f o 1 0 urse · june, july, august 2014 the alabama nurse • page 3 the president’s message...

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Princeton, MNPermit No. 14

IndexASNA Board of Directors . . . . . . . . . . . . . . . . . . . . 2

CE Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-19

Convention Registration (Pull out section) . . . . .9-12

ED’s Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Elizabeth A. Morris Clinical Education

Sessions – FACES . . . . . . . . . . . . . . . . . . . . . . . 6

Legal Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

LPN Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Membership News . . . . . . . . . . . . . . . . . . . . . . . . 7

President’s Message . . . . . . . . . . . . . . . . . . . . . . . 3

Research Corner . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Save The Date . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Circulation to more than 82,000 Registered Nurses, Licensed Practical Nurses and Student Nurses in Alabama Alabama State Nurses Association • 360 North Hull Street • Montgomery, AL 36104

Inside Alabama Nurse

ASNA/AANS ConventionOct. 2-4, 2014

Bryant Conference CenterTuscaloosa, AL

Register Online @ alabamanurses.org

or use form on 1

CE Corner:Alcohol Withdrawal

Contact Hours:2.5 ANCC/3.0 ABN

Pages 14-18

urse Cari

ng fo

r You for Over 100 Years

Provided to Alabama’s Nursing Community and Funded by the Alabama State Nurses Association.

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Phone 334-262-8321

NJune, July, August 2014 Volume 41 Issue 2

Obtaining a distinctive license plate for a special cause or organization is not easy. It requires approval from the Department of Revenue, Department of Public Safety and the Legislative Oversight Committee. We worked hard and NOW have approval for a cool tag for nurses of all specialties and nurse supporters!

But, getting the tags OUT to you is also a process. Here’s how it works:

1. You must pre-order your tag online at the following link: ht tps://precommit.mvtr ip.alabama.gov/UserCommit /CommitToPurchaseApplication/16.

2. When more than 1,000 nurses or supporters have pre-ordered, YOU will be notified by the AL Dept. of Revenue to go by your county license-tag office and pick up your tag. It is smart to coordinate the pick-up with your normal renewal month. Otherwise, you may pay the $50 for the distinctive tag twice within a year…not cool. It’s OK to coordinate. After you receive the Dept. of Rev. notice, your tag will be held at the office until your renewal month rolls around and you go pick it up.

3. When you pick up your tag, you must have the original receipt from your order with you along with the existing tag form you carry in your car.

4. From that point forward you just follow the procedure you have done every year at the next annual renewal month.

Out of 86,000 nurses in the state, along with friends and relatives, we are confident that we will cross the 1,000 pre-order mark soon. However, if folks procrastinate… we only have one year to make that goal and our year ends April 30, 2015. Once the 1,000 mark has been crossed, the tags will be available in every county every year, no matter how many are ordered each year. What happens to your money if we don’t make the 1,000 pre-orders? The Foundation’s portion of the $50 (which is $41.25) will be returned to you or you can choose to leave it as a tax deductible gift for nursing scholarships. A number of other states have nursing tags, but truly, Alabama’s is the coolest and most beautiful. So, LET’S GET GOING… AND BRAG WITH YOUR TAG! Go the the above link on the Alabama Department of Revenue’s site and pre-order your tag. Soon you will see them everywhere!

First Nurse Auto License Plate Approved by the Legislature

Get Yours Now!

Join

ASNA!

Benefits far exceed dues... See Join ASNA @ alabamanurses.org

for more information.Scanning this QR code takes you to the

Quick Application

• Over $200 Tax Deduction• Save $150 on ANCC Renewal• Free 1 hr. Attorney – (Any Need!) A $300 Value

The Alabama Nurse is sent to all licensed nurses in Alabama. Most of you are not members. We need you!

Joining is easy!

Visit our website atwww.alabamanurses.org

Exhibitors Registration

• The Alabama Nurse June, July, August 2014

ASNA Board of Directors

President: Arlene Morris, EdD, MSN, RN, CNEPresident-Elect: Brian Buchmann, BSN, RN, MBAVice President: Diane Buntyn, MSN, RN, OCNSecretary: Donna Everett, RN, CICTreasurer: Marilyn Rhodes, EdD, RN, MSN, CNMDistrict 1: Colin Tomblin, BSN, RNDistrict 2: Julie Savage Jones, MSN, RN-BCDistrict 3: Rebecca Huie, DNP, ACNPDistrict 4: Marilyn Sullivan, DSN, RN, CPE, FCNDistrict 5: Tammy Smith, MSN, RNCommission on Professional Issues: Gennifer Baker, RN, MSN, CCNSSpecial Interest Group:Advance Practice Council: Charlotte Wynn, MSN, CRNP

ASNA Staff

Executive Director, Dr. John C. Ziegler, MA, D. MINDirector Leadership Services,

Charlene Roberson, MEd, RN-BCASNA Attorney, Don Eddins, JD

Administrative Coordinator, Betty ChamblissPrograms Coordinator, April Bishop, BS, ASIT

Our Vision

ASNA is the professional voice of all registered nurses in Alabama.

Our Values

• Modelingprofessionalnursingpracticestoothernurses

• AdheringtotheCode of Ethics for Nurses• Becomingmorerecognizablyinfluentialasan

association• Unifyingnurses• Advocatingfornurses• Promotingculturaldiversity• Promotinghealthparity• Advancingprofessionalcompetence• Promotingtheethicalcareandthehumandignityof

every person• Maintainingintegrityinallnursingcareers

Our Mission

ASNA is committed to promoting excellence in nursing.

Advertising

For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, [email protected]. ASNA and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.

Acceptance of advertising does not imply endorsement or approval by the Alabama State Nurses Association of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. ASNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of ASNA or those of the national or local associations.

The Alabama Nurse is published quarterly every March, June, September and December for the Alabama State Nurses Association, 360 North Hull Street, Montgomery, AL 36104

© Copyright by the Alabama State Nurses Association.Alabama State Nurses Association is a constituent member of the American Nurses Association.

Alabama nurse

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www.alabamanurses.org Save The Date!

October 2-4, 2014The Alabama State Nurses

Association will hold its 101st Annual Convention co-sponsored by the Alabama Association of Nursing Students at the Bryant Conference Center in Tuscaloosa, AL. We invite each of you to attend. Thursday, October 2, 2014 will be a Pre-Convention CE day. This is a great opportunity for all you RNs, who haven’t quite met the ABN requirements during the RN renewal cycle, to finish getting your 24 hours. LPN’s are also encouraged to attend. Friday and Saturday, October 3rd, and 4th will be the Full Convention days. You’ll have the opportunity to hear a quality Keynote Address. ASNA members who are delegates to the convention will have the opportunity to debate on issues of current concern to the association and the nursing community. Complete convention registration materials are printed in the pull-out section of this issue of The Alabama Nurse. Mark your calendars today and plan to attend an exciting convention.

Alabama Board of Nursing Vacancies

You May Be Selected To Serve!There will be 2 RN positions open and 1 LPN position

open as of January 1, 2015. The term of Pamela Autrey, Nursing Practice and Carol Stewart, Advanced Practice and Greg Howard, AFLPN will expire December 31, 2014. Applications must be in the ASNA office by July 15, 2014. RN applications ONLY are available from the ASNA office. Call Betty!

PUBLICATION The Alabama Nurse Publication Schedule for 2014

Issue Material Due to ASNA OfficeSep/Oct/Nov August 4, 2014Dec/Jan/Feb2015 October 27, 2014

Guidelines for Article DevelopmentThe ASNA welcomes articles for publication. There is no payment for articles published in The Alabama Nurse.1. Articles should be Microsoft Word using a 12 point font.2. Article length should not exceed five (5) pages 8 x 11.3. All reference should be cited at the end of the

article.4. Articles should be submitted electronically.

Submissions should be sent to:[email protected]

orEditor, The Alabama Nurse

Alabama State Nurses Association360 North Hull Street

Montgomery, AL 36104

Condolences to:April Bishop, ASNA Programs Coordinator in the death of her

Mother-in-Law

The family of Murlene Sides, MEd, RN, former ASNA president (1986-1987). Murlene did a lot to

promote nursing in Alabama including working at the Alabama Department of Public Health, serving as the State

Nursing Director and retiring as the Director of the Long-Term Care

program in Alabama.

FacultyTenure track Assistant/Associate Professor Obstetric/Women’s Health and Community Health; Position open until filled. Responsibilities include classroom/clinical teaching; PhD preferred, MSN required; Minimum of three (3) years experiential background in clinical specialty area; Minimum of three years teaching experience in academic setting.

Send applications to:[email protected]

June, July, August 2014 The Alabama Nurse •

The President’s message

Arlene Morris, EdD, MSN, RN, CNE

Nurses and student nurses from across the state recently gathered in Montgomery for ASNA’s Faculty and Clinical Education Series (FACES). Each gained application of knowledge to strengthen practice while enjoying the collegiality with nurses across the state and the graciousness of our hosts. As an additional benefit, Alabama Lieutenant Governor Kay Ivey answered questions from the audience related to nursing issues following her presentation, resulting in her heightened awareness of concerns to the profession of nursing! I encourage all nurses in Alabama to carefully consider candidates as they begin campaigns. Let them know your concerns regarding healthcare and environmental issues and the future of nursing as a profession and its practice in our state. A staffer or legislator may wish to consult you as nursing issues arise. Consider volunteering for ASNA’s Legislative Committee.

