – this is known as periodic breathing. True apnoea is defined as episodes that last more than 20 seconds. This often happens because the Page 50
breathing centre of the brain has not yet matured. The healthcare team will probably recommend either caffeine treatment, which stimulates the breathing centre, or support with a ventilator. Studies suggest that most babies will have overcome apnoea by 37 to 40 weeks corrected age. However extremely premature babies may not achieve this until 43 weeks corrected age. Bradycardia During an episode of apnoea some babies’ heart rates may drop called bradycardia. Cyanosis This term refers to a bluish skin tone, caused by a lack of oxygen. This happens because blood that is low in oxygen is blue-purple, while oxygen-rich blood is bright red. In dark-skinned people, cyanosis may be more noticeable in the lips, tongue or nail beds. Nasal flaring If the baby’s nostrils open widely or flare out, this could be a sign that she is having to work hard to breathe. Recession If the baby’s airways aren’t fully open she may suck in the centre of her chest to breathe. When this happens, you may notice a dip between the ribs. Rapid breathing This problem, known as tachypnoea, is often a sign of distress. The baby’s team will examine her and may carry out investigations to determine the cause and appropriate treatment. Bronchopulmonary dysplasia (BPD) This condition, formerly known as chronic lung disease of infancy, is the diagnosis given to babies who need extra oxygen at 36 weeks corrected age. The more premature the baby, the more common BPD is. It may be made worse by artificial ventilation, which may be used in the early weeks of life to improve the baby’s chance of survival but can cause scarring or inflammation in the baby’s lungs.
fluid is absorbed so that after birth she can take in the surrounding air. Premature babies are at high risk of developing breathing problems because their lungs are not yet mature enough to make this switch without some extra help. • The healthcare team will aim to use a ventilation (breathing) strategy that is as gentle as possible, because in some cases artificial breathing machines (ventilators) can cause lung problems such as broncho pulmonary dysplasia
Types of Ventilation Support on the Baby Unit Mechanical ventilation through an Endotracheal tube (intubation) A plastic tube is inserted through the nose or mouth into the windpipe and air or an air–oxygen mix is blown in and out of the lungs under pressure. The machine does most or all of the breathing for the baby.18
Continuous Positive Airway Pressure (CPAP) Short prongs or a mask are positioned by the nostril or nose, and air or oxygen is blown in at a constant pressure. The baby does all of her own breathing, but the machine helps keep the lungs open in between breaths. Continuous positive airway pressure (CPAP) with nasal devices (nCPAP) is widely used in the
• Many premature babies need help with breathing for a while. Until the baby is born, the lungs are filled with a liquid that helps them grow and develop. During labour and birth this Ann. SBV, Jan-June2015;4(1)
A pair of small prongs is used to deliver extra oxygen through the nostrils. This option is used when the baby does not need pressure to keep the lungs open, but needs a little extra oxygen to maintain sufficiently high oxygen levels in her bloodstream. A modified version of this is called Vapotherm, which allows higher levels of oxygen to be delivered through prongs, and works in a similar way to CPAP (above).
Incubator oxygen It is possible to control the oxygen level in most incubators. This is another way of adjusting the amount of oxygen that the baby breathes.
Role of nurse –a gist in respiratory care • Assess infant’s color, perfusion, respiratory rate, heart rate, position and oxygen saturation. • Document frequency and severity of episodes and type and amount of stimulation required to interrupt the event. • Ensure bag and mask set-ups with oxygen available at infant bedside. • Maintain paO2 and oxygen saturation levels. • Recognize importance of weaning oxygen and other ventilator parameters. • Recognize complications arising from RDS, intubation and mechanical ventilation. • Utilize proper endotracheal suctioning techniques. • Provide mouth and skin care. • Maintain proper positioning. 2.Thermal care
A baby with BPD may go home on oxygen and some will need to continue this therapy for several months, or even years. If this happens, you will be supported by specialist nurses in the community.
Breathing Support for Premature Babies
Nasal prong oxygen
respiratory management of newborns. nCPAP can improve oxygenation, maintain lung volume, lower upper airway resistance, reduce obstructive apnoea, and most importantly eliminate an ETT/ventilator and the associated risks.[1,2] Ann. SBV, Jan-June2015;4(1)
Simple methods to maintain a baby’s temperature after birth include drying and wrapping, increased environmental temperature, covering the baby’s head (e.g., with a knitted cap), skin-to-skin contact with the mother and covering both with a blanket 3 . Delaying the first bath is promoted, but there is a lack of evidence as to how long to delay, especially if the bath can be warm and in a warm room. Kangaroo Mother Care (KMC) has proven mortality effect for babies <2,000g. Equipment-dependent warming techniques include warming pads or warm cots, radiant heaters or incubators and these also require additional nursing skills and careful monitoring .Sleeping bags lack evidence for comparison with Page 51
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skin-to-skin care or of large-scale implementation. There are several trials suggesting benefit for plastic wrappings but, to date, these have been tested only for extremely premature babies in neonatal intensive care units.
Role of nurse –a gist in thermal care • Monitor temperature & observe for instability • Methods to keep baby warm / prevent heat loss -skin-to-skin contact, cover/wrap, hats, • Plastic wrapping for preterm neonates in • delivery suite and then humidification • Maintain the neutral thermal environment 3.Feeding: A premature baby’s diet will be carefully balanced to suit the tiny digestive system while meeting the needs of the growing baby.
Knitted cap
What kind of nutrition does a premature baby need? When the baby is first born, the healthcare team may give fluids and nutrition through an intravenous (IV line) if the baby is extremely premature or has breathing difficulties . Alternatively, the doctors may decide that the baby is mature enough to take milk through a small tube that is passed through the nose into the stomach. Breast milk is the best choice for the baby. . If the baby is too weak, expressed milk can be fed through a tube.
Introducing Milk Feeds
Skin to skin contact
It is important for milk feeds to be introduced in a timely way - not too quickly but not too slowly - and the team will have the expertise to decide this. This progression must be very gradual because premature babies - especially those born at 34 weeks or less - are slow to cope with milk that goes into their stomachs and have more problems with absorbing nutrients.
Supplements/supplementary formula for premature babies Babies who are born early miss out on a lot of the nutrition that term babies receive during the final weeks of pregnancy, including key vitamins and minerals that are important to help them grow and become strong.
Pre warmed incubator Page 52
Breast milk is best for the baby, but she may also need extra vitamins and minerals for growth, so many premature babies are given supplements. There are also formula milks specially designed for Ann. SBV, Jan-June2015;4(1)
premature babies to ensure they get all the nutrients they need.
How will a baby feed if the baby is too weak to breastfeed? • Through an IV line. A baby who is born very prematurely will initially be fed through an IV line. This carries the nutrients she needs directly into her blood supply. This may last anything from a few hours after birth to days, weeks or longer, depending on how premature she is and whether she has any digestive problems. • Through a tube. Even if the baby is able to digest milk, she will not be mature enough to co-ordinate sucking, swallowing and breathing until about 32-34 weeks, so until then she will need to be fed through nasogastric tube or through an orogastric tube. The baby may continue tube feeding while she is learning to breast, cup or bottle feed, to make sure she gets enough food.
Breastfeeding the premature baby Giving birth prematurely does not prevent the mother from making milk for the baby. The extra stress, fear, discomfort and fatigue that go along with the birth of a premature baby can cause a slow start with milk production, but with patience and support the mother can express and breastfeed successfully. Breastfeeding the premature baby will boost her health and will help the mother to develop a bond with her.
Why breast milk is best for premature babies Health professionals generally advise women to breastfeed if they can. Breast milk has many health benefits for premature babies, and is recommended by neonatologists wherever possible.
The benefits of breastfeeding: • It’s good for the preterm baby. Breastfeeding will help to build the baby’s health and strength as well as protecting from viruses and bacteria, which can cause infection. The milk provides antibodies and other substances that help the baby’s immature gut and immune system. Breast milk is easier for a small baby to digest than Ann. SBV, Jan-June2015;4(1)
baby formula. Preterm babies are particularly vulnerable to necrotizing enterocolitis, so the mothers should be encouraged to breastfeed or express her milk. • It creates bond between mother and premature baby. Once the preterm baby is able to feed directly from the breast, you will also get regular skin-to-skin contact with her. 4.Infection prevention Clean birth practices reduce maternal and neonatal mortality and morbidity from infection-related causes, including tetanus. Premature babies have a higher risk of bacterial sepsis. Hand cleansing is especially critical in neonatal care units. However basic hygienic practices such as hand washing and maintaining a clean environment are well known but poorly done. Unnecessary separation from the mother or sharing of incubators should be avoided as these practices increase spread of infections. Recent cluster-randomized trials have shown some benefit from chlorhexidine topical application to the baby’s cord and no identified adverse effects. The skin of premature babies is more vulnerable, and is not protected by vernix like a term baby’s. Topical application of emollient ointment such as sunflower oil or Aquaphor reduces water loss, dermatitis and risk of sepsis and has been shown to reduce mortality for preterm.
