Western medicine has been the main form of healthcare in Singapore for many years. However, recently we seen TCM enjoys considerable popularity as a complementary form of healthcare. According to Singapore’s media release in 2001, it has been estimated that about 45% of the population in Singapore had ever consulted a TCM practitioner in the past, and about 12% of daily outpatient attendances opt to see TCM practitioners here.

In t

What is foot reflexology?

Foot reflexology is a form of foot massage and sometimes accompanied by acupressure techniques that targets at points on the foot that are correspond to parts of the organ of the body.

As according to Byers (1983), the reflex areas or points in the feet are correspond to all of the glands, organs, and parts of the body.

Theories 

It has been known from studies that foot reflexology has a positive effect on anxiety reduction and pain reduction. It can also improve the blood supply, and promote homeostasis (Micozzi, 1996). As according to Nancy (2000), the effects were based on theories.

The energy theroy, which use electromagnetic field to direct engery to unblock the bloked pathways. The theroy of proprioceptive nervous receptors,  states that a connection exists between the area of the feet and the body organs and that reflexing the feet affects the organ.

Lastly, it is the lactic aci theory which explains that the lactic acid will deposite in the feet and flexology will crush the microcrystals and allows the free flow of energy.

Patients’ Privacy 

Lately, foot reflexolgy is more appealling to nurses, allied healthcare professionals because of its potential relaxation and pain relief effects. Besides, it is a form of avenue for human touch, it is non-invasive and just your pair of hands plus a little bit of skills.

When your are doing it professionally, it will not interfere with patients’ privacy in fact, it will show that you are showing care and concerns for your patients (Dobbs, 1985).

Head Related Illnesses

As documented in the ancient Traditional Chinese Medicine manual, Huang Di Nei Jin, the treatment for upper limbs illnesses can be effective addressed via lower extremeties. That is what is know as the “Shan Bin Xia Qiu”. This is a popular approach used by many Acupuncturist for treating head related illnesses including strokes.

The Acupuncturist will acupuncture the patients’ feet to help them to relief any discomforts. So, based on the same concept, foot reflexolgoy will be helpful to give refreshing feelings and experiences after that. If you have done foot reflexology before, you will know what I mean.

Increased Relaxations 

A research was done by Ferrell et al. (1991) on the use of foot reflexology to reduce pain for cancer patients. It was reported that patients with cancer experienced decreased pain specially after foot massage.

It was also observed that there was a decrease in patients’ heart rate and diastolic blood pressure and increase in skin temperature which were the results from their increased relaxation (Meek.1993).

Protect Yourself First 

Nurses who wish to incorporate reflexology in their practice can study it from accredited schools. Attaining a certification, although does not mean anything very much to nurses but it is a best way to ensure the use of technique on the patients will correct.

However, I would suggest that the practioners must be aware of your body constitutions as there could be lost of qi after performing the therapy. You must know when to stop when you are tired, and taking long breaks when necessary. I know that you are eager to help others but you must know how to protect yourself first.

Reference.

Byers, D.C. (1983). Beter health with foot reflexology. St. Pertersburg, FL: Ingham Publishing.

Dobbs, B.Z. (1985). Alternative health approaches. Nursing Mirror, 160(9), 41-42.

Ferrell, et. al. (1991). Pain as a metaphor for illness. Part II: Faily caregivers’ management of pain. Oncology Nursing Forum, 18, 1315-1321.

Meek, S.S. (1993). Effects of slow stroke back massage on relaxation in hospice clients. Image, 25 17-21

Micozzi, M.S. (Ed.) (1996). Fundamentals of complementary and alternative medicine. New York: Churchill Livingston.

Nancy et. al. (2000), The Effects of Foot Reflexology on Anxiety and Pain in Patients With Breast ad Lung Cancer. EBSCO Publishing, Vol 27 No 1.

PRESENTED BY:

Steven Yip          Andy Tan
Maurice Wong      Melvin Kwan

Outline:

Introduction
Current Practice
“Burning Question”
Reasons For Change
Literature Review
Appraisal and Synthesis of Evidence
Recommendations for Best Practice
Integration of New Practice
Summary
References

Clinical Best Practice - NGT

Introduction

Critically ill patients are difficult to feed often resulting in MALNUTRITION!
Giner et al., Barr et al., 2004, found out that ICU patients, 43% to 88% are often malnourished.

