Nursing Care Plan For Sickle Cell Anemia

Sickle cell anemia or sickle cell disease a genetic blood disorder, which passed down through families, characterized by red blood cells that assume an abnormal, rigid, sickle shape. Red blood cells contain an iron-rich protein called hemoglobin. This protein carries oxygen from the lungs to the rest of the body.

In sickle cell anemia, hemoglobin, in the presence of low oxygen tension (caused by hypoxia, acidosis, dehydration or fever), it's crystallizes quickly, causing RBCs to bend in to crescent (or sickle) shape. The sickle cells accumulate then obstructing capillary flow throughout the body.

The thickened blood results in capillary stasis, obstructed blood flow and thrombosis. Ischemia occurs distal to thrombosis, causing further oxygen depletion and sickling, which can lead necrosis. The body hemolyzes the fragile sickle cells, quickly producing severe anemia.

Possible causes of sickle cell anemia is

genetic inheritance, that the child inherits the gene that produces hemoglobin S from two healthy parents who carry the defective gene.

Nursing Care Plan For Sickle Cell Anemia:

Assessment findings in sickle cell anemia is vary with the child's age. Before age 4 months, symptoms are rare (because fetal hemoglobin prevents excessive sickling).

• Infants: Splenomegaly from sequestered RBCs, Colic from pain caused by an abdominal infarction and Dactylitis or hand-foot syndrome from infarction of the small bones of the hands and feet.
• Toddlers and preschoolers: Hypovolemia and shock from sequestration of large amounts of blood in spleen and Pain at site of vaso-occlusive crisis.
• School age children and adolescents: Enuresis, Extreme pain at crisis site, Poor healing of leg wounds from inadequate peripheral circulation of oxygenated blood, Delayed growth and development and delayed sexual maturity, History of pneumococcal pneumonia and other infection due to atrophied spleen and Priapism.

Diagnostic evaluation for sickle cell anemia:

• Laboratory studies show hemoglobin level is 6 to 9 g/dl (in toddler).
• RBCs are crescent-shaped and prone to agglutination.
• Less than 50 % hemoglobin S indicates sickle cell trait, but if more than that indicate sickle cell disease.

Nursing Diagnosis for sickle cell anemia:

1. Acute pain.

2. Ineffective tissue perfusion (peripheral).

3. Risk for infection.

4. Deficient knowledge.

5. Ineffective individual coping.

6. Compromised family coping.

Treatment for sickle cell anemia:

• Bed rest.
• Hydration with I.V fluid (may be increased to 3 L {2.8 qt} per day during crisis).
• Short term oxygen therapy (long term oxygen decreases bone marrow activity, further aggravating anemia).
• Treatment of acidosis as necessary.
• Transfusion therapy as necessary

Planing and goals of nursing care plan for sickle cell anemia:

• The child will maintain adequate levels of blood oxygen concentration.
• The child's progressive sickling process will be halted.
• The child will receive pain relief.
• The child will be free from infection.
• The parents and child will verbalize knowledge about the condition, treatment and option for genetic counseling.

Nursing Intervention for sickle cell anemia:

• Administer sufficient pain medication to promote comfort (lack of pain relief can cause further sickling).
• Assess cardiovascular, respiratory and neurologic status.
• Assess vision to monitor for retinal infarction.
• Assess for symptoms of acute chest syndrome from a pulmonary infarction to identify early complications.
• Give large amount of oral or I.V fluids, to prevent fluid volume deficit, induce hemodilution and prevent further sickling and additional complications.
• Maintain the child's normal body temperature, to prevent stress and maintain adequate metabolic state.
• Monitor vital sign and intake-output to assess renal function and hydration status.
• Reduce the child's energy expenditure to improve oxygenation.
• Provide proper skin care to prevent skin breakdown.
• Remove tight clothing to prevent inadequate circulation.
• Teach the child relaxation techniques to decrease the child's stress level.
• Suggest family screening and initiate genetic counseling to identify possible carries of the disease.

Health teaching to child with sickle cell anemia and family members to ensure adequate knowledge about condition and treatment:

• Avoiding high altitudes.
• Avoiding activities that promote the crisis, such as excessive exercise, deep sea diving or mountain climbing.
• Avoiding aspirin use, which enhances acidosis and promotes sickling.
• Recognizing sign of infection and action should take to prevent infection.
• Seeking early treatment of illness to prevent dehydration.

Nursing Evaluation for sickle cell anemia:

• The child will improved hemoglobin level without sign and symptoms of sickle cell crisis.
• The child will be infection-free at discharge.
• The child will continue to perform age-appropriate developmental task.
• The child's parents will monitor child health status, avoid situations that precipitate a crisis and seek early aggressive medical care for infection or sign of crisis.
• The parents relate an awareness of the child's condition, the importance of early treatment and option for genetic counseling.

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Assessment of Acute Pain

Assessment of Acute Pain

   Accurate assessment of acute pain is essential for the development of an effective pain management plan. Nurses play a pivotal role in the assessment of pain, owing to the nature of their relationship with patients. Pain assessment can be challenging because of the subjectivity and multidimensionality of the pain experience. The patient's self-report of pain includes the sensory, emotional, psychological, and cultural components of the pain experience, which cannot be captured on the unidimensional tools typically used in practice. A comprehensive pain assessment includes pain location and quality, aggravating and alleviating factors, timing and duration, pain relief and functional goals, and intensity. The effectiveness of any previous pain treatment, as well as the effects of pain on quality of life, should also be determined.

   The comprehensive pain assessment should be performed when patients present with pain to the healthcare setting and at the onset of new acute pain. To determine treatment effectiveness and guide further interventions, subsequent pain assessments should focus on the nature of the pain, pain intensity, and responses to treatment. Pain assessment tools should be valid and reliable for the patient population in which they are used.

Unidimensional pain intensity scales.

   Unidimensional scales are quick and easy to use, provide rapid feedback about the effectiveness of interventions, and are valid and reliable measures of pain intensity. Because the unidimensional scales measure only intensity, they cannot substitute for a comprehensive pain assessment. The unidimensional pain intensity scales used most often in the clinical setting are:

- Numeric Rating Scale (NRS), also known as the Numerical Pain Intensity Scale (NPI);
- Visual Analog Scale (VAS); and
- Verbal Descriptor Scale (VDS).

Numeric Rating Scale.