Role of nurse –a gist in infection prevention • Clean birth practices reduce maternal and neonatal mortality and morbidity from infection-related causes, includingtetanus • Hand cleansing is especially critical in neonatal care units. • However basic hygienic practices such as hand washing and maintaining a clean environment are well known . • Chlorhexidine topical application and topical application of emollient ointment such as sunflower oil or Aquaphor reduces water loss, dermatitis and risk of sepsis
Goals of Nursing Care to Promote Parental Attachment • Opening the intensive care nursery to parents • Transporting the mother to be near her infant Page 53
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• • • • • • • • • • •
Maternal day care for premature infants Rooming in for parents Individualized nursing care plans Early discharge Listening to parents during the infant’s hospitalization and after discharge Parent support groups Programmed contact and reciprocal interaction Transporting the healthy premature infant to the mother Home-based interventions for young parents Discussion with parents after discharge Kangaroo care
Conclusion Globally, progress is being made in reducing maternal deaths and child death after the first month of life. Improvements in the quality of antenatal care, from care during labor until the delivery room and neonatal care have reflected in the survival of premature and very low birth weight babies in different regions and countries of the world
Reference: 1. Gregory GA, Kitterman JA, Phibbs RH, Tooley WH, Hamilton WK. Treatment of the idiopathic respiratorydistress syndrome . N Engl J Med. 2009;284:1333–134 2. Morley C, Davis P. Continuous positive airway pressure: current controversies. Curr Opin Pediatr. 2004;Pg141–143 3. Costa R, Padilha MI, Monticelli M. Production of knowledge about the care given to newborns in neonatal IC: contribution of Brazilian nursing. Rev Esc Enferm USP 4. Barbosa AL, Chaves EMC, Campos ACS. Caracterização dos recém-nascidos em ventilação mecânica em uma unidade neonatal. Rev RENE. 2007;8(2):35-40. 5. Davis P, Davies M, Faber B. A . Arch Dis Child Fetal Neonatal Ed. 2001;85:F82–F85. 6. Trevisanuto D, Grazzina N, Doglioni N, Ferrarese P, Marzari F, Zanardo V. A new device for administration of OXYGEN in preterm infants in Intensive Care Med. 2005;Pg859–864. 7. . Squires AJ, Hyndman M. Prevention of nasal injuries secondary to NCPAP application in the ELBW infant. Neonatal Netw. 2009;28:13–27. Robertson NJ, McCarthy LS, Hamilton PA, Moss AL. Arch Dis Child Fetal Neonatal Ed. 1996;pg 209–212. 8. Cartlidge P. The epidermal barrier. Semin Neonatol. 2000;5:273–280. 9. Analysis using data from Blencowe et al., Cousens et al., 2011; Liu et al., 2012 10. Yong SC, Chen SJ, Boo NY. Arch Dis Child Fetal Neonatal Ed. 2005;90:F480–483. 11. Health Epidemiology Reference Group and World Health Organization estimates of neonatal causes of death (Liu et al. 2012) 12. Annamma Jacob,” Clinical Nursing Procedure – The art of
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NursingPractice,2nd edition, Jaypee Publishers, 2009Page No : 621 – 624. 13. D.C.Dutta,Textbook of Obstetrics, 6th edition, New Central book agency (P) LTD, 2004, Page No : 426 – 429. 14. Myles,Textbook of Midwives, 14th edition, Elseiver Publications, , 2003Page No: 719 – 723. 15. Adele Pillitteri , Maternal and Child Health Nursing – Care of the child bearing & child rearing family,” 4th edition, Lippincott Williams and Wilkins Publichers,2011 Page No: 123 -131. 16. Lowdermilk,maternal and child health healthnursing mosby publication 17. Annamma Jacob,Rekha.R;Clinical Nursing Procedure:Art Of Nursing Practice;secondedition;jaypeepublishers:NewD elhi; 2010;page no.236-240. 18. Marilyn.J.hockenberry,Wongs Essentials Of Paediatric Nursiing ,8 thedition,Mosby Elsevier publications,2009,page no.394 19. O.P.Ghai,Essential Paediatrics7 thedition,CBS Publishers,2010,page no.194 to 198 . 20. Achars.S , Text Book Of Pediatrics, 6th edition, orient Longman publishers,2000 Chennai. 21. Behrman .G, Text Book Of Pediatrics, 15th edition, prism books pvt.Ltd.,2000 Bangalore. 22. Cloherty J, Stark A, Eichenwald E.Manual Of Neonatal Care. 6th ed. Lippincott, Wilkins and Williams. .2008 pg.121 23. Nelsons , Text Book Of Pediatrics, 4th edition, Elsevier sounders, Philadelphia. 2000 24. Allen D. Improving Health the Indian Way. Indian Journal of Maternal and Child Health; 2009 June 8: 79(7): 210-1. 25. Meharban Singh. Essential pediatrics for Nurses. Sugar publications. 2004. 26. Mathur NB. Neonatal priorities in developing countries. Paras publications.2001. 27. Meharban Singh. The art and science of baby and child care. 2nd edition. Sugar publications. 2004. 28. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of Home-Based Neonatal Care and Management of Sepsis on Neonatal Mortality. Lancet; 2007 Aug 7: 9194 (1999): 1955-61. 29. Basu AM, R Stephenson. Low Levels of Maternal Education and the Proximate Determinants of Childhood Mortality: A Little Learning Is Not a Dangerous Thing. Indian Journal of Pediatrics; 2005 no. 9: 2011-23. 30. .De NC. Impact of Maternal and Child Health Strategy on Child Survival. Indian Pediatrics; 1998 no. 2: 188-90. 31. Chandrashekar S, RS Rao, NS Nair, PR Kutty. SocioDemographic Determinants of Antenatal Care. Tropical Doctor; 1998.28(4): 206-9. 32. Mathur N B, A K Gargye, and V J Rajput. Knowledge Attitude and Practice of Perinatal Care Amongst Traditional Birth Attendants (Dais) Trained Vs. Untrained. Indian Pediatrics; 1993. 20(11):837-42. 33. .Mavalankar D, K Vora, M Prakasamma. Achieving Millennium Development Goal 5: Is India Serious?. Bull World Health Organization; 2008. 86(4): 243-43A. 34. Mavalankar D V, C R Trivedi, R H Gray.Levels and Risk Factors for Perinatal Mortality in Ahmedabad, India. Bull World Health Organization; 2001. 69(4): 435-442. 35. .Ramani K V, D Mavalankar. Health System in India. Opportunities and Challenges for Improvements. Journal of Health Organization Management; 2006. 20 (6): 560-572. Ann. SBV, Jan-June2015;4(1)
Contemporary nursing approaches in induction of labour S.Lavanya, V.Poongodi, R.Umamaheswari *
Abstract
Labour induction involves the stimulation of uterine contractions to produce delivery before the onset of spontaneous labour. This procedure has been commonly used since the synthesis of oxytocin (Pitocin) in the 1950s; labour is currently induced in about 13 percent of live births in the United States. Most labour inductions are for postdate pregnancy which occurs in about 10 percent of live births. Intrapartum nurses bear significant responsibility for assessing, supporting, documenting, and verbally communicating labour progress to birth attendants, families, and the women themselves. Contemporary research allows for a wider range of normal labour progress than in the past. Reduction in the rate of primary cesareans is needed to improve maternal and neonatal outcomes. Application of the contemporary evidence on induction of labour is an important aspect of the challenge being faced, to translate the evidence into practice. Key words: Induction, Intrapartum, Contemporary, Maternal outcome.
Introduction: Induction of labour is the artificial initiation of labour before its spontaneous onset to deliver the fetoplacental unit9. The frequency of induction varies by location and institution. The rate of induction in Canada has increased steadily from 12.9% in 1991–1992 to 19.7% in 1999–2000. The rate reached a high of 23.7% in 2001–2002, decreased slightly to 21.8% in 2004–2005, and has since remained steady. When undertaken for appropriate reasons, and by appropriate methods, induction is useful and benefits both mothers and newborns22. The goal of induction is to achieve a successful vaginal delivery that is as natural as possible. Women who are having or being offered induction of labour should have the opportunity to make informed choices about their care and treatment in partnership with their health care provider10.
