Diabetes: A Nursing Analysis

Ms. Rita is a 15 year old female. She is a known case of poor control of sugar level since one month without regular medication. When patient was admitted to hospital her random blood sugar =300mg/dl. She had no history of vomiting, breathlessness, altered sensorium or bowel trouble. She had a history of weight loss. On her initial examination she was calm, conscious and cooperative and well oriented to time, place and person. Her BP was 140/90mmhg, pulse-80 per minute, abdomen soft non- tender and no organomegaly. She had a history of polyuria and weight loss and increased thirst. Chest vesicular breathing, no added sound. CVSSI, S2 heard normally.

Investigations:-
Urine Color                Pale, turbid
Reaction                     6.0
Albumin                     + + +
Sugar                          + +
Ketones                     Negative
Glucose (F)               303mg/dl
Hb                              8.3gm/dl
TLC                            9000/Ul
DLC                            N-49%L-47%M-2%E-2%
Platelets                    4.15 lacs
Total cholesterol     160mg/dl
DHLcholestrol         30mg/dl
LDL                           100mg/dl
VLDL                         30mg/dl
Triglycerides            150mg/dl
T. Cholesterol ratio           5.33
Glucose (F)             253mg/dl

FINAL DIAGNOSIS:-Type 1 Diabetes mellitus

Diabetes Mellitus type 1 is a chronic disorder of carbohydrate, fat and protein metabolism. A defective or deficient insulin secretary response, which translates into impaired carbohydrate (glucose) use, is a characteristic feature of diabetes mellitus (Goodman and Gillman’s, 2001).

Type 1 diabetes is also called Insulin Dependent Diabetes Mellitus (IDDM) and was previously referred to as juvenile onsetdiabetes. It occurs due to decreased insulin production and unchecked glucose production by the liver. Insulin enables the sugar to get out of the blood and into the cells where it is needed for the cells to function.Diabetes results from a severe, absolute lack of insulin resulting in reduction in beta cell mass. Beta cells are a type of cell in the pancreas in areas called the islets of langerhans. These beta cells produce insulin. The function of insulin is to counter the action of a number of hyperglycemia-generating hormones and to maintain low blood glucose levels. Due to lack of insulin sugar will not be able to get into the cells so, there will be a high concentration in the blood. On the other hand, high amount of insulin shifts too much sugar into the cells and there will be not enough sugar left in the blood (Mohan, 2000). Lack of insulin affects them because insulin allows for the absorption of glucose by cells in the body and is secreted by the beta cells, in response to elevated glucose in the blood (Chatterjea, 2000).

To treat the high level of glucose insulin was given to the patient. Insulin works to lower blood glucose by promoting the transport of glucose into cells and by inhibiting the conversion of glycogen and amino acids to glucose (Smeltzer, 2004).

Ms. Rita was suffering from polyuria which is increased amount of urine (Smeltzer, 2004). When the blood glucose level is significantly elevated, (it is also mentioned in the above paragraph) the kidneys are unable to handle the workload and therefore allow the excess glucose to spill over into the urine. The glucose in urine acts osmotically means higher concentration to lower concentration to draw more water into the urine, resulting in polyuria (Cotran, 2000).

Mrs. Rita’s urine was pale and turbid color. It occurs because concentration of glucose in the blood rises. The renal threshold for glucose is, usually 180 to 200mg/dl. When blood glucose increases, the kidneys may not reabsorb all the filtered glucose and the glucose than appears in the urine making it pale and turbid (Smeltzer et al, 2004).

She had a problem of Polydypsia which means excessive thirst. As explained above glucose in the urine is increase, rising the osmotic pressure of the urine, this ways pulls the water along with the glucose in to the urine which leads to excessive urination called polyuria, causing a lack of overall body fluids making the blood hypertonic. This hypertonicity provokes the brain to initiate thirst as a compensatory mechanism of dehydration so that loss of water can be fulfill (Chaudhuri, 2002).

She was suffering from problem of weight loss. Loss of tissue mass occurs in the insulin- dependent form of the disease (the consequence of glycosuria) that characterizes the illness. Role of insulin is to provide entry of glucose into the cells. Insulin deficiency result in non utilization of glucose as it cannot enter into the cells leading to impaired synthesis of protein, fat and simultaneously cause accelerated breakdown of proteins and fats for production of energy causing a catabolic state. It means there is accelerated breakdown of fat and muscle secondary to insulin deficiency leading to weight loss.

Ms. Rita’s blood pressure was 140/90mmhg. The reasons for the increased blood pressure are hyperinsulinemia, glucose intolerance and reduced level of HDL cholesterol. In a normal physiological state nitric oxide synthesis is stimulated by insulin besides decreased synthesis and responsiveness to non insulin resistant states have been associated with increased level of endothelin-1 and potent vasoconstrictor and proarthero sclerotic vascular hormone associated with hypertension 4ia,, e.of Pathologrica..outh.within the central nervous system, all these hormonal changes may play a major role in the gastr(Kumar and Clark, 2005).

Overall management was good and Ms. Rita discharged in satisfactory condition.

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REINVIGORATE TO LIFE WITH THERAPEUTIC HYPOTHERMIA

Successful resuscitation and therapeutic hypothermia determines the best clinical outcome after a cardiac arrest. Therapeutic hypothermia is not limited to cardiac arrest but its been used extensively in patients with stroke, traumatic brain injuries, during cardiac catheterization surgeries and neonatal resuscitations. Hypothermia increases the chances of good neurological outcome. American Heart Association’s chain of survival emphasizes the need for post cardiac arrest care and recommends therapeutic hypothermia during Return of Spontaneous Circulation (ROSC) management and care.

Physicians and researchers have been using this for ages. Hippocrates recommended the use of topical cooling to stop bleeding .In the early 1990, it was found that mild hypothermia, even after the cardiac arrest had benefit for the brain. Peter Safar added the word H after the A,B,C,D…. of resuscitation. The history of inducing hypothermia began in the 1950s with elective moderate hypothermia (28-32) of the brain for the protection and preservation of the brain. Recently, former formula1 champion Michael Schumacher was kept in therapeutic hypothermia after traumatic brain injury. Four randomized control trials done among 417 patients who were successfully resuscitated from cardiac arrest proved that, it improves neurologic outcome.

Therapeutic hypothermia otherwise also known as mild therapeutic hypothermia, induced hypothermia is of two types invasive and non invasive. Invasive methods include intravascular cooling catheters and ice cooled infusions whereas non invasive methods include cooling pads, fans, alcohol baths, cooling blankets, ice packs, perfluorocarbon into the nasal cavity. There are different types of cooling which ranges from mild cooling (32-34) to severe cooling up to 28 .

AHA recommends that all unconscious patients achieving ROSC after out-of-hospital VF cardiac arrests receive induced hypothermia it also state that induced hypothermia may be beneficial in non-VF arrest for out-of-hospital or in-hospital arrest.