As you consider how your nursing profession relates to your livelihood, I strongly encourage you to join ASNA. Membership numbers matter in discussions with state and federal legislators! ASNA’s historical impact on your practice and licensure is well documented. Personal benefits are numerous, and year-round activities at district and state levels provide for various interests and levels of experience in nursing. Consider volunteering for ASNA’s Membership Committee.

Alabama’s history during tornado season prompted the ASNA House of Delegates and Board of Directors to ask its Commission on Professional Issues to lead efforts for nurses to be prepared to be responders to various disasters. The 2014 goal is to increase nurses who have completed online courses, and are listed on registrations to be called

in disaster events. Districts are involved in a competition to be recognized at ASNA’s 2014 Convention as the district which has the most nurses who have completed. Please choose one of the suggestions and notify your ASNA district president of your completion:

• TheAlabamaDepartmentofPublicHealth(ADPH)Alabama Responds volunteer network registration link is at https://alresponds.adph.alabama.gov/ ADPH has a variety of online courses available by clicking on the ADPH Training Network’s On Demand link, Featured Products link, or by logging into the Learning Center Management System to locate relevant emergency preparedness content.

• TheAmericanRedCrossprovidesopportunitytoregister as a volunteer at https://volunteerconnection.redcross.org/?nd=login and provides multiple resources at http://www.redcross.org/prepare/disaster-safety-library

• TheCentersforDiseaseControlandPrevention’sHealth Alert Network provides links to various content areas at http://emergency.cdc.gov/planning/index.asp

The 2014 ASNA Convention is around the corner, scheduled for Oct. 2-4 in Tuscaloosa. Registration is open now through ASNA’s website (alabamanurses.org). The ASNA Award committee is taking applications (forms are available on the website), and the Governance committee is taking proposals for resolutions, and districts will be seeking delegates to attend ASNA’s House of Delegates. Be involved!

Delegates will represent ASNA as a member of the American Nurses Association at the annual Membership Assembly in June. This event includes meetings with U.S. senators and representatives, and discussions about scope and standards of nursing practice with other state nursing associations across our country. Issues are similar, and approaches to ensuring nursing’s future roles are shared. ASNA membership numbers provide the basis for delegates’ weighted votes, so again, membership matters!

A Musical Look at NursingGreg Howard, LPN

Learning the scales, ’Your Scope of Practice’ is mandatory in each performance.

And as healthcare continues to challenge us in every performance to sing a solo, some of us are skilled in “back up” but willing to accept written ‘solos’ when its within our range. The days of ‘Choirs and Trios’ are not in high demand.

If you are a Soprano ‘RN’ you will have top billing. If you are a ‘Tenor’ LPN, you do backup as a rule and if you are a “Baritone Unlicensed Person, you perform at the will of those in charge. And of course there is the ‘Conductor’, ‘EO/Administrator’ who writes and conduct all performances.

So how do we make music? By working together and following the notes as well as direction from the Conductor. The goal is to harmonize and bring pleasure and comfort to our audience ‘the Patient.’

If we are out of ‘key’ and continue to perform at a substandard level, we could be reported to the ‘Union,’ “Board of Nursing.” So my advice is to watch your melody, stay in harmony and perform within your range.

Regardless of the position we hold we must keep the “P.D.R.” Pride, Determination and Resilience.

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Don Eddins, BS, MS, JD

An Alabama nurse was recently awarded approximately $15 million in a federal whistleblower lawsuit involving Medicare fraud.

The award to the Monroeville nurse who aided the federal government in its fraud claims against her former employer, Amedisys, was part of a $150 million settlement under the federal False Claims Act, which dates to the Civil War, when President Abraham Lincoln was concerned with contract fraud.

The Louisiana based company, which operates in 37 states, was accused of asking the home-health nurse to bill for services not provided or which were not necessary, according to persons familiar with the case.

My advice to registered nurses is always to conduct your business with the utmost integrity. If your employer asks you to do something that is illegal, refuse to do it. In this case, the nurse was rewarded handsomely for blowing the whistle on a fraudulent practice. But if a nurse is caught in a scheme involving fraud, the nurse can lose that hard-earned license or, even worse, be accused of a crime. Your license is more important than any job – even if the questionable practice is not covered by a whistleblower statute.

The nurse involved in the Amedisys matter was fired for refusing to be part of a scheme that the federal government determined to be fraudulent. She lost her job and probably went through some tough times, but ultimately her reward was great.

I have represented one or more Alabama nurses who were asked to perform duties that I questioned, although not of a purely fraudulent nature. It is my advice to quit the job before you lose your license.

Often nurses, particularly heads of single families, feel like they have to submit to directives of employers, because they need the income. However, if the practice is illegal or questionable, don’t do it.

If you as a registered or licensed practical nurse in unsure of whether a practice is legal or ethical, ask an independent source. You probably won’t get a strictly unbiased answer from a supervisor with the firm performing the practice, so ask someone else. Maybe a supervisor with another company. Or a nursing school professor from the school you attended. Or, the Alabama State Nurses Association.

Your nursing license is too important to be taken from you. Make certain that any duty you perform is not the least bit questionable.

Dr. John C. Ziegler, MA, D., MIN.

Professionals Know the Value of an Association

At ASNA we spend a lot of time and energy trying to help nurses understand ASNA’s value to them. Why be a member of the Alabama State Nurses Association? What difference does it make if I participate? What’s in it for me? What’s in it for my profession? Why should I renew this year? These are all valid questions and they deserve answers. The ASNA staff in Montgomery wants you to hear about and experience the full value of your membership. We print and distribute flyers, work hard on the website, host relevant events and provide unique opportunities for professional development. In all these efforts we try to communicate and deliver value to our members. Surprisingly, ASNA membership is less than 2% of the 86,000 nurses in the state. Those 2% have provided a statewide voice for nurses through the publication you are reading, The Alabama Nurse, since 1947. They have also “carried the water” for your profession through numerous forms of advocacy.

I am told that over the years recruiting members has never been a problem! That is a fact. The CASH VALUE OF OUR BENEFITS EXCEEDS THE DUES! If I saw you on the street and offered you five hundred dollars in exchange for two hundred, would you take it? (Assuming the currency is real) Of course you would! At ASNA we don’t have the “it cost too much” problem. We can prove that the cash value of your benefits exceeds the dues. No, our challenge is turning “joiners” into “belongers.” A belonger knows membership in their association is critical personally and in the grand scheme of things. They either engage in volunteer activities, professional development opportunities, etc., or they wisely discern that their support strengthens the association and it’s advocacy for their career. Even if they are unable to visibly serve, they understand the essential power of collective support and the importance of each link in the chain. I have heard organizational experts describe the hierarchy of membership as a variation of one of the following: Board members, Committee chairs, Committee members, helpful volunteers and both visible and invisible advocates. The downward slope of commitment has been described as: Show up to receive value, but not to produce it, verbally loyal but rarely seen, connections, like: “the boss told me to join” or a disengaged member waiting for the next invoice to decide to stay or leave.

I wish I had the power to persuade you to join ASNA. Or for our members, I wish that I could encourage you to ask your friends to join. I don’t have that power. But, you do. I have heard many, many stories from nurses that have attested to the value of ASNA, the lasting relationships they’ve formed and the satisfaction of having a voice in legislation or policies affecting their profession.

Gaining and retaining members…it boils down to friend-to-friend, co-worker-to-co-worker, colleague-to-colleague connections working to make their association valuable and effective. Simply put, ASNA is not an organization…it is an organism composed of nurses who understand the value their association brings to them and their profession. If you’re one of the 98% that are not on the team, join the Navy Seals (figuratively speaking) of nursing, ASNA! Belong, receive and make a difference. Joining is easy. Swipe the QR code on the cover of the Alabama Nurse to join with your smart phone. Or, go to www.alabamanurses.org and click the join tab at the top. You’ll be glad you did.

The E.D.’s NotesLegal Corner

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Redstone Arsenal’s Dr. Cindy Cooke (pictured right); a nurse practitioner for the past 15 years has been elected President-Elect of the American Association of Nurse Practitioners (AANP). Her term begins June 21st; when Dr. Cooke will begin heading the AANP’s Board of Directors working on behalf of the nation’s nurse practitioners.

UAH’s Dr. Lori Lioce (pictured left), long-time ASNA member has been elected VP of Operations. She serves as Clinical Associate Professor and Simulation Coordinator at The University of Alabama in Huntsville. Her clinical background as a registered nurse and nurse practitioner is in emergency medicine. In addition to VP of Operations for INACSL, she serves on the

American Nurse’s Association (ANA) editorial board for The American Nurse, the ANA Code of Ethics Revision Steering Committee, the ANA-PAC Leadership Society and as the Alabama State Representative for the American Association of Nurse Practitioners. For INACSL she serves on the Standards Committee (since 2011) and the International Chapter Development Task Force. Dr. Lioce is a fellow of the American Association of Nurse Practitioners.

