nurseszone_admin, Author at Nurses Zone | Source of Resources for Nurses

New Evidence-Based Guidelines for Diabetic Foot Management

News Author: Miriam E. Tucker
CME Author: Charles P. Vega, MD

CLINICAL CONTEXT
Limb complications, including amputation, are one of the devastating consequences of diabetes. The authors of the current guidelines note that the lifetime prevalence of foot ulcers among patients with diabetes is approximately 25%, and diabetic foot ulcers (DFUs) are associated with reduced quality of life as well as a higher risk for early mortality. DFUs precede up to 85% of cases of major limb amputations among patients with diabetes.

DFUs may be classified in terms of their etiology as ischemic, neuropathic, or a combination of these 2 pathologic processes. During the past 2 decades, an increasing proportion of ulcers are classified as ischemic or neuroischemic in nature, and it is now estimated that at least 65% of DFUs have an ischemic component. Because of the high prevalence of peripheral arterial disease in this population, the American Diabetes Association recommends that all patients with diabetes receive screening with an ankle-brachial index test at age 50 years. Moreover, patients with a DFU should also receive a toe blood pressure test or a test for transcutaneous partial pressure of oxygen at the toe.

Appropriate care of the feet among patients with diabetes and vigilant, evidence-based treatment of DFUs can save patients from major limb surgery. The current guidelines by Hingorani and colleagues emphasize the best foot care practices for patients with diabetes.

SYNOPSIS AND PERSPECTIVE
New evidence-based, clinical-practice guidelines on diabetic foot management cover 5 areas: ulcer prevention, offloading, osteomyelitis diagnosis, wound care, and peripheral arterial disease.

This diabetic foot guideline is the first developed by a multidisciplinary panel, which conducted separate systematic literature reviews for each of the 5 topics.

The document, sponsored jointly by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine, was published as a supplement to the February issue of the Journal of Vascular Surgery by Anil Hingorani, MD, of New York University Lutheran Medical Center, Brooklyn, and colleagues.

“The reality is there’s not a lot of really good level 1 evidence for treating these ulcers. That’s why we had three different specialties who are all involved in caring for these patients to put their heads together and [determine] what’s the best evidence we have to take care of this very difficult problem,” Dr Hingorani told Medscape Medical News.

Asked to comment, endocrinologist and diabetic foot expert Jan S. Ulbrecht, MD, of Pennsylvania State University, State College, told Medscape Medical News, “I think it’s a hugely ambitious and comprehensive document, from a very distinguished group of authors.”

Dr Ulbrecht added that although he takes issue with a few specific points, “There can be no doubt that if all care followed these guidelines, diabetic foot disease would be markedly diminished.”

Five Recommendations: Examine Feet at Every Visit

The panel issued 5 recommendations for the care of the diabetic foot:

1. For prevention of foot ulceration, the panel advises adequate glycemic control, periodic foot inspection, and patient and family education. For high-risk patients, including those with significant neuropathy, foot deformities, or previous amputation, custom therapeutic footwear is recommended.

Patients with diabetes should have their feet examined at every visit, Dr Hingorani said, “because it’s such a devastating problem. If you can get it when it’s small, it’s a much smaller problem.”

Use of the old standby Semmes-Weinstein monofilament is still considered standard as a screening tool, he noted.

However, Dr Ulbrecht cautioned against spending time on patient education for those in whom no problems are detected with the monofilament, noting no evidence exists that such efforts provide benefit and may instead cause unnecessary worry.

“In fact, I tell patients with good sensation and not obviously very poor circulation to do as anyone else would. They do not need to add the burden of paying special attention to their feet to all the other burdens of diabetes.”

2. In patients with plantar diabetic foot ulcer, the panel recommends offloading with a total contact cast or irremovable fixed-ankle walking boot. For those with nonplantar wounds or healed ulcers, specific types of pressure-relieving footwear are recommended.

“The evidence for total contact casting for diabetic foot wounds is very, very strong. One of the most important recommendations is offloading and it’s one of the least utilized,” Dr Hingorani noted.

Dr Ulbrecht, who has done research on offloading, wholeheartedly agrees.

3. In patients with a new diabetic foot ulcer, the recommendation is a probe-to-bone test and plain films, followed by magnetic resonance imaging (MRI) if a soft-tissue abscess or osteomyelitis is still suspected after the probe-to-bone test.

Dr Hingorani said that there has been too much reliance on bone scans and that after probing the bone, examining the wound, and performing a simple x-ray, “the MRI is the most sensitive, specific, and accurate test….It is more expensive, but if you’re spending a lot of money on tests that aren’t accurate you’re not getting the diagnosis.”

4. Debridement is recommended for all infected ulcers, with treatment of those infections based on the 2012 guidelines published by the Infectious Diseases Society of America. The current document provides detailed recommendations on comprehensive wound care and various debridement methods.

For ulcers that do not improve by more than 50% after 4 weeks of standard wound therapy, adjunctive options are advised. The document lists several, including negative pressure therapy, various biologics, and hyperbaric oxygen therapy.