Nursing care plays a pivotal role in preventing irreversible brain damage and adverse outcomes after cardiac arrest. A close and continuous monitoring of vital signs which includes temperature, pulse, blood pressure, oxygen saturation ECG, input output and shivering scale monitoring should be performed during the maintenance phase of Inducing therapeutic hypothermia. Intravenous fluids with glucose content should be avoided. Close observation s required as patient is under analgesia and sedation. There is a high risk for getting infection if there is any delay in wound healing, aspiration and ventilator associated pneumonia. Fluid and electrolytes such as potassium, magnesium phosphorous calcium should be monitored and replaced. Other laboratory values such as haemo concentration, PT, INR, PTT should also be checked at frequent intervals.

Re warming plays a crucial role in Therapeutic hypothermia;warming should be done at a slow pace to prevent complications. Rebound hyperthermia seizure, cerebral edema, hypotension and ventricular fibrillation are other potential life threatening complications.

A prospective cohort study of four years conducted among 67,48 patients from 538 hospitals concluded that after in- hospital cardiac arrest, therapeutic hypothermia was used rarely and once initiated the target temperature was commonly not achieved. Post cardiac arrest care is a multidisciplinary approach. Ignorance, lack of knowledge, lesser facilities could be the reason for not initiating post cardiac arrest care, educational modules, simulation exercises, protocol development and continuing education can increase awareness and can translate laboratory researches into bedside actions.

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NURSES – NO MORE HANDSHAKES

As Nurses we offer handshakes to meet patient’s expectations and to develop a rapport with them. In developing countries such as India, shaking hands has become common, especially in the large cities among nurses and other health care workers dealing with patients.^{1, 2} Ritualistic touching plays a crucial role in many cultures. Though handshakes give a profound impact in better patient outcomes, it also has the potential for greater efficiency of pathogen transmission, and handshakes are known to transmit bacteria.^3,4In India though significant advances have been made in infection control, inadequate practices and surveillance systems persist and there is often a high risk. Several food borne disease outbreaks have been reported which are associated with poor personal hygiene. The US Centers for Disease Control and Prevention says that one in 25 hospitalized patients develop an HAI and 75,000 patients with HAIs die during their hospitalization each year. Scientists at Aberystwyth University in Wales have shown that a shake transfers more bacteria compared to other forms of hand-on-hand action. Health care providers like nurse’s hands spread potentially harmful germs to patients that leads to healthcare-associated infections (HAI) i.e., infections acquired in health care also called as “nosocomial” and “hospital” infections.⁷According to WHO, out of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection. The endemic burden of HAI is also significantly higher in low as well as middle income than in high-income countries, in particular in patients admitted to intensive care units and in neonates.⁵

So what next? Will fist bumps (also called dap, pound, fist pound, brofist, donsafe, spudding, fo’ knucks, box, Bust, pound dog, props, Bones, respect knuckles, bumping the rock, or knuckle crunching) replace handshakes in the hospital or any public places? Fist Bumps are basically an urban form of greeting one another by the bumping of fists together, meant as a form of respect.

When you do a fist bump, a smaller amount of surface area is in contact between the two hands. According to a new study “Fist bumping” transmits less bacteria than either handshaking or high-fiving while still addressing the cultural expectation of hand-to-hand contact among patients nurses and clinicians.⁶ A British study has found that high-fives pass less germs as the traditional greeting and the fist bump is even cleaner.⁷In an another study the West Virginia researchers found that the individuals who shook hands had four times as many pathogens on their hands as the individuals who fist-bumped, according to results published last year in the Journal of Hospital Infection.⁸

There have been calls in the Journal of the American Medical Association to ban handshakes from hospitals and make it a global best practice.⁹ American Medical Association, suggested that hospitals, clinics and other healthcare facilities post signs with messages as “Handshake-free zone: to protect your health and the health of those around you, please refrain from shaking hands while on these premises.”¹⁰

If we go back to the Victorian age; when on meeting someone you bow or curtsy from a respectful distance . NURSES – NO MORE HANDSHAKES. Next time you want to say “hi,” show off how casual you are with a friendly fist bump or just bow and say a Namasthe!

The question remains if healthcare facilities implement the fist bump and make it a global best practice.

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Telehealth Nursing in India is a Global Best Practice

As Indian population is growing rapidly and it has become the second highest in the world, there is a huge need to have more healthcare facilities. Most of the hospitals require more number of nurses and doctors who can treat patients quickly and efficiently. To fulfill this need, technology has provided a boon called as Telemedicine and further now it is growing as Telehealth Nursing.

Telehealth Nursing is a very novel concept in India. It is one of the Global Best practices, which is in the initial stage in India. First, let us understand what is “Telehealth Nursing” . According to American Telemedicine Association (ATA), telehealth nursing is defined as the use of telehealth/telemedicine technology to deliver nursing care and conduct nursing practice. Nurses are directly engaged in the virtual delivery of healthcare through telehealth nursing.

Telehealth nurses require the same nursing skills and knowledge similar to nurses practicing in specialty areas. Along with this they should have the ability to understand and apply technology to the best of their capability to assess and communicate the patient’s physical and mental status. Nurses also need to understand that even technology has some limitations and certain aspects in nursing are dealt with physical presence rather than virtual presence.

Telehealth Nursing is an extension of Telemedicine. Now, let us understand little bit about Telemedicine. According to ATA (American Telemedicine Association), it is broadly defined as the delivery of any health care service through any telecommunication medium, for example, a patient consulting a physician, nurse or allied health professional via a video conference, rather than face to face or in person, or a patient with a chronic condition utilizing an in home device to monitor vital signs and transmit data to a nursing center for assessment and medical intervention.

Patients and health care personnel such as physicians, nurses, and technicians living in different geographical places can communicate easily with the help of telemedicine. The senior Director of communication at ATA states that “the one thing that ties all telemedicine together is that it involves a clinical health care service, it directly contributes to the health and well being of the patients, and the patient and provider are separated by some geographic distance.

We Indians are becoming more technology savvy and it is need of the hour to understand and utilize Telehealth Nursing and telemedicine to our best advantage, as we are hugely populated. People should get all nursing and medical facilities even if they are in different geographical areas.

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Finding the Right Post Graduate Nursing Program

A previous blog, Benefits of a Higher Nursing Degree, to Internationally Educated Nurses, discussed the importance of a higher nursing degree while pursuing a career as a Global Nurse. This blog discusses how an IEN can go about deciding on to find the right post graduate nursing program at a leading academic institution overseas.

As written in the blog referred above, nurses typically explore the option of enrolling for a higher degree for reasons of career growth, better remuneration, building higher competence, or interest in the subject matter. In addition, factors such as whether to pursue the higher nursing degree part-time or full-time, and the ability to relocate influence the choice of academic institution, and by extension the post graduate nursing program.

What are the steps involved in choosing a post graduate nursing program? Let’s first consider the reasons for wishing to enroll for a higher nursing degree. If the reasons are career growth and remuneration, then the first step is to do carry out a bit of background research (future casting) on current in-demand specializations and future healthcare trends, in the country of interest. If the reasons are a desire to shift to academics or to move into management, the options are far clearer and more limited.

Once an IEN has drawn up a list of potential specializations or programs, the next step in the decision process is deciding whether relocation is an option, in order to pursue the post graduate nursing program. Ideally, an IEN should not be constrained by geography, when taking a decision on which academic institutions to shortlist, as this freedom allows the aspiring student to choose the best institutions for a particular specialization. However, financial and personal factors may constrain the IEN to limit the choice of potential academic institutions to specific geographies; in which case compromises will need to be made with respect to the quality of the program and the profile of the academic institution.