   The NRS can be used graphically (visually) or verbally. When used graphically, the NRS consists of a vertical or horizontal line that is anchored by the number 0 on the bottom or the left side and the number 10 on the top or the right side. Patients are instructed to rate the intensity of their pain on this scale, with "0" indicating no pain, and "10" indicating the worst pain imaginable.

Visual Analog Scale.

   The VAS is a 10-cm (100-mm) line on which the patient is asked to place a mark that corresponds with his or her current pain intensity. The line is then measured from the beginning to the patient's mark, and this distance is translated into a pain intensity score ranging from 0 to 10. The format of scale, coupled with the need for a marking implement and for the patient to be able to clearly visualize and mark the line, make the VAS impractical to use in the clinical setting.

Verbal Descriptor Scale.

   The VDS uses the verbal descriptors "no pain," "mild pain," "moderate pain," "severe pain," "very severe pain," and "worst pain possible." This scale can be administered verbally or visually, and the patient is instructed to pick the words that best describe his or her current pain intensity.

Pain assessment in older adults.

   Older adults deserve special consideration in a discussion of pain assessment. As the number of older adults in society increases, it is important to understand the effect of pain on this population and determine the appropriate assessment and management techniques. Older adults with mild to moderate cognitive impairment can self-report pain. Many unidimensional pain tools have been tested in older adults, and several of these tools, including the NRS, have been validated for use in this population. In addition to the NRS, the Faces Pain Scale-Revised (FPS-R) and the Iowa Pain Thermometer (IPT) have been validated for use with older adults. When compared with other commonly used pain intensity scales (NRS, VAS, VDS, and FPS-R), the IPT was the scale most preferred by both younger and older adults, supporting findings that older adults prefer scales with verbal descriptors.

Hierarchy of Importance of Pain Measures

   In many situations, particularly in the acute care setting, it is not possible to obtain a patient self-report of pain intensity. Patients who are critically ill, sedated, confused, delirious, or otherwise cognitively impaired may be unable to report pain. The assessment of pain in this population is challenging because no single objective strategy, such as observation of behaviors or vital signs, provides sufficient information to assess pain. Nurses often rely on heart rate, respiratory rate, blood pressure, and other physiologic data to confirm the presence of pain; however, these variables are the least sensitive indicators of pain and may be affected by many other factors.

   In response to this challenge, the ASPMN published a position statement that recommends a comprehensive, hierarchical approach to the assessment of pain in nonverbal patients, which provides the framework for a decision-making process that can be used to manage pain in nonverbal patients. The hierarchical approach has 5 key steps:

1. When possible, obtain self-report.
2. Look for possible pathologies, procedures, or other causes of pain.
3. Observe for behaviors that may indicate the presence of pain.
4. Obtain input from caretakers who know the patient and the patient's usual behaviors and responses
    to pain.
5. Use an analgesic trial and observe for changes in behavior.

Step 1: Patient self-report of pain.

   The hierarchy affirms that the patient's self-report is the most reliable indicator of pain and the sole indicator of pain intensity. Ascertaining the patient's report of pain should always be attempted first. Reliability of the patient's self report may diminish with advancing cognitive impairment, but many valid and reliable tools are available that may be effectively used with cognitively impaired persons. No method has been identified to establish a patient's ability to reliably use a self-report tool; it is therefore helpful to have several tools available in the clinical setting so that the tool that yields the most consistent results for the individual patient may be selected. Once identified, this tool should be used at each assessment.

Step 2: Assumption of pain.

   If a reliable self-report of pain cannot be elicited, the next step in the hierarchy is to consider whether the patient has a condition that is typically associated with pain or is undergoing procedures that are generally considered painful. In such cases, the nurse should "assume that pain is present" (abbreviated "APP" for documentation when approved by facility policy and procedure) and provide the appropriate treatment. It is never appropriate to assume that a patient who is unresponsive, nonverbal, confused, demented, or delirious cannot feel or is not feeling pain. Similarly, pain must be assumed to be present and treated if the patient who is receiving paralytics or sedatives has an underlying painful condition or is undergoing painful procedures.

Step 3: Behavioral indicators of pain.

   The third step in the hierarchy requires the nurse to observe the patient for possible indicators of pain, such as grimacing or other indicative facial expressions, bracing, rocking, or changes in activity. Recognizing that certain behaviors may indicate pain, researchers have developed behavioral pain assessment tools for use in patients who cannot self-report. Many of these tools yield a behavioral score that can help determine the presence of pain, and when changes are noted, can be used to evaluate the effectiveness of interventions; however, a behavioral score is not a pain intensity score. If the patient cannot report the intensity of his or her pain, then the intensity is unknown.

Tools for pain assessment include:

1.  The Critical Care Pain Observation Tool (CPOT) was designed to assess pain in critically ill adults.

     It uses facial expression, body movement, muscle tension, and ventilator compliance or

     vocalization as pain indicators.

2. The Payen Behavioral Pain Scale, which uses facial expression, upper extremity movement, and

     ventilator compliance as pain indicators, may also be used for critically ill adults who are intubated.

3. The Pain Assessment in Advanced Dementia (PAINAD) is used to assess pain in patients who have

    dementia or Alzheimer's disease and are nonverbal. It uses breathing, negative vocalization, facial

    expression, body language, and consolability as pain measures.

   City of Hope Research (Visit&Contact: cityofhope.org) provides a brief summary and critique of many of the tools that have been developed for the assessment of pain in nonverbal patients. Validity and reliability have not yet been fully established for some of these tools. As with pain intensity scales, behavioral tools should be used only in the patient populations for which they were intended and in patients who are able to respond with the requisite behaviors for each tool. Although many tools have been developed to aid in the assessment of pain, the patient's self-report of pain intensity remains the most dependable method of pain assessment.

Step 4: Solicit information from caregivers and family members.

   A surrogate who knows the patient's usual behavioral responses can provide input about pain behaviors, which can be valuable in identifying the patient's unique responses to pain.

Step 5: Analgesic trial.