ASNA member Dr. Teresa Gore (pictured right), Associate Clinical Professor at Auburn University School of Nursing has been elected President-Elect of the INACSL. Dr. Gore is also a member of Sigma Theta Tau International, Theta Delta Local Chapter (STTI), and Golden Key Honour Society. The INACSL supports the work of global simulation educators and facilitators for both the practice setting and academia in nursing and healthcare.

If you would like to recognize a nurse leader, contact ASNA at [email protected].

Alabama Nurses Honored by

Recent ElectionsIncreased use of noninvasive ventilation could save more lives for patients with chronic obstructive pulmonary disease

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) account for 1.5 million emergency department (ED) visits and 726,000 hospitalizations each year in the United States. Over the last 20 years, noninvasive ventilation (NIV) has emerged as a potentially useful treatment in AECOPD patients with acute respiratory failure. NIV commonly refers to positive-pressure breathing support delivered through a nasal or full-face mask. Since earlier, small studies have shown that NIV use resulted in fewer complications and shorter hospital stays than invasive mechanical ventilation (IMV), researchers decided to look at the use of NIV treatment in a much larger patient population.

Their study of 67,651 ED visits for AECOPD found that NIV use, compared with IMV, was associated with a reduction of inpatient mortality of 46 percent, shortened hospital length of stay by 3 days, reduced hospital charges by approximately $35,000 per visit, and modestly reduced risk of iatrogenic pneumothorax. The frequency of NIV use (including combined use of NIV and IMV) varied widely among hospitals, ranging from 0 percent to 100 percent with a median of 11 percent. Hospitals in the Northeast and in nonmetropolitan areas were early adopters. Although NIV use increased between 2006 and 2008, the utilization of NIV remained low (16 percent in 2008).

The researchers asked why, given its demonstrated efficacy (both in their study and earlier studies), NIV has not been more widely adopted. Previous surveys have identified several reasons, including lack of physician knowledge, insufficient respiratory therapist training, inadequate equipment and the time required to set up NIV. One incentive to promote NIV use in clinical practice is the cost-effectiveness of NIV compared with usual treatment, mainly resulting from less use of the ICU. The researchers believe that increasing the use of NIV as recommended in the guidelines may help reduce COPD mortality. This study was supported by AHRQ (HS20722).

See “Comparative effectiveness of noninvasive ventilation vs invasive mechanical ventilation in chronic obstructive pulmonary disease patients with acute respiratory failure,” by Chu-Lin Tsai, M.D., Wen-Ya Lee, M. S., George L. Delclos, M.D., and others in the April 2013 Journal of Hospital Medicine 8(4),pp. 615-172 MWS

Research Corner

Emergency CareEmergency department patients with heart attack, respiratory conditions, or sepsis at risk of unplanned transfer to the ICU

Emergency department (ED) patients who are admitted to the hospital and require unplanned transfer to the intensive care unit (ICU) within 24 hours of arrival on the ward have previously been found to have higher case-fatality rates than do patients admitted directly to the ICU from the ED. It is possible that with better recognition and intervention in the ED, a portion of these unplanned ICU transfers and their subsequent adverse outcomes could be prevented, suggest researchers in a new study. They assessed 4,252 patients who were admitted to the ICU from the ED within 24 hours of arriving at the ED. The investigators found that ED patients admitted with respiratory conditions, heart attack or sepsis were at relatively high risk of unplanned ICU transfer.

In their evaluation of 178, 315 ED non-ICU admissions to 13 Kaiser Permanente Northern California community hospitals, researchers found an average unplanned ICU transfer rate of 1 in 42. One in 30 ED patients admitted for pneumonia, and 1 in 33 admitted for chronic obstructive pulmonary disease were transferred to the ICU within 24 hours. Although less frequent than hospitalizations for respiratory conditions, patients admitted with sepsis were at the highest risk of unplanned ICU transfer (1 in 17 ED non-ICU hospitalizations). Both heart attack and stroke patients also had high risks of unplanned ICU transfer.

Patients with the aforementioned conditions might benefit from better triage from the ED, earlier intervention, or closer monitoring to prevent acute worsening of their condition. However, since the case-fatality rate was unplanned ICU transfer of patients hospitalized for sepsis, heart attack, or stroke was no higher than with their direct admission to the ICU, the researchers believed that quality improvement efforts should be targeted towards those patients with respiratory conditions such as pneumonia and COPD. This study was supported by AHRQ (T32HS00028, HS19181, HS 18480).

See “Risk factors for unplanned transfer to intensive care within 24 of admission from the emergency department in an integrated healthcare system,” by M. Kit Delgado, M.D., Vincent Liu, M.D., Jesse M. Pines, M.D., and others in Journal of Hospital Medicine 8(1), pp.13-19, 2013. MWS

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Elizabeth A. Morris Clinical Education Sessions – FACES ‘14

Our annual Elizabeth A. Morris Clinical Education Sessions–FACES 2014 was held on Tuesday, April 23, 2014 at the Eastmont Baptist Church in Montgomery. We had another tremendously successful event, with over 450 attendees, an outstanding lineup of excellent speakers and presenters, and a list of terrific exhibitors. This was our ninth year, and the church staff was as always, very supportive and welcoming. Those of you that enjoyed lunch at the church can also testify that the prepared meal was delicious. This year we had an extensive series of tracks from which to choose.

A Special Thank You to our Exhibitors and Sponsor at

Elizabeth A. Morris Clinical Education Sessions (FACES)

Sponsor:Arthur L. Davis Publishing Agency, Inc.

Exhibitors

Alabama Organ CenterAuburn University/Auburn Montgomery Schools of NursingThe Gideons InternationalHurst Review ServicesJackson HospitalJacksonville State University College of Nursing & Health SciencesSylvia Rayfield & Associates, Inc./ICAN Publishing Inc.Troy University School of NursingThe University of Alabama Capstone College of NursingUniversity of South Alabama College of Nursing

AL Lt. Gov. Kay Ivey talks about citizen advocacy and issues affecting nursing in Alabama.

Attendees get the latest on diabetes and earn valuable contact hours.

Approximately 450 participated at FACES ‘14.

Dr. Constance Smith Hendricks explains her project.

Students and practicing nurses benefit from FACES ‘14.

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APPLICATION FOR MEMBERSHIP

Please Circle New Application Renewal ANA ID# _________________ Today’s Date: _____________

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Read and sign the authorization below. Enclose a check made payable to ASNA for the first month’s dues (see rates listed above). This amount will be deducted from your checking/.credit card account each month.

By signing the form below, I am authorizing ASNA to withdraw annual/monthly dues from the financial institution I have designated. If paying by automatic bank draft, I have enclosed a check for the first month’s payment. Bank drafts will occur on or after the 15th day of the month, Credit Cards will be charged on or after the 1st of the month.

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Payments to ASNA/ANA are not deductible as charitable contributions; however 70% of your dues are tax deductible as a professional organization for Federal Income Tax Purposes.

Please return this completed application with your payment to ASNA 360 North Hull St., Montgomery, AL 36104 or Fax to 334-262-8578

Membership NewsThe University of North Alabama is accepting applications for the position of Tenure-Track, Assistant Professor of Nursing . This position is a full-time, nine-month, tenure-track faculty appointment at the Assistant Professor rank . A master’s degree in nursing from an accredited institution and an unencumbered nursing license in the State of Alabama are required; a doctoral degree is preferred .

To view additional information and/or apply for this position, please visit the University of North Alabama Online Employment System at http://jobs .una .edu . Applications will only be accepted through this system . For questions, please email employment@una .edu or call 256 .765 .4291 . UNA is an equal opportunity employer committed to achieving excellence and strength through diversity . UNA seeks a wide range of applicants for this position so that one of our core values, ethnic and cultural diversity, will be affirmed .

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Membership News

Information regarding the ASNA

Scholarships is available online at

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Act now – deadline is

July 1, 2014.

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Serve on an ASNA Committee for

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If you are willing to serve, please indicate your choice(s) on this form and

return it to the ASNA office.

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2014 Annual Convention

Awards Nominations Made Incredibly Easy

The Awards nomination process just got easier. You can now nominate some deserving person/organization for ASNA awards by going to the ASNA website at www.alabamanurses.org. On the home page click on “ASNA Awards Criteria/Nomination Forms”. All the awards and the criteria are listed. You can go under the awards and enter the information right on line or you can download the form, fill it in and send it back to ASNA by email, mail or fax. For a person, you can download and fill out the Biographical Form or you can send in a Curriculum Vitae (CV) if you like. You can download a letter of support form, fill it out and send it back to April at ASNA or you can send in a letter by mail, email or fax. Awards for this year must be sent in by July 23, 2014. There are a lot of very special people out there we need to honor and recognize for their efforts. Please take the time to do this. We challenge each of the Districts to send in a nomination for each of the awards. Come on – Make the Awards Committee’s job harder; it would thrill us.

So You Are An ASNA Delegate

Being a Delegate to a state convention can be an exciting experience but one that also has some inherent responsibility. As you may know, the House of Delegates (HOD) is the governing and official voting body of the Alabama State Nurses Association (ASNA). The House meets annually. Members of the HOD have a crucial role in providing direction and support of the work of the Alabama State Nurses Association. Delegates are elected to the HOD to work for the betterment of ASNA and the nursing profession. Each delegate is expected to study the issues thoroughly, attend each session of the HOD (including the Open Forums), and engage in active listening and debate. Also, delegates are encouraged to use the extensive resources and collective knowledge available at each meeting to provide direction and support for the work of the organization. Such a commitment benefits the individual delegate, the association, and the nursing profession.