Based on the decision on whether to stay put or to relocate, the IEN can draw up a list of academic institutions that offer the post graduate nursing programs of interest. The following criteria can be used to evaluate academic institutions prior to shortlisting them:

• Reputation

Although this sounds like a no-brainer, the reason behind listing this criterion is that an aspiring student needs look beyond how well-known an academic institution is, and find out how good the academic institution is in the post graduate nursing programs shortlisted by the student. Famous academic institutions have very competitive  student-admission norms and can be quite expensive, while not boasting of the best reputation in a specific nursing specialization.

• Faculty

A good process to evaluate the strength of an academic institution in a specific nursing specialization is to go through the faculty roster for that specialization. Well-known names, frequent and impactful publications (in terms of citations and publication in high-impact journals) on the subject matter, and the quantity and quality of doctoral programs in the department are good proxies to judge the quality of the faculty.

• Industry Partnerships

Depending on the specialization chosen, aspiring students should also investigate industry partnerships that the selected academic institutions boast of, as they would be important in determining the quality of the practicum or the internship, if either of these are part of the course structure.

• Course Fee

Leave the cost of the program decision criterion for the last. Once the aspiring student has shortlisted a couple of academic institutions and a specific post graduate nursing program in each of them, only then should the student look at the course fee. The reason for this is because student loans are not too difficult to arrange, and it makes no sense cutting corners on a program that is going to demand a significant quantum of the student’s time and thinking for the next couple of years. Furthermore, many institutions offer scholarship programs that the student can apply to.

INSCOL Academy offers post-graduate nursing programs, targeted at IENs, in specific nursing specialisations, in nursing management, and in nursing education, in a choice of colleges and universities in Canada, the UK, and the USA:

INSCOL Academy also arranges for part-scholarships for the programs on offer, so that a portion of the financial burden is taken off the IEN’s shoulder. So, if, as an IEN, you have prepared your shortlist of post graduate nursing programs, give INSCOL Academy a call for guidance on the most suitable options available to you.

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Nursing: Is it a Feminine profession?

The answer to the above question is both “Yes” and “No”. The reasons for the ambiguous answer are many, and some of these will be discussed in this blog.

If someone asks me what my profession is, I casually tell them that I am a “nurse”. Many times people wonder how males can become nurses. The majority of the population in India (except in Kerala) view nursing as a feminine profession. They have their own seemingly solid reasons for doing so. We all know that nursing is a noble profession, and that it needs an attitude of caring, a passion to serve, and hard work. Our society adheres to a stereotype that ascribes all these qualities to women only, perceiving men as generally not possessing these qualities. However, as with all stereotypes, the facts on the ground cannot be categorized so clearly into black and white: both genders display attitudes of caring and of a passion to serve, albeit at different levels of frequency.

These days the nursing sorority is changing, with a lot of men taking up nursing as a profession; especially since there are attractive career opportunities for Indian nurses overseas.  In India too, there is a growing need for male nurses in hospitals: in the fields of Psychiatry and Critical Care, hospitals need more male nursing staff. The conventional view of nursing is changing rapidly and the stereotype is gradually breaking, so much so that in future we can safely refer to a nursing fraternity, in addition to a nursing sorority.

According to an article in the Times of India, the Rajiv Gandhi University of Health and Sciences (RGUHS) – a University for medical and paramedical sciences – states that  the number of males taking nursing as a profession has doubled over the last five years. In the academic year 2007-08, only 97 males registered for the B. Sc. Nursing course, as against 276 females. The equivalent figures in the academic year 2010-11 were 2454 and 5270, respectively. Similarly, men are being represented in PG nursing courses as well. The 2007-08 figures showed only 26 males opting for the M. Sc. Nursing course, as against 91 females; but the number surged to 98 males in the academic year 2010-11, as against 216 females.

In conclusion, it is clearly evident that nursing is not just for women; even men can take up nursing as a profession and be successful. An earlier blog talked about Nursing as an Attractive Career Option for Men, and if you found this blog interesting you may find that too.

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Benefits of a Higher Nursing Degree, to Internationally Educated Nurses

You worked hard to graduate with a nursing degree or a nursing diploma, and then you completed a post-basic nursing program abroad, to further your knowledge and skills, and to prepare you for a career as an Internationally Educated Nurse (IEN).

Now that you have settled into a promising career as a Registered Nurse (RN) in a healthcare organization abroad, why would you even wish to consider enrolling for a higher nursing degree or for further specialization? Well, here are a few good reasons:

1. Higher Remuneration

A higher qualification does translate to higher remuneration. As pointed out in a previous blog, Nursing as an Attractive Career Option for Men, in the USA male nurses tend to earn more than their female counterparts, in the same role, on account of their higher qualifications. Job sites such as Monster quantify these wage differences, listing out the highest paying nursing jobs.

2. Better Patient Care

A series of studies in studies in the United States and Canada, between 2003 and 2006, covering close to 300 hospitals, 23,000 nurses, and 300,000 patients, found a link between an increased proportion of RNs with Bachelor’s degrees in acute care hospitals and significantly decreased patient mortality rates (Aiken, Clarke, Cheung, Sloane &Sliber, 2003; Estabrooks, Midodzi, Cummings, Ricker &Giovanetti, 2005; Tourangeau, et al., 2006). It is not clear why this should be so, but it is hypothesized that more qualified nurses are better prepared to handle complex patient needs.

3. Career Options

A higher nursing qualification or specialization opens up a variety of career opportunities within nursing. Also, a careful selection of complementary specialization can act as a hedge against cyclical surpluses in specific nursing specializations.

4. The Knowledge Thrill

Finally, a higher qualification can be rewarding just for the pleasure one gains from acquiring the latest knowledge in a subject or practice that one is passionate about. The workplace is a great setting to clarify one’s professional interests and inclinations, and with work experience some nurses come to the realization that they would like to pursue higher studies in areas that deeply interest them, for the sheer sake of keeping at the cutting-edge of knowledge in the respective specializations.

A higher nursing  can be pursued either through a continuing education program or by taking a sabbatical or by taking a career-break. Which option to pursue will depend on the nature of the higher degree – some programs are not available in a continuing education format; the policies of the employer – some employers offer sabbatical leave, while others do not allow sabbaticals; and, the individual’s ability to juggle multiple responsibilities – work, academics, family.

Choosing the right specialization is crucial to ensuring that the higher nursing degree helps, and not hampers, a nurse in her or his career. If the reason for going in a higher degree is interest in a subject matter, then the choice is fairly straightforward. However, if the reasons for embarking on the higher degree are better career prospectors higher levels of competence, then the prospective student would do well to indulge in some future-casting:

• Check popular job portals to get an idea about the nursing specializations (or super-specializations) that are in demand currently, and their respective remunerations. It is not always certain that the trends will remain unchanged over the next two years that one takes to complete one’s higher nursing program, however,  knowing current trends is useful.

• Keep abreast of healthcare industry trends in one’s geography. For example, in Western societies, the greying of the population is only going to increase, so a specialization in gerontology is a safe choice. Alternatively, with the shift from therapeutic medicine to preventative medicine,  the demand for Nurse Practitioners is only going to increase.