Indications: • Postdate pregnancy • Premature rupture of the membranes 9
• Pregnancy-induced hypertension or preeclampsia24 • Chorioamnionitis11,13 • Severe intrauterine fetal growth retardation • Significant maternal medical problems, such as diabetes mellitus with pregnancy at term2
Contraindication • • • • • • • • •
Prolapsed umbilical cord. Prior classic uterine incision. Pelvic structural Abnormality. Active genital herpes infection Contracted pelvis12,14 Abnormal fetal heart rate. Multifetal gestation. Placenta previa & vasaprevia Malpresentation.
Pre induction assessment: The goal of labour induction is to achieve a successful vaginal delivery, although induction exposes women to a higher risk of a Caesarean section than spontaneous labour. Before induction,
* S.Lavanya, Asst.Prof., V.Poongodi, Asst.Prof., R.Umamaheswari , Asst.Prof., Dept. of OBG, KGNC, Puducherry 607402, India.
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there are several clinical elements that need to be considered to estimate the success of induction and minimize the risk of Caesarean Section21. Factors that have been shown to influence success rates of induction include the Bishop score, parity (prior vaginal delivery), BMI, maternal age, estimated fetal weight, and diabetes. The Bishop score was modified in 1974 as a predictor of success for an elective induction. The initial scoring system used 5 determinants (dilatation, length, station, position, and consistency) that attributed a value of 0 to 2 or 3 points each (for a maximum score of 13). Bishop showed that women with a score of > 9 were equally likely to deliver vaginally whether induced or allowed to labour spontaneously. Favourable Pre induction Bishop score of > 6 is predictive of a successful vaginal delivery . Assessment of cervical status is fundamental for the clinician to estimate the likelihood of a successful vaginal delivery. Of the Bishop score criteria for predicting successful induction, the most important is cervical dilatation, followed by effacement, station, and position, with the least important being consistency. The rate of failed induction is higher for women with a very low Bishop score (0 to 3) in both nulliparous and parous women15,16. Modified Bishop Score11,12: Parameters 0 Cervical <1cm dilatation(cm) Cervical >4 length(cm) Fetal head -3 station
Consistency Position
Firm Posterior
1 1-2cm
2 3 2-4cm >4cm
2-4
1-2
<1
-2
-1/0
+1/+2
Average Middle or anterior
Soft -
-
Contemporary Approaches in Induction of Labour: There are a number of ‘alternative’ or ‘natural’ induction methods available here. Trying to force the mother/baby to do something it is not ready to do is an intervention whether it is with medicine, herbs, therapies, techniques… or anything else. Interventions of any kind can have unwanted effects and consequences. However, ‘interventions’ (massage, acupuncture, etc.) that are aimed at relaxing the Page 56
mother and fostering trust, patience and acceptance may assist the mother/baby to initiate labour if the physiological changes have already taken place3,20. Numerous nonmedical methods for cervical ripening and labor induction have been employed. Although popular with midwives, most are not routinely used by obstetricians23. 1.Exercise: Walking, of all other physical activities, can help to induce labour naturally. When you walk, be upright so that the head of the baby presses on the pelvic area, precisely on the cervix. This pressure stimulates the release of oxytocin, that helps in progression of labour. Walking can help the baby take the heads-down position to initiate natural birth, due to the effect of gravity6. 2.Nipple Stimulation: Pulling on the nipples very firmly in a motion intended to simulate a baby’s suckling stimulates uterine contractions and has been used to induce labor . It usually works within about 72 hours in women with favorable cervix on Bishop scoring . Breast stimulation causes the uterus to contract, likely through increased levels of the hormone oxytocin, which stimulates contractions. It is typically recommended to be done manually for about 30 minutes at a time on one or both nipples, repeated twice daily. There is little data on safety but it does not appear to be associated with any complications. Safety has not been evaluated in highrisk pregnancies. A plus is that nipple stimulation is associated with reduced postpartum hemorrhage1 3.Belly massage:There is a need for an expert to perform this massage to jump-start the process of labour. In India, many massage therapists practice belly massage that could initiate labour naturally,especially if the overdue.Massaging specific points on the belly helps release oxytocin6,20. 4.Eating tropical fruits: There is a reason why pregnant women are advised against consuming pineapple, mango and papaya during pregnancy. These fruits contain a proteolytic enzyme called bromelain that can bring in labour. However, when one has crossed the expected due date, consuming such fruits makes total sense. The enzyme contained in such fruits helps to soften the cervix and initiate labour. The flipside is that there is no evidence that this process works and is safe for pregnant women. Also, the enzyme content in these fruits is very minimal so you need to consume as many as six to seven of them to initiate labour. The most-likely Ann. SBV, Jan-June2015;4(1)
side-effect of this overdose could be a severe case of diarrhea6.
a laxative for sure. Apart from that, it can also give rise to symptoms like nausea and vomiting3,20.
5.Spicy food:It is believed that having spicy foods just before labour can help in dilation, induce uterine contractions and help in smooth, troublefree labour, however, this traditional belief isn’t scientifically proven yet. Gorging on spicy foods during the expected delivery day, when contractions have not set in could possibly irritate the intestine and hence cause the uterus to contract6.
9.Acupressure and Acupuncture: Acupressure is the application of pressure usually using the fingertips, in place of needles, on acupuncture points. Firm pressure is applied for several minutes, repeated several times daily. Acupuncture has been used to ripen the cervix and induce labor. It is a harmless method if clean needles and proper techniques are used1.
6.Dance therapy: Belly dance during pregnancy is a good choice. It is a fun exercise for pregnant women and keeps the hormonal and energy levels in check. Practicing some moves can help to induce labour. The reason being, swaying of hips and belly will help the baby turn into the heads-down position and press on the cervix to help it dilate naturally. Avoid any vigorous moves that can harm the baby or lead to fetal distress6.
These are alternative therapies that many people resort to, induce labour naturally6. In acupressure, specific points in the body are stimulated to initiate uterine contractions, while in acupuncture, needles are inserted on specific points of the body that could initiate labour3. 10.Massage with primrose oil: Evening Primrose Oil has been used extensively by midwives to “ripen” the cervix when taken in doses of about 1500 mg orally and the oil of several opened gel caps also applied directly to the cervix for up to a week prior to when you hope to go into labour1.
7.Herbal tea:Herbs, especially blue cohosh and cotton root bark are popular amongst midwives, including certified nurse midwives, to stimulate labor. They are typically used in the form of alcohol extracts, taken in doses of several milliliters at a time, Massaging the perineum with evening primrose repeated up to 4 times/day, or more often under oil can help the cervix to loosen and dilate. However, skilled guidance. Thus the use of herbs to induce avoid using this herb and herb extract if pregnancy labor should preferably be done under the guidance is considered as a high-risk one6. of a midwife or other reliable health professional skilled in the use botanical medicines in pregnancy1,3. 11.Homeopathy:This can pose to be the safest to induce labour naturally. Homeopathy drugs can help Raspberry leaf tea can do wonders during labour. to set in uterine contractions when prescribed by a Sipping on raspberry tea during labour can help to registered homeopath. These drugs usually have no dilate the cervix and strengthen the entire pelvic side-effects. However, their efficiency is not proven area. It is packed with vital minerals and vitamins yet6,26. and plays a key role in initiating the labour process. It may be taken in a strong tea, prepared using ¼ oz. Safe Care Practices for Labour (about 4 grams) of the dried herb to 1 pint of water, Induction: steeped for 20 minutes, and several cupfuls taken daily until labor commences. It is not associated Intrapartum nurses bear significant responsibility with causing preterm labor and has been associated for assessing, supporting, documenting, and verbally with decreased complications at birth for the mother communicating labor progress to birth attendants, families, and the women themselves5. and baby1. 8. Consuming castor oil: Castor oil is considered to be a natural element in inducing labour. Many practitioners also advise pregnant women to consume specific doses of the oil mixed with milk, if she has crossed her due date. How castor oil helps to induce labour is not known completely but the oil acts as Ann. SBV, Jan-June2015;4(1)
• No elective labor inductions before 39 completed weeks of Gestation7 • Cervical readiness before labor induction7. • Standard oxytocin protocol, including a standard concentration and standard dosing regimen7. Page 57
Annals of SBV
• In case of uterine hyperstimulation appropriate and timely intervention6. • Continuous monitoring of women with partograph8. • Check pre induction score. • Documentation of indications for induction of labour4. • Monitor the women with cardiotocography. • Assessment of the progress of labour22. • The nurse should be able to give support and encouragement to the woman to help her cope with the contractions, and appropriate pain relief should be available if it is required17. • Good communication between the team members.