If a delegate in unable to attend the 2014 ASNA House of Delegates, his/her district nurses association (DNA) should be notified at once. When alternate delegates are substituted for delegates, it is the responsibility of the District President to notify ASNA of the change immediately.

Important information for ASNA Delegate RegistrationDelegates are encouraged to register for convention

in advance to expedite the on-site credentialing process. See the registration form in the pull out section of this issue for registration fees. Full registration includes, Thursday Evening Awards Dinner, Friday and Saturday breakfast and lunch. Additional tickets can be purchased for these events. Utilize the special pullout section of The Alabama Nurse to register for convention. Please note the cut off date for the hotel discount is September 1, 2014. ASNA has blocked a certain amount of rooms for this convention. Please consider that off-site hotel registration of delegates causes a financial hardship to the organization if the room block is not met.

To ensure eligibility for the credentialing process, delegates are required to present their current ANA membership card and one picture ID at the Delegate Registration desk. If you do not have a current membership card please contact April Bishop, Programs Coordinator for assistance. Each delegate will be issued a name badge, a delegate ribbon, and informational materials upon proof of identification. The name badge and delegate ribbon must be worn in order to be admitted to the floor of the House of Delegates.

Please call the ASNA office at 1-800-270-2762 or 334-262-8321 if you have questions or concerns.

Convention 2014Preliminary Exhibitors

SponsorArthur L. Davis Publishing Agency, Inc.

Exhibitors

Alabama Organ CenterAuburn University/Auburn Montgomery Schools of NursingHurst Review ServiceJackson HospitalSylvia Rayfield & Associates/ICAN Publishing, Inc.Troy University School of Nursing

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Thursday, October 2, 20147:45 am Registration/Coffee

8:15 am Education Topic, Dr. Marsha Adams

9:00 am – 1:15 pm Posters

9:30 am – 11:30 am ASNA Board of Directors (Hotel Capstone)

9:30 am – 11:40 am Mini Intensives Creative Teaching Improving Professional Presentations, Drs. Gretchen McDaniel & Arlene Hayne Using the Socratic Method In the Nursing Classroom, Drs. Moniaree Jones, Allison Terry, & Ginny Langham OR Cardiac Surgery History of Cardiac Surgery: How Nursing Made a Difference, Paula Midyette, MSN, RN, CCRN, CCNS

11:40 am – 1:15 pm Lunch on your own (optional box lunches available for purchase)

1:15 pm – 4:40 pm Mini Intensives

Leadership Academy Presentations, 2014 Leadership Class OR Disaster Intensive Surge Capacity & Resource Management Evacuation: Essentials of Planning & Implementation Principles of Patient Handling During Evacuation, ARRTC (Advance Regional Response Training Center)

4:15 pm – 5:00 pm Registration

5:00 pm – 6:30 pm ASNA House of Delegates

6:30 pm President’s Reception (Hotel Capstone)

7:00 pm Awards Banquet (Hotel Capstone)

Alabama State Nurses Association2014 Annual Convention Agenda

Tuscaloosa, AlabamaAll Sessions in Bryant Conference Center unless otherwise noted

All Continuing Nursing Education sessions, including Posters, are 1.0 (ANCC/1.2ABN) contact hours

Friday, October 3, 20148:00 am – 12 noon Registration/Continental Breakfast

8:00 am – 5:00 pm Silent Auction

8:00 am – 1:00 pm Exhibits

9:00 am Seizing Opportunities to Fulfill Your Leadership Potential, Dr. Suzanne Prevost

10:15 am A Message Driven Interview, Dr. Arlene Morris

11:15 am Harnessing Nurses Political Power, Janet Haebler, MSN, RN

12:15 pm Lunch in Exhibit Hall

1:30 pm House of Delegates Keynote Presentation, Janet Haebler

5:30 pm The American Nurse (movie)

7:00 pm Free Night

Saturday, October 4, 20147:15 am – 7:30 am Registration

7:30 am – 8:30 am Breakfast Buffet (Hotel Capstone)

7:30 am – 8:30 am Advance Practice Council Breakfast (Hotel Capstone)

7:45 am – 8:30 am Voting (Hotel Capstone)

8:30 am – 2:30 pm Advance Practice Council/Capstone College of Nursing Pharmacology Symposium

7:45 am – 12:30 pm Posters

9:00 am Alabama Board of Nursing Update, Genell Lee, MS, RN, JD

10 am House of Delegates

12:30 pm Lunch & Closing Session History of Bryce, Steve Davis

Alabama State Nurses Association’s (ASNA) nomination and election of Officers shall be conducted in accordance with Robert’s Rules of Order, 10th Edition during the official

meeting of the ASNA House of Delegates (HOD).

1. NOMINATIONS A. Nominations Committee a. Nominations from the Nominations Committee shall be accomplished according to ASNA Bylaws. B. Nominations from the floor of the HOD shall be accomplished according to Robert’s Rules of Order, 10th Edition. Preliminary Ballot for ASNA Convention

Candidates for 2014-2016President-Elect/Delegate Rebecca Huie, DNP, ACNP

Write-in candidate: _________________________

Treasurer: Ellen Buckner, DSN, RN, CNE Debra Litton, DNP, RN, MBA


Commission on Susan Hayden, RN, PhDProfessional Issues Lindsey Harris, MSN, FNP-BC(Vote for 4) Write-in candidate: _________________________

Nominating Committee Gayle Stinnett, RN (District 1)(Vote for 2) Lauren Yeager, MSN, RN (District 2) Patricia Green, RN, MSN, NE (District 2)


Nominations and Election of Officers1. ELECTION OF OFFICERS A. Elections will be by secret ballot. B. Only credentialed delegates will be allowed to vote at the ASNA Convention. See ASNA website (alabamanurses.org) under members only section for convention information.



Name & Credentials: ____________________________________________

Address: _____________________________________________________

_____________________________________________________________ City State Zip

Day phone: ( ___ ) _______________ Fax: ( ____ ) __________________

E-mail: ______________________________________________________

Credit Card #: _________________________________________________

Exp. Date: _______________________________ CVV #:______________

Convention T-shirt size: _________________________________________

Registration: The Mable Lamb Educational Day registration includes lunch and continuing nursing educational sessions only. All may attend the ASNA Convention Keynote Address; but only those registered to attend Convention will receive continuing nursing education credit and may attend the banquet. Single day Convention registration includes meal functions and continuing nursing education fees. Individuals registering the day of the Convention will be issued food tickets ONLY if available. Additional guest tickets may be purchased for food functions only.

Payment: Amount of registration is determined by postmark if mailed or date received in case of phone, fax, or online. Payment or Purchase Orders must accompany registration in order to be processed. All registrations received after September 22, 2014 will be considered “at door” and processed on site.

Before September 22, 2014 will be considered early registration.

Confirmations: Confirmations are available to print immediately following your online registration. Registrations received via mail will receive an email confirmation within two weeks of receipt.

Cancellations: A written request must be received prior to September 22, 2014. A refund minus a $20 processing fee will be given. No refund will be given after September 22, 2014. We reserve the right to cancel the activity if necessary. In that case a full refund will be given.

Continuing Nursing Education:

The Alabama State Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation

Alabama Board of Nursing (Valid through March 30, 2017).

1.0 contact hour is awarded for each session attended, including Posters. A maximum of 7.0(ANCC)/8.4(ABN) contact hours may be earned. An additional 7.0(ANCC)/8.4(ABN) contact hours may be earned by attending the Pre Convention sessions.

Returned Check Fee: $30 returned check fee for any returned checks or dishonored payments.

How to Register for ConventionRegister online at http://alabamanurses.org or send registration form and payment to (check made payable to ASNA) ASNA, 360 North Hull Street, Montgomery, AL 36104-3644 or if paying by credit card Fax to 334-262-8578 (do not mail if faxing or registering on line).

For hotel reservations, contact the Hotel Capstone at 1-800-477-2262 or www.hotelcaptstone.com Room rates are $109.00 for a King/Double. Please inform the hotel that you are part of ASNA when making reservations by September 1, 2014 TO BE INCLUDED IN THE ROOM BLOCK. Reservations made after that date will be based on a space and rate availability 320 Paul Bryant, Tuscaloosa, Alabama 35040

Fees1.) Mabel Lamb Continuing Education Day Workshops, Thursday, October 2, 2014 (Lunch on your own, but box lunches may be purchased in advance- see registration form below).