   The last step of the hierarchy of measures is an analgesic trial, which involves observing the patient's behavior before and after administration of a low dose of analgesic medication. An improvement in behaviors after the analgesic dose helps confirm the presence of pain and serves as the basis for a pain treatment plan. If the patient does not respond to the trial, an increase of the analgesic dose or trial of a different analgesic should be attempted. If the behaviors do not improve despite optimal titration of the analgesic regimen, causes of the behaviors other than pain should be considered

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Feeling Your Patient's Pain

   For most of us, medical students and physicians alike, treating patients in pain can be, well, a pain. Aside from having to know which medicines to use and how to use them, there's the issue of not being able to objectively measure what we're treating, as well as the unfortunate reality that some patients abuse narcotics. Patients in pain can really put our bedside manners to the test.

   The following are some pearls, from the perspective of a general internist who works with medical students and who was a medical student himself not all that long ago, on how you can interact with people who are hurting. By "pain" I'm referring to the physical kind, although the same principles may apply for emotional pain.

1. Address pain before you address anything else.

   As a medical student, you may be the first person on your team to sit down with a patient to interview and examine him. If you are pressed for time, you may be tempted to proceed with this even if the patient is in pain. It's easy to justify; after all, the sooner you get information from the patient, the sooner you can help him, right?

   While there are certain situations where pain has to be put on the back burner, these are very rare. Imagine how distressing it must be for the patient to be asked questions about family history or to get a full neurological exam when writhing from abdominal pain. (Believe me, I've seen it happen.) Show the patient that you care by getting your resident or attending physician and making sure that the person's pain is addressed first and foremost.
2. When a patient says he's in pain, even if he has a history of substance abuse, believe him.
If you haven't seen a situation like this yet, you will:

"A patient comes in to the hospital after a fall and complains of excruciating leg pain – "15 out of 10," he says. He looks uncomfortable but not that uncomfortable. The leg is visibly bruised but, according to the x-ray, not broken. The patient is a "frequent flyer" with a history of substance abuse. Your resident's or attending physician's assessment? He's exaggerating, probably playing the system for pain meds."

   In general, if a patient has reason for pain and says that he's in pain, I believe him. I call this the "innocent until proven guilty" principle. Nothing is potentially more toxic to the therapeutic relationship than questioning the veracity of what a patient is telling us from the very beginning.

   Pain is, by its very nature, subjective. There is no way for us to definitively know if another person is in pain. That said, just because we can't objectively quantify pain doesn't mean we should dismiss it.

   Don't get me wrong; I'm always on the look-out for narcotic abuse. If a patient says he is in pain but he seems completely comfortable, or if I know the patient is getting narcotics from multiple providers, I'll respectfully question the claim of pain. Otherwise, I'm going to take his word for how he feels. Keep in mind that even people with a history of substance abuse can experience excruciating pain. Between the 2 evils of undertreating pain or inadvertently indulging addiction, I'd much rather err on the side of the latter.

3. Empathize, but realize that you don't really know how the patient feels.

   When faced with someone who is suffering, many medical students want to share their own struggles as a way of trying to empathize with that person. For instance, if you have a patient who broke her arm and is in pain, and you once broke your arm, it's only natural to want to talk about your experience.

   Tread carefully here. This goes back to the point that pain is an intensely personal experience. While some patients might find it comforting to hear someone who isn't in pain say that he's been through something similar, others might find it isolating or condescending.

   I encourage my medical students to let the patient take the lead. Share a personal experience only if the patient gives you an opening, and only if you are comfortable sharing it. Otherwise, keep the focus on the patient. Show her you care by giving her space to talk. One of the most meaningful things that we as healthcare providers can do for someone in pain is just be there, and listen.

   In summary, treating a patient in pain can be challenging. But, like with most obstacles, the flipside is that it presents an opportunity to make a difference. As a medical student and later on as a doctor, if you give patients the benefit of the doubt, realize that you don't know exactly how they feel, and address their pain first, you'll go a long way toward establishing a strong relationship.

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Assessing Pain When the Patient Cannot Self-report

   Pain is completely subjective, and the gold standard of pain assessment is self-report by the patient. Several assessment tools can facilitate determining the patient's assessment of pain intensity, and hospitals nationwide have implemented policies and procedures outlining the use of these instruments.

   The most commonly used self-report tools in patients who are able to quantify their pain are the 0-10 numerical pain rating scale and the 0-10 Wong-Baker FACES pain rating scale or the Faces Pain Scale-Revised; many patients who can self-report pain but are unable to quantify it may be able to select the face that best characterizes their pain on a faces pain rating scale. However, not all patients are able to report pain using customary assessment tools, and this presents a significant challenge for the healthcare team who must ensure that pain is recognized and treated appropriately.

   For patients unable to report pain through traditional methods, an alternative approach based on the Hierarchy of Pain Measures is recommended (Table). The key components of the hierarchy are as follows:

- Attempt to obtain self-report;
- Consider underlying pathology or conditions and procedures that might be painful;
- Observe behaviors;
- Evaluate physiologic indicators; and
- Conduct an analgesic trial.

Table. Hierarchy of Pain Measures

   1. Attempt to obtain the patient's self-report, the single most reliable indicator of pain. Do not assume that a patient cannot report pain; many cognitively impaired patients are able to use a self-report tool, such as the Wong-Baker FACES Scale, Faces Pain Scale-Revised, or Verbal Descriptor Scale.

   2. Consider the patient's condition or exposure to a procedure that is assumed to be painful. If appropriate, assume pain is present (APP) and document APP when approved by institution policy and procedure.

   3. Observe behavioral signs (eg, facial expressions, crying, restlessness, and changes in activity). Many available behavioral pain assessment tools will yield a pain behavior score and may help to determine whether pain is present. However, a behavioral score is not the same as a pain intensity score. Pain intensity is unknown if the patient is unable to provide it. A surrogate who knows the patient well (eg, parent, spouse, or caregiver) may be able to provide information about underlying painful pathology or behaviors that may indicate pain.

   4. Evaluate physiologic indicators with the understanding that they are the least sensitive indicators of pain and may signal the existence of conditions other than pain or a lack of it (eg, hypovolemia, blood loss). Patients may have normal or abnormal vital signs in the presence of severe pain. The absence of elevated blood pressure or heart rate does not mean the absence of pain.

   5. Conduct an analgesic trial to confirm the presence of pain and to establish a basis for developing a treatment plan if pain is believed to be present. An analgesic trial involves administration of a low dose of nonopioid or opioid and observing patient response. The initial low dose may not be enough to elicit a change in behavior and should be increased if the previous dose was tolerated, or another analgesic may be added. If behaviors continue despite optimal analgesic doses, other possible causes should be investigated. In patients who are completely unresponsive, no change in behavior will be evident and the optimized analgesic dose should be continued.