Conclusion: Labor induction appears to be a safe alternative to spontaneous labor. Regardless of the method employed, it is essential that the patient and her obstetrician understand the rationale for inducing labor, the risks of the method chosen, and the options that will be considered in case of failed induction. The goal of labor induction must always be to ensure the best possible outcome for mother and newborn23. Practitioners need to apply clinical judgement and evidence-based medicine to justify that induction is superior to continuation of pregnancy. The benefit of induction over the continuation of a pregnancy is not always clear, but there are some tools to evaluate the likelihood of a successful vaginal delivery24,25. In particular, perinatal nurses have a wide array of skills useful to laboring women’s comfort and coping that can be further developed through maintaining normal physiologic processes without unnecessary technologic interference.
labour Induction. The American Journal Of Maternal /Child Nursing. 2007.(Dec;2007). 8. Jayne klossner N. Introductory maternity nursing . Philadelphia : lippincott williams and wilkins ;2006. P 255-257. 9. Adele pillitteri . maternal and child health nursing care of the child bearing and child rearing family. 5th edition Lippincott 2007 .p564 10. Deitra leonard lowdermilk . maternity and womens health care 9th edition . Missouri; Elsevier ;2007. P 947-951 11. Marie Elizabeth . midwifery for nurses 1st edition New Delhi: CBS publishers ; 2010 . P 283-86 12. Susan mattson . core curricullam for materal and newborn nursing. 3rd edition Philadelphia; Elsevier : 2004 . P 290 13. Shirish sheth. Essential of obstetrics. 1st edition New Dehi :jaypee brothers ; 2004 . p 274-80 14. Helen varney. Nurse midwifery. London : jones and bartlette ublishers ; 1987 . p 201 15. Shela balakrisnan . textbook of onstetrics 2nd edition Hyderabad ; paras medical publishers . 2013 . p558-563. 16. Yurtsever S. Labor Induction.2013. 17. Bukola F.Unmet need for Induction of Labor in Africa: secondary analysis 2012.(Aug 31,2012). 18. David Rakel. Reproduction (2012) .p25 19. Mackenzie IZ. Reproduction. 2006. ( June 1 2006). P34. 20. Induction of Labor:Balancing risk.2015 sep;16 .p320 21. National guideline clearing house. Induction of Labor.2010 Nov.(Revised 2014 March).. 22. Lawani OL.Obstetric outcome and significance of Labor induction: The new England Journal of Medicine.2014 (Dec; 16 ). 23. Andrew M Kaunitz , Luis Sanchez. Induction of labour. 2012.p225 24. Induction of Labor-Post dates Pregnancy. The new England Journal Medicine. 25. Walker KF.Induction of Labor; Advanced maternal age; Perinatal outcome. 2012 Dec;11 26. Robin Weiss. Ways to induce Labor :medically.1990.
Elavarasi.R, ArunaDevi. M, Ruma Shanthini.K, Guna.S *
Abstract
The spectrum of infectious disease is changing rapidly in conjunction with dramatic societal and environmental changes. Worldwide, explosive population growth with expanding poverty and urban migration is occurring; international travel and commerce are increasing; and technology is rapidly changing, all of which affect the risk of exposure to infectious agents. Infectious diseases are emerging, re-emerging, and increasing in the United States, taking a toll in both morbidity and mortality. A major cause of the emergence of new diseases is environmental change (for example, human encroachment into wilderness areas and increased human traffic through previously isolated areas). The re-emergence of some diseases can be explained by evolution of the infectious agent (for example, mutations in bacterial genes that confer resistance to antibiotics used to treat the diseases). In partnership with representatives from health departments, other federal agencies, medical and public health professional associations, and international organizations has developed a strategic plan to address emerging infectious disease threats. The plan contains four goals that emphasize surveillance, applied research, prevention and control, and public health infrastructure. To ensure sustainability, plan implementation will be approached in stages, as a long-term endeavor with emphasis on extramural programs. As health-care reform proceeds priority should be given to strengthening partnerships between health-care providers, microbiologists, and public health professionals to detect and control emerging and re-emerging infectious diseases. Key words: emerging, environment, infectious disease
Introduction Infectious diseases are dominant public health problem even in the 21st Century and world’s leading cause of death for children and adolescents. WHO estimates 25% of the total 57 million annual deaths that occur worldwide are caused by microbes and this proportion is significantly higher in the developing country1. In 1997, WHO formulated world health day theme focusing on these issue as “Emerging Infectious Diseases- Global Alert: Global Response”8
References: 1. Labour induction : The low down on natural approaches from a midwife .2013Aug;27. 2. Andrew Kim, Jefferson H, Harman. Current trends in cervical ripening and Labor induction.1999.(Aug 1 1999). 3. Abigail H Natenson .Inducing labour at home:Is it right for you. 4. Elizabeth Johnson eparsoneault .Elective induction of labour and early term delivery. 5. Lisa Hanson, Leona Vandeuesse. Supporting Labour Progress towards Physiologic Birth . Journal of Perinatal & Neonatal Nursing. June 2014.Vol 28. P101-107. 6. Debiani arora. 12 ways to induce labour naturally .2014 Dec; 09. 7. Katheen Rice Simpson. Perinatal Patient Safety: Elective
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The burden of morbidity and mortality associated with infectious diseases falls most heavily on people in developing countries, and particularly on infants and children (about three million children die each year from malaria and diarrheal diseases alone)4.
Emerging & Re-emerging zoonotic diseases, food borne and waterborne diseases & diseases caused by multi resistant organism constitute the major threats in India. In the first half of 2014, Ebola caused over 200 deaths in West Africa and over 500 people contracted Middle East Respiratory Syndrome (MERS).2 There were more than 145 fatal cases of MERS. There has been a remarkable progress in the prevention, control and even eradication of infectious diseases (Smallpox) with improved hygiene & development of antimicrobials and vaccines. However, tragically, with optimism came a false sense of security, which has helped many diseases to spread with alarming speed.2
* R.Elavarasi, ArunaDevi.M Ruma Shanthini.K, Guna.S Asst.Professors., Dept. of Community Health Nursing, KGNC, Puducherry 607402, India.
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Emerging and re-emerging disease
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Emerging Diseases: The term “emerging infectious diseases” refers to diseases of infectious origin whose incidence in humans either has increased within the past two decades or threatens to increase in the near future. They are caused by a newly evolved organism or an organism that has undergone a mutation resulting in a new strain; they may result from the introduction of the organism to humans from another species; or they may result from dissemination of the organism from its existence in a small, circumscribed range of infection (which may not even be apparent or cause only slight illness) to susceptible populations.6 These include new, previously undefined diseases as well as old diseases with new features. These new features may include the introduction of a disease to a new location or a new population (e.g. it may present in youth where previously it was only seen in the elderly); new clinical features, including resistance to available treatments; or a rapid increase in the incidence and spread of the disease. 14
Hemorrhagic fever with renal syndrome(HFRS)
2003
Corona virus
SARS
HTLV-1
T-cell lymphomaluekemia
2009
H1N1
Pandemic A(H1N1) 2009 influenza
1982
E coli O157:H7
HUS
1982
Borrelia burgdoferi
Lyme disease
1977
Hantaan virus
1980
1982
HTLV-2
Hairy cell leukemia
1983
HIV
AIDS
1983
H.Pylori
Peptic ulcer disease
1986
BSE agent
Examples of Emerging Infectious Diseases:
1988
HHV- 6
In the past 20 years, at least 30 new diseases have emerged to threaten the health of hundreds of millions of people.
