Medication Management

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Medication History

Healthcare providers and nurses are required to obtain a complete list of medication from each patient on admission in order to comply with the Joint Commission 2019 National Patient Safety Goal # 3 ( NPSG 03.06.01) and other accreditation standards. Healthcare staff should educate each patient about the rationale for collecting information about medication history and current list to improve compliance with the process. All healthcare facilities should develop a medication management plan in order to promote patient safety and prevent adverse outcomes.

Providers

It is often difficult to persuade patients to provide a complete list of home medication. It has been surprising to notice that a lot of patients do not know the correct instructions about their medications. Some patients love to keep their medication and are not always willing to share information with healthcare staff.

Providers are responsible to obtain complete medication history and current list from each patient. They will complete a medication reconciliation based on clinical symptoms and treatment plan. A medication reconciliation requires medication review and validation for continuation or discontinuation. Therefore, the providers will decide what medication to order and discontinue during the entire length of stay. They are also responsible to approve the use of home medication and other therapeutic substitution. Providers often mention medication plan in their admission note. Finally, a complete Medication order must include the right patient, medication, dose, frequency, time, indication, and route.

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Nurses

Nurses are responsible to collect medication history and enter the information in the medical record. If patients are unable to provide the name of the medication, nurses can obtain description of the medication and indication ( 1 pink tablet daily for blood thinner). Nurses should inform patients or health care partner to bring the actual medication in pharmacy dispensed bottle. Nurses should not prepare medication because it is not within the profession’s scope of practice. However, Nurses can reconstitute medication based on manufacturer or pharmacy guidelines.

Nurses do no complete medication reconciliation but rather add information in a database for safety and cross reference. Nurses should educate patients about not keeping medication in their possession while under the care of medical professionals to prevent therapeutic duplication and possible harm . Nurses should secure all patients’ home medication and return medication based on discharge instructions. Nurses should verify medication order and also use critical thinking during medication administration to prevent medication errors.

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Unfortunately, providers are human being and do make mistakes. Nurses are the last discipline to conduct medication verification prior to administration. Therefore, prudence is highly recommended during medication administration. I successfully caught many medications errors during my years of nursing, so nursing vigilance can prevent adverse outcomes. I always verify the last time someone removed the medication from the dispenser or the last time it was signed as given to prevent error. Nurses should review medication that requires therapeutic lab monitoring closely by following agency’s guidelines. Finally, nurses should educate patients about new medication, the indication, side effects and adverse reactions.

Pharmacy

In most facilities pharmacy staff is responsible to procure, prepare , dispense medication, review provider’s order and validate the order for nursing to administer. Pharmacy also clarifies order with provider when indicated and provides specific supplies to facilitate safe medication management. Pharmacy is also very resourceful and can be consulted for medication guidance. Pharmacy also manages therapeutic dosing and lab associated with some medication. Please review your facility’s policy for guidance.

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Medication management requires a multidisciplinary team approach and can be complex in some instances. Healthcare professionals are responsible to discuss medication management with every patient and provide education to patient or health care partner in accordance with Joint Commission and organizational standards. Successful medication management can prevent adverse outcomes and patient’s harm.


Heat Exhaustion

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Last week, I discussed heat stroke and hope my readers learned safety tips to prevent injury during extreme heat wave. Most people confuse heat stroke with eat exhaustion, so I will establish the difference today in a few paragraphs.

CAUSES

The condition is due to heat exposure in combination with humidity and/or strenuous activity in high temperature. It is failure of the body to maintain core temperature i.e normal body temperature. The human body is often unable to regulate its temperature if physically over exerted. Therefore, the body looses its natural ability to cool down by producing less sweat. The condition can be alcohol induced or associated with dehydration. If the symptoms persist, it can lead to heat stroke which is a more severe heat related condition associated with prolonged heat exposure. Please read previous post to learn about heat stroke.

SYMPTOMS

Symptoms can be sudden or progressive and include some of the following signs: sweating, rapid pulse, moist skin, faintness, dizziness, fatigue, hypotension, weakness, muscle cramps, nausea and headache.

RISK FACTORS

The following are risk factors:

Pediatric and geriatric population, immunocompromised individuals, obesity, heat sensitivity and individuals under certain medical treatment or prescribed drugs.

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MANAGEMENT or PRECAUTIONS

Seek medical assistance if symptoms are severe. Consult a medical provider before engaging in serious physical exercise. Avoid the heat, protect your skin from the heat, apply sun cream, stay hydrated, wear loose clothing and do not stay in hot car.

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Untreated heat exhaustion can rapidly progress to heat stroke which is considered to be a medical emergency. It is important to follow safety measures when exposed to the heat. You should avoid prolonged exposure to the heat and ensure you are well hydrated and medically cleared before engaging in physical activities in the heat. You can prevent organ damage related to untreated heat stroke if you follow the safety tips mentioned above.

