“I have met the patient and she is me.”

Failure to Assess

INSIDE

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OFFICIAL NEWSLETTER

Volume 28 – Number 3 May/June 2019

Stephanie Huckaby and Michele Houghton

SSupport surfaces can be key in preventing skin breakdown. The National Pressure Ulcer Advisory Panel (NPUAP) (2007) defines a support surface as “a specialized device for pressure redistribution designed for management of tissue loads, microclimate, and/or other therapeutic functions (i.e. any mattresses, integrated bed system, mattress replacement, overlay, or seat cushion, or seat overlay)” (p. 1). There are many different types of support surfaces to aid in the prevention of hospital-acquired pressure injuries. The sheer volume of available options in support surfaces can lead to confusion when trying to determine which support surface is best for your patient. This arti-cle will aid bedside nurses in differentiating between active or reactive support surfaces and assisting in selecting the correct surface.

When an individual receives a hospital-acquired pressure injury, the experience can be devas-tating to the individual and family due to the pain, disfigurement, and life-altering treatments. The cost to the healthcare facility can reach millions of dollars due to the increased nursing time required to care for hospital-acquired pressure injuries, the cost of renting specialty equipment, nutritional sup-plements, dressing supplies, increased length of stays, litigation, and potential payments – not to men-tion the facility reputation and public reporting. Brem and colleagues (2010) estimated the average cost associated with stage IV pressure injuries and related complications is $129,248 per incident. Prevention of hospital-acquired pressure injuries and prompt treatment at the onset of a new injury can limit the tissue damage and emotional trauma to the individual as well as the monetary and rep-utational damages to the organization. Placing the individual on the correct surface to redistribute pressure from the load-bearing surfaces is critical for both prevention and healing. As the nurse, do you choose an active or reactive surface?

Reactive surfaces can be a powered or non-powered support surface with the capability to change its load distribution properties only in response to applied load (NPUAP, 2007). In essence, the individual’s bony prominences are enveloped into the mattress. Reactive support surfaces pro-vide a continuous low pressure that allows for the redistribution of the skin interface pressure over as large an area as possible. These support surfaces can be gel, foam, low air-loss, or air fluidized. Alternating pressure can be applied via cyclic changes in loading and offloading. This surface may be ideal for individuals with adequate bed mobility to turn and reposition themselves and who have no existing pressure injuries.

Hyperemesis Gravidarum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Oral Agents for Type 2 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Tinnitus and Hearing Impairment in the Veteran Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Medicinal Marijuana: What Nurses Must Know (Part I) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

CNE

PLUS

An active surface is a powered surface with the capacity to change its load distribution properties with or without applied load (McNichol, Watts, Mackey, Beitz, & Gray, 2015). The second edition of the Prevention and Treatment of Pressure Ulcers: Quick Reference Guide (European Pressure Ulcer Advisory Panel, NPUAP, & Pan Pacific Pressure Injury Alliance, 2014) recommends the use of an active surface (overlay or mattress) for individuals at higher risk of pressure ulcer development where frequent manual repositioning is not possible. Active surfaces mimic natural body movement by alternating the inflation and deflation of separate air bladders within the mattress. The alternating inflation and deflation encourages tissue per-fusion. This surface would be ideal for individuals who have limited bed mobility, have had previous pressure injuries, or have existing pressure injuries.

General recommendations for support surface selection include considera-tion of the individual’s need for pressure redistribution based on the following fac-tors:

Level of immobility and inactivity. •Need for microclimate and shear reduction. •Size and weight of individual. •Risk for development of new pressure injury. •Number, severity, and location of existing pressure ulcers. •

Many organizations utilize a pressure risk scale to help determine which sur-face should be provided for a patient given the individual risk factors present. Keep in mind, however, the use of support surfaces does not negate the need to turn and reposition the less mobile patient manually.

Stephanie Huckaby, MSN, RN-BC, NEA-BC, CSSGB, is Director of Nursing, Surgical Specialty Service Line, UT Southwestern Medical Center, Dallas, TX. She may be contacted at Stephanie.Huckaby@UTSouthwestern.edu Michele Houghton, BSN, RN, CWON, is a Nurse Clinician, Baystate Medical Center, Springfield, MA. She may be contacted at bookshelf06016@yahoo.com

References Brem, H., Maggie, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., … Vladeck, B. (2010). High coat

of stage IV pressure ulcers. The American Journal of Surgery, 200(4), 473-477. doi:10.1016/j.amjsurg.2009.12.021

European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel (NPUAP), & Pan Pacific Pressure Injury Alliance. (2014). Prevention and Treatment of Pressure Ulcers: Quick Reference Guide (2nd ed.). Cambridge Media: Perth, Australia.

McNichol, L., Watts, C., Mackey, D., Beitz, J.M., & Gray, M. (2015). Identifying the right surface for the right patient at the right time: Generation and content validation of an algorithm for support surface selection. Journal of Wound Ostomy Continence Nurses, 42(1), 19-37. doi:10.1097/WON.0000000000000103

National Pressure Ulcer Advisory Panel (NPUAP). (2007). Support surface standards initiative (S31). Retrieved from https://www.npuap.org/resources/educational-and-clinical-resources/support-surface-standards-initiative-s3i/

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Volume 28 – Number 3 May/June 2019

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Institute.

Prevention of hospital-acquired pressure injuries and prompt

treatment at the onset of a new injury can limit the tissue damage and

emotional trauma to the individual as well as the monetary and reputational

damages to the organization.

Instructions for Continuing Nursing Education Contact Hours

Hyperemesis Gravidarum

Deadline for Submission: June 30, 2021

MSNN1903 To Obtain CNE Contact Hours 1. For those wishing to obtain CNE contact hours,

you must read the article and complete the evaluation through the AMSN Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to www.amsn.org/library

2. Evaluations must be completed online by June 30, 2021. Upon completion of the evaluation, a certificate for 1.3 contact hour(s) may be printed.

Fees Member: FREE Regular: $20

Learning Outcome After completing this learning activity, the

learner will be able to identify care priorities for the pregnant woman with hyperemesis gravi-darum in the medical-surgical practice setting.

Learning Engagement Activity Study Figure 1 to identify priority nursing con-

siderations for commonly used drugs for hyper-emesis gravidarum.

The author(s), editor, editorial committee, con-tent reviewers, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.

This educational activity is jointly provided by Anthony J. Jannetti, Inc. and the Academy of Medical-Surgical Nurses (AMSN).

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP 5387. Licensees in the state of California must retain this certificate for four years after the CNE activity is completed.

This article was reviewed and formatted for contact hour credit by Michele Boyd, MSN, RN-BC, AMSN Education Director.

4

Hyperemesis GravidarumCNECONTINUING

NURSINGEDUCATION

Cynthia D. Rothenberger

Abstract: Hyperemesis gravidarum is severe nausea and vomiting in early preg-nancy which leads to weight loss, dehydration, and ketosis. This article provides the medical-surgical nurse with information about caring for a woman with hyperemesis gravidarum.