1988
Hepatitis E virus
Year identified
Agent
Disease
Rota virus
Infantile diarrhea
1975
Parvovirus
Aplastic crisis in chronic hemolytic anemia
1976
cryptosporidium
1977
Ebola virus
Ebola hemorrragic fever
1977
Legionella pneumophillia
Legionnaries’ disease
1973
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Acute and chronic diarrhea
1989
Hepatitis C virus
Bovine spongiform encephalopathy in cattle(Mad cow disease) Exanthemsubitum Enterically transmitted non-A, non-B hepatitis Parentally transmitted non-A, non-B hepatitis
Vibrio cholera O 139
New strain associated with epidemic cholera
1992
Bartonella henselae
Cat scratch diseases
1995
HHV-8
Association with kaposi’s sarcoma in AIDS patients
1992
1996
Prion
CJD
1997
Influenza A virus(H5N1)
Avian fly(bird flu)
Ann. SBV, Jan-June2015;4(1)
The emerging infectious diseases account for 26 per cent of annual deaths worldwide. Nearly 30 per cent of 1.49 billion disability-adjusted life years (DALYs) are lost every year to diseases of infectious origin.4
Disease
Infectious Agent
Chikungunya
Chikungunya virus
Re-Emerging Disease: “Re-emerging infectious diseases are those diseases that once were major health problems globally or in a particular country and then declined dramatically, but are again becoming health problems for a significant proportion of the population” 2
Cholera
Vibrio cholera 0139 (bacterium)
It often appear in epidemic proportions E.g.: TB, Cholera, Dengue, Malaria, H1N1 influenza, Ebola2 Re-emerging infectious diseases may occur because of the development of resistance to antimicrobial agents (as with gonorrhea), breakdown in public health measures (as with tuberculosis), and other reasons. Also included under the umbrella of emerging infectious diseases are agents that already existed and were widespread in humans but are newly recognized (e.g., herpes virus 6, now known to cause roseola) and association of an infectious agent with a chronic illness (e.g., Helicobacter pylori and peptic ulcer disease).15 The re-emergence of some diseases can be explained by the failure to immunize enough individuals, which results in a greater proportion of susceptible individuals in a population and an increased reservoir of the infectious agent. Increases in the number of individuals with compromised immune systems (due to the stress of famine, war, crowding, or disease) also explain increases in the incidence of emerging and re-emerging infectious diseases.18 The disease in question involves all the major modes of transmission i.e. spread either from person to person, by insects or animals or through contaminated water or food.22
Ann. SBV, Jan-June2015;4(1)
Cryptosporidiosis
Dengue Fever
Diphtheria
H5N1 influenza
Malaria
Cryptosporidium
parvum(protozoan)
Dengue Virus
Corynebacterium
diptheriae(bacterium)
influenza H5N1 virus Plasmodium species (protozoan)
Contr ibuting Factors viral genome mutation enabled infection of new mosquito vectors and expanded transmission evolution of new strain of bacteria combining increased virulence and long-term survival in the environment inadequate control in water supply; international travel; increased use of child-care facilities urbanization, international travel, and inadequate vector-control measures interruption of immunization program due to political changes living close to H5N1-infected poultry drug resistance; favorable conditions for mosquito vector
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Emerging and re-emerging disease
Annals of SBV Meningitis, Necrotizing Fasciitis (FleshEating Disease), Toxic-Shock Syndrome, And Other Diseases
Group A Streptococcus (bacterium)
uncertain
pertussis (whooping cough)
Bordetella pertussis (bacterium)
refusal to vaccinate based on fears the vaccine is not safe; other possible factors: decreased vaccine efficacy or waning immunity among vaccinated adults
Polio (Infant Paralysis)
Rabies
Rift Valley Fever (RVF)
Rubeola (Measles)
Schistosomiasis
Trypanosomiasis
Poliovirus
–
Rabies Virus
breakdown in public health measures; changes in land use; travel
RVF Virus
–
Measles Virus
failure to vaccinate; failure to receive second dose of vaccine
Schistosoma Species (Helminth)
dam construction; ecological changes favoring snail host
Trypanosomabrucei (Protozoan)
human population movements into endemic areas due to political conflict; diagnosis is very difficult, and current treatments have severe secondary effects
Tuberculosis
West Nile Encephalitis
yellow fever
antibiotic-resistant pathogens; immunocompromised populations (malnourished, HIVinfected, poverty -stricken)
West Nile Virus
complex interactions between the virus, birds and other animals, mosquitoes, and the environment; emergence in U.S. and other regions likely due to global travel
yellow fever virus
insecticide resistance; urbanization; civil strife
Factors in Emerging and Re-emerging Disease: Factors that influence the emergence or re-emergence of infectious diseases include social and behavioral changes, climate changes, environmental alteration, political upheaval, migration and transport, natural disasters, travel, demographic shifts, the erosion of public health infrastructure decreasing surveillance, prevention and control, decline in experts in areas of infectious diseases, economics, and health care advances and technology20 The other factors also responsible for emergence and re-emergence of infectious diseases are: • • • • • • • • • • • • •
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Mycobacterium Tuberculosis (Bacterium)
Unplanned and under-planned urbanization overcrowding and rapid population growth Poor sanitation Inadequate public health infrastructure Resistance to antibiotics Increased exposure of humans to disease vectors and reservoirs of infection in nature Rapid and intense international travel Practice of modern medicine and relaxation in immunization practices Deforestation Failure to control carriers or breakdown in water and sanitation systems Changes in genetic makeup of the pathogen High risk human behavior Channeling of funds to other problems7 Ann. SBV, Jan-June2015;4(1)
monitoring systems to serve as part of the overall detection system. • In addition to partnership in global monitoring, WHO is working in countries to strengthen national disease detection and response through improved surveillance systems, and specialized training in epidemic preparedness and response. • A final role of WHO in this partnership is to help ensure a coordinated global response to infectious diseases of international importance, often with the technical expertise of the WHO Collaborating Centres or other centres of excellence9.
Global Initiative to Emerging Infectious Diseases:
WHO collaborating centres:
“Emerging and re-emerging infections reflect the constant struggle of microorganisms to survive”
The first global monitoring system is that of the WHO Collaborating Centres, specialized Laboratories and institutions with expertise in infectious disease diagnosis and epidemiology.
• Establishment of the Division of Emerging and other Communicable Diseases Surveillance and Control (EMC), by WHO (1995)9 • Strengthen national and international capacity in the surveillance and control of communicable diseases, including those that represent new, emerging and re-emerging public health problems, for which it ensures a timely and effective response8.
Role of WHO: When a significant public health event takes place, WHO’s comprehensive global alert and response system ensures that information is available and response operations are coordinated effectively21. The system includes the following functions: - Event-based surveillance, multi-hazard rapid risk assessment and event-based risk communications; - Critical information and communications platforms for decision support; and - Operations and logistics platforms for any WHO response to international public health risks21. The World Health Organization, as one of the partners in this global effort, is strengthening global Ann. SBV, Jan-June2015;4(1)
• Not able to fully respond to global needs. • Failed to keep up with changes in technology and were unable to provide the diagnostic support necessary to confirm the etiology of disease outbreaks. • Not enough Collaborating Centres in developing countries to ensure regional selfsufficiency10.
International Health Regulations (IHR): The International Health Regulations, or IHR (2005), represent an agreement between 196 countries including all WHO Member States to work together for global health security.21 The IHR help countries to prevent, detect, inform about and respond to public health events in facilitated.23 Three diseases are covered by the IHR – cholera, plague and yellow fever. Through International Health Regulations, countries have agreed to build their capacities to detect, assess and report public health events. WHO plays the coordinating role in IHR and, together with its partners, helps countries to build capacities. It also includes specific measures at ports, airports and ground crossings to limit the spread of health risks to neighboring countries, and to prevent unwarranted travel and trade restrictions so that traffic and trade disruption is kept to a minimum.21 Page 63
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CDC’s Plan to Prevent Emerging Infectious Diseases: CDC will implement the plan in coordination with: • State and local health departments (for surveillance) • Academic centers and other federal agencies (for research) • Health-care providers and organizations (for the development and dissemination of guidelines) • International organizations (for outbreak responses overseas)11.
Goals of CDC Plan: 1. 2. 3. 4.