Enteral nutrition is acknowledged as the preferred route of feeding (Heyland et al., 2003a).
However, underfeeding and intolerance are common problems (McClave et al., 1999).
Underfeeding and Overfeeding have been associated with undesirable outcomes.
Compromise the immune response, nutritional status, glycaemic control and diarrhea.

Besides under and over feeding, the delivery and tolerance of enteral nutrition is important.
Gut dysfunction, high gastric aspirates, vomitting, and abdominal distension are common problems.
This presentation attempts to investigate the best clinical practice in feeding a post stroke patient.
It is worthwhile to note that patient preferences are often neglected in the decision to use enteral feeding.
Current practice – Enteral Feeds

Indications for enteral nutrition:

Impaired swallowing or gag reflex
Cancer
Underlying condition may prevent eating
Ventilator-dependent or post operative patients
Stroke patients

Types of Nasogastric Tubes

Nasogastric tube (NG Tube) passes through the nose, down the throat and to the stomach;
Nasojejunal tube (NJ Tube) passes through the nose, down the throat, through the stomach and to the small intestine;
Gastrostomy Tube (G Tube) passes through a small cut in the skin directly into the stomach;
Gastroenteric or Transgastric jejunal tube (GJ Tube) passes through a cut in the skin directly into the stomach and extends into the small intestine;
Jejunostomy tube (J tube) passes through a cut in the skin directly into the small intestine;
Poor nutrition is common…

Silicone may cause slower flow and more frequent clogging…

But is anything being done to better the process??

“The Burning Question“

Reasons for Change
Improvements in delivery systems for enteral feeding, formulas and understanding of complications have made enteral feeding widely used, however,…Is there a better solution?

Literature Review
Bolus Feeding:

Also called intermittent feeding
Given over short periods of time several times throughout the day
Given by pump or gravity
Timing of feeds can be changed 2-3hrs between feeds to allow stomach to empty
Resembles normal pattern of eating-digestion

Continuous Feeding:

Given at a steady rate for as many hours as needed
A pump is used over the 24hr duration

Continous Feeding and Bolus Feeding Combined?

Sometimes bolus tube feeds are given during the day and continous feeds at night

Complications of Enteral Feeding

Aspiration Pneumonia
Cause serious local and systemic infections
Difficult to insert NGT
Risk of death (1%)
Uncomfortable and hence prone to being pulled out
Patient distress
Enteral Feeding

Klodell (2000) found that the preference for enteral nutrition, as opposed to parenteral, is universal.
Strict attention to patient positioning, as well as vigilant nursing care helps to minimize rates of complications with enteral access. 
However, controversy still remains regarding the route of administration.
Clinician driven decisions.
No strong evidence to support the preferential use of jejunal or gastric feeding tubes in Traumatic Brain Injury patients.

Enteral Feeding

Klodell et al (2000) also found that prokinetic agents such as metroclopramide in the initial 48hrs of enteral nutrition to  augment gastric emptying.
Klodell et al (2000) notes that gastric feeding in neurologically injured patients may be successful as early as 24hrs after the injury with the co-administration of drugs to facilitate gastric emptying.

Batson, S. (1997) found that gut dysfunction and elective stoppages for procedures were main reasons for preventing delivery of feeds.
Average daily gastric aspirate were compared over one month.
Average daily gastric aspirate were higher on the first few days of feeding.
The aspirate volumes then settled to a steady state at an average of +/-105mls.

Where a specific feeding protocol was employed, the average volume of feed delivered was 1418 +/- 505ml., the percentage of optimal feed delivered was 78 +/- 31%.
Where there was an absence of specific feeding protocol, the average volume of feed delivered was 1179 +/- 674ml, and the percentage of optimal feed delivered was 66 +/- 34%.
Discrepancies exist between the delivered and prescribed volume of feed. 
Causes suggested include the onset of diarrhea and nursing workload.

Diarrhea is invariably blamed on enteral feed.
Kandil et.al found that health volunteers did not show signs of diarrhea until they were fed more than 275ml/h.  This rate is far greater than any patient would receive, suggesting that feed is unlikely the cause.
Other causes have been identified:
Antibiotic, and other drug therapy, feed formula, contamination of feed
No clear cause but it seems likely that there are other more complex factors involved.