Dr Hingorani said, “There are hundreds of agents out there. We tried to establish some guidelines but couldn’t go over everything. There are no head-to-head comparisons….But the bottom line is if the wound’s not responding, you need to try a different treatment.”

5. The panel recommends measurement of ankle-brachial index in all patients with diabetes starting at age 50 years. Those at high risk by virtue of foot ulcer history, previous abnormal vascular examination, or intervention for vascular disease or known cardiovascular disease should have an annual vascular examination of the lower extremities and feet.

In patients with foot ulcer who have peripheral arterial disease, the panel recommends revascularization by either surgical bypass or endovascular therapy.

Dr Ulbrecht took issue with the universal ankle-brachial index recommendation, noting that, although inexpensive, it does take time and does not change management.

“I would argue there’s very little you do differently. Some experts say that once you diagnose vascular disease you should be more aggressive about telling patients not to smoke, to lower their cholesterol and blood pressure, etc. But you’re doing that anyway.”

However, despite the small areas of disagreement, Dr Ulbrecht emphasized that he found “nothing egregious” in the guidelines. “This is a consensus of a bunch of people, and mine is a single opinion….Basically, it’s a very impressive document, and I fundamentally think it’s a big contribution.”

Indeed, Dr Hingorani said, “Diabetic foot ulcer is a multidisciplinary problem, and these guidelines really do highlight that.

“It’s the first time bringing multiple disciplines together to look at this problem and tackle it,” he noted, adding that the panel expects to revise and update it as new information becomes available.

Dr Hingorani and the other panel members have disclosed no relevant financial relationships. Dr Ulbrecht is a part-owner of DIApedia, a research and development company that has developed offloading orthoses for at-risk diabetes patients.

GUIDELINE HIGHLIGHTS

• A multidisciplinary committee, which consisted of vascular surgeons, podiatrists, and physicians with expertise in vascular medicine, created these new guidelines on diabetic foot care.

• Patients with diabetes should undergo foot examinations at least yearly, and these examinations should include the Semmes-Weinstein test for neuropathy. Patients with symptoms should undergo routine screening that is more frequent: semi-annual screening for patients with neuropathy, and monthly or quarterly screening among patients with previous ulcer or amputation.

• Patients with diabetes who do not have a high risk for DFU do not require special footwear. However, patients with significant neuropathy, foot deformities, previous DFU, or previous amputation should be provided protective footwear.

• The glycated hemoglobin (HbA1c) level should be maintained at less than 7% (with strategies to prevent hypoglycemia) in order to prevent DFU and infection.

• The authors recommend against prophylactic arterial revascularization to prevent DFU.

• Patients with plantar DFU should receive a total contact cast or irremovable fixed-ankle walking boot to promote offloading. A removable cast walker may be applied in these cases if frequent dressing changes are required.

• For nonplantar DFUs, offloading should be promoted with devices such as a surgical sandal or a heel relief shoe.

• Patients with a diabetic foot infection and open wound should be assessed for possible osteomyelitis with a probe-to-bone test. This test carries a positive predictive value of 89% for osteomyelitis among high-risk patients.

• Plain radiographs of the foot should be completed in cases of suspected osteomyelitis, but the sensitivity and specificity of MRI is superior to those of radiographs.

• Patients with DFU should be monitored at least every 4 weeks for response to treatment. The goal of therapy should be a reduction in wound size of 10% to 15% per week.

• DFU dressings should maintain a moist wound bed, control exudate, and avoid maceration of surrounding intact skin. However, data are insufficient to recommend one type of dressing product vs another in the treatment of DFUs.

• Debridement of devitalized tissue around DFUs should be performed at intervals of 1 to 4 weeks, but no particular debridement technique is superior to others.

• DFUs that do not improve with a reduction of at least 50% of the wound area after 4 weeks should be managed with more advanced treatments, including negative pressure therapy, biologics, and hyperbaric oxygen therapy.

• Patients with diabetes should routinely undergo ankle-brachial index testing at age 50 years.

CLINICAL IMPLICATIONS

• To prevent DFUs, the current guidelines recommend routine screening of patients with diabetes at age 50 years with an ankle-brachial index test. Special footwear is not recommended for adults with diabetes at an average risk for DFU, nor is prophylactic revascularization recommended to prevent DFU. The recommendations call for a target HbA1c level of 7% or less.

• Patients with plantar DFU should receive a total contact cast or irremovable fixed-ankle walking boot to promote offloading, and DFU should be evaluated for healing at least every 4 weeks. Patients with a diabetic foot infection and open wound should be assessed for possible osteomyelitis with a probe-to-bone test. There is insufficient evidence to recommend one type of wound dressing vs another, provided that they maintain a moist wound bed and control exudate.

• Implications for the Healthcare Team: The best treatment for DFUs is prevention through educating patients with diabetes about foot care. The healthcare team should facilitate regular examination of the feet. If DFU develops, the team should ensure routine short-term follow-up and step up care for cases that fail to respond to therapy.

CLICK HERE for more resources on Endocrine Disorder management

Lumbar Puncture

Lumbar puncture is the introduction of a hollow needle into the subarachnoid space of the lumbar portion of the spinal column to diagnose suspected infection and remove blood or pus. Cerebrospinal fluid (CSF) is completely replaced about three times a day. Although about 500 mL of CSF is formed every day, much of it is reabsorbed into the blood. There are about 120 to 150 mL of CSF in the system at any one time.