Surveillance and Response Applied research Infrastructure and Training Prevention and control
Surveillance and response:
Objectives • Strengthen infectious disease surveillance and response. • Improve methods for gathering and evaluating surveillance data. • Ensure the use of surveillance data to improve public health practice and medical treatment. • Strengthen global capacity to monitor and respond to emerging infectious diseases.19
Applied Research: Research is essential in efforts to understand, prevent, control, and respond to new and reemerging infectious diseases. Objectives • Develop, evaluate, and disseminate tools for identifying and understanding emerging infectious diseases. • Identify the behaviors, environments, and host factors that put persons at increased risk for infectious diseases and their sequelae. • Conduct research to develop and evaluate prevention and control strategies in the target areas.19
Infrastucture and Training: Page 64
Objectives • Enhance epidemiologic and laboratory capacity. • Improve CDC’s ability to communicate electronically with state and local health departments, health-care professionals, and others. • Enhance the nation’s capacity to respond to complex infectious disease threats internationally, including outbreaks that may result from bioterrorism. • Provide training opportunities in infectious disease epidemiology and diagnosis throughout the world19
Prevention and Control: Emerging Diseases Objectives
• Implement, support, and evaluate programs for the prevention and control of emerging infectious diseases. • Develop, evaluate, and promote strategies to help health-care providers and other person’s behaviors that facilitate disease transmission. • Support and promote disease control and prevention internationally.20 Target Areas • • • • • • • • •
Antimicrobial resistance Foodborne and waterborne diseases Vector borne and zoonotic diseases Diseases transmitted through blood transfusions or blood products Chronic diseases caused by infectious agents Vaccine development and use Diseases of persons with impaired host defenses Diseases of pregnant women and newborns Diseases of travelers, immigrants, and refugees.20,22
Prevention and control: Re emerging diseases • Early diagnosis and prompt treatment • Vector control measures &Prevention of epidemics, for malaria • DOTS - for tuberculosis • Research initiatives for treatment regimens and improved diagnostics, drugs and vaccines • Strengthening epidemiological surveillance and drug-resistance surveillance mechanisms and procedures with appropriate laboratory Ann. SBV, Jan-June2015;4(1)
support for early detection, confirmation and communication.12,22
Community Health Nurse in Action: Community health nurse plays an important role in the prevention of emerging and re-emerging diseases and in the care of persons and families who have such diseases, it include, 1. Support, interpret, and disseminate the recommendations made by leading agencies. 2. Collaborate with other professions and policymaking groups in mutual support, endorsement, and evaluation of global strategies to prevent or reduce the threat of emerging microbial diseases. 3. Communicate with other nursing groups and recommend that they develop and disseminate to their own constituencies polices and standards to prevent the spread of emerging infections. 4. Identify mechanisms to promote appropriate prescriptions and use of anti-microbial agents. 5. Address strategies to enhance host resistance and immune competence 6. Take leadership in major initiatives to focus on preventive strategies. 7. Serve as a clear voice among policy makers for the support of public health, advocating support for public education, public health infrastructure and policies that protect the environment and promote ecological balance.16 Nurses may act to prevent or intervene include the following: • Educate clients about risks and personal hygiene, which can include guarding against tick exposure; cooking meat thoroughly and eating thoroughly cooked meat; using safer sex techniques; washing one’s hands after using the toilet, changing diapers, or exposure to fecal matter; and appropriate use of antibiotics to decrease inappropriate use of over-the-counter drugs and inappropriate requests for antibiotics from a provider. • Use of infection control procedures; it is important that nurses have the ability to institute appropriate controls and to educate patients, visitors, family, and personnel about infection control and appropriate hand washing. Ann. SBV, Jan-June2015;4(1)
• Maintain awareness of unusual disease clusters, outbreaks, or illnesses, and be especially alert for unexplained deaths in young people. • Institute or participate in immunization programs for adults and children, educate patients about the importance of immunization, and facilitate access to and availability of immunizations for those who need it. • Use techniques to enhance client adherence to medication regimens to prevent treatment failure and development of microbial resistance. • Participate in environmental cleanliness programs in the community and in the institution; this can encompass such items as adequate ventilation, air pollution, and basic public health measures such as safe water, elimination of places where birds roost and sources of standing water, and rodent control. • Examine prescribing practices to ensure appropriate use of appropriate antibiotics. • Be an advocate for clients about environment. • Obtain thorough patient histories, including an assessment of travel history, recreational activities, and potential • Exposures in the workplace, home, and community; for example manner in which workplace clothing in certain environments is handled can be important in transmitting infections and toxins to the home. • Assess diet practices (for example, the use of unpasteurized milk) and teach clients about proper nutrition and food handling. • Promote breast-feeding in countries in which there is a high risk of contamination of milk or infant formula. • Train local people in health education and practices with use of culturally acceptable and locally accessible material and practices.17 Role of research in prevention of emerging and re-emerging diseases: • Reestablish extramural program to support emerging infectious disease prevention and control activities • Initiate prevention effectiveness studies to assess impact of food preparation guidelines. • To develop a comprehensive computerized infectious disease database. • Provide more funds to the health care professionals on researches based on emerging diseases.
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• To receive support from national research agencies on control of vector, and environmental factors that lead to infectious disease emergence. • Increase research on surveillance and control; costs and benefits of prevention, control and treatment; diagnostic tests. • Based on the research evidences increased priority of personal and community health practices relevant to disease transmission • Promote in nursing education and curricula a population-based, epidemiologic, system approach for nursing practice and research.16
Conclusion For a country of size and population of India, the emerging infections remain a real challenge. A meaningful response must approach the problem at the systems level. A comprehensive national strategy on infectious diseases addressing the challenges of emerging and re-emerging infections cutting across all relevant sectors, both governmental and nongovernmental, should be in place. Identification of national centre of excellence and their capacity building is of critical importance. These centres of excellence should be encouraged to develop networking and partnerships between public health organizations to improve their individual scientific capacity, share best practices and expand collective knowledge base. Concerted efforts are also needed to develop advanced counter measures such as surveillance tools, diagnostic tests, vaccines and therapeutics through basic, translational and applied research. Sensitive rapid response mechanisms at various levels of health service are the cornerstone to detect public health threats and respond quickly enough to protect valuable human lives. National commitment and comprehensive efforts are necessary at all levels of health services in order to meet the threat of emerging and re-emerging infections.
References: 1. Altizer, S., et al. (2013) Climate Change and Infectious Diseases: From Evidence to a Predictive Framework (abstract) http://www.sciencemag.org/content/341/6145/514.abstract 2. Institute of Medicine. Emerging infections: microbial threats to health in the United States.Washington, DC: National Academy Press, 1992 3. CDC. Adoption of hospital policies for prevention of perinatal group B streptococcal disease -- United States, 1997. MMWR 1998;47:665-70.
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4. Fauci AS. Infectious diseases: considerations for the 21st century. Clin Infect Dis 2001; 32 : 675-85 5. Claire V. Broome, Emerging Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA, Vol. 4, No. 3, July–September 1998;358-59. 6. Bhatia R, Narain JP, Plianbangchang S. Emerging infectious diseases in East and South-East Asia. In: Detels R, Sullivan SG, Tan CC, editors. Public health in East and South-east Asia. Berkeley, USA: University of California Press; 2012.p. 43-78 7. Morse, S.S. 1995. Factors in the emergence of infectious diseases. Emerging Infectious Diseases [Serial online], 1(1). Available http://www.cdc.gov/ncidod/EID/index.htm. June 1999; 8. WHO (1997), World Health Day Report 1997. 9. WHO (1996), The World Health Report 1996. 10. WHO (1999), Removing Obstacles to Healthy Development, WHO Report on Infectious diseases. 11. Park K . Textbook of Preventive and Social Medicine. 22ndt ed. Jabalpur: Bhanot; 2013.310-13. 12. Morbidity and Mortality weekly report (MMWR), Centers for Disease Control and Prevention (CDC) September 11, 1998 / Vol. 47 / No. RR-15. 13. Kenrad E N, Carolyn M W, Neil M H, Graham. Infectious Disease Epidemiology. Maryland: AN Aspen; 2001. p 301-48. URL available from, http://www.ias.ac.in/jbioscii. (03.05.2013) 14. Morse SS. Factors in the emergence of infectious diseases. Emerging Infect Dis 1995; 1( 1 ):7-15. 15. Morse SS. Examining the origins of emerging viruses. In: Morse SS, editor. Emerging viruses. New York: Oxford University Press, 1993: 10-28. 16. Felissa.LC, Elaine L, Emerging Infectious Disease: Nursing Reponses; 1996, Nursing Outlook, 44(4), pg.no. 164-168. 17. 17. Pope AM, Snyder MA, Mood LH, editors. Nursing, health and the environment. Institute of Medicine, Washington, DC: National Academy Press, 1995. 18. Joseph D et.al, Emerging and Re-emerging Infectious Diseases; 2012, pg.no.3-5 19. Centers for Disease Control. Addressing emerging infectious disease threats: a prevention strategy for the United States (executive summary). MMWR 1994:43;1-18. Report No.:RR-5. 20. Dash AP, Bhatia R, Sunyoto T & Mourya DT, Emerging and Re-emerging arboviral Diseases in Southeast Asia; J Vector Borne Dis 50, June 2013, pp.77-84. 21. World Health Organization. strengthening health security by implementing the international health regulations (2005) available at http://www.who.int/ihr/alert_and_response/en/ 22. Goel N, Gurpeet H & Swami H, How to deal with Emerging and Re-Emerging infectious diseases globally. The Internet Journal of Biological Anthropology. 2006. 1(1), pp.no.14-18. 23. World Health Organization. Alert, response, and capacity building under the International Health Regulations (IHR),2nd ed; 2008. available at: http://www.who.int/ihr/ publications/9789241596664/en/
Community mental health initiatives Z. Ramaprabhu, I.Malini Pon Angel *
Abstract
Mental health services in India are neglected area which needs immediate attention from the Government, policymakers, and civil society organizations. Despite, National Mental Health Programme since1982and National Rural Health Mission, there has been very little efforts so far to provide mental health services in rural areas. With increase in population, changing life-style, unemployment, lack of social support and increasing insecurity, it is predicted that there would be a substantial increase in the number of people suffering from mental illness in rural areas. Considering the mental health needs of the rural community and the treatment gap, it is an attempt to remind and advocate for rural mental health services and suggest a model to reduce the treatment gap. Key words: Mental Health; Policy; Rural; Services; Treatment Gap; National Mental Health Program; District Mental Health Programme; National Rural Health Mission.