Pain Assessment Options in the Absence of Self-report

   Evidence-based guidelines recommend against the rating of pain intensity by anyone other than the person who is experiencing the pain. The importance of relying on self-report has been underscored by research over the years, which has shown a lack of correlation between the patient's perception of pain and that of nurses and other members of the healthcare team. Furthermore, the greatest discrepancies often occur at the highest pain levels.

   Various explanations for such discrepancies have been proposed, including care provider experience, patient gender, language barriers, and ability to distinguish pain behaviors from other behaviors. A principle of pain management is that the patient is the authority on pain intensity, and if he or she cannot report the intensity, then it is unknown.

   Estimation of pain by others. Research has shown that individuals who know the patient well (eg, parents, caregivers) often overestimate or underestimate the patient's pain. Discrepancies are influenced by a various factors, including the presence and level of cognitive impairment in the patient, caregiver gender, perceived burden of caregiving, preconceived ideas of acceptable pain relief, and fear of analgesic side effects. A concern has been raised that discrepancies occur when pain is more severe. Although individuals who know the patient should not be asked to rate pain intensity, they can facilitate assessment by providing the healthcare team with information about underlying painful pathology or behaviors that may indicate the presence of pain.

Exposure to painful procedures.

   When self-report cannot be obtained, the Hierarchy of Pain Measures calls for consideration of any potentially painful underlying conditions or procedures that the patient might be experiencing (Table). In this case, the patient has sustained painful traumatic injuries. He is also being subjected to endotracheal intubation, mechanical ventilation, and suctioning, all of which have been identified as painful procedures. However, he cannot report pain and is unable to demonstrate pain behaviors.

   According to the Hierarchy of Pain Measures, pain should be assumed to be present in such patients and treatment should be initiated with recommended starting doses of appropriate analgesics. The subanesthetic doses of propofol that are used for goal-directed sedation produce negligible analgesia. This underscores the importance of co-administering appropriate analgesics, such as nonopioids and opioids. Reassessing analgesic treatment may yield no change in behavior in unresponsive patients; therefore, the optimized analgesic dose should be continued.

   The patient's ability to self-report or the appropriateness of using a behavioral pain assessment tool should be evaluated regularly (eg, every shift). The decision to switch from assessment based on assumption of painful pathology to the use of behavioral tools or the patient's report of pain always depends on the patient's ability to demonstrate pain behaviors or report pain.

Patient behaviors.

   Patient behaviors often provide clues about whether a patient has pain. For example, facial expressions, restlessness, bracing, and changes in activity have been shown to be indicators of pain. Behavioral pain assessment tools facilitate pain assessment. One of the most commonly used tools in the ICU setting is the Critical-Care Pain Observation Tool (CPOT), which has been shown to be reliable and valid in a variety of critically ill patient populations. The tool requires evaluation of the following 4 categories:

   - Facial expression;
   - Body movements;
   - Muscle tension; and
   - Compliance with ventilator (intubated patients) or vocalization (extubated patients).

   A score of 0-2 is assigned to each category, depending on the degree of the patient's response. The maximum total score is 8. A limitation of many of the behavioral tools, such as the CPOT, is that they designate specific behaviors that must be observed, making it essential for nurses to carefully evaluate each patient for the patient's ability to demonstrate the requisite behaviors in the tool. In patients such as the one described above, behaviors are absent, rendering behavioral tools ineffective.

   Although it is tempting to rely on physiologic indicators, such as heart rate and blood pressure, vital signs have been shown to be the least sensitive indicators of pain and are known to be influenced by a variety of factors other than pain (eg, hypovolemia, blood loss, hypothermia, and anesthetic and analgesic agents).

Outcomes of Pain Assessment

   The healthcare team caring for this patient used the Hierarchy of Pain Measures as a framework for pain assessment. The patient was unresponsive, unable to self-report pain, and did not demonstrate any pain behaviors. As directed by the Hierarchy, those caring for him assumed that he had pain on the basis of his underlying painful pathology (eg, head trauma and ulnar fracture) and painful procedures (eg, endotracheal intubation, mechanical ventilation, and suctioning). A continuous IV morphine infusion at 2.5 mg/hour was initiated. Bolus doses of 1 mg IV morphine were administered before painful procedures. In addition, scheduled doses of IV acetaminophen and IV ibuprofen were administered around-the-clock.

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Universal HIV Screening Recommended by USPSTF

   The US Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen all people aged 15 to 65 years for HIV infection, according to a draft recommendation statement posted online November 20. The statement also recommends HIV screening for all pregnant women, including those who present at the time of labor, and for younger adolescents and older adults who are at increased risk.

   "The draft recommendation reflects new evidence that demonstrates the benefits of both screening for and earlier treatment of HIV," task force member Douglas K. Owens, MD, said in a USPSTF news release. "Because HIV infection usually does not cause symptoms in the early stages, people need to be screened to learn if they are infected. People who are feeling well and learn they are infected with HIV can begin treatment earlier, reduce their chances of developing AIDS and live longer and healthier lives."

   Although US prevalence of HIV infection is nearly 1.2 million and annual incidence is about 50,000, nearly one quarter of those infected are unaware that they are HIV-positive. Since the first reports of AIDS in 1981, more than 1.1 million people have been diagnosed with AIDS and nearly 595,000 have died from it.

   Combined antiretroviral therapy (ART) has been shown to reduce the likelihood of HIV transmission, and earlier initiation of treatment lowers the risk for AIDS-related complications.

In issuing this recommendation, the task force hopes to improve and maintain the health of persons who are already infected with HIV, to delay the onset of AIDS, and to lower the risk for HIV transmission. The USPSTF is offering the public an opportunity to comment on this draft recommendation until December 17 and will consider all public comments when writing its final recommendation.

   Clinicians should screen adolescents and adults aged 15 to 65 years for HIV infection, as well as younger adolescents and older adults who are at increased risk (grade A recommendation).

Although evidence is insufficient to define optimal time intervals for HIV screening, the statement suggests that a reasonable strategy would be 1-time screening of adolescent and adult patients to identify those who are already HIV-positive and repeat screening of those known to be at risk for HIV infection, those who are actively engaged in high-risk behaviors, or those living in a high-prevalence setting.