RATIONALE
● To determine or to rule out central nervous system infection;
● To determine the level of pressure in spinal column;
● To introduce drugs into the spinal canal (called an intrathecal injection).

INDICATIONS
Samples of CSF are taken for:
● Taking cell counts (a tiny number of white cells may normally be present);
● Measuring glucose and protein (also present in small quantities);
● Cytology, i.e. looking for abnormal cells;
● Immunoglobulin (antibody) studies;
● Bacterial or viral tests;
● Biochemical analysis.

CONTRAINDICATIONS
● Lumbar skin infection
● Platelet count less than 50,000/μL
● Degenerative joint disease
● Increased intracranial pressure

COMPLICATIONS
● Severe headache
● Meningitis from introducing bacteria into CSF
● Back or leg pain/paresthesia
● Accidental puncture of spinal cord
● Accidental puncture of aorta or vena cava
● Herniation of brain due to sudden decrease in pressure

PROCEDURE
Lumbar Puncture
Equipment
● Spinal tap tray
● Mask
● 22- to 23-gauge needle
● Syringe
● Manometer
● CSF specimen collection bottles
● Skin spray
● 1% lidocaine
● Povidone-iodine
● 22-gauge spinal needle
● Sterile gloves
● Fenestrated drape
● 2 × 2 gauze
● Tape

Procedure
● Position client in tripod (fetal) or lateral recumbent (fetal/child/adult) position.
● Have client clasp hands on the knees.
● Draw a line across the back between the top of the iliac crests. Locate the interspace between either L4-5 or L5 S1 (preferred) (Fig. 29.1). Mark with barrel of syringe.
● Open the spinal tray.
● Apply mask.
● Put on sterile gloves.
● Cleanse the skin 6 inches around the interspace with povidone-iodine in a circular motion.
● Cleanse the same area with 70% alcohol.
● Draw up 3 mL of 1% lidocaine.
● Assemble the manometer with the three-way stopcock.
● Inject the lidocaine at the site, raising a wheal in the skin. Inject 0.5 mL of lidocaine into the posterior spinous region.
● Insert the spinal needle with stylet in place through the skin just below the palpated spinous process. Angle about 15 degrees cephalad.
● If you hit bone or the needle meets with resistance, withdraw the needle slightly and redirect.
● Advance the needle slowly.
● After the needle is inserted a few millimeters, withdraw the stylet to see whether CSF is present. You may hear a popping sound when the needle penetrates the dura.
● Advance the needle 1 to 2 mm farther.
● Remove the stylet.
● Attach the manometer to the hub of the inserted needle. Note the level of pressure on the manometer.
● Open the stopcock to allow the CSF to flow into the test tubes. CSF collection usually takes 5 to 10 seconds. Do not attempt to aspirate CSF with a syringe.
● If blood returns, remove needle and discard.
● Repeat procedure with fresh needle.
● Remeasure level of pressure. Do not withdraw CSF if pressure is significantly different.
● Label the tubes (See table below).
● When enough CSF has been obtained, replace the stylet and remove the needle.
● Spray the skin.
● Cover the insertion site with a 2 × 2 pressure dressing and leave in place for 2 hours.
● Send tubes to laboratory within 2 hours for analysis (See table below). Do not refrigerate the tubes.

Labeling Tubes

TUBE NO	PURPOSE OF TEST
1. Biochemistry	Glucose, protein
2. Bacteriology	Varying shades of pink to coral red; Gram stain, culture (bacterial); Indicate whether the following are needed (Fungal culture, TB culture, Viral culture)
3. Hematology	Cell count, differential
4. Optional	VDRL,India ink (fungal), Cytology, Myelin basic protein, Oligoclonal bands

TB, tuberculosis; VDRL, Venereal Disease Research Laboratory.

Normal Cerebrospinal Fluid

TEST	NORMAL VALUE	INDICATION
Opening pressure	50 to 200 mm H2O	No intracranial pressure, No obstruction
WBC glucose	<5/mm3 50% to 80% of serum glucose	No infection, No hypoglycemia or hyperglycemia
Protein	15 to 45 mg/dL	No hemorrhage, No tumors, Nontraumatic tap
Color	Clear and colorless	No bacteria, WBCs, or bleeding
RBC	<20	Nontraumatic tap

WBC, white blood cell; RBC, red blood cell.

