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| Posted: 29 Dec 2010 10:49 PM PST One thing is absolutely necessary for the nursing profession to survive – nursing research, emphasized Elizabeth Allen, MSN, RN, manager of accreditation services at Emerson Hospital, Concord, MA. “When you sit down at the table with medicine, or attend a fiscal meeting, you need to be able to present in a professional manner with data that augments the points you’re trying to make. We can’t explain and substantiate our practice any other way,” she said. So, when in 2004, Allen was asked to lead a nurse-driven initiative to enhance early nursing research efforts at Emerson, she was immediately on board. “There was a core group within nursing working on research, which is a very vital part of Magnet-designated facilities,” she explained. “We have a good beginning on the path to gain Magnet status. “The integration of nursing research into a nursing culture is a progressive process – you just can’t make it happen overnight. You need to support those early pioneers who conduct nursing research, and let other nurses see each other succeed in investigating clinical questions,” she said. Progressive Process Like many other clinicians, Allen gained an appreciation for nursing research during graduate studies. “I’ve been a nurse since 1972, after graduating from a hospital-based nursing school, and I became interested in nursing research while earning my master’s in nursing in 1999 from Regis College [Weston, MA],” she said. “I learned the value of nursing research, and became a convert during those graduate studies.” Today, Allen co-chairs the Nursing Research Council along with Peg Bitter, RN-BC, a staff nurse recently promoted to associate nurse manager. “We use a mentorship model, with me coaching her in how to lead a committee,” Allen noted. “We’ve been meeting monthly to create the infrastructure so the nurse at the bedside who has questions about the correct practice or policy, or who wants to challenge those practices or policies, is able to access the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and other clinical reference databases on the nursing unit.” Bitter recalled her initial introduction to nursing research at Emerson. “I was talking with one of the nurse practitioners and mentioned I had worked as a research assistant at Brigham and Women’s Hospital [Boston] when I was in nursing school,” she recalled. “Research is something I’ve always been interested in, so I went to the first meeting of the Nursing Research Council and learned they wanted a staff nurse to serve as co-chair – and I’ve been on the committee ever since.” Solid Foundation The shared-governance model at Emerson provided a solid foundation for involvement of nurses from all organizational levels and clinical specialties. “If you have nurses with different educational backgrounds and practice levels on a research committee, the more seasoned ones can say to younger colleagues, ‘Let me tell you my story,’ and serve as role models to stimulate research questions,” Allen said. “Today, when someone says to me, ‘I feel like this is happening,’ I can respond, ‘How can we measure it?’ When a nurse presents an idea, I can say, ‘Sure, put together a research proposal and let’s see what it does for our patients, families and staff. To me, the nursing process and research process are one and the same.” “It’s been a way to grow within the Emerson community,” Bitter added. “I’ve worked here more than 20 years, but it took awhile before I got involved in committees. That involvement really enriches your practice as you become engaged in something outside your own nursing unit.” Medical librarians at Emerson have been invaluable allies in the nursing research development process. “Our past librarian Nancy Serotkin was instrumental in helping nurses from all units learn how to find answers to their questions in the professional literature, and she received our first Friends of Nursing Award,” Allen said. “Our current librarian, Melinda Marchand, met with Nancy and I to continue that culture.” Changing the Culture Four years ago, nurse leaders at Emerson brought in Patricia Rissmiller, DNS, PNP, RN, associate professor in the graduate program in primary healthcare nursing at Simmons College, Boston, as a facilitator and adviser to the Nursing Research Council. “Emerson was looking for someone to be on board to get the research part of its Magnet proposal more solid and to strengthen the process of critical thinking,” Rissmiller recalled. “When I began my work with them, there were some isolated projects, but now we have more ongoing investigations, we’re participating as part of the IRB [Institutional Review Board], and we’ve increased the nursing staff’s understanding of evidence-based practice as the basis for research.” Working with council members, Rissmiller encouraged a number of process changes to reflect research principles. “That’s what Magnet is so clear about – it’s fine to have some research projects going, but you really need to change the nursing culture to incorporate research into practice,” she explained. “For example, all nursing policies and procedures that go through the Professional Practice Council now include citations from the professional literature to support those best practices.” A True Inspiration Rissmiller’s support and influence helped spark a culture change at Emerson. “Pat [Rissmiller] is so approachable, and has an inquisitive personal style that inspires nurses to pursue clinical questions through nursing research,” Allen explained. “She makes people believe nursing research is not as daunting as we first thought when we heard the term. She distills the research process down to a manageable mental model for nurses, [see Breaking It Down] and that’s what stimulates people like Candice Kruszkowski, MSN, CPNP, RN, to tackle research