The percentage of prescribed feeds delivered depends on the volume of prescription. 
When smaller volumes are prescribed, the percentage delivered is higher.  1200ml over 24hrs versus 2000ml over 24hrs.
Rest periods are used to “catch-up” on feed schedules. 
Use of a rest period seems an effective way of ensuring the patients receive the prescribed amount of feed.
Delivery rate was 95-75% of prescribed feed with a rest period.
The researcher also notes that this aspect requires further investigation. 

In another study by Serpa, et al (2003), it was found that it was acceptable practice that whenever 80% of the energy needs are supplied by 72hrs, the replenishment program should be considered adequate.
Undeniably there will be deficits of actual supplied and prescribed amounts, but according to the researcher, this shortcoming is small and justified in circumstances of critical disease.
(Note:  Two groups of 14 critically ill patients were randomly assigned to intermittent or continuous tube feeding.)

Chapman (1992) found that written protocols are a simple and effective method of increasing enteral feed delivery.
Delivery rate of >85% was achieved for patients with written protocols.
Delivery rate of >75% was achieved for patients without written protocols.
All researchers agree that more research is need to be done in this area for results to be more conculsive.

Appraisal and Synthesis of Evidence
Bolus versus Continuous Feeding
Bolus Feeding
Preferred by most clinicans
Promote the cyclical surges of gut hormones
However, delayed gastric emptying may hinder ability to handle bolus milk feeds
resulting in feeding intolerance – (Dumping Syndrome)
Causes diarrhea if given too fast and too much
Higher risk of aspiration if feeding intolerant.

Continuous Feeding
May be more efficient by increasing energy absorbed
Improved nutrient absorbtion
But may alter the cyclical pattern of gut hormones affecting metabolic homestasis
Should not be given overnight in patients who are at risk of aspiration

The Evidences speak for Themselves
The use of electronic pumps, slow administration even in cases of bolus prescription,
careful selection of diet and
positioning of tube,
prevention of abdominal distension or
high gastric residues and
constant monitoring of patients.

Recommendations – Best Practices
Health care professionals should aim to provide adequate nutrition to every patient.
It should be the hospital policy that results of an admission nutritional screening are recorded in the notes of all patients with serious illness or those needing major surgery.
Nutritional support is needed when oral take is absent or likely to be absent for a period of >5-7 days.  Earlier intervention may be needed in malnourished patients.
Choice of route in consultation with clinician and dietician.
Adoption of a written protocol for feed regimes in conjunction with the clinical care pathway,
The use of electronic pumps to administer feeds,
Proper positioning into semi-fowler position (if not contra-indicated) for feeding,
Use of prokinetics to encourage gastric emptying.
Constant monitoring of patient for abdominal distension.
Consultation with dietician and clinician if patient develops feeding intolerance or diarrhea.
Allowing breaks in feeding to let gastric PH fall will help prevent bacterial overgrowth during ETF.
Allows the gut to “rest’

Ethical Issues

Enteral feeding should not be started without consideration of all related ethical issues and must be in a patient’s best interests.
In cases where a patient cannot express a wish regarding Enteral feeding, consulting widely with all carers and family is essential.

Integration of New Practice

Presentation to the Medical Board and governing body, PTs, Dieticians
Propose changes to current hospital protocols and guidlines
Provide education, roadshows
Monitor for compliance, audits
Competency audits for nurses

Enteral feeding is the preferred modality of support for seriously ill patients
Who have acceptable gastrointestinal function but are unable to maintain oral diet.
Further future studies conducted should include longer periods and populations with different risk factors to advance the knowledge about these widely adopted therapeutic techniques.

REFERENCES

Axelsson, K., Asplund, K., Norberg, A., Eriksson, S. (1989) Eating problems and nutritional status during hospital stay of patients with severe stroke.  Journal of American Dietary Association. 8.1092

Giner, M., Lavino, A., Meguild, M.M. & Gleanson J.R. (1996)  In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists.  Nutrition 12, 23-29.