Introduction Health is “a state of complete physical, social, and mental well being and not merely the absence of disease or infirmity”[1,2] Nevertheless, our health system is pre-occupied with curative health care services and disease prevention, with little attention on social and mental well being. Among these, mental health and wellbeing is the most neglected one[3,4] particularly in rural areas.[5,6]. Silence on mental health services in rural India in the National Rural Health Mission (NRHM) is a serious matter of concern. The omission of mental health in the NRHM mission document becomes even more serious in the backdrop of the uneven performance of the National Mental Health Program (NMHP, 1982) and District Mental Health Programme (DMHP) which is operational in only 125 districts out of 626 districts of India. With various flaws and implementation constraints in the NMHP and DMHP, there has been very little efforts so far to improve the rural mental health services.[7,8]
Meaning: need for community mental health intiatives Mental illness constitutes nearly one sixth of all health-related disorders. With the population increase, changing values, life-style, frequent disruptions in income, crop failure, natural calamity(drought and flood), economic crisis, unemployment, lack of social support and increasing insecurity, it is fearfully expected that there would be a substantial increase in the number of people suffering from mental illness in rural areas.[9] Among priority non-communicable diseases in India, mental illness constitutes 26 percent share in the burden of disease and available data suggest that there would be a sharp increase in this incoming years. Projections suggest that the health burden due to mental disorders will increase to 15% of Disability Adjustment Life by Year (DALY ) by2020.[10,11] Despite NRHM initiatives and improvement, general health services in rural area are not adequate and are struggling with infrastructural, human resources and other problems. Only 31.9 percent of all government hospital beds are available in rural
* Mr. Z. Ramaprabhu, Lecturer, Miss.I.Malini Pon Angel, Asst. Lecturer Dept. of Mental Health Nursing, KGNC, Puducherry 607402, India.
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area compared to 68.1 percent of urban populationAt the national level the current bed population ratio for government hospital beds for urban area (1.1 beds/1000 population) is almost five times the ratio in rural areas(0.2beds/1000population). [12].There is a short fall of 8%of doctors in Primary Health Centers (PHC), 65% of specialist at Community Health Centres (CHC), 55.3% of male health workers, and 12.6% of female health workers.[13,14]
Supporting study: The study by the National Commission on Macroeconomics and Health(NCMH) shows that at least6.5% of the Indian population has some form of serious mental disorders, with no discernible rural–urban differences.[15,16] • Epidemiological studies done in last two decades shows that the prevalence of mental disorders range from 18 to 207 per 1000 population with the median 65.4 per1000 at any given time.[17] • Most of these patients live in rural areas, far away from any modern mental health facilities. The overall individual burden for rural areas cannot be estimated with the available studies. • Nevertheless, considering the fact that 72.2 percent of population lives in rural areas, with only about 25 percent of the health infrastructure, medical man- power and other health resources, it may be summarized that the number of people affected with any mental and behavioral disorder would be higher in rural areas.[18]
Community mental health intiatives • NGOs and civil society groups are involved in providing mental health service delivery and community mental health and have done commendable job. • Many of them have set up day care centers, half-way homes, long-stay homes, counseling centers, suicide prevention centers, school mental health programmes, disaster mental health care, and community based programmes for the mentally ill. • Nevertheless, most of their services are “extension clinics” concentrated in urban areas with little attention on rural areas. Some of NGOs doing commendable jobs are MedicoPastoral Association, Bangalore; Paripurnata, Page 68
Kolkata; SCARF and the Banyan, Chennai; Richmond Fellowship Society (Bangalore, Lucknow, and Delhi); Cadabams, Bangalore; and Ashadeep in Guwahati.[19,20] • Interestingly most of these efforts are concentrated in Southern states and in urban areas. NavBharat Jagriti Kendra (NBJK), Hazaribagh is one of few organizations working in rural areas in partnership with23NGOs in 14 districts of Bihar and Jharkhand. Secondly, their initiatives have been isolated to pockets with limited funds and have not been supported by the government, both at the Centre and state level. • Thirdly, the continuance and the quality of services is a serious concern where the staffs lack professional training and skills. • Fourthly, we have failed to recognize, learn from their experiences and extend these efforts in rural areas. It emerges that these NGOs can supplement in providing mental health services but they cannot be an alternative to provide mental health care services in rural areas considering the need and treatment gap.[21]
Challenges • The epidemiological situation and available health service system shows that providing mental health services in rural areas is a challenging task, which needs infrastructural, architectural, and programmatic correction in the existing National Mental Health programme and District Mental Health programme.[22] • Lack of trained human resource for mental health care and treatment is an other challenge, considering few institutions available for mental health professional training. • Besides these, major challenge is lack of political commitment and realization that mental health is an important aspect of our health system which has far reaching implication for the development of the country. • Considering the limited or no service availability; the treatment gap is huge in rural areas. Even if all 3000 psychiatrists available in the country are involved in face to face patient contact and treatment for 8 hours a day, five days a week, and see a single patient for a total of 15-30 minutes over a 12 month period, they would altogether provide care for about 10%-20% of Ann. SBV, Jan-June2015;4(1)
the total burden[23] of serious mental disorders, Surprisingly it is almost similar to the estimated treatment gap of ninety percent.
Human resources and infrastructure GAP The people in rural areas are unable to access the services of the qualified doctors and other mental health professionals, where just 0.2 psychiatrists, 0.05 psychiatric nurses, 0.03 psychologists per 100,000 people (see Table1), and 0.26 mental health beds per 10,000 Populations, 0.2 in mental hospital and 0.05 in general hospitals [24](seeTable2) are available for the whole country. Table 1: Professional per 1, 00000 populations
Number of psychiatrists Number of neurosurgeons Number of psychiatric nurses
Number of neurologists Number of psychologists Number of social workers
2001* 0.4
2005** 0.2
0.06
0.06
0.04
0.05
0.05
0.05
0.02
0.03
0.02
0.03
Source:*Atlas, Country Profile, 2001.World Health Organization. **Mental Health Atlas, 2005. World Health Organization. Table 2: Psychiatric beds per 10,000 populations
Total psychiatric beds Psychiatric beds in mental hospitals Psychiatric beds in general hospitals Psychiatric beds in other settings
2001*
2005**
0.26 0.2
0.26 0.2
0.05
0.05
0.01
0.01
Source:*Atlas, Country Profile, 2001.World Health Organization. **Mental Health Atlas, 2005. World Health Organization. Ann. SBV, Jan-June2015;4(1)
Interestingly, the number of availability of psychiatrist has gone down during 2001 and 2005. To make the resources equitable, India needs about 140,000psychiatristswhereas we have about 3000 psychiatrists and75% of them are working in urban areas where less than 28% of the population lives. The government expenditure on mental health is another concern where it spends just 0.83percent of its total health budget on mental health.