questions. “We’re hoping Candice is one of many seeds that will be planted through Pat’s influence and with the support of the Nursing Research Council,” she added. Kruszkowski is a long-time member of the Nursing Research Committee, and credits colleagues in that group with encouraging her to go on for an advanced degree and certification as a nurse practitioner. “Pat Rismiller is the one who got me interested in expanding my nursing role to incorporate advanced practice,” she explained. “My graduate studies helped me realize the value of nursing research, and convinced me it is possible for bedside staff to carry out meaningful research projects.” Sandy Keefe is a frequent contributor to ADVANCE. Breaking It Down As an associate professor in the graduate program in primary healthcare nursing at Simmons College, Boston, Patricia Rissmiller, DNS, PNP, RN, knows very well how daunting the term “nursing research” can be to bedside clinicians. When she was asked to serve as a consultant to the Nursing Research Council at Emerson Hospital, she emphasized the importance of breaking down the research process into manageable pieces. “We began with seminars focused on reading and critiquing a research article, teaching nurses to ask whether the study is valid and reliable enough to justify changing their nursing practice,” she said. “That’s an important question within evidence-based practice.” Bedside Investigators A pediatric nurse practitioner who still engages in hands-on nursing care through a per diem position at the VNA Care Network & Hospice in Massachusetts, Rissmiller has a low-key style when involving staff nurses in research topics. “Every day we say, ‘How come we’re doing this?’ in our heads, but typically don’t view those thoughts as research questions,” she said. “We can engage staff nurses in research by giving them the skills and tools they need – teaching them to read scholarly literature and supporting them in their inquiries.” It’s important to empower nurses to question and investigate their own practice. “I like to point out to nurses in clinical settings, particularly at the staff nurse level, they’re right there where the action is,” Rissmiller said. “I’ll say to them, ‘You have millions of questions every day and you just need to select one to frame and explore within the context of nursing research.’” In-hospital Research Peg Bitter, RN-BC, an associate nurse manager at Emerson who co-chairs the Nursing Research Council, echoed that message. “I’ve learned through my council work to view research as something I can do, rather than something in a journal that other people have done,” she explained. “I can take a small idea and turn it into a project, something I’m planning as part of the requirements for my online master’s program through University of Massachusetts at Amherst. I’m excited about doing the project and then presenting and publishing my findings with other nurses.” Rissmiller credits Elizabeth Allen, MSN, RN, manager of accreditation services at Emerson, with following through in a way that engages nursing staff. “Liz [Allen] is a very detail-oriented person with great follow-up, and things just get done under her leadership,” she noted. “The biggest challenge facing Emerson was getting staff nurses involved, since many had been there 30-plus years without any real involvement in nursing research. “We encourage them to think of nursing research within the context of nursing practice, instead of something that’s done only at the doctoral level.” Asking Questions When Candice Kruszkowski, MSN, CPNP, RN, needed a project as part of her master’s program through Simmons College, Boston, she decided to tackle a clinical issue from her work at Emerson Hospital, Concord, MA. “I wanted to see what I could do to improve the experience for children undergoing invasive procedures like voiding cystourethrograms (VCUGs),” she said. “The idea for medicating children during those procedures has been kicking around the unit for a period of time. Mallory Harrison, our child-life specialist, greets children on arrival and walks with them through the whole process. She heard from parents of children who weren’t medicated, telling her what a horrible experience it was and how they barely got through it.” The VCUG studies, while essential for diagnosis and treatment, cried out for improvement. “VCUG is really a miserable procedure; we take children who are 2-3 years old and just potty-trained, fill their bladders with contrast media, and then tell them to pee on the radiology table,” Kruszkowski explained. “It’s difficult and frightening for these young patients.” When nurses in the same-day surgery unit began administering nasal Versed prior to VCUGs, Kruszkowski noticed a marked improvement in the youngsters’ responses. “Most of the children don’t remember a thing because of the amnesiac effect of the drug; those who do often have a positive recollection,” she said. “One child wanted to have his birthday in the radiology suite because it had been such a wonderful experience!” Since then, the protocol has been adopted by the hospital, and is used for interventional radiology procedures, such as VCUGs, and in same-day surgery, as well. Nasal Versed has been highly effective in 99 percent of the cases, so clinicians rarely have to use any other medications or interventions to control pain or anxiety during these procedures. By asking the right questions, Kruszkowski created a win-win situation. “She was a graduate student with a research requirement, as well an employee at Emerson,” said Patricia Rissmiller, DNS, PNP, RN, associate professor in the graduate program in primary healthcare nursing at Simmons College. “The hospital provided her with good access to patients and great support, and in turn she provided results to share with the community about how well the hospital cares for children undergoing these procedures.”