Heyland, D.K., Dhaliwal, R., Drover, J.W., Gramlich L. & Dodek, p. (2003)  Canadian Clinical practice guidelines for nutritonal support in mechanically ventilated, critically ill patients. JPEN 27, 355-373.

McClave, S.A. & Snider, H.L. (2002) Clinical use of gastric residue volumes as a monitor for patients on enteral tube feeding. JPEN 26, S43-S50.

Reid, C. (2006) Frequency of under and over feeding in mechanically ventilated ICU patients:  Causes and possible consequences.  The British Dietetic Association 19 pp 13-22.

Serpa L., Kimura, M., Faintuch, J., (2003).  Effects of continuous versus bolus infusion of enteral nutrition in critical patients.  Clinc. FAC, MED S. Paulo 58(1): 9-14, 2003.

Thomas, D. (2007)  Annals of Long-term Care, Clinical Care and Aging.  Retrieved from www.annalsoflongtermcare.com/article/857 on april 11, 2007.

Kandil HE, Oper FH, Switzer BR, Heitzer WD (1993) Marked resistance of normal subjects to tube-feeding induced diarrhea; the role of magnesium. Am J Clin Nutr 57:73-80.

Klodell, C., Carroll, M., Carrillo, E., Spain, D. (2000)  Routine intragastric feeding following traumatic brain injury is safe and well tolerated.  The American Journal of Surgery.  Vol 179, Issue 3, pp. 168-171.

Chapman G, Curtas S, Meguild M (1992) Standardized enteral orders attain caloric goals sooner:  a prospective study, JPEN J Parenter Enteral Nutr 16:  149-151.
 

Legal and ethical issues are always evolving around us whenever we are nursing our patients. Hopefully, this article will keep you thinking and  get you to recall events that you have encountered. 

Whatever you are doing, whether they are ethically correct or you are just obligated to do what you are told to do or do what you peer expects you to do; you are answerable only to yourself.

Clearly state the problem

The problems faced here are: 1) whether to withdraw the feeding tube from Mr. M; and 2) who is the person to make that decision. Mr. M’s mother, who did not raise him, has vowed to remove his feeding tube, and has threatened to take legal action against the hospital over its refusal to stop feeding her son. However, Mr. M’s brother, who is a nurse, believed that his brother had responded to physiotherapy sessions and this has raised hopes for his recovery. He claimed that his mother had no right to decide his brother’s fate, and insisted on continuing the feeding. Who should decide Mr. M’s fate - his mother, his brother or the medical professionals?

Medical, Social, Legal and Ethical Issues Considered

According to the Multi-Society Task Force (1994), if the cause of the Persistent Vegetative State (PVS) is traumatic, it is considered permanent if the PVS persists beyond 12 months. For Mr. M’s case, his PVS was caused by a car accident and he had only been treated for PVS for six months.

Lo (2000), believes that an individual in a vegetative state is able to breathe on his own, but cannot experience pain or obey verbal commands. He or she has periods of sleeping and waking, and the eyes can be open but he or she is unaware of the environment. This can last for at least a month.

Mr. M had opened his eyes for up to seven minutes. Medically, no one could ascertain that Mr. M would never recover. If he were able to regain consciousness, would he be able to get back to his pre-morbid state? If not, who would take care of him? Who would bear the expensive medical cost in the long run?

Get the facts

Mr M suffered head injuries in a car accident and is in a persistent vegetative state (PVS). As defined by the American Academy of Neurology, PVS is “a clinical condition of complete unawareness of the self and the environment accompanied by sleep-wake cycles with either complete or partial preservation of hypothalamic and brainstem autonomic functions” (Multi-Society Task Force, 1994).

Although there is a possibility of misdiagnosis of PVS (Andrew, Murphy, Munday & Littlewood, (1996)), Mr. M’s brain scans have shown no improvement since he was hospitalized. If the feeding were to be stopped, he will be extremely dehydrated and starved. His body would be emaciated and shrunken. No one would know if he suffered greatly during the period of nutrition deprivation. The average length of survival of patients in PVS is 2 to 5 years. Only a few have been reported to survive for more than 15 years (Lo, 2000).

Mr. M and his brother were raised by his paternal grandparents, and this raises the question as to whether his mother knows what Mr. M’s wishes are. She vowed to remove his feeding tube but his brother, who is a nurse and has a close relationship with him, insisted to continue his feeding.