Select one of the following choices for sessions:

Morning: Educators _____ Clinical ____Afternoon: Leadership Academy _____ Disaster Intensive ____

Fees: ___ ASNA member $45 ___ Non-member $65

NOTE: Add $10 to above fees if received after September 25, 2014

2.) Convention, Thursday night, October 2, 2014; and Friday & Saturday, October 3-4, 2014 (includes tickets to all meal functions listed in this application) – Select one of the following choices:

ASNA Delegates Only (must register for entire convention)*

Received on or before September 22, 2014 ___ $224

Non – Delegates – Full convention *

Received on or before September 22, 2014 ___ ASNA Member $270 ___ Non Member $345

Daily Registration *

Received on or before September 27, 2014 ___ ASNA Member $150/day ___ Non Member $185/day

Note: After September 25, 2014, add $20 to above prices – meals may not be available if received after September 22, 2014

Additional Meal/Function Tickets (for guests or those meals not included in your registration)

Thursday, October 2, 2014 – President’s Reception ________$15

Thursday, October 2, 2014 – Awards Banquet Select One ( ) Chicken Piccata or ( ) Herb Rubbed Pork Loin ________$50

Friday, October 3, 2014 – Lunch ________$30

Saturday, October 4, 2014 – Breakfast Buffet ________$25

Saturday, October 4 , 2014 – Luncheon ________$30

Total Enclosed: $ ____________

*ASNA Special Dues members (65+/Retired or Completely Disabled) receive an additional 10% discount on registration.

Optional Box Lunch $10 Thursday, October 2, 2014 _____ Yes ______No

INDICATE BANQUET CHOICE

Thursday, October 2, 2014

____Chicken Piccata____Herb Rubbed Pork Loin

ASNA Convention 2014 RegistrationRegister online at http://alabamanurses.org



Alabama State Nurses Association Advance Practice Council&

The University of Alabama Capstone College of NursingPresent The

2014 Annual Pharmacology Symposium

Saturday, October 4, 2014Bryant Conference Center, Tuscaloosa, AL _____________________________________________________________________________________________

Goal: Examine the best care practices at the end of life

Cost: $25 Optional Breakfast $70 Workshop

Contact Hours: 5.0 (ANCC) 6.0(ABN)

7:30 am Networking Breakfast/Advance Practice Council Meeting

8:30-9:30 am The Pharming Phenomenon, Kim Inman-Smith, MSN, RN

9:30-10:30 am HPV and Gardasil, Leigh Ann Williams, MSN, RN & Beth B. Taylor, MSN, RN

10:45-11:45 am Emerging Oral Cancer Therapy: Implications for Primary Care, Dr. Kristi Acker

11:45 am-12:30 pm Lunch (provided)

12:30-1:30 pm TBA, Dr. Leigh Ann Poole

1:30-2:30 pm Antidepressant and Anti Anxiety Drugs, Dr. Stephanie Wynn

2:30 pm Evaluation

Accreditation:

The Alabama State Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Alabama Board of Nursing Provider Number ABNP0002 (valid until March 30, 2017).

Refunds: If cancellation is received in writing prior to Sep. 22, 2014 a refund (minus a $20.00 processing fee) will be given. After Sep. 22, 2014 no refund will be given. We reserve the right to cancel the program if necessary. A full refund will be made in this event. A $30 return check fee will be charged for all returned checks/payments.

ASNA’s 2014 Annual Pharmacology Symposium

Name: ___________________________________________________ Credentials: _______________________

Address: ____________________________________________________________________________________

___________________________________________________________________________________________

Day Phone: ( _____ ) ______________________ Email: _________________________________________

Payment Method: ____ Optional Breakfast $25 ____Workshop $70 After Sep. 22, 2014 add $15

Credit Card #: _________________________________________ ______ Check – Make Payable to ASNA

Signature: _______________________________________ Expiration Date: ___________ Security Code: _______

Confirmations by Email Only

Registration Methods:

Mail: ASNA 360 N. Hull St.Montgomery, AL 36104

Fax: 334-262-8578

Online: alabamanurses.org

Frances Liz Seal, BSN, RN (This paper was written as a senior student)

Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) have resulted in the greatest survival rate of any conflicts in which the United States has engaged. These wars have also been responsible for the most documented cases of the invisible wounds traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Though the Veterans Administration provides health care to veterans, more than 50% seek care in civilian hospitals which are not prepared to provide the level of care veterans and military personnel need. Civilian hospital education departments should educate nurses to provide holistic care for veterans by implementing competencies in military culture, TBI, and PTSD.

In order to provide holistic care to veterans, nurses must understand some aspects of military culture. The different branches in the military include the Army, Navy, Marine Corps, Air Force, and Coast Guard, each having its own unique motto, mission, and core values which have a significant impact in a veteran’s life. Though active components are full time military, the reserve component, which is part time military with civilian status, has been deployed in the past 12 years more than any conflict since the world wars. The nurse must understand that the deployed veteran can have difficulty reintegrating in their family and social life, and should integrate the family in the veteran’s plan of care. Along with the military culture are the invisible wounds of combat, TBI and PTSD.

TBI is called the signature wound of OIF and OEF. Traumatic brain injuries are caused by injuries to the head which result in declining cognitive functioning, putting veterans at risk for inability to fulfill their roles in society. The common symptoms of TBI are headaches, tinnitus, insomnia, irritability, memory loss, mood disorders, chronic pain, anger, and dizziness. By preparing nurses to notice these symptoms in their assessments, they can refer the veterans to outreach programs to help them receive care from those who can understand. TBI may also have comorbidities such as depression or PTSD.

Post-traumatic stress disorder has been prevalent in veterans due to the intensity of combat and missions. In order for a nurse to help a veteran with PTSD, the nurse must understand the condition. “PTSD is exposure to a traumatic event that involved actual or threatened death or serious injury and having a response that involves intense fear, helplessness, or horror” (Johnson et al., 2013, p. 33). Along with this definition, the nurse must be able to recognize the symptoms of intense flashback or nightmares, irritability, anger, difficulty concentrating, and social isolation. To provide care to the veteran with PTSD, the nurse should begin a therapeutic relationship and give the veteran the respect he or she deserves. The nurse should be mindful to prevent loud noises, address veterans by their names, knock before entering their room, be cautious with physical contact, and reorient the veteran as needed (Johnson et al., 2013). By taking these measures, the nurse can recognize and avoid triggers, help the veteran feel safe, and help them engage in reality.

These competencies of military culture, TBI, and PTSD should be implemented in civilian hospital education departments for nurses to provide holistic care to veterans. Understanding military culture is imperative for nurses to incorporate the backgrounds and mindsets of the veterans they will for whom they provide nursing care. Recognizing the symptoms and referrals for those with TBI or PTSD can also help start treatment to accomplish the veteran’s goals. Nurses in civilian hospitals can make a difference in the quality of life veterans have by starting with the education of their nurses.

ReferencesErmold, J. (2013). Military cultural competence. Retrieved from

http://deploymentpsych.org/training/training-catalog/military-cultural-competence/Heltemes, K., Dougherty, A., MacGregor, A., & Galarneau, M. (2011). Inpatient hospitalizations of U.S. military personnel medically evacuated from Iraq and Afghanistan with combat-related traumatic brain injury. Military Medicine, 176(2), 132-135.

Hoyt, T., & Candy, C. (2011). Providing treatment services for PTSD at an Army FORSCOM installation. Military Psychology, 23, 237-252. Johnson, B., Boudiab, L., Freundl, M., Anthony , M., Gmerek , G., & Carter , J. (2013). Enhancing veteran-centered care: A guide for nurses in non-VA settings. American Journal of Nursing, 113(7), 24-39.

Military Competencies for Nurses in Civilian

Hospitals

in Phenix City, Alabama,invites applications for the following full-time position:

Nursing Instructor

For the application procedure and deadline, and a detailed description of this position, including qualifications, visit our

website at www.cv.edu

CVCC is an Equal Opportunity Employer


CE Corner

Author: Charlene Roberson, MEd, RN, BC, Director of Leadership Services, ASNA

Goal: Improved care for hospitalized patients in alcohol withdrawal.

Target Audience: Nurses, nursing students, health care providers, or consumers interested in the withdrawal process.

At the conclusion of this activity the learner should be able to:

1. Implement a plan of care to ensure patient safety in alcohol withdrawal.

2. Review commonly administered medications for alcohol withdrawal.

Disclosures: The Author and Planning Committee declare no conflicts of interest.

Contact Hours: 2.5 contact hours (60 minutes equal 1.0 contact hour) or 3.0 contact hours (50 minutes equal 1 contact hour)

Activity is valid through May 1, 2016.

Accreditation: Alabama State Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission of Accreditation.

Alabama Board of Nursing (Exp. 30 March 2017)

Cost: $20 ASNA members $25 Non membersIf we mail this program to you, postage and

processing fee is $3.

Directions: Complete the written material as directed and the answer/evaluation form and send to:

Contact Information:Alabama State Nurses Association360 N. Hull StreetMontgomery, Al 36104Fax: 334-262-8758 or Email scanned documents to

[email protected].

A Continuing Education Certificate of Completion will be sent to you upon successful completion of both the evaluation and posttest. You must score at least 80% on the posttest for successful completion. Should you fail the posttest you will be offered the opportunity to retake the posttest for an additional $5.00 fee. Allow at least three (3) weeks after receipt of the certificate of completion for course to be placed on your official Alabama Board of Nursing transcript.

Introduction – Before discussing withdrawal issues it is essential to review the status of Ethanol (alcohol) use/abuse in the US. The task to quantify exact numbers is difficult as all reference sources differ somewhat. But somewhere between 5-10% of the American population has chronic alcoholism. Approximately 1.2 million hospital admissions are for problems related to alcohol, and of this number each year, there are approximately 500,000 separate episodes requiring some type of pharmacologic treatment. This is not 500,000 different individuals as the same person may require treatment more than once during any given year. The important fact is that so many individuals have alcohol issues, with or without their awareness, and often require treatment for non alcohol related problems (motor vehicle accidents, elective surgery, etc.). Once hospitalized they experience withdrawal symptoms. Therefore, it is essential for nurses to be cognizant of potential alcohol issues. Often younger men will also have comorbid issues with polysubstance abuse and/or mental health issues.