Sophia Georges MSN, RN


Choosing a Retirement Home or a Long Term Care Facility

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It can be overwhelming to find a safe retirement home or long term care facility. It is beneficial to plan for retirement living ahead of time to avoid financial burden. Retirement living can be expensive, so it requires financial planning and some type of support system. There is no right nor wrong process, but there are some safety measures that should be considered when choosing a retirement home or long term care facility.

Operations

It is important to learn about the background of the facility you select. Past performance can be helpful and can influence decision making. You should also ask about maximum capacity and current operating beds or vacancies. Bed operations data might benefit you in many ways because retirement facilities strive to maintain the highest census or maximum occupancy when possible. You can also review financial statement online and perform comparative analysis within the region. You can save the information to disclose during a visit and while negotiating the contract. You should avoid facilities that are struggling financially because it might be challenging for them to meet their financial obligations which will affect their operations. Patients or residents should verify health care accreditation status and review patients’ complaints by visiting the health department’s website.

Physical Environment

As a Patient Safety Specialist, I highly value psychological safety and physical safety of every patient or resident. It is important to visit multiple facilities at different time of the day. You should select the busiest time of the day to conduct one of the visits in order to identify warning signs of substandard care. In addition, staff tends to be very busy and unable to provide undivided attention to patients or residents during peak hours. My biggest advice is to conduct a quick visual inspection of the physical environment i.e architectural designs, interior designs, entry points, exits, room sizes, showers, safety measures, cleanliness, clutter, medical equipment, nursing station, medication carts, treatment carts, shredder box, type of furniture, stained ceilings, dirty bathrooms, storage spaces, floor appearance, kitchen or pantry, common space, lighting, phones, computers, monitors, hand hygiene and physical security of the building or ward. In addition, you should address psychological safety i.e emergency plan and preparedness, active shooting training, inclement weather guidelines for staff, emergency response or medical emergency management, facility management, and chaplain service.

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Staff Level

It is important to inquire about staff mix in order to identify skill level , chain of command and supervisory authority. You should ask about continuous supervision during off shift because there is less nursing staff on duty at that time. It is safe to discuss availability of independent provider to address patients’ or residents’ medical concerns. You should also ask about approved staffing and nurse to patient ratio. There should be ancillary staff to assist with care planning and other personal needs. Futhermore, you should discuss Registered Nurse representation in the multidisciplinary team to review care planning and rehab to promote motor function. Lastly, it is crucial to discuss staff training and resources available to staff.

Rehabilitation Program

Rehabilitation program includes physical therapy, occupational therapy, recreation therapy, music therapy, arts, mental stimulation games, speech pathology, field trips, shuttle to local stores, group exercises and many more. It is very important to choose a facility with aggressive and effective rehabilitation program with the goal to promote physical activities and strength. The examples mentioned above should enable effective decision making. Next time you decide to transition to a retirement home or long term care, contact Nurse Sophie to assist you with the process.

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Patient Safety is my priority !

Sophia Georges MSN,RN


Preventing Heat Stroke

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Summer is the season to have fun with friends and family. Most people enjoy road trips, indoor and outdoor activities. I used to spend time with my grandparents in the country side when I was younger, and I truly enjoyed every moment I spent with them. As a nurse, safety is always my priority, and I love to educate others about healthy behaviors to avoid preventable injury. It was a hot day in Maryland today, and a heat advisory was in effect. Temperature was in the high 90’s, and it was hot and humid.

Heat Stroke

This condition occurs as a result of prolonged exposure to heat or following extreme exercise in the heat. The body overheats and temperature can rise up to 104 F (40 C) or higher. Normal body temperature is between 97(36 C) and 99 F ( 37.2 C). The condition requires emergency treatment to prevent acute multi organs failure due to severe dehydration, poor tissue perfusion and change in cardiac output. The brain is usually affected first, and most patients will demonstrate change in mental status, headache, dry skin, nausea, vomiting, fast breathing ( tachypnea) and racing heart rate ( tachycardia)

Wahoo Bay Beach Hotel Resort in Haiti.
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Treatment

You do not have to be a healthcare professional to save lives. If someone that you know exhibits the signs and symptoms mentioned above, please call emergency response (911) and ensure the scene is safe. Create a shade to prevent additional exposure to heat, remove heavy clothing, try to cool the body down with water, cool towels, fans, ice packs or use a spray bottle. Never feed nor offer drink to anyone who appears to be in acute distress unless you are a trained healthcare professional. Avoid excessive cold application to prevent nerve damage. The rule is to apply cool compress for 30 minutes or less.

Who is at Risk?

Pediatric and Geriatric population are at greater risk compare to young adults. However, young adults with underlying health conditions should consult their primary care providers before engaging in activities under the heat. Anyone with compromised health system is at risk ,and others with heat sensitivity might also be at risk.

Prevention

Consult a medical provider before engaging in strenuous outdoor physical activities, know your limitation, wear appropriate clothing, stay hydrated with water instead of soda or caffeinated drinks, wear a hat, apply broad-spectrum sun cream with SPF of at least 15, wear shades and never sit in heated car.