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| Posted: 29 Dec 2010 10:45 PM PST AIDS is usually marked by a very low number of CD4+ lymphocytes, followed by a rise in the frequency of opportunistic infections and cancers. Doctors monitor the number and proportion of CD4+ lymphocytes in the patient’s blood in order to assess the progression of the disease and the effectiveness of different medications. About 10% of infected individuals never progress to this overt stage of the disease and are referred to as nonprogressors. OPPORTUNISTIC INFECTIONS. Once the patient’s CD4+ lymphocyte count falls below 200 cells/mm3, he or she is at risk for a variety of opportunistic infections. The infectious organisms may include the following: * Fungi. The most common fungal disease associated with AIDS is Pneumocystis carinii pneumonia (PCP). PCP is the immediate cause of death in 15-20% of AIDS patients. It is an important measure of a patient’s prognosis. Other fungal infections include a yeast infection of the mouth (candidiasis or thrush) and cryptococcal meningitis. AIDS DEMENTIA COMPLEX AND NEUROLOGIC COMPLICATIONS. AIDS dementia complex is usually a late complication of the disease. It is unclear whether it is caused by the direct effects of the virus on the brain or by intermediate causes. AIDS dementia complex is marked by loss of reasoning ability, loss of memory, inability to concentrate, apathy and loss of initiative, and unsteadiness or weakness in walking. Some patients also develop seizures. There are no specific treatments for AIDS dementia complex. MUSCULOSKELETAL COMPLICATIONS. Patients in late-stage AIDS may develop inflammations of the muscles, particularly in the hip area, and may have arthritislike pains in the joints. ORAL SYMPTOMS. In addition to thrush and painful ulcers in the mouth, patients may develop a condition called hairy leukoplakia of the tongue. This condition is also regarded by the CDC as an indicator of AIDS. Hairy leukoplakia is a white area of diseased tissue on the tongue that may be flat or slightly raised. It is caused by the Epstein-Barr virus. AIDS-RELATED CANCERS. Patients with late-stage AIDS may develop Kaposi’s sarcoma (KS), a skin tumor that primarily affects homosexual men. KS is the most common AIDS-related malignancy. It is characterized by reddish-purple blotches or patches (brownish in African-Americans) on the skin or in the mouth. About 40% of patients with KS develop symptoms in the digestive tract or lungs. KS may be caused by a herpes viruslike sexually transmitted disease agent rather than HIV. The second most common form of cancer in AIDS patients is a tumor of the lymphatic system (lymphoma). AIDS-related lymphomas often affect the central nervous system and develop very aggressively. Invasive cancer of the cervix (related to certain types of human papilloma virus [HPV]) is an important diagnostic marker of AIDS in women. Read more: http://www.healthline.com/galecontent/aids-1/5#ixzz19X4qw0X1
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| Posted: 29 Dec 2010 09:42 PM PST Acute retroviral syndrome is a term used to describe a group of symptoms that can resemble mononucleosis and that may be the first sign of HIV infection in 50-70% of all patients and 45-90% of women. Most patients are not recognized as infected during this phase and may not seek medical attention. The symptoms may include fever, fatigue, muscle aches, loss of appetite, digestive disturbances, weight loss, skin rashes, headache, and chronically swollen lymph nodes (lymphadenopathy). Approximately 25-33% of patients will experience a form of meningitis during this phase in which the membranes that cover the brain and spinal cord become inflamed. Acute retroviral syndrome develops between one and six weeks after infection and lasts for two to three weeks. Blood tests during this period will indicate the presence of virus (viremia) and the appearance of the viral p24 antigen in the blood. After the HIV virus enters a patient’s lymph nodes during the acute retroviral syndrome stage, the disease becomes latent for as many as 10 years or more before symptoms of advanced disease develop. During latency, the virus continues to replicate in the lymph nodes, where it may cause one or more of the following conditions: PERSISTENT GENERALIZED LYMPHADENOPATHY (PGL). Persistent generalized lymphadenopathy, or PGL, is a condition in which HIV continues to produce chronic painless swellings in the lymph nodes during the latency period. The lymph nodes that are most frequently affected by PGL are those in the areas of the neck, jaw, groin, and armpits. PGL affects between 50-70% of patients during latency. CONSTITUTIONAL SYMPTOMS. Many patients will develop low-grade fevers, chronic fatigue, and general weakness. HIV may also cause a combination of food malabsorption, loss of appetite, and increased metabolism that contribute to the so-called AIDS wasting or wasting syndrome. OTHER ORGAN SYSTEMS. At any time during the course of HIV infection, patients may suffer from a yeast infection in the mouth called thrush, open sores or ulcers, or other infections of the mouth; diarrhea and other gastrointestinal symptoms that cause malnutrition and weight loss; diseases of the lungs and kidneys; and degeneration of the nerve fibers in the arms and legs. HIV infection of the nervous system leads to general loss of strength, loss of reflexes, and feelings of numbness or burning sensations in the feet or lower legs. Read more: http://www.healthline.com/galecontent/aids-1/4#ixzz19X3rJbNN
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