Abnormal Cerebrospinal Fluid Values

TEST	NORMAL	ABNORMAL	INDICATION
Appearance	Clear	Cloudy, Bloody	Infection, Hemorrhage, obstruction, or traumatic tap
Appearance		Brown, yellow, orange	Elevated protein, RBC hemolysis present for ≥3 days
Protein	15 to 45 mg/dL	Increase	Tumors, trauma, hemorrhage, diabetes mellitus, polyneuritis, blood in CSF
Protein		Decrease	Rapid CSF production
Gamma globulin	3% to 12%	Increase	Multiple sclerosis, neurosyphilis, Guillain-Barré syndrome
Glucose	50% to 80%	Increase	Systemic hyperglycemia
Glucose		Decrease	Systemic hypoglycemia, Bacterial or fungal infection, meningitis, mumps
Cell count	0 to 5 WBCs, No RBCs	Increase	Active disease, meningitis, tumor, abscess, infarction, multiple sclerosis
Cell count		RBCs present	Hemorrhage, traumatic tap
VRDL	Nonreactive	Positive	Neurosyphilis
Chloride	118 to 130 mEq	Decrease	Meningitis, TB
Gram stain	Negative	Gram-positive or -negative organisms	Bacterial meningitis

RBC, red blood cell; CSF, cerebrospinal fluid; WBC, white blood cell; VDRL,Venereal Disease Research
Laboratory; TB, tuberculosis.

Nursing considerations
● Lumbar puncture is a strict aseptic technique requiring full sterile procedures.
● Encourage patients to drink well before and after the procedure.
● Positioned the patient carefully, laying on one side in a curled up position with the lumbar spine exposed (knees drawn up to the chest). Moving the patient’s back closer to the edge of the bed will make access to the lumbar spine easier. Support the patient in this position throughout the procedure.
● A small local sterile dressing is applied to the spinal site after removal of the needle.
● Headache is a common complaint following lumbar puncture. The patient should lay flat for 6-12 hours afterwards, as sitting up may make any headache worse.
● In myelograms, the patient’s head should be kept raised for up to 24 hours afterwards to prevent contrast medium in the spinal canal from entering the skull. This may caused seizures if it passes around the brain (Blows, 2002).
● Have the client avoid strenuous activity for first 24 hours after procedure.

Post Procedure Care
● Monitor vital signs and neurological status.
● Assess LP site for bleeding or CSF leak every 15 minutes for one hour. Maintain patient in supine position for 1 hour or as ordered.
● Assess for presence of headache and nausea. Administer analgesic and antiemetic as ordered.
● Report to physician of any significant changes in vital signs or neurological status, including pupillary changes, swelling, bleeding or CSF leak at LP site, tingling or loss of sensation/function of lower limbs, changes in bowel or bladder control, headache or nuchal pain or rigidity.

BIBLIOGRAPHY
● American Thoracic Society. Lumbar puncture; 2000. www.thoracic.org.
● Fischbach F. A manual of Laboratory and Diagnostic Tests. 6th ed. Philadelphia, PA: Lippincott; 2001.
● Intermed Communications, Inc. Diagnostics: An A-Z Guide to Laboratory Tests. Springhouse, PA: Intermed Communications, Inc; 2000.
● Neurology. Protocol for lumbar puncture; 2002. http://www.neuro.nwu.edu.

CLICK HERE for more resources on Laboratory and Diagnostics Test

Aspirin use may be reduced the risk of Bile duct cancer !

Evidence from new study provides anticancer properties of aspirin, after finding the drug may be effective for reducing the development of bile duct cancer.

There are three types of bile duct cancers: intrahepatic, perihilar, and distal. Perihilar bile duct cancer begins in the hilum – where the left and right hepatic bile ducts join – while distal bile duct cancer develops further down the small intestine.

According to the American Cancer Society, bile duct cancer is uncommon relative to other cancers, affecting around 2,000-3,000 people in the United States every year.

However, survival rates for bile duct cancer are low; the 5-year relative survival rate for people diagnosed with intrahepatic bile duct cancer is only 15 percent, while the 5-year survival rate stands at 30 percent for those diagnosed with perihilar or distal bile duct cancers.

Now, new research – recently published in the journal Hepatology – suggests aspirin use may reduce the likelihood of developing bile duct cancer.

Aspirin users up to 3.6 times lower risk for bile duct cancer

To reach their findings, co-lead author Dr. Jonggi Choi and colleagues, from the Mayo Clinic College of Medicine in Rochester, MN, assessed the aspirin use of 2,395 individuals with bile duct cancer who visited the Mayo Clinic between 2000-2014.

The data were compared with 4,769 healthy controls who were matched for age, sex, race, and residence.

Aspirin was used by 591 (24.7 percent) patients with bile duct cancer and 2,129 (44.6 percent) healthy controls.

Compared with individuals who did not use aspirin, those who did use aspirin were 2.7-3.6 times less likely to develop bile duct cancer, the researchers report.

Additionally, on analyzing the results by the three bile duct cancer subtypes, the team found that the risk of each subtype varied with certain factors. These factors included primary sclerosing cholangitis – inflammation and scarring of the bile ducts – cirrhosis, hepatitis B, diabetes, and smoking.

“This supports the hypothesis that the three CCA [cholangiocarcinoma] subtypes are distinct diseases and that each subtype thus has its own susceptibility to risk factors,” say the authors.

Aspirin may target pro-inflammatory enzyme to prevent bile duct cancer

While the researchers are unable to explain exactly how aspirin may protect against bile duct cancer, they suggest it may be down the anti-inflammatory properties of the drug.

“Chronic persistent inflammation is one of the key elements that promotes cancer of the bile ducts, and well-known risk factors for bile duct cancer have all been shown to increase the risk for bile duct cancer by inducing chronic inflammation of the ducts,” explains Dr. Choi.

