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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