Unhealthy alcohol use is a very general concept describing any pattern of alcohol consumption which increases risk to self or others in general or for developing physical problems. This is any time a person consumes alcohol in excess of the accepted health-related guidelines. The National Institute on Alcohol Abuse and Alcoholism provides the following guidelines: more than one drink daily, more than seven drinks weekly, or exceeding more than three drinks/day for women in general or for men over 65. For men under 65 alcohol consumption should not exceed more than two drinks daily, more than 14 drinks weekly, or more than 4 drinks on any single day. A standard drink is 14 Gm of alcohol (12 oz can of beer or 5 oz of 5% table wine, or 1.5 oz 40% {standard} liquor). If a person occasionally exceeds these limits it is unlikely to proceed

Alcohol Withdrawalto alcohol-related concerns. The problems are long term excessive consumption of alcohol.

Frequency/Morbidity/Mortality – In the past the death rate from alcohol withdrawal (AW) was anywhere to 20-35%. Not all individuals sought help for AW so numbers are not exact. Most important, in the past 30 years this number has steadily declined due to early and intensive care. In the United States only about 5% of individuals with alcohol withdrawal now progress to DT. However, the mortality rate of untreated DT remains near 35%; whereas, if treated the death rate is about 5%. Many alcoholics in withdrawal have other medical or traumatic conditions not related to the withdrawal process. The mortality rate from less severe alcohol withdrawal (any person not in DT) is very low and almost always related to the other medical or traumatic conditions.

Pathophysiology – Withdrawal symptoms occur when the use of a substance capable of causing tolerance is reduced or discontinued. Tolerance is defined when the long-term use of an agent produces an adaptation so that a larger and larger amount of the substance is needed to achieve the desired effect. Factors that affect tolerance include the substance itself as well as frequency and duration of use. The body adapts to the substance presence either at the metabolic or cellular level. Some people have more pronounced withdrawal symptoms than others despite consuming the same amount of alcohol - probably related to genetics. Generally, withdrawal symptoms are fairly rare in the general population as most individuals drink episodically and never develop tolerance.

Alcohol depresses the central nervous system overall. It simultaneously increases inhibitory functions and reduces excitatory tone or functions. A heavy drinker needs a constant present of alcohol to maintain homeostasis. The mechanism is that alcohol binds at the postsynaptic GABA receptors which are major inhibitory neurons/neurotransmitters in the brain. A result of activating these receptors is a release of chloride, which leads to hyperpolarization the cell. This leads to a decreased firing rate of neurons resulting in sedation. Prolonged use of alcohol decreases these receptor functions and thus causes tolerance and not sedation. As this develops, the person remains alert at alcohol concentrations that would produce lethargy or even coma in others.

Glutamate is an excitatory neurotransmitter. It binds with N-methyl-D-asparate (NMDA) and produces neuronal excitement as a result of calcium influx. Alcohol inhibits this neuronal excitement. An alcoholic adapts to an increased sensitivity to glutamate to maintain homeostasis .

When someone, who is a heavy drinker reduces the amount of alcohol either suddenly entirely or cuts back the body’s neurotransmitters are stimulated or rebound causing withdrawal symptoms such as fever, hypertension, tachycardia, hyperventilation, seizures, DT, and hallucinations. This action forces the brain to compensate by increasing the synthesis of excitatory neurotransmitters, but alcohol has inhibited these. This results in an increase in neuroexcitability, which in turn contributes to withdrawal seizures. The result is alcohol craving and explains why opioid antagonists, i.e. benzodiazepines are used to prevent this craving. Benzodiazepines stimulate GABA receptors which in turn decreases neurotransmitter activity and sedation. Thus the person achieves more of a homeostatic state without alcohol.

Symptoms – Symptoms of AW are usually absent in the first 24-72 hours after admission. Often the person has been admitted for other reasons, such as trauma. If they are in the advanced stages of withdrawal such as seizures or “full-blown” DT they should be admitted to the Intensive Care Unit for careful follow-up of the hemodynamic profile. Persons having active withdrawal symptoms from alcohol should not be moved because of the risk of seizures. In uncomplicated cases of withdrawal where the vital signs are normal and they respond to sedation they may be treated as an outpatient.

Sex and Age – Men are more often seen with chronic alcoholism and withdrawal symptoms. It is rare to encounter an individual under 20 years of age with alcohol withdrawal symptoms as a period of time is needed to develop tolerance. Withdrawal symptoms are only noted after the individual tolerant to alcohol is deprived of the agent. DT is a rarely noted in individual under 30 years of age.

The Withdrawal Clinical ProfileThe history will reflect daily abuse for at least 3 months

or an individual who has consumed large quantities for

at least a week prior (binge drinking) to the withdrawal symptoms. The symptoms appear 6-12 hours after the last drink and will subside with the ingestion of alcohol. The hangover is often an early and mild form of alcohol withdrawal; this explains why ingesting additional alcohol often relieves the hangover. Individuals who have developed significant tolerance have 4 separate phases of withdrawal as follows:

Stage I – Mild symptoms – usually occur within 6 hours of last drink - insomnia, mild anxiety, anorexia, GI upset, headache, diaphoresis, palpitations, and trembling. These symptoms will resolve within 24-48 hours or progress to Stage II. If no progression is noted they can may treated with ambulatory management. Not all patients have all of these symptoms and the ones experienced are usually consistent in each reoccurring episode of withdrawal.

Stage II – Occurs 24-36 hours after last drink and consists of an excessive adrenergic effects (i.e.), low-grade fever, hyperventilation, tachycardia, systolic hypertension, intense anxiety, diaphoresis, tremor, hallucinosis, and insomnia.

Alcoholic hallucinosis occurs in up to 25% of all patients with a history of excessive alcohol intake. Misperceptions and misinterpretations of real stimuli in the environment characterize these sensory experiences. Most often the hallucinosis consists of bugs, snakes, or rodents. The person remains aware of person, place, and time. Auditory sounds are heard less often and if experienced it is persecutory and usually the voice of someone they know. This is not to be confused with hallucinations. This condition does not always proceed to DT.

Stage III – This occurs at 12-48 hours (peak occurrence 24 hours) after the last drink. Up to one-third of individuals in severe withdrawal may have these seizures which are sometimes called “rum fits”. It consists of a brief, generalized tonic-clonic seizure, which is not preceded by an aura. They often are in a cluster of 1-3 separate seizures with a brief postictal period. Localized or partial seizures are sometimes noted. These seizures usually terminate spontaneously and are easily controlled with the administration of a benzodiazepine. Status epilepticus occurs in up to 3% of cases of alcohol withdrawal. When present the person should be evaluated for other conditions such as a head injury as alcoholics are prone to head injuries due to life style while drinking. Somewhere between 30%-50% of all individuals with seizures proceeds to DT.

Stage IV – This is DT and it occurs 48-72 hours after the last drink. Often it occurs immediately following a seizure. Note: only about 5% of all patients in alcohol withdrawal progress to DT. It is more common in patients who have a long history of alcohol abuse and who have a prior history of significant withdrawal symptoms. This may be triggered by head injury, infections or debilitating illnesses. All of the before mentioned symptoms occur but they do not improve in fact they become more pronounced. This condition when untreated will last from 2-7 days. In addition the person often develops additional physical complications such as cardiac failure or pneumonia.

Alcohol Withdrawal Clinical ProfileFeeling jumpy, nervous, shaky, restless, or increased activityExcitementAnxietyIrritability and easily excited and/or belligerent, uncooperative behaviorLabile emotionsDepression FatigueInability to concentrate or think clearly Rapid mood shiftsPalpitationsHeadacheDiaphoresis (especially palmer and around the face)Nausea and vomitingAnorexiaInsomniaConfusion and/or disorientationHallucinosis (usually visual but may be auditory)Hypersensitivity to light, sound, and touch

CE Corner continued on page 15


Delirium (severe, acute loss of mental function)Decreases mental status including lethargic, somnolent, deep sleep for more than a daySeizures and/or tremors

Treatment 1.) Screening, brief intervention, and referral to

treatment (SBIRT) This is the quality indicator identified by the Joint Commission on Accreditation for Health Care Organizations (JCAHO) for hospitalized care for an alcoholic. A patient will be stabilized and then discharged and referred to outpatient treatment.