Introduction Hyperemesis gravidarum (HG) is

the most common reason that women are hospitalized in early preg-nancy. Not only does HG cause signif-icant symptoms, it can also lead to maternal and fetal complications (The American College of Obstetricians and Gynecologists [ACOG], 2018). Because HG occurs before viability, women are often admitted to a med-ical-surgical unit. The aim of this arti-cle is to educate medical-surgical nurses about HG so they can provide holistic, quality care.

Case Study: Part 1 M.K., a 24-year-old female, was

admitted to the medical-surgical unit for hyperemesis gravidarum and dehy-dration at 10 weeks gestation. She had been nauseous with daily vomiting since 4 weeks gestation. The vomiting increased over the past 2 weeks and she had not eaten or drank for 3 days. Her weight decreased from 168 pounds (pre-pregnancy) to 156 pounds (7.1% decrease). Her blood pressure was stable, but she was tachycardic (heart rate = 114 beats/minute). M.K.’s urine was concentrated with increased specific gravity and +3 ketones. Electrolytes were within normal limits. An ultrasound was completed in the emergency department which ruled out multiple gestation and molar preg-nancy. Intravenous (IV) hydration (1,000 mL LR with 100 mg thiamine) at 150 mL/hour was started prior to transfer to the medical-surgical unit.

What is HG? The majority of women (50-80%)

experience some nausea and vomiting

during pregnancy. Approximately 0.3-3% of pregnant women are diagnosed with HG. Although definitions of HG vary, the condition is generally diag-nosed when a woman experiences per-sistent vomiting that begins before 9 weeks of gestation which is not related to other medical conditions, demon-strates signs of acute starvation such as ketosis, and experiences weight loss of more than 5%. The diagnosis is only made after other possible causes of nausea and vomiting have been ruled out, such as peptic ulcer disease, gas-troenteritis, pancreatitis, hepatitis, cholecystitis, urinary tract infection, adverse effects of medications, meta-bolic conditions, and neurologic disor-ders. For most women, the symptoms resolve by the end of the first half of pregnancy (ACOG, 2018). In many cases, HG can be managed at home. Hospital admission is advised if the nau-sea and vomiting cannot be adequately controlled, she loses more than five percent of pre-pregnancy body weight, and has electrolyte imbalances, ketonuria, hemodynamic instability, or a change in neurologic status. Prompt treatment may prevent complications for the woman and fetus (ACOG, 2018; Royal College of Obstetricians & Gynecologists, 2016).

In addition to the discomfort asso-ciated with persistent nausea and vom-iting, HG can contribute to significant maternal and fetal complications. In affected women, HG can cause dehy-dration, electrolyte imbalances, anemia, and nutrition deficiencies. Frequent vomiting can cause esophageal injury (ACOG, 2018, Fiaschi, Nelson-Piercy, Gibson, Szatkowski, & Tata, 2018). Psychosocial effects may include

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depression and posttraumatic stress disorder. Although these complications are usually reversible with timely treatment, Wernicke’s encephalopathy can develop and lead to long-term maternal neurologic deficits or death (London, Grube, Sherer, & Abulafia, 2017). Research on the effect of HG on the developing fetus is unclear. There may be an association with preterm delivery, low birth weight (ACOG, 2018), and deliv-ery by cesarean section (London et al., 2017).

Etiology and Risk Factors Although the exact cause of HG is unknown, many fac-

tors are thought to contribute. One leading theory is that the high levels of human chorionic gonadotrophin, which occur early in pregnancy, causes HG. Elevations in estrogen and progesterone may also make HG more likely to occur. Some research indicates that there may be a genetic predis-position (London et al., 2017). In the past, HG was thought to be associated with preexisting mental illness or an exag-gerated response to stress. There is no evidence to support this theory (ACOG, 2018).

There are some factors which increase the risk of devel-oping HG. Women who have a large placenta, such as in mul-tiple gestation or molar pregnancy, are more likely to expe-rience HG. Family history of HG in a sister or mother increases the risk. Other factors include a history of motion sickness, migraines, HG during a previous pregnancy, or car-rying a female fetus (ACOG, 2018).

Non-pharmacological Management There are a number of dietary and non-pharmacologic

interventions which may be helpful for managing nausea and vomiting during pregnancy. The woman is generally given nothing by mouth upon admission to the hospital. Consultation with a registered dietician for nutrition assess-ment and individualized medical nutrition therapy is recom-mended. When the patient is able to take in food, small fre-quent bland meals may be better tolerated. Common dietary recommendations include avoiding spicy or fatty foods, elim-inating iron supplementation, and minimizing odors, while increasing intake of bland, dry foods as tolerated. A folic acid supplement can be substituted for her prenatal vitamin, and iron supplementation may be held. Some research indicates that ginger capsules (250 mg) four times daily may be helpful (ACOG, 2018).

Complementary therapies are also used to manage symptoms of HG. Acupressure, using wrist bands at the P-6 (Neiguan) pressure point which is located three finger breadths proximal to the wrist crease, may decrease nausea in HG. Evidence about efficacy of acupuncture and electrical stimulation bands is mixed (ACOG, 2018). Although these non-pharmacologic or complementary strategies may not be effective during the severe nausea seen in HG, they are unlikely to be harmful and may be appropriate for a woman with HG to try.

Pharmacologic Management Pharmacologic management of HG focuses on minimiz-

ing nausea and vomiting, restoring electrolyte balance, main-taining hydration, and maximizing nutritional status. IV fluid administration with vitamins is a priority intervention upon admission. IV thiamine supplementation is initially recom-mended to prevent Wernicke’s encephalopathy, followed by hydration with a dextrose solution. Although no single antiemetic drug is strongly recommended, a combination of drugs, with different mechanisms of action, may be used.

Until the individual is tolerating oral intake, medications which can be administered via other routes should be used. A proactive approach to treating nausea and vomiting is rec-ommended (ACOG, 2018; Royal College of Obstetricians & Gynecologists, 2016). Information about antiemetics which are commonly used for women with HG can be found in Figure 1.

Enteral and Parenteral Nutrition In women who cannot tolerate oral intake for a pro-

longed period of time and continue to lose weight, enteral or parenteral nutrition may be needed to support maternal and

Drug Class Priority Nursing Considerations

Pyroxidine (ex: vitamin B6)

Decreases severe nausea and vomiting in pregnancy.

Often administered with doxylamine. Extended release pyroxidine + doxalymine may be more effective.

Antihistamines (ex: doxylamine, diphenhydramine)

Side effects include dizziness, sedation, dry mouth and constipation.

Some may be administered via the IV route (ex: diphenhydramine).

Dopamine Antagonists (ex: metoclopramide, promethazine)

Phenothiazines (ex: promethazine) may cause more sedation and dystonia.

Metoclopramide is associated with a higher risk of tardive dyskinesia and contraindi-cated in women taking other medications which cause extrapyramidal symptoms.

Serotonin 5-HT 3 Inhibitors (ex: ondansetron)

Side effects include drowsiness, fatigue, headache, constipation, and prolonged QT interval. Women with a personal or family history of long QT interval, or electrolyte imbalances, should have cardiac monitoring.