Barriers in implementing community mental health services Barriers in seeking help in rural area are many. Major barriers in seeking help are unavailability of mental health services, low literacy, socio-cultural barriers, traditional and religious beliefs, stigma and discrimination associated with mental illness.[25] Unavailability of mental health services and lack of resources, particularly in terms of human resources, financial constraints, and infrastructure are one of major barriers which makes access to mental health services in rural areas more difficult. The services available in urban areas are far and costly; and difficult to utilize and access due to various reasons. Lack of awareness and recognition of CMD (common mental diseases) with prevailing stigma and discrimination is an important issue and barrier which is closely associated with low literacy in rural areas. Other barriers are low political will of Central and state governments and unclear plan of action and policy. Another barrier is resistance to decentralization, and resistance by mental health professionals and workers, whose interests are served by large hospitals. Above all, major barrier is difficulties in integrating mental health in Primary Health Care.[26] Primary health care workers are overburdened with lack of supervision and specialist support. Other barrier is that medical students and psychiatric residents are often trained only in mental hospital settings within adequate training of general health work- force and lack of infrastructure for supervision in the community. Another important barrier is mental health leadership of the country which often lacks public health skills. Those who are in leadership positions are psychiatrists, trained in clinical management, without formal Public health training. Besides, them a job barrier and challenge is resistance by psychiatrists to accept others as leaders. Page 69
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Future prospects
Com-
Proposed decentralization and synchronization of National Mental Health Programme (under 11thFiveYear Plan,2007-2012)[27]with National Rural Health Mission is a good opportunity and has a wider prospect. We can hope that this will ensure Primary Health Centre (PHC) based mental health services to the rural population. Involving and training village level Accredited Social Health Activists (ASHA) is another opportunity. Adding a module on community mental health and training ASHAs will definitely help in early detection, treatment, and rehabilitation of patients in the community in the rural areas. Presently, most of the rural people approach traditional healers (religious saints, tantriks (black magicians), unregistered medical practitioners, and quacks) for treating mental health problems. Considering people’s faith in them and lack of trained professional, training these traditional healers could help in alleviating mental illness in rural areas.[28] Developing short-term special curriculum based training for medical officers is another prospect which will help in providing clinical services at block level.
Health
Recommendations by the government to intiate community mental health services presently, the Government of India is providing mental health services in 125 districts through District Mental Health Programme under NMHP. There is need to integrate NMHP and DMHP with NRHM Programme to provide mental health care, services and support to each and every individual in rural areas. Table 3. Model of mental health care and service in rural areas. Personnel Mental Health
Institution
District Health
Society
Level
Role
Special
is insti-
tutional
care and
State level
Treatment of severe mental health disorders
services Civil
surgeon
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District level
Planning, implementation, and service delivery
munity Centre
Primary Health Centre Com-
munity Care Self
Care/
Family Care
Psychiatrist
Medical officer in-
charge
ASHA
On one
lakh population
munity mem-
mental health disorder
Block (on30,000 population) Village/
Community
Family/ Com-
Treatment for common
Family
Counselling/identification/ referral
Care,support, education, acceptance, and in addressing stigma and discrimination
Care
Conclusion The rural mental health services are neglected area which needs immediate attention considering the burden of disease and treatment gap. District Mental Health Programme needs restructuring and convergence within the NRHM. The “extension clinic” approach needs to be replaced with integration of mental health services with general health services, particularly under NRHM. Involving ASHAs under NRHM is an opportunity to provide mental health services at doorsteps in rural areas. Lastly, ensuring bottom up approach and community ownership are must to achieve universal mental health services, care and support in rural areas.
References 1.
bers
Which mental health care and services can be strengthened in rural areas are increasing the availability of resources, improving equity in their distribution, and enhancing efficiency in their utilization. Besides, there is also a need to emphasize the role of specialists in filling the treatment gap. Building capacity of other health workers, particularly ASHA under the NRHM programme may help in demand generation as well as referral. Following suggestions or strategies in combination can be used for strengthening the rural mental health care services:[29] 1. Convergence of National Mental Health Programme/ District Mental Health Programme under National Rural Health Mission Programme and using existing PHCs and sub-centres to provide mental health services; 2. Capacity building of Rural/registered Medical Practitioners/Primary Health care doctors/ ASHA workers/ teachers/Aanganwadi workers on tailor made modules; 3. Advocacy through community, social and other bodies and involvement of religious leaders, teachers, local community leaders with key stakeholders; 4. Targeted awareness programme using available rural media; 5. Provision of social security to the mentally ill patients; and 6. Training for caregivers and relatives. Ann. SBV, Jan-June2015;4(1)
2. 3. 4. 5. 6.
7. 8. 9. 10. 1 1 . 1 2 .
World Health Organization (1948) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York,1922June1946,signedon 22 July1947bytherepresentatives of61States(Official Records of the World Health Organizati on,no.2,p.100),andenteredintoforceon7 April 1948. World Health Organization(2006) Constitution of the World Health Organization-BasicDocuments,45th Edition, Supplement. Kumar, A.(2010)Mental health services in India: A case study of Jahangirpuri. LAP Lambert Ac ademic Publishing, Germany. Kumar, A.(2001)Mental health in a public health perspective. The Bihar Times, Bihar. Thara,R., Padmavati,R. and Srinivasan,T.(2004) Focus on psychiatry in India. British Journal of Psychiatry, 184, 366373. Meltzer, M. (2008) Mental healthcare in India: Prescribing the right policy. Pepperdine Policy Review. http:// publicpolicy.pepperdine.edu/policy-review/2008v1/ mentalhealth-care.htm. Kumar, A. (2005) National rural health mission and mental health. Health Action, 18. Ministry of Health and Family Welfare, Government of India. (2005) National Rural Health Mission (2005-2012) Government of India(1982) National Mental Health Programme forI ndia. Ministry of Health and Family Welfare, Government of India, New Delhi. Director General of Health Services (1990) National Mental Health Programme: A progress report (1982-1990),New Delhi. N a t i o n a l Mental Health Programme for India. (1982) Government of India, Nirman Bhavan, New Delhi. I s a a c ,M.K.(1988)‘Bellary District Mental Health Programme’Community MentalHealthNews,11&12, ICMR-CAR on Community Mental Health. NIMHANS,
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Bangalore. 1 3 . K u m a r, A. (2005). District Mental Health Program inIndia:A case study.Journal of Health and Development, 14. W i g , N.N. and Murthy, R.S. (2009) Mental health care― need to expand its reach. The Tribune. 1 5 . Pa t h a r e ,S .(2011) Less than 1% of our health budget is spent on Mental health. Info Change News &Features. 1 6 . N a t i o n a l Commission on Farmers (2006) Serving farmers and saving farmers, fifth and final report. Government of India, Ministry of Agriculture, Shastri Bhavan, New Delhi. 1 7 . C h a t t e r j e e ,P.(2009)Economic crisis highlights mental health issues in India.TheLancet,373, 1 8 . Pa t h a r e ,S.(2011)Lessthan1%ofourhealthbudget is spent on mental health. 1 9 . R e p o r t of the National Commission on Macroeconomics and Health(2005)National Commission on Macroeconomics and Health Ministry of Health & Family Welfare Government of India, New Delhi. 20. The World Health Report (2001) Mental health: New understanding, new hope. World Health Organization, Geneva. 21. Gururaj,G.and Issac,M.K.(2004)Psychiatric epidemiology in India: Moving beyond numbers. In: Agarwaal, S.P., Goel, D.S., Salhan, R.N., Ichhpujani, R.L. and Shrivatsava,S., Eds., Mental Health An Indian Perspective(1946-2003),Directorate General of Health Services, Ministry of Health and Family Welfare,NewDelhi, 2 2 . M u r r a y,C.J.L.andLopez,A.D.The global burden of disease. A comprehensive assessment of mortality and disability from diseases,injuries and risk factors in1990 And projected to 2020. 2 3 . N a t i o n a l Commission on Macroeconomics and Health Background Papers—Burden of Disease in India(New Delhi, India). (2005) Ministry of Health & Family Welfare, New Delhi. 24. National Mental Health Programme (2010) National Institute of Health and Family Welfare. 25. Gururaj,G., Girish,N. and Isaac,M.K.(2005) Mental, neurological and substance abuse disorders: 26. Yadav,K.,J arhyan,P., Gupta, V.and Pandav,C.S.(2009) Revitalizing rural health care delivery: Can rural health practitioners be the answer? Indian Journal of Community 27. Ministry o f Health and Family Welfare, Government of India.ChapterI: Overview of the National Health System. In: Report: Task Force on Medical Education for the National Rural Health Mission. 28. M i n i s t r y of Health and Family Welfare, Government of India (2007) Bulletin on rural health statistics. 29. WHO-AIMS Report on Mental Health System in Uttarkhand, India. (2006) WHO and Ministry of Health, Dehradun, Uttarkhand, India.
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Annals of SBV Sri Balaji Vidyapeeth
(D eemed
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to be
U niversity , u / s 3, UGC A ct , 1956)
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