• Contact organizations, such as INSCOL Academy, that specializes in delivering higher nursing degree programs to Internationally Educated Nurses. INSCOL Academy offers a variety of customized & exclusive programs to working professionals and to those interested in pursuing a full-time academic program & a career progression: post-graduate programs in Critical Care Nursing, Acute Complex Care, Palliative Care, Community Mental Health, and Gerontology; Master’s programs in Nursing & Healthcare and Nursing Education.

Although this blog is about the usefulness of a higher nursing degree, don’t be constrained by the “nursing” in higher nursing degree. For example, with the increasing diversity of most societies in the developed world,  learning a new language, although not contributing directly to a nurse’s professional knowledge, can be a very useful career investment too.

The motivation to pursue a higher nursing degree has to come from within an individual, since the sacrifices required to be made are not going to be trivial. The benefits of such a move are clear to see, and the most important decision a practicing nurse has to make is whether the costs (personal and professional) are worth the final pay-off.

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HYPOTHYROIDISM – A NURSING ANALYSIS

In this draft case, hypothyroidism is critically analyzed using global best practices and with focus on altered physiology and path physiology. Mrs. Smith (name changed for the reason of confidentiality), a 60-year old, female patient, was presented with chief complaints of cold intolerance, weight-gain despite decreased appetite, bradycardia, constipation, fatigue, lethargy and puffiness of eyes. At the time of admission of the patient the following parameters were recorded:

Vital signs                                                            Lab Test
BP -      130/90                                                      Hb -          13.8 gm/dl [12-16 gm/dl]
Pulse – 50/min                                                      TLC -       11,000 [4,000 – 11,000/ul]
RR -     20/min                                                       Platelets -   2.45 lacs [1.50 – 4.0 lacs]
Spo₂ -   95%

Renal Function Test                                         Thyroid Test  
B. urea        – 2.5[10-40mg/dl]                          TSH -        7 µIU /mL   [0.25-5.0µIU/mL]
B. creatinines – 1.2 [0.5-1.4mg/dl]                    T3     -       0.80nmol/L [0.92-2.33nmol/L], T4 – 40nmol/L [60-120nmol/L]

Critical Analysis:
Mrs. Smith came to the hospital with signs and symptoms of hypothyroidism (Black & Hawks, 2005). Hypothyroidism is a hormonal disorder which affects the neuroendocrine control of the body. Hypothyroidism is a clinical syndrome resulting from the deficiency of the thyroid hormones: T3 (tri-iodothyronine) and T4 (thyroxin). This disorder can range from sub-clinical hypothyroidism with no obvious symptoms, to severe hypothyroidism with overt symptoms (Smeltzer et al, 2004).

In hypothyroidism there is decrease in production ofT3 and T4 by the thyroid gland. From the above diagrammatic representation, it can be clearly made out that when there is decreased production of T3 and T4, there occurs a negative feedback cycle directed at the hypothalamus. Usually, when the hypothalamus does not have a negative feedback, it starts increasing the production of TRH (Thyrotropin-Releasing Hormone) which acts on the pituitary gland to increase the production of TSH (Thyroid-Stimulating Hormone). In hypothyroidism, in spite of raised TSH levels, T3 and T4 levels are low because the thyroid gland is unable to produce them in sufficient quantities (Tripathi, 2003) (Kasper et al, 2001).

Mrs. Smith had puffiness of both eyes when she came to the hospital. She also had non-pitting edema. Non-pitting edema occurs due to increased quantities of hyaluronic acid and chondroit in sulfate binding with the protein occurring in the interstitial space, causing the total quantity of interstitial fluid to increase. Since this interstitial fluid is of a gel nature, it is immobile, and consequently the edema in hypothyroidism is the non-pitting type (Guyton and Hall, 2006).

Normally, thyroid hormones increase active transport of ions through the cell membranes. One of the enzymes that increase its activity in response to thyroid hormones is Na+-K+-ATpase which increases the rate of transport of sodium and potassium ions through the cell membrane of tissues. This process uses energy and increases the amount of heat produced in the body. It has been suggested that this is one of the mechanisms by which thyroid hormones increases the body’s metabolic rate (Guyton and Hall, 2006). Since there was a deficiency of thyroid hormones in Mrs. Smith’s body, the activity of Na+-K+-ATpase enzymes decreases, leading to a decrease in the metabolic rate. The mitochondria inside the muscle fibers requires three chemicals – glucose, Vitamin –B, and the thyroid hormone T3 – to generate ATP (Adenosine Triphosphate) (Kasper et al, 2005). In Mrs. Smith’s body there is a decrease in T3, so ATP is depressed, leadingto energy within the cell for metabolism decreasing, resulting in decreased metabolism. The decrease in metabolism leads to dysfunction in Mrs. Smith’s body, like fatigue, which is due to the decrease in ATP levels and muscles not getting therequisite energy for relaxation. Cold intolerance is also due to the same process,as the decrease in ATP levelsresultsless heat being produced, leading to a fall in Mrs. Smith’s body temperature falls.Thedecreasein appetite, due to a decrease in the motility of the intestinal tract, is once again again attributable to a reducedbasal metabolic rate (Richard, 2005).

Mrs. Smith’s heart rate was 50 bpm (beats per minute). A heart rate of less than 60 bpm is regarded as bradycardia (Steadmen, 2000). Normally, T3 increases beta receptors in the blood. In Mrs. Smith’s body the decrease in T3 enzymes means less production of beta receptors, which leads to a fall in the heart rate, because beta receptors control the heart rate (Goldman and Ausiello, 2008).

Mrs. Smith also experienced weight gain despite the loss of appetite.This is due to the decreased secretion of thyroid hormones. The normal effect of thyroid on metabolic products is explained in flowchart 1 (Guyton and Hall, 2006), and how hypothyroidism leads to weight gain is explained in flowchart 2(Goodman and Gilman’s, 2002).

Constipation is another symptom which occurs due to decreased metabolism.Decrease in metabolism alters the function of the small intestine, whichmeans that the peristaltic waves of the small intestine are reduced, which give rise to constipation (Kumar & Clark, 2006).

Mrs. Smith was started on treatment with Levothyroxine sodium. Levothyroxine sodium acts, similar to endogenous thyroxine, to stimulate metabolism and reverse the metabolic rate.It also increases the rate of energy exchange and increases the maturation rate of the epiphyses. Levothyroxine sodium is absorbed rapidly from the gastrointestinal tract after oral administration. The aim of the treatment is to normalize increased thyrotrophic levels (TSH) (Katzung,2001)

To summaries, the above information will assist nurses to recognize early signs and symptoms of hypothyroidism,and recognize its effect on the regulation of body functions. This will help nurses intervene early and educate patients in self-care.

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Meeting Patient Expectations: Determinants and a Nurse’s Role

Each human being is unique and no two individuals are the same in their demeanor. This unproven fact becomes most evident when an individual becomes ill. In this current era of consumerism, people are highly conscious and knowledgeable about services they can expect from a merchant, and there are a number of public initiatives to make them understand what to expect, in a service or a product. Meeting such expectations, on the part of the merchant, results in customer satisfaction, which is the highest goal of a service or a product. This satisfaction could be brand-driven, technology-driven or due to the influence of other factors.