Corticosteroids (ex: methylpred-nisolone)

Mechanism of action is unknown.

Indicated only when other medications are ineffective.

Pregnancy Category C: Increased risk of cleft palate malformations.

Figure 1. Commonly Used Drugs for Hyperemesis Gravidar

Source: ACOG, 2018; London, Grube, Sherer, & Abulafia, 2017

fetal nutrition. Enteral tube feeding is generally well-tolerated and is the preferred strategy. Total parenteral nutrition via central line or a peripherally inserted central catheter during pregnancy carries a high risk of sepsis and thromboem-bolism. For this reason, total parenteral nutrition is indicated only as a last resort when other strategies have been ineffec-tive (ACOG, 2018).

Case Study: Part 2 M.K.’s admission orders included nothing by mouth, daily

weight and urine ketone testing every shift, a registered dieti-cian consultation, and anti-embolic stockings. M.K. was placed in a private room in order to decrease noxious environmen-tal stimuli and promote rest. The IV fluid was changed, as ordered, to D5W at 150 mL/hour, with 100 mg thiamine/day. Ondansetron 8 mg IV every 12 hours as needed for nausea was administered. One hour later, M.K. reported that the nausea had decreased significantly. Promethazine 12.5 mg IV every 6 hours as needed for nausea was also ordered. By the next morning, M.K. was able to tolerate ice chips. The certi-fied nursing assistant provided frequent oral care and was aware that ambulation should be supervised when promet-hazine was administered. The nurse supported a family-cen-tered care approach by encouraging family members and friends to visit and participate in care.

Psychosocial Considerations There is increasing recognition that the symptoms of

HG can have a significant psychosocial impact. A qualitative literature review found that women who experienced HG reported social isolation, a decreased ability to engage in self-care, financial hardship, and, in some cases, considered termi-nating the pregnancy. In addition, they self-reported guilt, depression, and anxiety. Healthcare providers need to recog-nize these potential consequences and assess women for symptoms. Social support should also be assessed. Raising awareness and providing education to other professionals, patients, and support persons may decrease the stigma asso-ciated with HG. Nurses can encourage women to express their feelings about the experience of HG, validate their experience, and provide information about coping strategies. If appropriate, women should be referred to peer support or mental health services (Dean, Bannigan, & Marsden, 2018).

Case Study: Part 3 After 3 days of hospitalization, M.K. was advanced to a

bland diet. Her heart rate and vital signs were within normal limits and urine was negative for ketones. M.K. reported only intermittent mild nausea and no emesis for the past 24 hours. She regained three pounds. M.K met with the regis-tered dietician and developed an individualized meal plan which included small, frequent meals every 2-3 hours and intake of at least eight glasses of water each day. An order was written for discharge to home and follow up in 3 days

with the obstetrician. M.K.’s spouse and family members agreed to help with household responsibilities so that she could rest as needed. She was instructed to notify the obste-trician if she was unable to tolerate oral intake or fluids, experienced an increase in nausea, or lost weight. In addition, the nurse encouraged M.K. to notify her provider if she noticed feelings of anxiety or depression.

Summary Women who experience HG during early pregnancy

may be admitted to a medical-surgical unit. Collaborative care priorities include minimizing nausea and vomiting while restoring fluid volume, electrolytes, and adequate nutrition. Nursing care also focuses on minimizing the psychosocial impact of HG on women and their families. Cynthia D. Rothenberger, DNP, RN, ACNS, BC, is an Assistant Professor of Nursing, Alvernia University, Reading, PA. She may be contacted at cynthia.rothenberger@alvernia.edu

References Dean, C., Bannigan, K., & Marsden, J. (2018). Reviewing the effect of

hyperemesis gravidarum on women’s lives and mental health. British Journal of Midwifery, 26(2), 109-119. doi:10.12968/bjom.2018.26.2.109

Fiaschi, L., Nelson-Piercy, C., Gibson, J., Szatkowski, L., & Tata, L.J. (2018). Adverse maternal and birth outcomes in women admitted to a hospital for hyperemesis gravidarum: A population-based cohort study. Paediatric and Perinatal Epidemiology, 32(1), 40-51. doi:10.1111/ppe.12416

London, V., Grube, S., Sherer, D.M., & Abulafia, O. (2017). Hyperemesis gravidarum: A review of recent literature. Pharmacology 2017, 100(3-4), 161-171. doi:10.1159/000477853

Royal College of Obstetricians & Gynecologists. (2016). The manage-ment of nausea and vomiting of pregnancy and hyperemesis gravi-darum (green-top guideline No. 69). Retrieved from https://www.rcog.org.uk/en/guidelines-research-services/guide-lines/gtg69/

The American College of Obstetricians and Gynecologists (ACOG). (2018). ACOG practice bulletin No. 189: Nausea and vomiting of pregnancy. Obstetrics and Gynecology, 131(1), e15-e30. doi:10.1097/AOG.0000000000002456

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7

oral hypoglycemic medications used to treat persons with type 2 diabetes.

Jane F. Marek, DNP, MSN, RN, is an Assistant Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. She may be contacted at jfm2@case.edu

References American Diabetes Association. (2018). 8.

Pharmacologic approaches to glycemic treatment: Standards of medical care in diabetes—2018. Diabetes Care, 41(Suppl. 1), S73-S85. doi:10.2337/dc18-S008

Centers for Disease Control and Prevention (CDC). (2017). National diabetes statistics

report, 2017: Estimates of diabetes and its burden in the United States. Retrieved from http://www.diabetes.org/ assets/pdfs/basics/cdc-statistics-report-2017.pdf

Salpeter, S.R., Greyber, E., Pasternak, G.A., & Salpeter, E.E. (2010). Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. The Cochrane Database of Systematic Reviews, 4. doi:10.1002/14651858.CD002967.pub4

Steinberg, J., & Carlson, L. (2019). Type 2 dia-betes: A STEPS approach. American Family Physician, 99(4), 237-243.

The number of persons in the U.S. with diabetes continues to grow. The Centers for Disease Control and Prevention (CDC) estimate 30.3 mil-lion people (9.4%) of the U.S. popula-tion had diabetes in 2015 (CDC, 2017). Type 2 diabetes accounts for 90-95% of all cases of diabetes, so these data are likely to be representative of type 2 dia-betes. Conditions known to increase the risk for complications include smoking, overweight and obesity, hyper-tension, hyperlipidemia, elevated hemo-globin A1C, and sedentary lifestyle. In acute care settings, diabetes was listed as a diagnosis in 7.2 million hospital dis-charges in 2014 (CDC, 2017). Medical-surgical nurses, regardless of their prac-tice location, are likely to encounter patients with diabetes daily.