Severe Complications

Acute multi system failure and possibly death when treatment is delayed.

Go to Haiti and enjoy a nice summer vacation at the beach!

Sophia Georges MSN,RN


What is Dementia?

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Dementia is a disorder of some functions of the brain and mostly demonstrated by memory loss and impaired judgment. People who suffer from dementia often experience difficulty performing activity of daily living. The inability to complete certain tasks often leads to frustration. Some of the symptoms associated with dementia are exhibited by difficulty processing new information i.e short term memory deficit, trouble with speech, self care and inability to recognize objects and people. Dementia is not part of normal aging, but it is rather common in the geriatric population.

Alzheimer’s disease is the most common form of dementia and is demonstrated by short term memory deficit, difficulty with language and speech and trouble mimicking motor movements. Scientific evidence shows severe brain cells damage in dementia which prevent normal cell communication by creating plagues deposits. The brain cells damage also create threads of protein that are twisted into tangles. This action interferes with normal transport system and may lead to death of brain cells.

There are over five million of people currently diagnosed with dementia/Alzheimer’s disease in the United States, and scientist expect this number to grow bigger in the near future. The disease is mostly common among geriatric population (65 or older) Alzheimer’s disease is also considered to be the 6th leading cause of death, but people usually live twenty years following diagnosis. However, others with more severe symptoms live on average four to eight years.

Vascular dementia is related to blood vessels damage in the brain, and some of the symptoms include memory loss, poor concentration, poor motor coordination ( tremors and shuffling gait) Frontotemporal dementia is mostly associated with damage to the frontal and temporal lobes and often leads to extreme behavior i.e anger, rudeness and inappropriate social interaction. People with that type of dementia often demonstrate cognitive deficit, lack of judgment, poor impulse control and lack of motivation and committment.

I will not be able to cover all types of dementia because there are many types that can be diagnosed following serial testing. I had the opportunity to manage the care of a group of retired residents diagnosed with a type of Alzheimer disease, and the experience has truly gratifying and has enabled me to appreciate life. I observed behavioral changes almost every day among the residents and noticed they have difficulty to express their immediate needs. They also demonstrated delay in response to stimuli and delay reaction to immediate danger. Based on the pathophysiology mentioned above, I knew the delay was related to interference in communication due to brain cell damages. Care givers should strive to reduce safety risk among people living with dementia.

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Caring for People with Dementia/Alzheimer’s disease

As you can see, people living with Alzheimer’s disease can be unpredictable and require constant supervision to maintain their safety. The goal is to provide individual centered care to promote compliance and maximize outcomes. Care givers should incorporate activities that interest those living with the disease. It is highly recommended to collect clinical data about personal hobbies, profession, skills and different activities. I learned that patients with dementia lose the ability to control their impulses and therefore, unable to formulate intellectual judgment and often unaware of misbehavior. However, they are able to retain life skills acquired many years ago. For instance, they might clean all day if they used to be a housekeeper or love playing with the phone if they held telemarketing or communication jobs in the past. In summary, they are often 20 years behind and remain trapped in the past.

A former preacher might spend most of the day reading biblical scriptures whereas, a singer might spend the day singing old lyrics. I must also add that people living with dementia respond well to music and art therapy. I strongly encourage relationship building in order to promote trust. When developing a care plan for people with dementia, it is important to include simple tasks that are short and easy to mimic, consider individual cognitive level and physical ability and modification in physical environment to promote safety. By now, I hope you understand that patience is very important when caring for people with dementia.

Managing Aggressive Behaviors

My professional’s approach when caring for patients with dementia is to monitor acute changes in behavior or mental status. Most acute illnesses in the geriatric population are demonstrated with neurological changes. When patients exhibit signs and symptoms of increased confusion, aggressive behavior, withdrawal , lack of interest in activities, I try to deescalate the situation first , assess vital signs, provide appropriate treatment when indicated and obtain orders from a provider for diagnostic testing to rule out acute processes. As the care giver, I have to protect the patient and understand that aggressive behaviors are often underlying symptoms of undiagnosed conditions. Care givers can also engage in different activities with patient and should strive to keep Alzheimer’s patients busy most of the time. Cognitive simulation exercises are very beneficial to those patients.

In conclusion, it is very challenging to care for people with dementia. However, person centered care often promotes collaboration and better outcomes. Aggressive behaviors are often associated with acute illness or process and should be managed immediately to prevent rapid decline. The geriatric population is expected to increase in the next 25 years with baby boomers reaching retirement age, so nurses should acquire disease specific knowledge and participate in training in order to provide patient centered care. Alzheimer’s disease is not associated with aging, but is mostly common among geriatric population. With patience and critical thinking, care givers will successfully provide safe care to patients living with dementia. Pharmacological intervention is often based on series of trial until patients demonstrate symptoms management.

Safety Advice: Never fight patients or people living with dementia!

Sophia Georges MSN, RN