In healthcare too, patient satisfaction or meeting a patient’s expectations, is one of the major goals of any healthcare provider, and this is determined by the patient’s experiences during the duration of the patient’s interaction with the healthcare provider. The most challenging job for a healthcare provider is to attain patient satisfaction. This article sets out to discuss the determinants of customer satisfaction in a healthcare setting.

There is no mutually agreed definition of what is patient satisfaction. The University of New South Wales, Australia, (2009) worked out a definition to conduct research on ‘Complaints and patient satisfaction: a comprehensive review of the literature’. According to this definition, patient satisfaction is defined as the degree to which the patient’s desired expectations, goals and or preferences are met by the healthcare provider and/or service.

Determinants of patient satisfaction

A number of studies have been conducted on the topic of ‘how to make the patient really satisfied or what makes the hospital stay for a patient a better experience’. A survey was conducted by Brown, Sandoval, Levinton, and Blackstien-Hirsch (2005) to unveil the most efficient ways of improving satisfaction in emergency departments. A questionnaire on patient satisfaction, mailed to 20,500 patients who visited 123 Emergency Departments (EDs), was used to develop ordinal logistic regression models for overall quality of care, overall medical treatment, willingness to recommend the ED to others, and willingness to return to the same ED. The survey found out that the four main predictors are “perceived waiting time to receive treatment,” “courtesy of the nursing staff,” “courtesy of the physicians,” and “thoroughness of the physicians.”

Another retrospective study was conducted in France by Boyer, Antoniotti, Sapin, Doddoli, Thomas, Raccah, and Auquier, (2003), with the objective of looking for the relationship between a patient’s satisfaction and the quality of care, in two diseases (diabetes, lung cancer), and which was evaluated by the French-validated Questionnaire of Satisfaction of Hospitalized patients (QSH).  Quality of care is measured by some objective indicators, in accordance with recognized guidelines. The results surprisingly found that there is a negative correlation between accreditation and patient satisfaction (r = – 0.23; p < 0.05) and that the least-satisfied patients are not those who have the worst quality of care. Furthermore, a link has been highlighted between the “specific” quality of care and the satisfaction with nurses, but not with the doctors (p > 0.05).

Based on the literature, the determinants in most of the studies considered few or all from the following: “thoroughness of the physicians”, “perceived waiting time to receive treatment”, “technology used in care”, “accreditation by the international bodies”, “key attributes of staff behavior”, “handling complaints by the nurses”, “courtesy of the nursing staff”, and “courtesy of the physicians”. Researchers have found it very difficult to measure patient satisfaction.

What factor highly contributes to patient satisfaction?  Nursing care!

Many a times, how a patient feels in hospital is not merely based on the quality or complexity of treatment even though this decides patient outcome, as quality of care is a nebulous concept for the patient, and varies from person to person. However, some of studies have shown up nursing service as the strongest determinant of patient satisfaction. Al-Mailam (2005) conducted a study in Kuwait to determine the extent of patient satisfaction with the care provided at the hospital, at all levels, and to correlate patients’ satisfaction with nursing care in particular, with their overall satisfaction. 420 patients participated in the survey. The results found out that the extent of overall patient satisfaction with the quality of care provided at the hospital was found to be quite high (Excellent, 74.7%; Very good, 23.7%). Individually, nursing care received the maximum patient satisfaction ratings (Excellent, 91.9%; Very good, 3.9%). A positive correlation (r = 0.31, P = .01) was noted between the patients’ perception of nursing care and their overall satisfaction with the medical care provided at the hospital. Significant positive correlation (r = 0.36, P = .01) was also found between overall patient satisfaction and their reported intentions of returning and recommending the hospital to others. The study concluded that overall patient satisfaction is linked with quality nursing care, which, in turn, depends on the quality of leadership practiced at the institution.

Similarly, another study has been conducted in US by Otani and Kurz (2004), with the primary objective of finding out which attributes play a more important role in increasing patient satisfaction and behavioral intentions to return to and recommend the hospital; using a comprehensive set of healthcare attributes. This study found that among six attributes, nursing care showed the largest parameter estimate for the patient satisfaction and behavioral intentions models. Thus, simply improving the nursing care attribute seems to be the most effective action to enhance patient satisfaction and behavioral intentions.

By understanding and acknowledging the fact that empowering nursing will benefit hospitals and raise the level of satisfaction of patients, healthcare facilities worldwide have started to implement nursing-focused policies and to provide a pivotal role for nurses. Studies have also reinforced the importance of having nurses sit in on all interviews for potential new employees, as well as sit on policy and procedures committees, and contribute to complaint management system designs (Cohen, Delaney and Boston 1994, “Patient complaints: guidance for nurses.” Nursing Standard, 1992).

All these revelations highlight the importance of nursing as a key player in patient satisfaction and recommend the widening scope of operation and the role of nurses in healthcare institutions. This is a good indication of the growth opportunity for nurses, but at the same time it stresses on the importance of an individual nurse’s competency and all-round skills,  over and above bedside procedures.

Challenges in meeting patient expectation

According to the National Advisory Council on Nurse Education and Practices 2010 report, to the U.S. Department of Health and Human Services, the medical knowledge-base that had previously been doubling every five to eight years is expected to begin doubling every year. Nurses simply will not be able to keep up with this freshly generated information without an advanced education and a system supporting life-long learning. Meeting patient expectations is considered the biggest challenge of nurses in future.  At time when medical knowledge, technology and patient expectations are changing fast, continuing education and learning, and practicing life-long self-learning skills are the only one way to achieve the level of an ideal nurse; one who is skilled enough to guarantee patient satisfaction in the modern era.

• Center for Clinical Governance Research in Health, University of New South Wales (2009). Complaints and patient satisfaction: a comprehensive review of the literature. [Report] retrieved on 17 June 2014 from http://www.health.vic.gov.au/clinicalengagement/downloads/pasp/literature_review_patient_satisfaction_and_complaints.pdf

• Lyder C (2012). Viewpoint: Why nurses will require a stronger back in 2012: Six key challenges facing the nursing community. February. Vol. 7 No. 2. Retrieved on 18 June 2014  from http://www.americannursetoday.com/article.aspx?id=8742&fid=8714

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Nursing As An Attractive Career Option For Men

Nursing, in modern times, has not been perceived as a profession to be pursued by men; as a vocation, perhaps, through a religious order. You may find it surprising, though, that until the late 1800s nursing was a service primarily rendered by men.

It wasn’t until Florence Nightingale started advocating professional nursing care at the frontline, during the Crimean War (1853 – 1856), did women nurses start making their presence felt on battlefields, in Europe. In the USA, men were still performing a majority of the nursing duties during the American Civil War (1862 – 1865). It was during World War I (1914 – 1918), and the demand for able-bodied men, that governments started mandating “only women” for nursing services.

This mandate became so well entrenched that, even as late as 1980 men were not allowed admission into a majority of the nursing colleges in the USA. Today, although there aren’t any restrictions to men entering the nursing profession, the percentage of men in nursing is still very small (9 – 10%); thanks to the historical legacy, and to (Western) societal perceptions formed during this period when most of nursing was out of bounds to men.