Just as the number of persons with diabetes has increased, so have the number of oral pharmacologic agents available for treatment with new drugs continuing to appear on the market. Traditionally, initial treatment strategies for persons with type 2 diabetes con-sisted of lifestyle modification, met-formin, and sulfonylureas. In 2019, approximately 40 different medications are available to manage patients with type 2 diabetes (Steinberg & Carlson, 2019). To achieve the best outcomes, an individualized, interprofessional approach, including lifestyle modifica-tions and pharmacologic therapy, is needed to meet an individual’s glycemic goals. Other factors when choosing the best pharmacologic agent include considering the drug’s effectiveness, risk of hypoglycemia, effect on renal function, adverse effects, route, cost, impact on weight, and the individual’s history of cardiovascular disease (American Diabetes Association, 2018). Despite the advent of new medica-tions, monotherapy with metformin remains first-line treatment unless contraindicated or not tolerated. Ongoing evaluation of the effectiveness of the treatment and medication regi-men may necessitate adding medica-tions of different classes, including insulin. Table 1 summarizes common

If you have any questions or comments regarding the “Pharmacology Updates” column, or if you are interested in writing, please contact Column Editor Jane F. Marek at jfm2@case.edu

Classification Medication Action Adverse Effects

Biguanides Metformin Decrease hepatic gluconeogenesis and lipogenesis

Risk of B12 deficiency with long-term use, gastrointestinal (GI) side effects, was associated with lactic acidosis but insufficient evidence to support increased risk (Salpeter, Greyber, Pasternak, & Salpeter, 2010)

2nd generation Sulfonylureas

Glipizide, glyburide

Increase insulin secretion

Hypoglycemia, dizziness, GI side effects

Meglitinides Repaglinide, meteglinide

Increase insulin secretion

Hypoglycemia, headache, angina, GI side effects, increased uric acid levels

Thiazolidinediones Rosiglitazone, pioglitazone

Increase sensitivity to insulin and decrease hepatic glucose production

Hypoglycemia, congestive heart failure, edema, fracture, upper respiratory infection

Alpha-glucosidase inhibitors

Acarbose, miglitol, voglibose

Act in intestine to inhibit polysaccharide reabsorption and delay glucose absorption

Flatulence, bloating, hepatotoxicity

Dipeptidyl 4 (DPP-4) inhibitors

Sitagliptin, saxagliptin, alogliptin

Inhibit glucagon release, increase insulin secretion, and decrease serum glucose levels

Hypoglycemia, congestive heart failure, pancreatitis, acute renal failure, upper respiratory infection, arthralgia

Sodium-glucose cotransporter 2 (SGLT2) inhibitors

Dapagliflozin, canagliflozin

Act in proximal tubules to inhibit glucose reabsorption and decrease glucose levels

Hypotension, dyslipidemia, genito-urinary tract infection, fracture, decreased renal function, diabetic ketoacidosis

Dopamine-2 agonists

Bromocriptine Act in hypothalamus to decrease insulin resistance and decrease glucose production

Hypo/hypertension, dizziness, syncope, drowsiness, dry mouth, sinusitis, rhinitis, GI side effects

Table 1. Oral Hypoglycemic Agents for Treatment of Type 2 Diabetes

Oral Agents for Type 2 Diabetes

Pharmacology Updates

Military personnel face a number of occupational expo-sures during their service, both in times of war and peace (U.S. Department of Veterans Affairs, 2015). Examples of such exposures include lead, radiation, chemicals, solvents, noise or vibrations. Noise exposure can result from gunfire, machinery, rockets, heavy weapons, aircraft or jets, and explo-sives, to name a few. These exposures can lead to varying

degrees of tinnitus or hearing loss. For nurses working in medical-surgical settings, interacting with veterans affected with tinnitus or hearing loss is quite likely. While many veter-ans are receiving treatment and care for these exposures, the number affected may be higher than what is reported as long-term effects of exposure may not surface until years after service members separate from the military. Any level of hearing loss can influence a person’s ability to communi-cate or engage in social interactions (National Academies of Sciences, Engineering, and Medicine, 2016). Persons with tin-nitus or hearing loss may also suffer economic burdens (U.S. Department of Veterans Affairs, 2016). In addition, quality of life and overall health can be negatively affected by the inabil-ity to hear.

Prevalence Within the United States, an estimated 30 million people

over the age of 12 have some degree of hearing loss (National Academies of Sciences, Engineering, and Medicine, 2016). According to the U.S. Department of Veterans Affairs

(2018), hearing impairment and tinnitus are the top two compensated service-connected disabilities of all recipients, affecting over 2.9 million veterans. The total number of serv-ice-connected disabilities for the entire auditory system exceeded 3.1 million, with males accounting for almost 2.9 million of those disabilities. Table 1 provides a snapshot of the prevalence of tinnitus and hearing loss across several periods

of service of all compensated recipients. Since the Korean conflict, the percentage of these service-connected disabili-ties have decreased within the overall disabilities for each era. However, a large number of service members are still experiencing these health-related issues.

Of recent focus and attention is Iraq and Afghanistan veterans due to the possible relationship of hearing impair-ments and blast injuries, which are hallmark injuries for this group of veterans. In one review, the researchers discussed a major challenge to understanding hearing impairment and tinnitus is that these conditions are often lumped together, making it difficult to differentiate prevalence and risk from other hearing conditions (Theodoroff, Lewis, Folmer, Henry, & Carlson, 2015). Further, the researchers suggest that future studies should “use assessment methods that are more con-cise in defining what constitutes these conditions” (Theodoroff et al., 2015, p. 83). Swan and colleagues (2017) conducted a study of an Iraq and Afghanistan veterans’ cohort of 570,332 veterans to describe the prevalence of hearing loss and tinnitus with common post-deployment

Tinnitus and Hearing Impairment in the Veteran Population

8

Joining ForcesVisit amsn.org/joiningforces for more information on caring for the unique needs of members of the military.

Period of Service (POS)

Total Number with Tinnitus

Percentage of POS Disabilities

Total Number with Hearing loss

Percentage of POS Disabilities

World War II 22,617 13.59% 32,212 19.36%

Korean Conflict 54,381 18.97% 65,278 22.77%

Vietnam Era 531,692 9.95% 504,056 9.43%

Gulf War Era 944,930 6.35% 355,424 2.39%

Peacetime 233,360 9.23% 200,615 7.94%

Table 1. Prevalence of Selected Service-connected Disabilities of all Compensated Recipients

Source: Department of Veterans Affairs, 2018

If you have questions or comments regarding the “Joining Forces” column, or if you are interested in writing, please contact Column Editor Brenda Elliott at brendaelliott6@gmail.com.

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ing loss fact sheet at https://www.research.va.gov/pubs/docs/va_factsheets/HearingLoss.pdf

Nurses who interact with veterans with hearing loss should assess for use of hearing aids or other interventions currently in place. Nurses should also assess whether or not the veteran is receiving care through the VA so care can be coordinated if necessary. In some instances, the veteran may not know whether or not he/she is eligible for services through the VA, in which case referral may be the best action. A number of service organizations, such as the American Legion and Veterans of Foreign Wars, are great resources to help veterans who may need assistance getting started on the process. In addition, charitable organizations like Hearing Loss Association of America offer free membership to veter-ans. The organization can act as an advocate for veterans, assisting them in staying connected to the hearing world. Resources compiled in Table 2 range from organizations who offer social support to financial assistance in obtaining hear-ing aids, and everything in between.