2.) Medication management involves providing a substitute medication that has cross-tolerance to the chronically ingested substance. The selected medication will react at either specific receptor sites such as methadone in opiate withdrawal or reduce specific symptoms such as barbiturates in alcohol withdrawal. Non hospitalized patients in withdrawal will self medicate with either alcohol as their drug of choice or other sources such as rubbing alcohol, mouth wash, or cough medicines to reduce the unpleasant symptoms. Detox regimes titrate cross-tolerant medications. The amount and frequency is directly related to the severity of the person’s symptoms. The goal is to gradually wean the person off the tolerant substance using ever decreasing dosages spaced further and further apart. Overall these individuals will require more medication than non alcoholics. Often nurses who are new to substance abuse treatment or treatment of persons in withdrawal may be uncomfortable with the amount of medication given to a individual in withdrawal. The employer should provide in service training in medication protocols. The most common drugs are as follows:

Benzodiazepines (drugs of choice for withdrawal)Chlordiazepoxide (Librium) is inexpensive and has a

relatively long half-life. It has long been established as the “gold standard” for alcohol withdrawal symptoms. The drug decreases all levels of the CNS and probably increases GABA activity. The usual dose is 25mg to 100 mg IV/IM every 2 hours until AW is controlled. In an emergency may give up to 50 mg to 100 mg IV every 5 to 15 minutes until sedated. The total dose in a 24 hours period should not exceed 300 mg. The person should be tapered gradually.

Use the drug cautiously in patients with low albumin levels, narrow angle glaucoma, hypotension, or hepatic failure.

Diazepam (Valium) is usually the first drug of choice in treating withdrawal symptoms because of the rapid onset of action and prolonged duration of effect. The drug depresses all levels of the CNS and probably increases GABA activity. The dosage should be individualized and carefully monitored as it can lead to progressive apnea and hypotension. The usual dosage is 5-10 mg IV every 2-15 minutes. The dosage may be increased up to 20 mg IV and given frequently up to several hours or until the person is lightly sedated. Large doses may need to be given, to achieve the desired results. Use with caution in patients with hepatic disease, low albumin levels, or with other CNS depressants.

Oxazepam (Serax) is usually used to treat Level I alcohol withdrawal. The 15-30 mg dose is given orally. Most often it is seen in an outpatient setting. Contraindication includes narrow angle glaucoma, history of substance abuse, and severe uncontrolled pain.

Lorazepam (Ativan) takes about 20 minutes to achieve the peek effect. One side effect is the lowering of blood pressure. The blood pressure should be monitored very frequently. The usual dose is 1-2 mg IV bolus every 2-5 minutes until the desired effect is achieved (patient is sedated). Be especially diligent for oversedation or respiratory depression occurring about 20-30 minutes after the last dose as the drug peaks slowly. This is the drug of choice if the person has profound liver involvement. It is a very effective drug for withdrawal symptoms when the person is able to take oral medications.

Midazolam (Versed) has a very brief half-life. Persons receiving this need a constant infusion to maintain sedation. The drug is expensive and no more effective that other benzodiazepines. The drug is used when other cross-tolerant drugs are not available or when an intravenous access is readily available. The usual dose is 2 mg bolus dose followed by a titrated intravenous solution. It is contraindicated with narrow angle glaucoma and hypotension.

Barbiturates (drugs of choice if person does not respond to benzodiazepines)

Phenobarbital (Luminal) effectively reduces the symptoms of withdrawal. It use is limited due to hypotension and respiratory depression. Persons on CE Corner continued on page 16

CE Corner continued from page 14 this drug may need mechanical ventilation. The usual dose is 3-5 mg/kg of body weight IV or IM. It may be repeated every 30-45 minutes until the person is sedated, hypotension occurs or 15mg/kg have been administered. Contraindications are hypotension and known sensitivity.

Pentobarbital (Nembutal) is a short acting drug that may be given IV at the rate of 100mg IV over 1-2 minutes every 5-15 minutes until the person is sedated. The main contraindication is liver failure.

Cardiovascular Agents (these drugs are used in conjunction with other medications and never used as

monotherapy)Clonidine (Catapres) decreases blood pressure and pulse

rate (less predictable). Very useful in opiate withdrawal as it diminishes excessive lacrimation, diarrhea, and tachycardia. The usual dose is 0.1-0.2 mg orally every 8 hours. Monitor cardiovascular status while on the drug and abrupt discontinuation may cause rebound hypertension. Rarely used in alcohol withdrawal.

Propranolol (Inderal) decreases blood pressure, heart rate, and tremor. It has no effect on alcohol cravings nor does it reduce the severity or incidence of seizures or delirium. The usual dose is 1 mg IV initially and should not exceed 0.1 mg/kg of body weight in 24 hours. The drug should gradually be discontinued as an abrupt cessation may lead to an increase in hprerthyroid symptoms including a thyroid storm. In addition the drug may decrease signs of hypoglycemia.

Magnesium sulfate is given for magnesium replacement. The symptoms of low magnesium level resemble acute alcohol withdrawal, i.e. seizures, tachycardia, tremors, and hypereflexia. The administration of magnesium in individuals with low magnesium levels usually reduces the amount of sedation needed. In addition the administration prevents seizures with individuals with low magnesium levels. The usual dose is 1 gram every 6 hours for four doses. It is recommended not to exceed more than 1-2 grams per hour.

VitaminsVitamin (Vitamin B-1) is an essential cofactor of many

metabolic processes. Most alcoholics have a low level of Thiamin. Thiamin deficiencies are noted by the presence of

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Beriberi or Wernicke-Korsakoff (thiamin dementia). Giving IV glucose can precipitate the Wernicke encephalopathy. This may be prevented by administering Thiamin either before (preferably) or at the same time as glucose. The IV dose depends on the patient profile and may be anywhere from 50 mg-500 mg. Care should be taken not to administer the Thiamin too rapidly as the patient may develop heart failure due to cardiac stress. Resolution of acute symptoms of Wernicke-Korsakoff may be noted quickly with the administration of Thiamin.

Phytonadione (Vitamin K- 1, Aqua-Mephyton) should only be used in patients with hypoprothrombinemia. A deficiency in Vitamin K-1 is a frequently noted in individuals with chronic alcoholism and cirrhosis. The usual dose is 5-25 mg PO, IV, or IM depending on the patient’s profile.

AntidotesAlcohol is administered in very rare cases to individuals

who do not become sedated with the usual cross-tolerant medications. The administration of Alcohol is considered a last resort. The recommended dosage is a 10% solution given at a rate of 50-75 ml/hour. The dosage should be tapered as soon as possible and discontinued within 24-48 hours. Use extreme caution if the patient has also ingested other depressants. It should be noted that IV administration may cause thrombophlebitis and an oral administration may cause severe gastritis.

Propofol (Diprivan) is a last resort drug for patients who are not responding to benzodiazepines and barbiturates. It is only used in individuals who are in unresolved DT and/or Status Epilepticus. Once it is discontinued you will note a rapid recovery from the sedation. A side effect of prolonged use may be hyperlipidemia. The initial dose is 0.2 mg/kg of body weight and the maintenance dose will be 0.1-0.2 mg/kg of body weight. The object is to taper the patient off this drug as soon as possible.

Nursing Management – The major goals of nursing care include

1.) maintain homeostasis and prevent physical complications.

2.) prevent violence either directed to self or others. 3.) reorient the person to reality related to sensory or

perceptual alterations. 4.) decrease the patient’s discomfort.5.) provide education and opportunities for follow- up

treatment for patients and family.

Patients with alcohol dependency, whether acknowledged or not, and who experience acid-base imbalances, arrhythmias, electrolyte imbalances, hemorrhage, infections, or hemorrhage are at a greater risk of developing withdrawal symptoms than non drinkers. The immediate priority is an assessment and if alcohol dependency is suspected additional alcohol assessments are indicated. Several tools are available in the public domain and may be downloaded from the web. One is the World Health Organization The Alcohol Use Disorders Identification Teat (AUDIT) located at http://www.integration.samhsa.gov/AUDIT_screener_for_alcohol.pdf

Another is The National Institute on Alcohol Abuse Helping Patients who Drink too Much: A Clinician’s Guide located at http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm Another guide for evaluating a person who has abruptly stopped drinking after prolonged use is the Clinical Institute of Withdrawal Assessment for Alcohol Scale, revised (CIWA-Ar) located at http://chce.research.va.gov/appsPAWS/content/quiz.htm

Once the person has been immediately assessed they need to be stabilized. Persons in alcoholic withdrawal should be monitored for dehydration. The intense diaphoresis, hyperventilation, vomiting and restricted oral intake all contributes to dehydration. If the patient has ingested large quantities of cold medicines they should be monitored for Acetaminophen (Tylenol) toxicity. The nurses role is essential here with monitoring vital signs, administration of medications and fluids and observation of potential changes in condition. It is essential to keep the patient safe and comfortable thus reducing the stress and anxiety for patient and family in a non judgmental way. During the detox process the person needs frequent reevaluations. Depending on the vital signs and agitation level the person may need evaluations every 15 minutes progressing to hourly then less frequent. Once the person is stable the medications may be ordered according to clinical symptoms (HR or BP) or just routinely around the clock in gradually decreasing dosages. If medications are given according the clinical symptoms more frequent assessments are needed. Conversely if dosed automatically the assessments are reduced to every 4-6 hours. In clinical studies it has been shown that patients dosed according to a clinical profile receive less medication overall. If in acute withdrawal, the person is usually placed in an Intensive Care Unit (ICU). As the person is stabilized other monitoring is essential such as nutritional status, potential for bleeding especially if liver damage is present. As they progress through detox they need to be monitored for depression, psychosis, suicidal or homicidal thoughts. A goal is to reduce stimuli and sometimes in ICU this is difficult. An agitated patient should not be moved for fear of inducing a seizure. General supportive care is essential. If nausea and vomiting is present they probably need to be NPO - although craving of water is fairly common and drinking leads to more nausea and vomiting - perhaps a few ice chips. During this state the patient is often irritable and uncomfortable. Again, a non judgmental approach is essential. Some institutions continue to restrain during agitation. Follow institution’s guidelines with the intent to remove restrains as soon as possible. If restrained evaluate skin, safety, and comfort. With sedation they usually ‘settle down’ within several hours. If agitated and thrashing around they will burn more calories, have elevated vital signs, etc. and will need more supportive care. As they improve provide education about the disease process (abuse, dependence, risk of developing other diseases, and withdrawal) and opportunities for follow up care. This needs to be provided to patient and family. A determination will need to be made to ascertain the best way to provide information.