With the projected acute shortage of nurses in the developed world, nursing is now, more than ever, an extremely attractive career option for men; coming at a time when traditional sources of blue-collar male employment, such as manufacturing and construction, are drying up on account of increased productivity or greater mechanization. Overcoming this shortage will require potential employers to increase wages significantly higher than the inflation rate, as mentioned in a previous blog.

So, the demand and the wages render nursing an attractive career for men (and women too), but what are the issues to keep in mind while opting for a career in nursing?

• The first is, of course, the perception that nursing is a woman’s job. Going against this stereotype will require a good deal of character and resolution, especially when explaining the choice to one’s near and dear, and to friends. Overcoming this perceptual obstacle is half the battle won.
• There are few male role models in nursing, for men choosing to join the profession, given the near-historical absence of men from this profession. So, advice, from a male perspective, on handling academic and professional pressure, specializations to opt for, etc. is hard to come by.
• Choosing the right specialization is important. Women-specific specializations, e.g. Obstetrics & Gynecology, can be avoided, and during one’s career there may be situations when female patients may be more comfortable being taken care of by a female nurse. That said, male nurses tend to like specializations such as Anesthesia, Emergency & Trauma, Critical Care, Flight nursing, Oncology, Orthopedics, Psychiatry, Education, and Nursing management, to name a few.
• Discrimination against male nurses, in the workplace, may be gradually fading but a male nurse should be prepared for it. Such discrimination may manifest itself solely on account of gender, or on account of relationship with the physician, or even on account of communication issues with female counterparts. In many cases discrimination is perceived and not practised, because the male nurse is operating in an unfamiliar situation where he is a (gender) minority.

It’s not all caution and taking care, though. There are a few advantages to being a male nurse: especially around patients who are violent or aggressive, or when physical strength is required (to lift or support a patient). And, strangely enough, at least in the USA, although men represent less than a tenth of the nursing population, they earn more their women counterparts in the same roles. This anomaly has been explained through the fact that male nurses tend to be better qualified than their female counterparts, for the same roles.

When it comes down to making a decision, it should be noted that nursing is a professional vocation, and any man opting for it as a career will first need to decide on whether he is going to find satisfaction and contentment in caring for an unwell fellow human being. If the answer is yes, then the issues outlined above will easily be resolved. If not, the career may not turn out to be as attractive as the salary promises.

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Bringing Information Technology to Indian Nursing – Global Best Practices

Nursing is changing worldwide, as technology becomes more sophisticated and percolates into more practices within the nursing discipline. Having said that, there is an imperative need to introduce information technology in the Indian nursing system. At present, Indian nurses are unable to cope with work pressure due to the quantum of data generated in each of the cases they handle. This volume of data manifests itself in heavy paperwork, which nurses, attached to hospitals, are mandated to complete, to the detriment of their core nursing functions (Ball et al, 2000). In addition, Ball et al (2000) state that cost-cutting, at healthcare institutions, and consumerism have also created more pressure on nurses today.

Malpractice crises have forced nurses to focus more on complete and detailed nursing documentation. It is here that the adoption of information technology will significantly ease a nurse’s workload. Digital documentation and instant access to up-to-date information on a patient’s history, test results, and physician notes saves energy (that is otherwise spent duplicating documentation)and time (that is otherwise spent chasing down relevant documents in other departments). Not with standing the demonstrated benefits, rolling out an information technology platform is not easy and requires determination and perseverance from the implementers. The problem with introducing information technology is that, like in other fields, many nurses are resistant to any change in the existing system: especially, older generation nurses. Change, even if beneficial, is not always welcomed by the beneficiaries of such change.

Advances in biomedical technology and the use of sophisticated electronic equipment is already creating stress among nurses. Further compounding the stress, Ball et al (2000) argue that it is unfortunate that beneficiary nurses are not adequately involved in the selection and implementation of the information technology platform. Consequently, core nursing functions suffer too. The solution is to roll out information technology platforms in the nursing field, with the co-option and co-operation of the nursing staff. Indian nurses have to learn practices such as electronic recording and become more technologically savvy, so that their productivity can be improved and quality standards in delivering nursing care improved.

Marquis and Huston (2006) state that there are three reasons for change: firstly, to solve a problem or issue; secondly, to improve quality; and, thirdly, to decrease unnecessary workload for the particular working group. In the case of implementing information technology in nursing care, in India, all the three criteria are fulfilled: the problem of poor quality nursing care; addressing this problem using IT platforms; and in doing so, improve the efficiency and effectiveness of the nursing staff through the reduction in unnecessary paperwork.

Many developed countries such as Canada, UK, and USA have already implemented information technology in nursing field. Even in India, several corporate hospitals have started to utilize information technology. Having said that, there is still huge scope for Indian nurses to further benefit from information technology, in ways  which will reduce their workload even more. Needless to say, there will be, initially, stress and resistance to change; but as times rolls on, nurses will gain familiarity of any such new IT systems. IT is one global best practice that needs to be adopted by Indian nursing forthwith.

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The Need for Change in the Indian Healthcare System With Respect to Infection Control

Does the Indian healthcare system provide a comprehensive range of health services? Is the healthcare system entirely independent? Does the system operate under different management, rules and political authority? If yes is your answer to these queries, then one has to wonder how far the healthcare system is useful to India’s citizens? Can a middle-class family, let alone an impoverished family, afford good healthcare, in India? The answer to that question is still open.

Today we live in the amidst of a host of infections: both known and unknown. How are healthcare organizations and institutions recognizing this fact and acting on this recognition? Are patients treated in a hospital free of infections, and has the treatment been effective? If the answers are yes, do we have evidence to this effect, which is research-based, detailing strategies or protocols? For instance, many bacterial contagions were effortlessly treated with antibiotics previously; unlike the present where such contagions have been difficult to control, on account of the antibiotic resistance built up by the bacteria. Some examples are those of the Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteria (common in hospitals) and the tuberculosis-causing bacteria, Mycobacterium tuberculosis. Under the circumstances, it is not surprising that, more than any disease, antibiotic resistance is rapidly growing as one of the most dangerous threats to individual wellbeing currently, as per the World Health Organization (WHO). Being healthcare paramedics, it is important that we understand the implications of this threat, after every medical or nursing intervention: an understanding that will enable us to ensure effective and quality healthcare delivery.

Let us take a look at how the United Kingdom’s NHS (National Health Service) functions. In the UK, the NHS is primarily sponsored by the government. It delivers a wide array of public well-being services, a majority of which are free at the point of use, for legal resident of the UK. Thus, the healthcare in the UK is structured independently and also operates under different management, rules, and political authority. Complementing this service, the NMC (Nursing and Midwifery Council) keeps updating treatment regimens and protocols, by analysing latest research outcomes on new medical or nursing interventions; which further strengthens the delivery of high-quality care through the NHS.

For example, a nurse witnessing a patient’s fall in a hospital set-up follows the ABCDE approach for client care assessment and uses the SBAR approach to inform senior health personnel, about that patient’s health condition, using relevant processes for the reporting. Such an approach is not widely practised in the Indian Scenario. Applying such an approach in the Indian healthcare system will help healthcare providers prioritise their work, report relevant and adequate information,  and provide effective patient care.