Nursing Care Auditory deficits have the potential to impact many

facets of health and wellbeing (Alamgir et al., 2016). People who suffer with tinnitus may also experience fatigue, stress, trouble concentrating, trouble remembering, depression, anxiety, irritability, and sleep disturbances (Mayo Clinic Staff, 2018). According to Alamgir and colleagues (2016), hearing impairment and noise-induced hearing injury “results in dis-torted and incomplete communication leading to isolation and withdrawal and subsequently results in lower sensory input” (p. 2). While auditory disorders are a global concern, they can be especially problematic for military service mem-bers and veterans who may be suffering other physical and mental health issues such as traumatic brain injury and post-

conditions such as traumatic brain injury, post-traumatic stress disorder, and other post-concussive conditions such as vertigo/dizziness and headaches. The researchers reported that vertigo/dizziness, visual problems, and both otologic and jaw pain were associated with increased rates of auditory dysfunction.

Etiology of Tinnitus Tinnitus is a bothersome sensation of hearing sound

when no outward sound is present such as hissing, clicking, roaring, buzzing, whistling, or ringing (Mayo Clinic, 2019). It can be present in one or both ears, range from mild to severe, and occur intermittently or continuously. Structural problems in the ear, auditory nerves, or auditory pathways can cause tin-nitus. The inner ear cell damage associated with tinnitus is often a result of age-related hearing loss, exposure to loud noise, earwax blockage, or ear bone changes (Mayo Clinic, 2019).

Hearing Loss According to the Centers for Disease Control and

Prevention (CDC) (2018), hearing loss is categorized into four types: auditory neuropathy spectrum disorders, conduc-tive, sensorineural, and mixed. Auditory neuropathy spectrum disorders occur when sound enters the ear normally, but due to damage of either the hearing nerve or inner ear, sound is not organized in a manner that the brain understands. Conductive hearing loss, which can sometimes be treated with surgery or medicine, is caused by something that stops sounds from moving through the outer or middle ear. Sensorineural hearing loss occurs when there is a dysfunc-tion in the way the inner ear or hearing nerve works. This type of hearing loss can sometimes be improved with the use of hearing aids. When a person has both conductive and sen-sorineural hearing loss it is called mixed hearing loss (CDC, 2018). Hearing loss can further be designated based on sever-ity: mild, moderate, severe, or profound.

Current Research and Resources The U.S. Department of Veterans Affairs (2016) has been

working with a number of national organizations and researchers to examine the extent of hearing loss and tinni-tus within the active military and veteran populations. A few key milestones they have achieved over the past three decades include:

Collaboration with the National Institute for Health in •1992 to develop advances in hearing aids. Establishment of the National Center for Rehabilitative •Auditory Research (NCRAR) in 1997. A 2005 publication of a comprehensive protocol for the •management of tinnitus called Progressive Tinnitus Management (PTM). Linked jet propulsion fuel to auditory processing prob-•lems in 2014 through conducting research.

To learn more about these milestones within the U.S. Department of Veterans Affairs (VA), you can access the hear-

Resource Website

Department of Veterans Affairs (VA)

https://www.research.va.gov/topics/ hearing.cfm

Hearing Health Foundation (HHF)

https://hearinghealthfoundation.org/ veterans/

Hearing Loss Association of America (HLAA)

https://www.hearingloss.org/hearing-help/communities/veterans/

American Tinnitus Association (ATA)

https://www.ata.org/

American Academy of Audiology (AAA)

https://www.audiology.org/

Better Hearing Institute (BHI)

http://www.betterhearing.org/hearingpedia/hearing-loss-resources

Heroes with Hearing Loss Resources (HHLR)

https://heroeswithhearingloss.org/solutions/

Table 2. Hearing Loss Resources for Healthcare

Providers and Veterans

Academy of Medical-Surgical Nurses www.amsn.org

10

traumatic stress disorder (Swan et al., 2017). Quality of life concerns should be explored and addressed when feasible.

Nurses working in all care settings need to assess for military or veteran status, as well as for occupational expo-sures. If hearing loss is known or suspected, special care should be taken to reduce the amount of excess and/or extraneous noise as much as possible. Since hearing dysfunc-tion can vary from individual to individual, determining what accommodations, if any, is essential in providing the highest quality, patient-centered care. Ensure individual privacy by not raising your voice so loudly that others may hear you. Healthcare providers should avoid walking up behind a serv-ice member or veteran with known hearing dysfunction, especially if other comorbid conditions are present.

Difficulty hearing can have a potential negative impact on learning. Comprehension could be affected when those with hearing loss receive education such as discharge instructions. Therefore, it is important for nurses to use a multi-modal approach to teaching, such as visual handouts and demon-

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strations. Nurses should make extra effort to communicate with individuals on a face-to-face level, with a clear voice, and at a normal pace. It may be necessary to sit closer to some individuals and give instructions using short, simple sen-tences. Having the family or caregiver present during educa-tion is recommended if the individual consents. Utilizing a teach back method is one way to ensure receipt and under-standing of instructions.

Conclusions With the number of service members and veterans who

may have hearing impairment or tinnitus, it is important for nurses working in medical-surgical settings to be armed with knowledge regarding how this deficit could influence overall care. Nurses can have a positive impact on health outcomes by providing patient-centered care, focused on ensuring indi-viduals with hearing impairment or tinnitus fully understand their treatment plan or discharge instructions. If you suspect a veteran may be experiencing hearing difficulties but has not been evaluated by the VA for service-connected disability, encourage them to seek help.

Brenda Elliott, PhD, RN, CNE, is an Adjunct Professor, Wilson College, Chambersburg, PA. She may be contacted at brendaelliott6@gmail.com References Alamgir, H., Turner, C.A., Wong, N.J., Cooper, S.P., Betancourt, J.A., Henry,

J., … Packer, M.D. (2016). The impact of hearing impairment and noise-induced hearing injury on quality of life in the active-duty military population: Challenges to the study of this issue. Military Medical Research, 3(11), 1-8. doi:10.1186/s40779-016-0082-5

Centers for Disease Control and Prevention (CDC). (2018). Types of hearing loss. Retrieved from https://www.cdc.gov/ncbddd/hear-ingloss/types.html

Mayo Clinic. (2019). Tinnitus. Retrieved from https://www. mayoclinic.org/ diseases-conditions/tinnitus/symptoms-causes/ syc-20350156

National Academies of Sciences, Engineering, and Medicine. (2016). Hearing health care for adults: Priorities for improving access and affordability. Washington, DC: The National Academies Press.