“Aspirin is an anti-inflammatory agent and may reduce the risk of bile duct cancer by reducing inflammation through inhibition of the cyclooxygenase enzyme,” he adds. “Previous studies have shown that aspirin also blocks additional biological pathways that promote cancer development.”

The researchers believe their findings suggest aspirin use could be a viable strategy to lower the risk of bile duct cancer.

“Until now, there has been little evidence of a potential role for aspirin in the prevention of bile duct cancer. Our study provides the first evidence for this.”
Dr. Roongruedee Chaiteerakij, co-lead study author

However, the authors say further research is needed to determine whether the drug is safe and cost-effective for this purpose.

NURSING AND MIDWIFERY COUNCIL OF GHANA SCHOOLED NURSES AND MIDWIVES ON NEW REQUIREMENTS FOR RENEWAL OF PIN/AIN

The Nursing and Midwifery Council of Ghana will from January 2017 roll out the new requirements for the renewal of Professional Identification Number (PIN) and Auxiliary Identification Number (AIN) for practitioners.

The new system is to expand the requirements for renewal of license to include other accredited professional activities other than participation in workshop. Under the current system the requirement for the renewal of PIN/AIN is a participation or attendance of workshops of five (5) days duration or Thirty (30) Contact hours.

With the new system credit points will be needed for renewal of license. This could be earned in areas like Research, Publishing of professional education books or journals, active membership of professional or regulatory bodies, clinical supervision and audits, provision of psychological interventions, lecturing, teaching, facilitating workshops, using of partograph in monitoring labour and many other areas.

The new PIN/AIN renewal policy is in accordance with section 55 (f) of Part III of the Health Professions Regulatory Bodies Act, 2013 (Act 857) which mandates the Council to among other things, “ determine and implement post-registration, continuing education and continuing professional development programmes for practitioners”.
At a durbar of nurses and midwives in the Eastern and Western regions, the Council schooled practitioners and students on the new accredited Continuous Professional Development (CPD) programs which will be used as a requirement for the renewal of license. The practitioners and students were also educated on the functions of the Council.

Speaking on behalf of the Registrar, Mrs. Philomina Wolley and Mrs. Dorothy Gyinae leaders of the delegation that visited nursing and midwifery training schools and clinical facilities in the Eastern and Western regions noted that unlike previous situations where CPD programs were classroom centered, practitioners will now have the opportunity of scoring professional education points beyond the classroom.

Practitioners were encouraged to identify, select and engage in relevant CPD activities that will help them in their personal and professional learning goals. The Council has also indicated that it shall not hesitate to apply sanctions enshrined in Section 73 of Part III of the Health Professions Regulatory Bodies Act, 2013 (Act 857) to practitioners who fail to renew their license.

A copy of the new accredited CPD programs for the renewal of PIN/AIN could be obtained from the download section of the Council’s website.

Nursing has ‘let itself down’ on research, says RCN chief exec

The nursing profession has failed to identify priorities for research that make a difference to practice, while existing evidence is not easily accessible, the head of the Royal College of Nursing has said.

RCN chief executive and general secretary Janet Davies said that, while nurse research was often “interesting academically”, it was not necessarily useful.

“We haven’t systematically determined what sort of research we need to manage a nursing service” Janet Davies

Speaking at a conference for senior nurses, which was jointly run by the RCN and NHS England, she said the profession was still yet to “systematically” prioritize the gaps in research that were needed, in particular for managing nursing services.

Meanwhile, evidence that had already been produced – such as work on the difference nurse staffing levels make to patient care – was difficult to find, she claimed.

“This is an area where we have, as a profession, let ourselves down,” said Ms Davies. “It is very difficult to find evidence of our practice and it is very difficult to find the research around things such as registered nurses making a difference, staffing levels making a difference, input of care.

“And we haven’t systematically determined what sort of research we need to manage a nursing service and in order to provide a nursing service. And when we look at the topics people choose for PhDs, it can be quite sad really,” she said.

She added: “It’s great they’ve got this great level of knowledge and PhD, but is it use-able, is it going to make a difference to practice or to managing nursing services? Quite often not. It’s interesting academically.”

Nursing and Midwifery Council of Ghana Cancels Result of 10 Candidates

The Nursing and Midwifery Council of Ghana (N&MC) has cancelled the entire results of Ten (10) candidates for flouting examination rules and regulations during the November, 2015 Nurse Assistant Clinical (NAC) written licensing examination.

The candidates who were students from the Health Assistants Training School Seikwa, in the Brong Ahafo Region, have also been barred from sitting for the licensing examination for two consecutive times for sending foreign materials into the examination hall.

The action taken by N&MC is in accordance with section 1 (a), (c) and 3 (a) of the Rules and Regulations for Dealing with Licensing examination irregularities.

Blood Culture Nursing Considerations

Description
A blood culture is performed to isolate and aid in the identification of the pathogens in bacteremia (bacterial invasion of the bloodstream) and septicemia (systemic spread of such infection). It requires inoculating a culture medium with a blood sample and in cubating it. Blood cultures can identify about 67% of pathogens within 24 hours and up to 90% within 72 hours.