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Will Nursing Be The Highest Paid Profession In The Future?

The question is rhetorical, of course, and the answer is no. The reason, though, the question is being asked is because of the large projected worldwide shortage of nurses within the next decade-and-a-half.

The shortage is expected to arise on account of an increase in the demand for nurses. This increase in demand is linked to a variety of factors:

• The world’s aging population is going to be needing more nursing care. The United Nations’ World Population Aging 2013 report has some interesting facts about the imminent greying of the world’s population. Population aging is happening on account of decreasing mortality and declining fertility, and the global share of older people (aged 60 years and above) will increase from 11.7% in 2013 to a projected 21.1% in 2050; or, in terms of numbers, from 841 million in 2013, to more than 2 billion in 2050.
• Lifestyle changes are resulting in a spike in chronic conditions such as diabetes, obesity, and hypertension; conditions which will require increased medical intervention.
• Advances in medical science are making it possible for an individual to survive severe trauma, albeit with significantly reduced functional capabilities. Such individuals will require regular nursing care.
• The move from therapeutic care to preventative care is going to place additional stress on the nursing fraternity, as nurses will constitute an inordinate proportion of the healthcare professionals driving preventative healthcare.

The demand has started rising in the developed world, and will gradually spread to the less developed world and least developed countries. The US Bureau of Labor Statistics (BLS) projects the employment of registered nurses to grow 19%, in the USA, from 2012 to 2022; faster than the average for all occupations.

As a counterpoint to the increased demand for nurses in the developed world, are the constraints to supply in meeting this demand. The reasons for the supply constraints are primarily:

• An increase in the number of nurses leaving the workforce, in the developed world, as the “baby boomers” generation reaches retirement age.
• There is little or no nurse staffing surplus left to cut in large healthcare institutions, as most cuts were carried out at the turn of the last century; and on account of the realization that nurse staffing is closely associated with patient outcomes – quality of care reduces with a decrease in the nurse-to-patient ratio.
• Given the lead time required to train a registered nurse, and the fact that the nursing profession still carries vestiges of its vocational origins, there is a significant lead time for new supply to narrow the demand gap.

This mismatch between demand and supply, as any person with an understanding of economics will tell you, will first result in an increase in wages. A paper, by Joanne Spetz and Ruth Given, modeling wage growth and supply in the US market, arrives at the conclusion that wages, adjusted for inflation, “must increase 3.2 – 3.8 percent per year between 2002 and 2016, with wages cumulatively rising up to 69 percent, to end the shortage”.

Hence the question: will nursing be the highest paid profession in the future? However, as wages increase, affected parties (healthcare organizations, governments, etc.) will look at tempering this increase through initiatives outside the healthcare profession.

Two developments will have a direct impact on wages that nurses can command:

• Developments in robotics will make the job of nurses easier, thereby increasing their productivity. While it may be inadvisable and certainly unfeasible in the near future, to have robots play a direct role in patient care, they can certainly assist a nurse deliver better care, more efficiently.
• Advances in medical science – specifically in genetics/epigenetics and stem cell research – may allow medical practitioners to alleviate the deleterious effects of old age (dementia, lower immunity, disequilibrium, and brittle bones) to such an extent as to reduce the burden on a country’s healthcare system.

Any which way, these are interesting and exciting times for the nursing profession, and the rhetorical question headlining this blog is just a concise articulation of the sign of the times.

We would be interested to hear your thoughts on the wage-potential of the nursing profession.

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Florence Nightingale and International Nurses Day

The 12^th May, each year, is celebrated as International Nurses Day. This day allows nurses to celebrate their profession and to show the world that nurses are the backbone of the healthcare system. Many people wonder why International Nurses Day is celebrated on 12^th May. The reason is simple: it is the birthday of the great Florence Nightingale, who was the founder of modern nursing, and who was responsible for establishing nursing as a profession.

Florence Nightingale was born on the 12^th May, 1820, into a rich, upper-class British family. Her father William Edward Nightingale named her Florence after the city she was born in: Florence, in Italy. Nightingale was fortunate in that her father believed women should be educated, contrary to social convention during the Victorian era, and he personally taught her Italian, Latin, Greek, philosophy, history, writing, and mathematics.

She took up nursing, against her family’s (mother’s and sister’s) wishes. She learned basic nursing skills at Germany, in July 1850, where she received training at The Institution of Protestant Deaconesses, at Kaiserswerth-am-Rhein.

Florence Nightingale achieved national fame during the Crimean War (1853 – 1856) when she worked very hard to provide the best nursing care to the British soldiers. During the Crimean War she was popularly known as “The Lady with the Lamp”, after her habit of making rounds at night. This fame and popularity allowed her to set up a fund, the Nightingale Fund, in 1855 for the training of nurses.

Florence Nightingale used the fund to set up the Nightingale Training School at St. Thomas’ Hospital on 9^th July 1860, the first secular nursing school. The first trained Nightingale nurses began work in 1855. The school still runs, as the Florence Nightingale School of Nursing and Midwifery, and is part of King’s College London. She also took an initiative in training midwives.

In 1859, Florence Nightingale wrote Notes on Nursing: What it is and what it is not, now considered a classic introduction to nursing, to serve as a key component of the curriculum at the Nightingale School and other nursing schools. The book sold well among the general public too. She assisted in setting up nursing schools in the USA, Australia, and Japan, through the alumni of the Nightingale School, and thereby achieved international recognition. She also carried out pioneering work in hospital planning; knowledge that quickly spread all around the world.

Despite suffering from ill-health in her later years, she was phenomenally productive, generating a large corpus of written work. In 1907, she became the first woman to be awarded the Order of Merit, an exclusive award from the British monarch, for her achievements. She died on 13^th August, 1910, at the age of ninety. As per her wishes, her family declined the offer of a burial in Westminster Abbey, and she is buried in the graveyard at St. Margaret Church in East Wellow, Hampshire, England.

Her life and her achievements ensure that Florence Nightingale remains the biggest role model for nurses, throughout the world.

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Emulating, Rather Than Only Commemorating, Florence Nightingale This International Nurses Day

12^th May is International Nurses Day, celebrated by the International Council of Nurses (ICN) since 1965. The significance of the date, as we all know, is that it is the birth anniversary of Florence Nightingale, the founder of modern nursing. She established the first secular nursing school in 1860, the Nightingale Training School , at St. Thomas’ Hospital, London, and, in doing so, laid the foundation of professional nursing. Nursing programs the world over can trace their provenance to this act.

Florence Nightingale, however, was more than just a pioneer in the field of nursing, and we would be doing her a grave injustice by commemorating her birth anniversary solely for her nursing achievements, howsoever illustrious and decorated they may be. She was also a statistician, a social reformer, and a prodigious writer. Florence Nightingale was a polymath, and her achievements outside nursing too should serve as an inspiration to both nurses and to the general public.

Florence Nightingale was a pioneer in the graphical representation of statistics, and she was elected the first female member of the Royal Statistical Society. She is credited with developing a form of the pie chart now known as the polar area diagram,and sometimes referred to as the Nightingale rose diagram, to illustrate seasonal sources of patient mortality in the military field hospital she managed during the Crimean War. The illustration below depicts her graphical representation of the statistics. Her objective was to bring down mortality rates, and to do so she observed and collected data, collated it, analyzed it for insights, and rendered the data in forms easily understood by a layperson.