Swan, A.A., Nelson, J.T., Swiger, B., Jaramillo, C.A., Eapen, B.C., Packer, M., & Pugh, M.J. (2017). Prevalence of hearing loss and tinnitus in Iraq and Afghanistan veterans: A chronic effects of neurotrauma con-sortium study. Hearing Research, 349, 4-12. doi:10.1016/j.heares.2017.01.013

Theodoroff, S.M., Lewis, M.S., Folmer, R.L., Henry, J.A., & Carlson, K.F. (2015). Hearing impairment and tinnitus: Prevalence, risk factors, and outcomes in the US service members and veterans deployed to the Iraq and Afghanistan wars. Epidemiologic Reviews, 37(1), 71-85. doi:10.1093/epirev/mxu005

U.S. Department of Veterans Affairs. (2015). Occupational hazards. Retrieved from https://www.publichealth.va.gov/exposures/categories/occupational-hazards.asp

U.S. Department of Veterans Affairs. (2016). VA research on hearing loss. Retrieved from https://www.research.va.gov/topics/hearing.cfm

U.S. Department of Veterans Affairs. (2018). Veterans benefits administra-tion annual benefits report: Fiscal year 2017. Retrieved from https://www.benefits.va.gov/REPORTS/abr/www.hillrom.com

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Volume 28 – Number 3

Mental Health

If you have questions or comments regarding the “Mental Health” column, or if you are interested in writing, please contact Column Editor Catherine Skowronsky at skowroc@ccf.org

“I have met the patient and she is me.”

Sixty eight percent of adults with mental illness have medical comorbidities. Forty two percent of inpatient stays are a combination of psychiatric and medical problems (ECRI Institute, 2018). The medical-surgical nurse has what it takes to meet the needs of this patient population. The most important tool in your kit is yourself; your presence. The nurse-patient relationship is crucial to developing trust. This doesn’t mean you have to give into every request. It means being transparent, respectful, and keeping promises. These interventions become more important than the thermome-ter or incentive spirometer. Break out your best communica-tion tools. More impactful than any specific diagnosis are the individual’s behaviors. An important maxim of behavioral health states the behavior is not the reason. Look past the actions to the why (ECRI Institute, 2018).

For example, a person with schizophrenia may display paranoid features (Yeager, 2018). It helps to remember that the underlying emotion is fear. We may perceive the subject of that fear as irrational such as government spies or aliens. This false fixed belief or delusion is just as real to the individ-ual as the clock on the wall. Keep this in mind when the indi-vidual hides under the blanket and refuses medications. Upon entering the room, announce your presence and ask permis-sion before doing anything. As long as there is no urgent or emergent need, respect the individual’s right to refuse care. Clearly document the refusal and notify the provider. If you feel safe doing so, sit down and offer reassurance that you are there to help. Remember, you are approaching a very fright-ened person. They may feel threatened enough to lash out verbally or physically. Accept that you may not be able to take vital signs as often as usual. Do not argue with any delusions or hallucinations. Instead, thank them for sharing honestly with you and validate their feelings: That must be so frightening for you right now.

Perhaps the most distressing circumstance is the individ-ual expressing suicidal ideations. How do we protect some-one from him or herself? As of July, The Joint Commission will require all individuals admitted to a medical unit with a behavioral health diagnosis to be screened for suicide risk with an evidence-based tool. When we consider that risk fac-tors for suicide include serious physical illness, poor health prognosis, and an age greater than 65 years, it’s a good idea to screen all individuals on admission (Horowitz et al., 2013).

Asking about thoughts of ending one’s life does not increase the risk that they will do so. It provides an opportunity to honestly divulge something they may not feel they are able to

tell anyone else. When the individual reveals these thoughts, provide emotional reassurance and thank them for being honest: Thank you for sharing that with me. It will help me keep you safe today. Immediately provide for one-to-one direct observation at all times (Horowitz et al., 2013). Notify the provider and document what the individual told you using direct quotes. Regularly assess the environment for sharps left behind or ligature risks.

Alcohol, heroin, and cocaine have been around a long time, but the ongoing opioid crisis has brought the number of individuals with substance use disorder to new levels. Substance use disorder is a chronic disease of the brain that results from physical changes to the brain as a result of pro-longed substance use (The Joint Commission, 2015). It is not a character judgment but a brain disease. Poor health main-tenance, impact of drugs and alcohol on the body, and infec-tions related to self-injecting are just a sample of the medical hazards to the person with substance use disorder. Ask the individual about their use. Identify their choice of substance, last use, and history of withdrawal. These questions will help determine the risk of withdrawal. They can be asked by either the nurse or provider. Whatever our own feelings are about substance use, it is important to portray a non-judg-mental demeanor to build trust with the individual.

Thumbing through a psychiatric textbook we can find elements of ourselves. Like all chronic illness, mental health is on a spectrum. A person with schizophrenia whose symp-toms are managed with medication and counseling is as healthy as the person with diabetes managed with diet and insulin. As medical-surgical nurses, our specialty is not defined by one organ system or disease process. Our specialty is the whole patient across the wellness continuum. If indeed total health includes mental health, then we are all psych nurses.

Catherine M. Skowronsky, MSN, RN, ACNS-BC, CMSRN, is a Clinical Nurse Specialist, Medical-Surgical, Cleveland Clinic, Cleveland, OH. She may be contacted at skowroc@ccf.org

References ECRI Institute. (2018). 2018 deep dive: Meeting patients’ behavioral health

needs in acute care [executive brief]. Retrieved from https://www.ecri.org/Resources/Whitepapers_and_reports/PSO%20Deep%20Dives/DeepDive_Behavior_execbrief.pdf

Horowitz, L.M., Snyder, D., Ludi, E., Rosenstein, D.L., Kohn-Godbout, J., Lee, L., … Pao, M. (2013). Ask suicide-screening questions to everyone in medical settings: The asQ’em quality improvement project. Psychosomatics, 54(3), 239-247. doi:10.1016/j.psym.2013.01.002

The Joint Commission. (2015). NPSG 15.01.01 suicide prevention resources. Retrieved from https://www.jointcommission.org/npsg_150101_suicide_prevention_resources/

Yeager, K.R. (2018). Vicarious Trauma, Compassion Fatigue and Burnout. Talk presented at Trauma Informed Care Workshop: The Cost of Helping: An Organizational Approach to Building Resiliency in the Helping Professions: Warrensville Hts, OH.

12

Failure to Assess: The 6 P’s of Acute Limb Ischemia for Post-Surgical Patients on the Medical-Surgical Unit

Dr. Rudolph Matas, considered the ‘Father of Vascular Surgery,’ began to practice novel vascular surgical techniques in the 1880s. These techniques and nursing assessments to support post-surgical vascular patients have significantly advanced over the past 140 years (Miller, 2016). In the last 20 years, acute limb sur-gery has changed in two important ways. First, surgical interventions transitioned from open techniques, such as throm-boembolectomy and bypass surgery, to the less invasive catheter-directed endovascular procedures. Second, with the refinements in surgical technique, the goals of care shifted from amputa-tion to limb salvage (Baril, Ghosh, & Rosen, 2014). When a post-surgical vascular limb patient is cared for on the medical-surgical unit, it is essen-tial that the nurse understand the surgery performed, be skilled in performing the appropriate neu-rovascular assessments, and antici-pate possible complications and interventions.