Bacteremia may be transient, intermittent, or continuous. The timing of sample collection for blood cultures varies; it usually depends on the suspected type of bacteremia (intermittent or continuous) and on whether drug therapy needs to be started regardless of test results.

Interfering Factors
• Previous or current antimicrobial therapy (possible false negative)
• Removal of culture bottle caps at the bedside (possible prevention of anaerobic growth)
• Use of the incorrect bottle and media (possible prevention of aerobic growth)

Precautions
• Avoid drawing blood from an existing IV catheter.
• Use a vein below an IV catheter or in the opposite arm.

Nursing Considerations

Before the Test
• Confirm the patient’s identity using two patient identifiers according to facility policy.
• Explain to the patient that the blood culture procedure is used to help identify the organism causing his symptoms.
• Inform the patient that he doesn’t need to restrict food and fluids.
• Advise the patient that he may experience slight discomfort from the tourniquet and needle punctures.

During the Test
• Put on gloves.
• Clean the venipuncture site with an alcohol swab and then with an iodine swab, working in a circular motion from the site outward.
• Wait at least 1 minute for the patient’s skin to dry, and remove the residual iodine with an alcohol swab or remove the iodine after venipuncture.
• Apply the tourniquet.
• Perform a venipuncture; draw 10 to 20 mL of blood for an adult.
• Clean the diaphragm tops of the culture bottles with alcohol or iodine (or other antiseptic agent per facility
policy), and change the needle on the syringe.
• If broth is used, add blood to each bottle until a 1:5 or 1:10 dilution is obtained. For example, add 10 mL of
blood to a 100-mL bottle. (The size of the bottle varies, depending on facility procedure.)
• If a special resin is used, add blood to the resin in the bottles and invert them gently to mix.
• If the lysis–centrifugation technique (Isolator) is used, draw the blood directly into a special collection and
processing tube.
• Indicate the tentative diagnosis on the laboratory request as well as current or recent antimicrobial therapy.
• Send each sample to the laboratory immediately after collection.

After the Test
• Apply direct pressure to the venipuncture site until bleeding stops.
• Assess the venipuncture site for hematoma formation; if one develops, apply direct pressure.
• Prepare to initiate antimicrobial therapy, as ordered.

Reference Values
Negative for pathogens

Abnormal Findings
Elevated Levels (Positive Cultures)
• Mild, transient bacteremia infections
• Infections due to Streptococcus pneumoniae and other Streptococcus species, Haemophilus influenzae, Staphylococcus aureus, Pseudomonas aeruginosa, Bacteroides, Brucella, Enterobacteriaceae, coliform bacilli, and Candida albicans
• Staphylococcus epidermidis, diphtheroids, and Propionibacterium (in immunocompromised patients)
• Mycobacterium tuberculosis and M. avium complex (in patients with human immunodeficiency virus infection)

Nursing Implications
• Institute appropriate infection control precautions as indicated by the causative organism.
• Adhere to standard precautions at all times.
• Expect to collect samples over the course of 2 consecutive days

Reference:
Brunner & Suddarth’s (2010). Handbook of laboratory and Diagnostic Test. New York: Lippincott Williams & Wilkins

SLEEP AND HEALTH EFFECTS: MORE THAN WE THOUGHT IT WAS

Oxford dictionary defines sleep as “a condition of body and mind which typically recurs for several hours every night, in which the nervous system is inactive, the eyes closed, the postural muscles relaxed and consciousness are practically suspended”.

Mirriam-Webster sees it “as the neutral periodic suspension of consciousness during which the powers of the body are restored”.

The MacMillan dictionary for students defines sleep as “a naturally recurring state characterised by reduced or absent consciousness, relatively suspended sensory activity and inactivity of nearly a voluntary muscle”.
A slightly more scientific definition can be found in Stedman’s Medical Dictionary which sees sleep as “a natural periodic state of the mind and body, in which the eyes usually close and consciousness is completely or partially lost, so that there is decrease in bodily movement and responsiveness to external stimuli”.
The common threads in these descriptions, which appear to be necessary element in the definitions of sleep, are:
• It is a naturally occurring state
• It is periodic and recurring
• It involves both the mind and the body
• It involves the temporary suspension of consciousness
• It involves relaxation and inactivity of muscles
We can see how sleep is an integral part of our overall health and mental wellbeing. Sleep helps our brain to function well. When we are sleeping, a lot of healing goes on, our brain gets ready for the following day. But when we do not sleep, we create health problems that are acute and chronic. When we do not sleep, we are susceptible to taking very wrong decisions; we become so irrational in thinking, leads to accident and business failure through inability to make the right decisions. We most times feel we are supermen when we burn candles into late nights working, most of us even brag about it “you cannot believe I slept at 2.00am this morning”. Bravo to you! Your friends see you as a hardworking superman but you can never quantify the cumulative harm you are doing to health.
It is important to know that adequate sleep improves:
• Learning
• Problem solving and decision making
• Emotional health
In terms of physical health:
• It keeps our organs healthy
• It regulates hormones. Some people feel hungry when they are not sleeping
• Sleep deficiency can also make people more prone to infections and reduce their immunity, this makes infection last longer
• Daytime performance and safety is also impacted by lack of sleep. Productivity and reaction time slows down as well.
• There are also evidences of micro sleep – people sitting in classes, meetings or conferences and dosing off. With this, you lose touch with details and this affects your decisions and your ability to learn new things.
• Inadequate sleep increases accidents on the roads and even in workplaces mostly amongst machine operators and those doing night rotation shifts.
So which ever balances the issue of sleep are weighed, it is safer to have adequate sleep knowing that our body will surely malfunction by the absence of sleep. We always think we have cheated nature by using the night meant for sleep and rest for the work we brought home from our offices. The body always have a way of demanding for it and we struggle with repayment, it is like paying for a loaf of bread already eaten. How difficult this always turns out. But we need to know there is a regulator called the “circadian rhythm” which is often referred to as the “body clock”. This is a 24-hour cycle that tells our bodies when to sleep and when to be awake. So this body clock waits for you in the day time to demand for the sleep owed during the night hours, this is why you see most people having micro sleep and dosing off at intervals during work.