   Clinicians should screen all pregnant women for HIV, including those of unknown HIV status who present in labor (grade A recommendation).

Evidence and Rationale

   The USPSTF updated their 2005 review on the benefits and harms of HIV screening in adolescents and adults by searching MEDLINE (2004 - June 2012) and the Cochrane Library (through the second quarter of 2012). Inclusion criteria were English-language randomized trials and observational studies comparing HIV screening approaches and reporting clinical outcomes, assessing the effect of initiating ART at different CD4 cell count thresholds and long-term harms, or reporting the effect of interventions on transmission risk.

   "Previous studies have shown that HIV screening is accurate, targeted screening misses a substantial proportion of cases, and treatments are effective in patients with advanced immunodeficiency," the USPSTF task force writes in its systematic review. "New evidence indicates that ART reduces risk for AIDS-defining events and death in persons with less advanced immunodeficiency and reduces sexual transmission of HIV."

   Evidence was convincing that standard and rapid HIV antibody tests are both highly accurate in diagnosing HIV infection.

   Evidence also was convincing that identifying and treating HIV infection in individuals with immunologically advanced disease (CD4 count <200 cells/mm 3) is associated with a substantially lower risk for progression to AIDS, AIDS-related events, and death.

   Evidence was adequate that starting ART earlier (at CD4 counts of 200 - 500 cells/mm 3) is associated with a lower risk for AIDS-related events or death.

   Finally, evidence was convincing that ART is associated with a markedly lower risk for transmission from HIV-positive persons to uninfected heterosexual partners and that identifying and treating HIV-positive pregnant women substantially lowers rates of mother-to-child transmission. Therefore, there are significant overall benefits of screening for HIV infection in adolescents, adults, and pregnant women.

   Although evidence is convincing that individual antiretroviral drugs, drug classes, and combinations are all associated with short-term adverse events, many are transient or self-limited, and there are often effective alternatives. Long-term use of certain antiretroviral drugs is linked to a small increase in risk for cardiovascular and other adverse events.

   "The overall harms of screening for and treatment of HIV infection in adolescents, adults, and pregnant women are small," the task force writes in its draft guidelines.

   "The USPSTF concludes that there is high certainty that the net benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial."

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Lung Screening May Encourage Smoking Cessation CME

News Author: Damian McNamara

CME Author: Charles P. Vega, MD, FAAFP Faculty and Disclosures

CME Released: 11/08/2012; Valid for credit through 11/08/2013

CLINICAL CONTEXT
There are more than 200,000 new cases of lung cancer diagnosed annually in the United States. However, effective screening strategies for lung cancer have remained elusive. Two major studies have recently evaluated the efficacy of lung cancer screening programs, and Barry and colleagues provide a review of this research. The Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) trial did not find a difference in the rate of lung cancer mortality in comparing a screening group receiving annual chest X-rays with a control group. However, the National Lung Screening Trial demonstrated that individuals receiving lung cancer screening with computed tomography experienced a 20% reduction in the risk for mortality compared with adults screened with chest X-ray alone.

Smoking is the most important risk factor for lung cancer, and previous research suggests that false-positive screening tests for lung cancer are associated with a higher rate of cessation from smoking. The authors of the current study examined variables associated with smoking outcomes in the PLCO study.

STUDY SYNOPSIS AND PERSPECTIVE
Former smokers are more likely to relapse if they are young; black or Hispanic; less educated; unmarried; have a lower income, lower body mass index, and no family history of lung cancer; or have smoked light or ultralight cigarettes, according to a secondary analysis of participants in the PLCO Screening Trial.

Of the 31,694 self-reported former smokers at baseline in the PLCO, 3.3% relapsed and reported on follow-up that they currently smoked, report Samantha A. Barry, BA, from the Prostate Cancer Decision Making and Quality of Life Research Department at Georgetown University Medical Center, Washington, DC, and colleagues in an article published online October 26 in the Journal of the National Cancer Institute.

In addition, long-term smokers and recent quitters were statistically significantly more likely to relapse (both P < .001), according to this secondary analysis of PLCO trial data.

"This relapse prediction model may be useful for identifying former smokers who may benefit most from relapse prevention interventions," the authors note.

Of the 6807 people who reported smoking at baseline, 65.2% said they still smoked on their subsequent questionnaire a median of 8.5 years later (range, 4 - 14 years). Those who were younger, black or Hispanic, or had a lower income or a lower body mass index were more likely to have continued smoking.

"Continued smoking was also more likely among heavier smokers, smokers of light or ultralight cigarettes, and those with greater secondhand smoke exposure," the authors write. "However, current smokers with higher body mass index or new tobacco-related diseases and smokers of unfiltered cigarettes were less likely to continue smoking. These characteristics may be useful in identifying smokers who are most in need of a smoking cessation intervention."

In terms of trial variables, only participation in the PLCO trial for a shorter time was associated with continuation of smoking (odds ratio, 0.85; 95% confidence interval, 0.82 - 0.88). The trial group randomization (screening vs control), screening center, and screening result were not significant factors.

Participants were approximately 60 years old, 50% were men, 90% were white, and about 50% had 2 or more comorbidities. They started smoking at an average age of 18 or 19 years. In addition, 10% reported receiving at least a single false-positive screening result, defined as a positive chest X-ray at 1 or more of the 4 annual assessments that was not followed by a lung cancer diagnosis within 3 years.

Receipt of a false-positive screen was not significantly associated with lower likelihood of smoking relapse or greater likelihood of smoking cessation, however, "suggesting that screening results may have only a short-term effect on smoking behavior," the authors note. "However, we found that being diagnosed with a new noncancer, tobacco-related disease was inversely associated with continued smoking, suggesting another possible teachable moment for altering smoking behaviors: Upon receiving a new diagnosis, smokers may be motivated to quit smoking and become more amenable to formal cessation programs."

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Smoking and Risk on Women’s Mortality Rates

CLINICAL CONTEXT
Smoking is widely recognized as the most important modifiable risk factor in preventing adult mortality in Western countries, but there has been little attention paid overall to sex-based differences in health outcomes of smokers. Huxley and Woodward addressed this issue in a systematic review comparing cardiovascular outcomes associated with smoking among women and men. Their results, which were published in the October 8, 2011, issue of the Lancet, demonstrate that the risk for cardiovascular events associated with current smoking was more profound among women compared with men. There was no sex-based difference in the cardiovascular risk of former smokers.