When caring for a patient after limb vascular surgery, the nurse needs to know the limb injury’s mechanism of action to understand the rationale for the surgical interven-tion and to anticipate and assess for potential complications. Patients may require vascular surgery on a limb as a result of trauma from falls, motor vehicle accidents, crush injuries, gun-shot wounds, and/or fractures. In addition, patients with peripheral arterial disease may develop atherosclerotic lesions that require surgical intervention. The types of limb surgeries include surgical revascularization, bone implants with hardware stabilization, joint replacement, bone stabiliza-tion with external fixation device, and debridement and flap surgery. Patients that undergo limb surgery, whether vascular, orthopedic, or orthopedic-trauma patients, may experience life altering complications including blood clots, compart-ment syndrome, fat emboli, infection, and/or acute limb ischemia which can lead to loss of function, chronic pain, and limb loss.

Acute limb ischemia (ALI) is the sudden decrease in limb perfusion that threatens the viability of the limb. This sudden loss of blood flow may result in reduced motor and sensory

function and can lead to fasciotomy, amputation, and possible loss of life (Shishehbor, 2014). In a large study of 100,000 Medicare patients, Baril and colleagues (2014) suggest ALI had a persistently high 1-year mortality rate of approximately

42% despite advances in surgical technique. In addition, more than 10% of surgical limb patients underwent an

amputation despite improvements in limb salvage. Nekkanti and colleagues (2018) report on a smaller cohort of 80 patients and suggest a 13% overall mor-tality rate and a 27% amputation rate.

These sobering statistics require that nurses develop and practice their assessment skills around ALI. Evidence suggests that patients —

without underlying arterial disease — who develop ALI have only 6 hours for revascu-larization before irreversible damage occurs (Nekkanti et al., 2018).

Post-operative orders for patients after limb surgery often specify that the nurse perform neurovascular checks on a periodic basis such as every 2 or 4 hours to assess

for limb hypoprefusion. The signs and symptoms of hypoper-fusion are encoded in the mnemonic known as the ‘6 P’s: Pain, Paresthesias, Poikilothermia, Pallor, Pulselessness, and Paralysis.’ It is important that the nurse both assess and doc-ument the neurovascular checks. A documentation time-stamp indicating the last known baseline assessment is criti-cal to track the progression of a change in patient condition. If the nurse notes a change in patient assessment, the nurse must report these findings to the patient’s provider to ensure that the patient has access to a timely treatment plan in order to optimize the chance of retaining an intact, functional limb.

Pain is often the first sign of ALI. The patient rates their pain higher than the mechanism of injury (Pechar & Lyons, 2016). Pain is an important first sign, and, while the nurse can medicate the patient, it is important for the nurse to report a pain level that is out of proportion to the injury to the patient’s provider.

Paresthesias occur before paralysis and represent a warning sign that limb paralysis may occur. The first signs of paresthesia include unexpected feelings in the limb of prick-

Safe Bedside Practice

If you have questions or comments regarding the “Safe Bedside Practice” column, or if you are interested in writing, please contact Column Editor Patricia J. Bartzak at patty@bartzak.com

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866-877-2676 Volume 28 – Number 3

ling, burning, tickling, itching, and skin crawling. Though not usually painful, paresthesias are often described as a ‘pins and needles’ sensation. Nurses should ask patients to describe how their limb feels and specifically inquire about the pres-ences of pins and needles as this assessment is a manifesta-tion of sensory loss.

The nurse is able to detect poikilothermia by feeling both extremities and assessing that one is cooler than the other. This nursing assessment should be practiced so that nurses are able to improve their skills to ensure that changes — even subtle changes — are detected.

Pallor is a color difference between two limbs. Nurses must develop a sense of color awareness in order to discern both subtle and more obvious changes in a patient’s limb color. Not all patients with limb ischemia will demonstrate changes in pallor. In dark-skinned patients, pallor may present as more gray or white; in yellow-skinned patients, pallor may be more of a grayish-green color; and pallor shows as pale-ness or a gray-blue in light-skinned patients (Sommers, 2011).

Pulselessness is assessed by placing two fingers on the dorsalis pedis and posterior tibial pulse points and then grad-ing the pulses on a scale of 0 to 4. A normal pulse is assessed at 3.

0: No palpable pulse. 1: A faint, but detectable pulse. 2: Diminished pulse. 3: Normal pulse. 4: A bounding pulse. Feeling for pedal pulses requires training and practice so

that nurses are able to discern differences in their assess-ments. If the nurse is unable to locate a pulse, a Doppler should be obtained to assess the pulses. If pulses cannot be heard via the Doppler, the patient’s provider must be noti-fied. A bounding pulse is an abnormal finding as this indicates that the heart is pumping hard for some reason, hence the arterial pulse feels excessively strong.

Paralysis of the limb suggests that the patient does not have the ability to move their limb. This can result from increased pressures in the compartments of the lower extremity. Compartment syndrome, a complication of neu-rovascular surgery, should be on the nurse’s differential list and reported to the provider.

Not all charting systems have the 6 P’s specified as fields for documentation. It is recommended that nurses advocate

for these fields to be included in system upgrades. Visualizing the actual fields prompts the nurse to ensure that all appro-priate parameters have been assessed. The nurse can submit suggestions to nursing leadership, nursing practice councils, and other change agents in the organization to make the doc-umentation congruent with the nursing assessment. If this is not possible, the nurse can chart a more thorough assess-ment as a nursing note to provide a broader description and context of the limb’s assessment, interventions, and follow-up.

In conclusion, post-operative vascular limb patients require medical-surgical nurses to perform timely, skilled, and organized assessments to detect ALI. With 6 hours or less until irreversible damage from hypoperfusion of the limb occurs, it is essential that 6 P’s of neurovascular assessments be documented and abnormal findings reported immediately. Medical-surgical nurses should advocate for the development of documentation tools that remind and ensure that the nurse fully assesses each parameter.

Patricia J. Bartzak, DNP, RN, CMSRN, is a Nurse Educator, Milford Regional Medical Center, Milford, MA. She is also an Expert Nurse Witness.

References Baril, D.T., Ghosh, K., & Rosen, A.B. (2014). Trends in the incidence,

treatment, and outcomes of acute lower extremity ischemia in the United States Medicare population. Journal of Vascular Surgery, 60(3), 669-677. doi:10.1016/j.jvs.2014.03.244

Miller, C.A. (2016). Dr. Rudolph Matas: Learned trailblazer, father of vas-cular surgery. Bulletin of the American College of Surgeons, 101(4), 43-44.