WHO IS AT MOST RISK FOR INADEQUATE SLEEP?
• People with limited time to sleep – Busy business men and Chief Executives
• People whose schedules conflict with their internal body clocks. Examples are shift workers or people who travel throughout the night
• Lifestyle choices that prevent people from getting enough sleep, examples are people who use drugs, caffeine and alcohol to stay awake
• Medical problems such as anxiety, stress and sleep disorders
• When we are on medications that interferes with our sleep

HOW MUCH SLEEP DO WE REALLY NEED?

Classification	Age	Recommended Hours of Sleep
The Elderly	>65 years	7 – 8 Hours
Adults	26 – 64 years	7 – 9 Hours
Young Adults	18 – 25 years	7 – 9 Hours
Teenagers	14 – 17 years	8 – 10 Hours
School Age	6 – 13 years	9 – 11 Hours
Pre-School Age	3 – 5 years	10 – 13 Hours
Toddlers	1 – 2 years	11 – 14 Hours
Infants	4 – 11 months	12 – 15 Hours
New-born	0 – 3 months	14 – 17 Hours

LONG AND SHORT TERM EFFECTS OF SLEEP
• Inability to concentrate
• Lack of patience
• Increased intake of high fat and high sugar food
• Increased risk for heart disease, heart attack, hypertension and stroke
• Increased risk of Type 2 Diabetes
• Clinical depression
• Increased risk of hormonal changes leading to lose of muscle and bone mass with aging

IMPROVING YOUR SLEEP
Maintain sleep hygiene: Make your bed room a place for sleep and not an extension of your office. Go into the bed room only when you are ready to sleep, go in with a conscious mindfulness that you are going to sleep. Leave every work and task behind and switch off the lights before getting into the bed.
You must make conscious efforts to make your bed room and your bed look attractive and inviting, do not treat your bedroom without concern and see it as a very important place where you end your day. Some people sleep better in hotel rooms than they do in their homes, the difference is only the sleep environment. You can make yours also relaxing.
You need to develop a sleep pattern, maintain roughly the same bed time and wake time throughout the entire week. Your body over time gets used to this timing.
Keep your bedroom dark and cool, keeping all kinds of lights out. If you must use light, use “sleep friendly” light bulbs. Television in the bedroom is a great source of distraction leading to sleep deprivation.
Do not use the bed as a dining table or desk; it defiles the term “BED”. This makes our bed attractive to ants and other crawling insects that in turn disturb our sleep.
Most importantly, do not bring in your gadgets or phones into your bed room when you are ready to sleep. If you must bring them in, you either switch them off or put them on silence mode. One email or an sms that drops into your phone can deprive you of sleep the entire night. Yes, global economies but your health must not be made to melt with it.

SCHEDULING YOUR MEALS AND PHYSICAL ACTIVITY
• Avoid caffeine 4 – 6 hours before bed time. It is advisable to avoid coffee after lunch time.
• Avoid alcohol 3 – 4 hours before bed time
• Do not eat large or high fat meals within 2 – 3 hours of bed time
• Include some exercise every day but avoid vigorous exercise 2 – 3 hours before bed time
• Learn mindfulness and meditation techniques to help you relax.

TRACKING SLEEP
Sleep diary: Popularly known as written log. You can use this to know the number of hours you sleep every day. Keep a sheet by your bed side, when you are ready to sleep write the time down, each time you wake up to use the convenience write wake up time and sleep time. This will help you know how many hours of sleep you are getting and how consistent it is.
Tracking device: These are electronic devices worn on the wrist, ankle, chest or head. It depends on the one you find convenient. It helps you track your hours of sleep, some of them also track both your stress level and your heart beat.
Smart Phone Apps: A number of these sleep tracking applications are on Play Store in your mobile phones, you can download them and use them to track your sleeping pattern.
Medical Evaluation is necessary if you suffer from severe sleep deprivation or disorders.

WHAT IS POOR SLEEP
When we talk about poor sleep, we are talking about a number of sleeps and sleep related disorders. Prominent amongst these are insomnia and chronic insomnia.
Insomnia is defined as a state of habitual sleeplessness or inability to sleep. This affects about 10% of a population.