Long-term data analysis on the health risks of smoking among very large groups of women has only recently been possible. The current study reports on mortality outcomes based on cigarette use in the Million Women Study.

STUDY SYNOPSIS AND PERSPECTIVE
Women who smoke lose at least 10 years from their lifespan. In particular, women who continue smoking past the age of 40 years have 10 times the hazards of those who quit smoking before that age.

Kirstin Pirie, MSc, from the Cancer Epidemiology Unit at the University of Oxford in the United Kingdom, and colleagues presented results from the Million Women Study in an article published online October 27 in the Lancet. Women were recruited for the study between the ages of 50 and 65 years and were followed up for between 9 and 15 years. The women in the study had a relatively low absolute death rate, possibly because various previous illnesses were excluded and possibly because the study included relatively healthy volunteers.

The study examined women in the United Kingdom and found that smoking accounted for two thirds of all deaths of smokers in their 50s, 60s, and 70s. Women smoking at baseline had a 12-year mortality rate of 2.76 (95% confidence interval, 2.71 - 2.81) when compared with never-smokers. For smokers younger than 70 years, the probability of death was 24% compared with 9% for never-smokers of the same age (absolute difference, 15%).

Women who stopped smoking by age 30 years avoided more than 97% of the lifetime hazard from smoking. Women who smoked until age 40 years and stopped had substantial hazards but were able to avoid more than 90% of the excess mortality caused by continuing to smoke. Women who stopped smoking at age 50 years avoided approximately two thirds the excess mortality seen in women who continue smoking at a later age. Women who quit smoking at the age of 40 years still have a mortality rate 1 to 2 times that of the never-smokers, however, and this increased mortality rate lasts for the next few decades of life.

Smokers typically experienced excess mortality from lung cancer, chronic lung disease, heart disease, and stroke, as well as other neoplastic, respiratory, or vascular conditions. For many of these diseases, the study identified a proportional excess risk in smokers that was even higher than that identified in previous studies.

The UK population was useful for studying because it includes a generation of women who smoked through adult life and reached old age. The authors seek to use the data from this study to predict the effect of smoking on female mortality outside the United Kingdom.

In a linked comment, Rachel Huxley, DPhil, from the University of Minnesota in Minneapolis and Mark Woodward, PhD, from Johns Hopkins University in Baltimore, Maryland, write, "The substantial hazards of smoking and the remarkable benefits of stopping now being seen among women in the UK emphasise the need for effective sex-specific and culturally-specific tobacco control policies that encourage adults who already smoke to quit and discourage children and young adults from starting to smoke."

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Hospital Emergency Response Teams: Triage For Optimal Disaster Response

Hospital Emergency Response Teams: Triage For Optimal Disaster Response
Penulis: Glarum, Jan
Impresum: AMSTERDAM: ELSEVIER; 2010
Kolasi: xii, 432 hlm.
Keyword: Hospital Emergency
ISBN: 978-1-85617-701-6

A hospital can continue to function during a disaster or terrorist attack if a Hospital Emergency Response Team (HERT) protects the facility by the establishing and staffing of an Emergency Treatment Area. For the first time, here is an entire text dedicated to developing a free-standing operational team capable of protecting the healthcare center and its employees. This unit, if properly designed, is mobile enough to operate at a remote site, offering services to less prepared facilities. Not only does the hospital gain operational capacity by creating such a team, it also goes a long way toward meeting JCAHO's accreditation requirements. This book covers information that in an emergency is crucial to emergency medical service personnel and hospital staff in the emergency department, nursing, clinician, and other technical or support positions. It is also required reading for community public safety personnel and those charged with community-level planning, allowing them to better understand hospital capabilities and needs in times of disaster.

-Common sense approach shows what really works, not what is theoretically achievable
-Forms, checklists, and guidelines can be used to develop concrete response plans, validate existing operations, or simply expand knowledge base
-The latest from OSHA, Joint Commission and NIMS (National Incident Management System)
-Cross-disciplinary author team ensures material is appropriate for all member of this important collaboration

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Heart Failure: A Clinical Nursing Handbook

Heart Failure: A Clinical Nursing Handbook
Penulis: Nicholson, Christopher
Impresum: HOBOKEN: JOHN WILEY & SONS; 2007
Kolasi: xi, 258 hlm.
Keyword: Congestive Heart Failure, Nursing
ISBN: 978-0-470-05760-5

This book provides a complete, easy-to-use handbook for nurses who see patients with heart failure. In recent years heart failure has become a high priority in health care. With more nurses caring for patients with heart failure and making decisions that are often complex, there is a clear need for those nurses to have access to good quality clinical information and guidance. This book is designed to be a practical, ‘one-stop’, handbook for the practitioner, supported by case studies and up-todate references throughout, providing all the topics the Practitioner or student may need in their work with patients with heart failure

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Family Health Care Nursing_Theory, Practice, And Research

Family Health Care Nursing_Theory, Practice, And Research
Penulis: Kaakinen, Joanna Rowe
Impresum: PHILADELPHIA: FA DAVIS; 2010
Kolasi: xxviii, 559 hlm.
Keyword: Family Nursing
ISBN: 978-0-8036-2166-4

For the nursing student. The previous edition of this title focused heavily on theory and research; this edition will enhance that material with a greater emphasis on clinical practice using theory and research as the evidence that supports the clinical content. This approach is more in-line with how nursing is taught today. Another key change will be in the organization of clinical content, presenting it according to the trajectory of illness. It will begin with health promotion and finish with end-of-life, incorporating caring for the family along this continuum in a variety of specialties.

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Family Nursing
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Medical / Nursing / General
Medical / Nursing / Nurse & Patient

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Expertise In Nursing Practice: Caring, Clinical Judgment and Ethics

Expertise In Nursing Practice: Caring, Clinical Judgment and Ethics
Penulis: Benner, Patricia E.
Impresum: NEW YORK: SPRINGER PUBLISHING COMPANY; 2009
Kolasi: xxvi, 497 hlm.
Keyword: Nursing Practice
ISBN: 978-0-8261-2544-6

Nursing practice is a complex and varied field that requires precision, dedication, care, and expertise. Clinicians must have both the skills and the tools to attend to changes in patients' responses, recognize trends, and understand the nature of their patients' conditions over time.