Nekkanti, M.K., Vivekanand, Suresh, K.R., Motukuru, V., Kolalu, S., & Kabra, A. (2018). Outcomes of limb and life in patients with acute lower limb ischemia presenting before and after the "golden six hours.” International Journal of Advances in Medicine, 5(4), 788-797. doi: 10.18203/2349-3933.ijam20182498

Pechar, J., & Lyons, M. M. (2016). Acute compartment syndrome of the lower leg: A review. The Journal for Nurse Practitioners, 12(4), 265-270. doi:10.1016/j.nurpra.2015.10.013

Shishehbor, M.H. (2014). Acute and critical limb ischemia: When time is limb. Cleveland Clinic Journal of Medicine, 81(4), 209-216. doi:10.3949/ccjm.81gr.13003

Sommers, M.S. (2011). Color awareness: A must for patient assessment. American Nurse Today, 6(1). Retrieved from https://www.american-nursetoday.com/color-awareness-a-must-for-patient-assessment/

When a post-surgical vascular limb patient is cared for on the medical-surgical unit, it is essential that the nurse

understand the surgery performed, be skilled in performing the appropriate neurovascular assessments, and anticipate

possible complications and interventions.

14

Medicinal Marijuana: What Nurses Must Know

Part I

Nurses strive to deliver quality care on a daily basis in establishments all over the country. By virtue of our profes-sion, we are required to practice according to the best avail-able evidence and to provide whole-person care to those who are entrusted to us. As changing laws impact the prac-tice of professional nursing, it is critical that we educate our-selves so that the quality care we provide is evidence-based, current, and relevant.

One needs to look no further than the local and national news over the past few years to see that laws concerning the use of medical and recreational marijuana have impacted—and will continue to impact—the practice of professional nursing. As of April 3, 2019, 33 states and the District of Columbia have legalized medical marijuana, and 10 states and the District of Columbia have legalized use of recreational marijuana (ProCon.org, 2019). As the beginning of a two-part series, this column provides an intro-ductory framework for what nurses need to know about providing safe care to individuals that use cannabis.

The National Council of State Boards of Nursing (NCSBN) (2018) released guidelines for the nursing care of patients using marijuana. These guidelines were created by the NCSBN Medical Marijuana Nursing Guidelines Committee in response to the lack of information available for nurses who care for people who use cannabis. After review of statistics, legislation, literature, and research on cannabis as a therapeutic agent was complete; and field experts were consulted regarding use, safety, and legal impli-cations; the formal guidelines were created (NCSBN, 2018). The NCSBN National Nursing Guidelines for Medical Marijuana include:

Nursing care of the individual using medical marijuana. •Medical marijuana education in pre-licensure nursing pro-•grams. Medical marijuana education in advanced practice regis-•tered nurse (APRN) programs. APRNs certifying medical marijuana qualifying conditions. •

All nurses should be aware of the “Six Principles of Essential Knowledge” (NCSBN, 2018, p. S19) identified dur-ing the creation of the guidelines:

The nurse shall have a working knowledge of the current •state of legalization of medical and recreational cannabis use. The nurse shall have a working knowledge of the jurisdic-•tion’s MMP [medical marijuana program]. The nurse shall have an understanding of the endocannabi-•noid system, cannabinoid receptors, cannabinoids, and the interactions between them. The nurse shall have an understanding of cannabis pharma-•cology and the research associated with the medical use of cannabis. The nurse shall be able to identify the safety considera-•tions for patient use of cannabis. The nurse shall approach the patient without judgment •regarding the patient’s choice of treatment or preferences in managing pain and other distressing symptoms (p. S19-S20).

Within the guidelines, specific recommendations for essential knowledge are called out that are applicable to:

Nurses who provide care for individuals using medical •marijuana.

Quality Matters

If you have questions or comments regarding the “Quality Matters” column, or if you are interested in writing, please contact Column Editor Cherie Rebar at Cherie.rebar@gmail.com, or Column Editor Nicole Heimgartner at nicole@heimgartner.us

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866-877-2676 Volume 28 – Number 3

Medical marijuana education that should be provided in •pre-licensure nursing programs. Medical marijuana education that should be provided in •APRN nursing programs.

Similarities exist between these specific recommenda-tions, while differentiation exist that are specific to the role and scope of the registered nurse, prelicensure student, and APRN student. For example:

Recommendation No. 1 for all three parties states, “The •nursing student shall have a working knowledge of the cur-rent state of legalization of medical and recreational cannabis use” (NCSBN, 2018, p. S29).

Key learning: •Cannabis is classified as a Schedule I Controlled •Substance by the Drug Enforcement Agency. This classification prohibits practitioners from prescrib-•ing cannabis and prohibits most research using cannabis. The process for obtaining cannabis for federally funded •research purposes is cumbersome. Certain jurisdictions have passed legislation legalizing •cannabis for medical purposes Certain jurisdictions have decriminalized or legalized •recreational cannabis use. “In 2009, the U.S. Attorney General took a position that •discouraged federal prosecutors from prosecuting peo-ple who distribute or use cannabis for medical pur-poses in compliance under the law of the applicable jurisdiction” (NCSBN, 2018, p. S8).

Recommendation No. 2 for all three parties states, “The •nursing student shall have general knowledge of the prin-ciples of an MMP” (NCSBN, 2018, p. S29).

Key learning: •MMPs (medical marijuana programs) are defined and •described by each specific jurisdiction based on that jurisdiction’s statute and rules. Laws and rules related to MMPs are evolutionary; con-•firm the most recent versions. Healthcare providers do not prescribe cannabis. •The MMP specifies qualifying conditions, the certifying •process, and the type of provider who can certify a qualifying condition. The MMP specifies whether APRNs can certify a quali-•fying condition and whether courses or training to par-ticipate in certification of an MMP-qualifying condition. Obtaining and administering cannabis for medical pur-•poses are limited to the individual and/or their desig-nated caregiver; the MMP specifies if designated care-givers are permitted and outlines the process for regis-tration as such. Jurisdictions determine if specific parties such as a hos-•pice employee, visiting nurse, personal care attendant,

or home health aide can act as a designated caregiver for purposes of administering medical marijuana.

In the July/August 2019 issue of MedSurg Matters!, we will discuss the remaining guidelines that are in place to help nurses give quality care to patients who use medical mari-juana. This will entail exploration of the endocannabinoid sys-tem as well as key nursing considerations regarding three main cannabinoids found in cannabis (THC, cannabidiol [CBD], and cannabinol [CBN]).

Cherie R. Rebar, PhD, MBA, RN, COI, is a Professor of Nursing, Wittenberg University, Springfield, OH; and Vice President and Educational Strategist of Connect:RN2ED, Beavercreek, OH.

Nicole M. Heimgartner, DNP, RN, COI, is Vice President and Educational Strategist, Connect:RN2ED, Beavercreek, OH. She may be contacted at nicole@heimgartner.us

References National Council of State Boards of Nursing (NCSBN). (2018). The

NCSBN national nursing guidelines for medical marijuana. [Supplement]. Journal of Nursing Regulation, 9(2). Retrieved from https://www.ncsbn.org/The_NCSBN_National_Nursing_Guidelines_for_Medical_Marijuana_JNR_July_2018.pdf

ProCon.org. (2019). 33 legal medical marijuana states and DC. Retrieved from http://medicalmarijuana.procon.org/view.resource.php?resourceID=000881

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