Sleep Apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep. This ultimately affects your ability to getting good enough sleep. Sleep apnea affects 20% of a population; many people have sleep apnea without knowing. It is important to always seek a Physician’s review.
Restless Leg Syndrome: If you have followed us in our blog www.ohsmcomng.blogspot.com, you will see the article we had written on restless leg syndrome. It is a must read. Restless Leg Syndrome popularly known as RLS, is a neurological disorder characterized by throbbing, pulling, creeping, or other unpleasant sensations in the legs and an uncontrollable, and sometimes overwhelming, urge to move them. One of the causes of RLS is excessive use of excess high heels shoes; this has become a global concern at workplace. This has a strong interaction with the duration of use, frequency of use and height of heels. Ladies are more involved in this, it makes them look really elegant but we must look at the health risk. When these unpleasant sensation starts, it will surely deprive you of sleep, 5% of a population suffer from RLS.
Circadian Rhythm disorders have 2% prevalence in a population group and this also leads to sleep lose or sleep deprivation.
Narcolepsy is another condition that is prevalent in 2% of a population. Narcolepsy is a condition characterized by an extreme tendency to fall asleep whenever in relaxing surroundings. This is witnessed every day in our environment, it is most common amongst new born. But this also tells us the relationship between a relaxed environment and sleep, so we must strive to make our bedroom more relaxing for the sake of good sleep leading to improved health outcomes.
Mild and moderate sleep complaints. This has 50% prevalent in a population, most people complain of these but they are never sure of what the real causes are but I am sure you will know that a number of factors are responsible after reading this article.
There is also a condition called dysomnia which is a diametrical opposite of insomnia. We will not be able to take all that now; I will need you to follow us in the next edition for the continuation of these issues bothering on sleep and health. We will be taking the concluding part in the next edition focusing on chronic insomnia, National Sleep Foundation Guidelines on Sleep and a number of other concepts.
I can be reached using ehi@ohsm.com.ng
Stay tuned!

MEMBER: International Commission on Occupation Health (ICOH)
World Safety Organisation (WSO)
Society for Occupational Health Psychologists (SOHP)
Initiator: 7.2 Initiative – A Not-For Profit Social Venture on Preventive Health

Reference: Dr. Punam Ohri-Vachaspati’s presentations in Arizona State University
http://www.howsleepworks.com/what_definition.html

Latest Nursing Jobs &
Clinical Update Alerts!

Latest Nursing Jobs in Nigeria

Nursing Jobs in USA, UK & Canada

NursesZone Survey

Author: nurseszone_admin

New Evidence-Based Guidelines for Diabetic Foot Management

New Evidence-Based Guidelines for Diabetic Foot Management

Lumbar Puncture

Aspirin use may be reduced the risk of Bile duct cancer !

Aspirin use may be reduced the risk of Bile duct cancer !

Aspirin users up to 3.6 times lower risk for bile duct cancer

Aspirin may target pro-inflammatory enzyme to prevent bile duct cancer

NURSING AND MIDWIFERY COUNCIL OF GHANA SCHOOLED NURSES AND MIDWIVES ON NEW REQUIREMENTS FOR RENEWAL OF PIN/AIN

NURSING AND MIDWIFERY COUNCIL OF GHANA SCHOOLED NURSES AND MIDWIVES ON NEW REQUIREMENTS FOR RENEWAL OF PIN/AIN

Nursing has ‘let itself down’ on research, says RCN chief exec

Nursing has ‘let itself down’ on research, says RCN chief exec

Nursing and Midwifery Council of Ghana Cancels Result of 10 Candidates

Nursing and Midwifery Council of Ghana Cancels Result of 10 Candidates

Blood Culture Nursing Considerations

SLEEP AND HEALTH EFFECTS: MORE THAN WE THOUGHT IT WAS

SLEEP AND HEALTH EFFECTS: MORE THAN WE THOUGHT IT WAS

Nursing and Midwifery Council of Ghana registrar commended Nurses and Midwives in the upper west region

Zika Virus: Guidance Updates

Latest News

Trending Discussion

Latest Nursing Jobs & Clinical Update Alerts!

Latest Nursing Jobs in Nigeria

Nursing Jobs in USA, UK & Canada

NursesZone Survey

Author: nurseszone_admin

New Evidence-Based Guidelines for Diabetic Foot Management

Aspirin use may be reduced the risk of Bile duct cancer !

Aspirin users up to 3.6 times lower risk for bile duct cancer

Aspirin may target pro-inflammatory enzyme to prevent bile duct cancer

NURSING AND MIDWIFERY COUNCIL OF GHANA SCHOOLED NURSES AND MIDWIVES ON NEW REQUIREMENTS FOR RENEWAL OF PIN/AIN

Nursing has ‘let itself down’ on research, says RCN chief exec

Nursing and Midwifery Council of Ghana Cancels Result of 10 Candidates

SLEEP AND HEALTH EFFECTS: MORE THAN WE THOUGHT IT WAS

Latest News

Trending Discussion

Latest Nursing Jobs &
Clinical Update Alerts!