This book clearly delineates the skills needed to become an expert nurse. In this new edition, the editors present a report of a six-year study of over 1,300 hospital nurses working in critical care. Expanding upon the study conducted in the previous edition, this new book documents and analyzes hundreds of new clinical narratives that track the development of clinical skill acquisition, including caring, clinical judgment, workplace ethics, and more. 

Highlights of this book:
Includes transitional guidance for nurses new to the field
-Discusses the primacy of caring and the importance of good clinical judgment
-Includes new practice models, including the Dreyfus Model of Skill Acquisition
-Provides guidelines for strengthening the nurse-patient relationship
-Presents implications for nursing education and patient safety

Ultimately, this work defines expertise in nursing practice. The book serves as a valuable resource that will enable nurses to expand their knowledge base, cultivate their clinical skills, and become successful experts in nursing practice.

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Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice

Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice
Penulis: Melnyk, Bernadette Mazurek
Impresum: NEW YORK: LIPPINCOTT WILLIAMS & WILKINS; 2011
Kolasi: xxii, 559 hlm.
Keyword: Evidence-based Nursing
ISBN: 978-1-60547-778-7

Thoroughly updated and now in full color, the Second Edition of this best-selling book is a user-friendly guide to implementing evidence-based practice in nursing and healthcare. "Real-life" examples assist readers in actualizing important concepts and overcoming barriers to implementation of evidence-based care.

This edition contains a new chapter on implementing evidence in clinical settings and emphasizes all the steps needed in making evidence-based practice part of a sustainable healthcare culture. Web alerts direct readers to Internet resources to further develop evidence-based practice knowledge and skills.

A bound-in CD-ROM contains checklists and other guides to aid readers in formulating clinical questions and appraising various types of quantitative and qualitative evidence.

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Drug Benefits and Risks: International Textbook of Clinical Pharmacology

Drug Benefits and Risks: International Textbook of Clinical Pharmacology
Penulis: Van Boxtel, Chris J.
Impresum: AMSTERDAM: IOS PRESS; 2008
Kolasi: xxiv, 882 hlm.
Keyword: Pharmacology
ISBN: 978-1-58603-880-9

This is an inclusive reference exploring the scientific basis and practice of drug therapy. The key concept is to look at the balance between the benefits and risks of drugs but in this context also the social impact which drugs have in modern societies is highlighted. Taking an evidence-based approach to the problem, the practice of clinical pharmacology and pharmacotherapy in the developing as well as the developed world is examined. For this purpose the book

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Cultural Awareness In Nursing And Health Care: An Introductory

Cultural Awareness In Nursing And Health Care: An Introductory
Penulis: Holland, Karen
Impresum: LONDON: EDWARD ARNOLD; 2010
Kolasi: xiii, 248 hlm.
Keyword: Healthcare, Nursing
ISBN: 978-0-340-97290-8

The second edition of this popular introductory text explores the many sensitive issues of culture, race and ethnicity as they affect patient care, including:

-health and illness beliefs, and their relationship to religious beliefs
-mental health and culture
-women's health in a multicultural society
-caring for older people
death and bereavement

All chapters have been updated to present the latest theory and practice and new chapters on men's health and cultural care, and migration and asylum seekers have been added, along with updated case studies and reflective exercises to help the reader link theory to practice.

This book is essential reading for all nursing students, as well as midwifery, allied health and health and social care students. It is also a useful reference for qualified nurses, midwives, health care assistants, assistant healthcare practitioners and allied health professionals.

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keyword: Language Arts & Disciplines / Linguistics / General
Medical / General
Medical / Nursing / General
Medical / Nursing / Issues
Social Science / Disease & Health Issues

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Critical Care Nursing Of Older Adults: Best Practices

Critical Care Nursing Of Older Adults: Best Practices
Penulis: Foreman, Marquis D.
Impresum: NEW YORK: SPRINGER SCIENCE+BUSINESS MEDIA; 2010
Kolasi: xx, 611 hlm.
Keyword: Geriatric Nursing
ISBN: 978-0-8261-1096-1

This book is an evidence-based, best-practices guide that directs the bedside care of critically ill elders. The book serves as a reference on major clinical issues for nurses working at the forefront of care-from nurses in critical care and step-down units to those in trauma and emergency departments. Nurse educators at all degree levels will also find this book to be useful as a textbook and resource for students.

The authors provide evidence-based, practical guidelines for both the complex clinical and management aspects of care. The book offers comprehensive coverage of all the issues caregivers need to be up to date on, including the standards of practice for geriatric care, new technologies, pharmacotherapy, pain management issues, ethical issues, and much more.

Key topics discussed:
-Strategies for patient safety for older patients in the intensive care setting
-Family responses to critical care of the older adult
-Infection, sepsis, and immune function
-Understanding and managing sleep disorders in older patients in the ICU
-Heart failure in the critically ill older patient
-Substance abuse and withdrawal in elderly patients

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Comprehensive Nursing Care In Multiple Sclerosis

Comprehensive Nursing Care In Multiple Sclerosis
Penulis: Halper, June
Impresum: NEW YORK: SPRINGER SCIENCE+BUSINESS MEDIA; 2011
Kolasi: xiv, 282 hlm.
Keyword: Multiple Sclerosis
ISBN: 978-0-8261-1852-3

Among the many responsibilities of the Multiple Sclerosis (MS) nurse, perhaps the most important is to help patients devise, learn, and implement self-care strategies to improve their wellness and quality of life. Taking a fresh perspective on the complex role of the MS nurse, this comprehensive clinical reference demonstrates how nurses can change the lives of patients with MS.

This newly revised edition is completely reorganized, refocused, and updated throughout to provide a stronger focus on instilling hope in patients and helping them regain their independence. The special feature of this new edition is the incorporation of the Morgante Conceptual Framework of Hope, a model of care that helps nurses integrate the concept of hope into clinical practice. The book also illustrates how to deliver nursing care that is both culturally sensitive and life span appropriate.