Laboratory and Diagnostic Tests The following are the most common work up studies:1. Complete Blood Count Evaluate for myelosuppression and thrombocytopenia Anemia (may be complicated by Gastrointestional

bleeding, dehydration and anemia) Megaloblastic anemia due to poor dietary intake as

evidenced by increased mean corpuscular volume2. Urinalysis may determine presence or absence

of alcohol or drugs (toxicology screen) as well as ketones.

3. Serum glucose Alcoholics who have liver disease have reduced

glycogen stores and alcohol impairs glyconeogenesis, thus hypoglycemia is common.

The side effects of withdrawal (anxiety, seizures, tremor, agitation, and diaphoresis) are very similar to hypoglycemia; therefore, a differentiation should be made.

4. Arterial blood gases are often abnormal and if so the patient should be worked up more fully.

5. Prothrombin Time is very useful determinant of a.) liver function, b.) active bleeding, and c.) determining clotting deficiencies.

6. Blood Type and Crossmatch is essential if the person has active bleeding.

X-Ray Studies 1. Chest X-Ray can evaluate for the following: Aspiration pneumonia – common in alcohol

withdrawal Cardiomyopathy and Congestive Heart Failure –

common in chronic alcoholism “Crack lungs” (only noted in crack cocaine smokers)

is sometimes misidentified as a pneumonthorax IV Drug abusers often have a lowered immune

system and are at risk for pneumonia2. CT Head Alcoholics have an increased risk of intracranial

bleeding often associated with slight trauma due to coagulation abnormalities and cortical atrophy

Electrocardiogram (ECG)The patient must be sedated enough to make this test

reliable. The Adrenergic Storm produced by the withdrawal symptoms may place enough demands on the heart to cause an infarction in susceptible individuals. During the withdrawal process most individuals have a prolonged QT interval. This reverts to normal once the acute phase of withdrawal is over.

Treatment GuidelinesIn an emergency prehospital setting alcoholics should

be given IV glucose cautiously. If the person is having a seizure the IV Glucose can precipitate acute Wernicke encephalopathy unless given Thiamin before or at the same time. Thiamin is not a drug normally carried by most First Responders. Probably if the person is transported to the Emergency Department immediately Wernicke encephalopathy will not develop; however, there are no exact time measurements as to its development. Most authorities do not withhold glucose until Thiamin has had an opportunity to enter the cells as glucose enters the cells immediately and Thiamin enter the cells several hours later. If a person is too combative to transport safely they should be sedated prior to transport.

Once the person enters the hospital setting the number one goal is to stabilize and prevent the progression to DT. They will immediately be given a substitute cross-tolerant drug to alcohol. The next move will be to determine if other pathology is occurring and start treatment immediately. If the person develops a seizure they are usually self-limiting; rarely does the person have more that 1-3 seizures and the seizure can usually be terminated with administration of a benzodiazepine. Hypoglycemia is treated with 5% Dextrose and concurrent administration of Thiamin (100mg IV).

Legal/Ethical IssuesThe seizures experienced by alcoholics are usually brief

and self-limiting. However, once they have had a seizure during withdrawal they are likely to have another in a future withdrawal episode. Alabama Law states that all seizures must be reported to the Department of Public Safety, Medical Records Division. The person will be required to relinquish their Drivers License for at least 6 months after being seizure free. At the end 6 months (of being seizure free) a neurological evaluation form may be obtained from the Department of Public Safety for physician completion. If there is physician clearance the driver’s license will be reinstated. However, the individual will need to be reevaluated every 6 months (new form) for two years. After this time the reevaluation will be annually for three years. After 5 years of being seizure free the person no longer needs to submit the neurological evaluation form.

Patients in withdrawal should be referred to appropriate service agencies for follow up treatment. In most areas of Alabama you may dial 211 for a list of follow up facilities. Support should also be offered to members of the family by contacting the same number.

Selected ReferencesDriver Rita K. Understanding and Managing Alcohol Withdrawal

Syndrome. American Nurse Today. 2013; 8 (6).Fullwood JE, Mostaghimi Z, Granger CB, Washam JB, Bride

W, Zhao Y, Granger BB. Alcohol Withdrawal Prevention: A Randomized Evaluation of Lorazepam and Ethanol - A Piolot Study. Am Jour Crit Care. 2013; 22 (5).

Hoffman RS, Weinhouse GL. Management of Moderate and Severe Alcohol Withdrawal Syndromes. Updated Mar 2014. http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawalsyndromes.pdf. Accessed April 28,2014.

Makdissi R, Stewart SH. Care for Hospitalized Patients with Unhealthy Alcohol Use: A Narriative Review. Addiction Sc and Clin Prac. 2013;8(11).

CE Corner continued from page 15

CE Corner Evaluation/Post Test continued on page 18

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Post Test

Select the one (1) best answer

1. Withdrawal symptoms occur when a substance capable of causing tolerance is withheld.

A. True B. False

2. GABA are stimulating neurotransmitters. A. True B. False

3. Symptoms of alcohol withdrawal are usually absent the first 24 hours after admission.

A. True B. False

4. A patient with active withdrawal symptoms should not be moved for fear of inducing a seizure.

A. True B. False

5. An aura always precedes a seizure in an individual in alcohol withdrawal.

A. True B. False

6. DTs are rarely noted in individuals under 30 because of lack of tolerance to alcohol.

A. True B. False

7. In alcoholic hallucinosis the person remains aware of person, place, and time.

A. True B. False

8. The benzodiazapine that is the “Gold Standard” for treatment of alcohol withdrawal is

A. Ativan B. Librium

9. The peek effect for Ativan is reached in _______ minutes.

A. 10 B. 20 C. 30

10. Thiamin (Vitamin B1) is essential for prevention of A. seizures B. encephalopathy

Evaluation/Post Test ~ Alcohol Withdrawal

2.5 (ANCC) 3.0 (ABN) contact hours Activity #: 4-0.958

Goal: Improved care for hospitalized patients in alcohol withdrawal.

Name, Credentials: __________________________________________ ____ Member ($20.00)

Address: __________________________________________________ ____ Non Member ($25.00)

________________________________________________________ ABN License#: _______________

City State Zip CC Security Code: ____________

Phone: ___________________________________ Email: _____________________________________

___________________________________ / __________ ____________________________________ Credit Card Number Exp. Date Signature

1 2 3 4 5 6 7 8 9 10

ACTIVITY EVALUATION

Circle your response using this scale: 3 – Yes 2 – Somewhat 1 – No

Objectives & Goals were appropriate. 3 2 1

Rate your achievement of the objectives for the activity1. Implement a plan of care to ensure patient safety in alcohol withdrawal. 3 2 12. Review commonly administered medications for alcohol withdrawal. 3 2 1

Program free of commercial bias. 3 2 1

On a scale of 1 – 5 / 1 (low) 5 (high) knowledge of topic before home-study 5 4 3 2 1

On a scale of 1 – 5 / 1 (low) 5 (high) knowledge of topic after home-study 5 4 3 2 1

How much time did it take you to complete the program? ______ hours ______ minutes.

ADDITIONAL COMMENTS:

CE Corner continued from page 16

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ASN and BSN Non–Tenure Track Lecturer or Tenure Track Assistant/Associate ProfessorTroy University School of Nursing ASN and BSN Program invites applications for full-time tenure or non–tenure track positions. The ASN position is on the Montgomery Campus and the BSN position is on the Troy campus. The

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CE Corner

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Goal: To demystify the approval process

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Refunds: If cancellation is received in writing prior to Sep. 1, 2014 a refund (minus a $20.00 processing fee) will be given. After Sep. 1, 2014 no refund will be given. We reserve the right to cancel the program if necessary. A full refund will be made in this event. A $30 return check fee will be charged for all returned checks/payments.

Steps to Become an Approved Provider

Name: ___________________________________________________ Credentials: _______________________

Address: ____________________________________________________________________________________

___________________________________________________________________________________________

Day Phone: ( _____ ) ______________________ Email: _________________________________________

Payment Method: _______$50 (Current Approved Provider) ______ $65 (Others) After Sep. 1, 2014 add $15

Credit Card #: _________________________________________ ______ Check – Make Payable to ASNA

Signature: __________________________________________________________________________________

Expiration Date: ______________ Security Code: _________

Confirmations by Email Only

Registration Methods:

Mail: ASNA 360 N. Hull St.Montgomery, AL 36104

Fax: 334-262-8578

Online: alabamanurses.org

ATTENTION RN’s

2014 IS RN’s RENEWAL YEARABN DEADLINE ISNOVEMBER 30th

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