Figure 1: Florence Nightingale’s Representation of Mortality Statistics in One Theatre of the Crimean War (Source: Wikipedia – http://en.wikipedia.org/wiki/File:Nightingale-mortality.jpg)

 

When she was at the front, during the Crimean War she believed the high death rates were due to poor nutrition and lack of medical supplies, rather than due to poor sanitary conditions at field hospitals. However, when she returned to England and began collecting evidence for the Royal Commission on the Health of the Army, she came to realise that most of the fatalities were actually on account of poor living conditions. She was broadminded enough to change her stance, and subsequently became a passionate advocate of sanitary living conditions; as well as made significant contributions to the subject of the sanitary design of hospitals.

Possibly on account of her systematic and syncretic approach to analyzing a problem, her thinking, in some areas of medicine, was far ahead of her time. She was an active proponent of preventative medicine, as opposed to therapeutic medicine, and realized that healthcare needed to be approached from a holistic rather than a symptomatic perspective: both of which reflect 21^st century healthcare trends.

Finally, in an age when women of means were expected to marry and bear children only, and were groomed accordingly, she had the courage of her passion and her convictions to blaze her own path.

These accomplishments of Florence Nightingale are as important as the work she carried out in the field of nursing, and should inspire global nurses today to approach their profession with the objective of improving healthcare practices and outcomes the world over.

In India, the National Florence Nightingale Award 2014 has gone to Dr. Punitha Vijaya Ezhilarasu, Professor and Head of the Department of Surgical Nursing, College of Nursing, Christian Medical College (CMC CON), Vellore. She will receive the award from the President of India on the 12^th of May.

Why don’t you drop in a line telling us who has been selected for this honour in your country?

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CPNRE Preparatory Course

INSCOL Academy in collaboration with Georgian College offers “Canadian Practical Nurse Registration Examination” Course for its Internationally Educated Nurses at its Mississauga Faculty in Ontario. The CPNRE Prep Course is designed to help Internationally Educated Nurses to gain knowledge and skills required to clear their Licensing Exam and become an RPN. The Course structure is extensively designed by the experienced faculty of Georgian College, Canada and consists of RPN competency based Practice Questions & Mock Tests.
To know more about the Course Details:
Call: (+1)905-673-1234
Email: admissions@inscolacademy.com

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Scenario Based Learning on Diabetes Type 1: A Nursing Analysis

Diabetes Mellitus type 1 is a chronic disorder of carbohydrate, fat and protein metabolism. A defective or deficient insulin secretary response, which translates into impaired carbohydrate (glucose) use, is a characteristic feature of diabetes mellitus (Goodman and Gillman’s, 2001).

Type 1 diabetes is also called insulin dependent diabetes mellitus (IDDM) and was previously referred to as juvenile onset diabetes. It occurs due to decreased insulin production and unchecked glucose production by the liver. Insulin enables the sugar to get out of the blood and into the cells where it is needed for the cells to function. Diabetes results from a severe, absolute lack of insulin resulting in reduction in Beta cell mass. Beta cells are a type of cell in the pancreas in areas called the islets of langerhans. These beta cells produce insulin. The function of insulin is to counter the action of a number of hyperglycemia-generating hormones and to maintain low blood glucose levels. Due to lack of insulin sugar will not be able to get into the cells so, there will be a high concentration in the blood. On the other hand, high amount of insulin shifts too much sugar into the cells and there will not be enough sugar left in the blood (Mohan, 2000). Lack of insulin affects them because insulin allows for the absorption of glucose by cells in the body and is secreted by the beta cells, in response to elevated glucose in the blood (Chatterjea, 2000).

To treat the high level of glucose insulin was given to the patient. Insulin works to lower blood glucose by promoting the transport of glucose into cells and by inhibiting the conversion of glycogen and amino acids to glucose (Smeltzer, 2004).

Ms. Rita Sharma was suffering from polyuria i.e. increased amount of urine (Smeltzer, 2004). When the blood glucose level is significantly elevated, (it is also mentioned in the above paragraph) the kidneys are unable to handle the workload and therefore allow the excess glucose to spill over into the urine. The glucose in urine acts osmotically i.e. higher concentration to lower concentration, to draw more water into the urine resulting in polyuria (Cotran, 2000).

Mrs. Rita Sharma’s urine was pale and turbid color. It occurs because concentration of glucose in the blood rises. The renal threshold for glucose is, usually 180 to 200mg/dl. When blood glucose increases, the kidneys may not reabsorb all the filtered glucose and the glucose than appears in the urine making it pale and turbid (Smeltzer et al, 2004).

She had a problem of Polydypsia, which means excessive thirst. As explained above, glucose in the urine increases, raising the osmotic pressure of the urine. This pulls the water along with the glucose in to the urine which leads to excessive urination called polyuria, causing a lack of overall body fluids making the blood hypertonic. This hypertonicity provokes the brain to initiate thirst as a compensatory mechanism of dehydration so that loss of water can be fulfilled (Chaudhuri, 2002).

She was suffering from a weight loss problem. Loss of tissue mass occurs in the insulin- dependent form of the disease (the consequence of glycosuria) that characterizes the illness. Role of insulin is to provide entry of glucose into the cells. Insulin deficiency results in non- utilization of glucose as it cannot enter into the cells leading to impaired synthesis of protein, fat and simultaneously causing accelerated breakdown of proteins and fats for production of energy leading to a catabolic state. It means there is an accelerated breakdown of fat and muscle secondary to insulin deficiency leading to weight loss.

Ms Rita Sharma’s blood pressure was 140/90mmhg. The reasons for the increased blood pressure are hyperinsulinemia, glucose intolerance and reduced level of HDL cholesterol. In a normal physiological state nitric oxide synthesis is stimulated by insulin besides decreased synthesis and responsiveness to non insulin resistant states have been associated with increased level of endothelin-1 and potent vasoconstrictor and proarthero sclerotic vascular hormone associated with hypertension (Kumar and Clark, 2005). The overall health management of Ms Rita was effective for recovery.

References:-

• Chatterjea, M. N. and Shinde, R. (2000) Text Book of Medical Biochemistry. 4th ed. New Delhi: Jaypee Brothers.
• Cotran, R. S., Kumar, V. and Collins, T. (2000) Pathologic Basis of Disease. 6th ed. India: Elsevier.
• Chaudhuri, S. K. (2002) Concise Medical Physiology. 4th ed. Calcutta: New Central book agency.
• Guyton, A. C. and Hall, J. E. (2006) Text Book of Medical Physiology. 11th ed. India: Elsevier.
• Goodman and Gillman’s. (2001) The Pharmacological Basis of Therapeutics. 10th ed. New York: McGraw-Hills.
• Kumar, P. Clark, M. (2005) Clinical Medicine. 6th ed. UK: Elsevier Saunders.
• Mohan, H. (2000) Text Book of Physiology. 4th ed. Delhi: Jaypee Brothers.
• Smeltzer, S. C. and Bare, B. G. (2004) Medical Surgical Nursing. 10th ed. London: Williams and Wilkins.

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