Key features:
-Uses detailed case studies to highlight the various roles of the MS nurse: the care provider, facilitator, advocate, educator, counselor, and innovator
-Incorporates the Morgante Conceptual Framework of Hope into every chapter
-Provides practical guidance on disease and symptom management, alternative medicine, sexuality and family planning, and pediatric patients
-Discusses how to maximize the effectiveness of pharmacotherapeutics

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Comprehensive Nursing Care For Parkinsons Disease

Comprehensive Nursing Care For Parkinsons Disease
Penulis: Bunting-perry, Lisette K.
Impresum: NEW YORK: SPRINGER PUBLISHING COMPANY; 2007
Kolasi: xxiv, 311 hlm.
ISBN: 0-8261-0237-9

The incidence of Parkinson's is growing as the number of older adults making up the general population increases. The demand for nurses who specialize in the care of patients with movement disorders is also increasing and it is crucial that they have a comprehensive manual for patient care.

Lisette Bunting-Perry and Gwyn Vernon have years of experience working with Parkinson's patients and have put together a team of internationally renowned clinicians who provide a truly comprehensive review of the information you need for the care of patients with this complex clinical profile. Comprehensive Nursing Care for Parkinson's Disease covers what is presently known about the disease and current evidence-based standards of care, including management through deep brain stimulation, palliative care for frail older adults with Parkinson's, medication management, nonmotor complications and psychosocial issues, and complementary and alternative approaches.

This is an indispensable bedside companion in caring for those with Parkinson's as well as a much needed catalyst for the evaluation of future patient needs and the further development of comprehensive models of care.

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Coeliac Disease: Nursing Care And Management

Coeliac Disease: Nursing Care And Management
Penulis: Griffiths, Helen
Impresum: NEW YORK: JOHNWILEY & SONS; 2008
Kolasi: xv, 200 hlm.
Keyword: Coeliac Disease, Nursing
ISBN: 978-0-470-51260-9

Coeliac Disease: Nursing Care and Management provides nurses with the knowledge and evidence base to understand the impact of the diagnosis of Coeliac disease, and examine the long term treatment and management of the condition. The authors take the reader through an investigative journey from the history of the disease through its pathology, characteristics, diagnosis, treatment and management. Clinical case studies bring to life both the physical and psychosocial aspects of care of patients making this an ideal text for clinical nurse specialists, Gastroenterology nurses and Endoscopy nurses.

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Clinical Teaching Strategies In Nursing

Clinical Teaching Strategies In Nursing
Penulis: Gaberson, Kathleen B.
Impresum: NEW YORK: SPRINGER PUBLISHING COMPANY, LLC; 2007
Kolasi: xiii, 298 hlm.
Keyword: Nursing, Study And Teaching
ISBN: 0-8261-0248-4

This second edition of Clinical Teaching Strategies in Nursing provides a thoroughly updated and comprehensive framework for planning, guiding, and evaluating learning activities for undergraduate and graduate nursing students in clinical settings. Recognizing that clinical settings require different approaches to teaching, the contributors present tools--working models, learning assignments and activities, simulations, the use of Grand Rounds for clinical education, and pointers on ethical and legal issues that may be encountered in clinical work--to help educators meet the challenges of this complex environment. New chapters on distance learning, the evaluation and grading of students in the clinical setting, and advances in the use of clinical simulation and simulation laboratories further enhance this compete guide.

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Clinical Coach For Effective Perioperative Nursing Care

Clinical Coach For Effective Perioperative Nursing Care
Penulis: Litwack, Kim
Impresum: PHILADELPHIA: FA DAVIS; 2009
Kolasi: xii, 361 hlm.
Keyword: Surgical Nursing
ISBN: 978-0-8036-2121-3

A CLINICAL COACH SERIES BOOK! This handy reference transitions from class to clinical to practice to provide the perioperative information needed in hospital operating rooms, ambulatory surgical units, critical care units, procedure labs, and free-standing surgical centers. It delivers everything nurses need to know to safely prepare patients for surgical procedures and monitor and care for them afterward. Prioritized bulleted lists, full-color illustrations, and concise tables provide access to essential, evidence-based knowledge.

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keyword: Medical Nursing Medical & Surgical
Medical / Nursing / Medical & Surgical
Perioperative Nursing - methods
Perioperative Nursing/ methods
Surgical nursing

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Capturing Nursing History: A Guide To Historical Methods In Research

Capturing Nursing History: A Guide To Historical Methods In Research
Penulis: Lewenson, Sandra B.
Impresum: NEW YORK: SPRINGER PUBLISHING COMPANY; 2008
Kolasi: xx, 236 hlm.
ISBN: 978-0-8261-1566-9

Named an Outstanding Academic Title for 2008 byChoice!

"This well written and well edited book fills a unique gap....[one of the] precious few [books] that focus on science or medicine and [one of] even fewer that cover the history of nursing."(Three Stars)--Doody's Book Review Service

While there have been many research texts in the nursing literature, and nursing history is both taught in courses and of popular interest to practicing nurses, there has never been a hands-on text that describes the process of doing historical research in nursing. This book, contributed by well-known and respected nurse historians, provides the necessary direction, guidance, and examples needed to conduct historical research. It covers such topics as historiography, biographical research, using artifacts in historical research, doing archival and other data searches, doing international historical research, and locating funding sources for historical research. Case studies will be used throughout to illustrate various methods and describe how, why, when, and where historical research is used in nursing.

Features of this edition:
-Provides direction and tools for conducting historical research
-Describes types of research, including biographical and oral histories
-Covers frameworks used to study historical events, such as social, political, feminist, intellectual, and cultural

-Addresses contemporary issues such as preserving and storing digitalized and tape-recorded data and obtaining institutional review board (IRB) approval for research, and addressing ethical and legal issues in historical research

-Includes case studies that provide a "how-to" guide to conducting research

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Cancer In Children And Young People Acute Nursing Care

Cancer In Children And Young People Acute Nursing Care
Penulis: Gibson, Faith
Impresum: HOBOKEN: JOHN WILEY & SONS; 2008
Kolasi: xvii, 413 hlm.
ISBN: 978-0-470-05867-1

Much has changed since the first book Paediatric Oncology: Acute Nursing Care (1999), therefore, this new edition encompasses these changes in relation to the practice itself and the evidence that underpins it.  Emphasis is placed on ensuring terminology is accurate, in keeping with the language of the current day. 

The book is divided into six sections: Chemotherapy, Haematopoetic Stem Cell Transplantation, General Surgery, Radiotherapy, Late Effects of cancer therapies, and Palliative Care.  There is a brief commentary at the end of each section/chapter by a ‘novice’ author but experienced practitioner, highlighting to the reader what is already known and what the section/chapter adds to their current knowledge and practice.

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