There was no mention of whether Mr. M had signed an advance medical directive (AMD), or whether he would want to end or sustain his life should he be in a PVS. It would be considered passive euthanasia if the feeding were stopped. This act is illegal unless an AMD has been signed and witnessed.

The case study does not mention Mr. M’s paternal grandparents’ views on this issue, but they are entitled to have a say since they raised the boys. Mr. M is also the single father of a child, who is about 15 years old. At this age, the child is not able to make any legal decisions. Ultimately the Courts may have to rule on who has to make the decision regarding Mr. M.

Four Major Ethical Principles

Autonomy

According to Staunton & Chiarella (2003, p.28), autonomy is “the right to self-determination, the ability to control what happens to us and how we behave”. A person should make his own decisions in life and that these decisions do not have consequences that violate another person’s autonomy. In this case, Mr. M did not have an AMD and is unable to consent to his treatment. Hence, only his surrogate guardian can make decisions on his behalf. Who should this be? A surrogate guardian should embrace Mr. M’s quality of life values rather than his/her own. Should this be Mr. M’s mother, who did not raise him, or his brother, who has grown up with him, or his paternal grandparents who has brought him up, or perhaps his child who is too young to know what is happening?

Beneficence

Beneficence is aimed at the wellbeing of the patient, and is the deliberate bringing about of positive actions or interventions (Hawley, 1977). Since only an autopsy can diagnose PVS in a patient, we cannot positively conclude that Mr. M is in that state. If he is indeed in a PVS, it can be concluded that he is unconscious and hence cannot experience pain and suffering (O’Mathuna, 1996). For argument’s sake, even pain can be experienced in a PVS, it would be more burdensome and more prolonged than any pain experienced with artificial feeding withdrawn. We cannot be sure that if Mr. M is ever going to recover and even if he does, what quality of life will be have? Is he going to be dependent on others for his daily activities till the end of his life?

Non-maleficence

The principle of non-maleficence means “above all, do no harm”, which serves to restrain one from causing hurt and by prohibiting actions which would cause harm (Hawley, 1997.). By withholding the artificial feeding for Mr. M, he will eventually die. Thus we are causing him great harm. Nurses have sworn to save lives, and most would not be able to stand idly by while the patient died a little more each day through their inaction. However, are there benefits to continuing the feeding? Perhaps this too causes harm to Mr. M. There are multitudes of reports in medical literature which document that delivering nutrition and hydration could cause discomfort in the dying process, such as vomiting, peripheral edema, and an increased risk of infection. Does that also mean that we are not causing any further complications and endangering the patient’s life? If he were aware of his current condition, would he continue to accept the treatment that we are administering? He may resist whatever is being done to him.

Justice

Justice is the fairness and equal distribution of burdens and benefits (Staunton & Chiarella, 2003). It is society’s expectations of what is fair and right. Healthcare professionals need to proceed with planning and giving care that incorporates the notion of ‘due care’ so that all persons - irrespective of socioeconomic status, race, gender or religion - are offered and given the appropriate health care according to their medical and nursing needs (Hawley, 1997). The justice for Mr. M is that he is entitled to receive the quality of care no matter whether the decision is to withhold or withdraw the feeding. However, with tight resources, will it be fair to prolong Mr. M’s life span at the expense of finance burden and emotional distress to the family? Moreover, how many PVS patients have recovered and do not need any subsequent medical attention?

Identify ethical conflicts

The main ethical conflict arises when one has to decide whether the preference is to stop feeding Mr. M after 6 months or to prolong his life by continuing the feeding. This is a dilemma for the healthcare professionals taking care of Mr. M and may require the intervention of the courts.

If the courts order the removal of the feeding tube, the question of the possibility of recovery may continue to haunt the healthcare professionals. They may also be guilt-ridden for causing him to suffer and die from hunger. Once the feeding tube is removed, Mr. M would probably die in 2 weeks.

On the other hand, if the feeding tube were not removed, what would be the cost of prolonging his life? The resources that are used to support vegetative patients could be allocated to other patients. Mr. M would also face repeated re-insertions of the feeding tube, possibly resulting in aspirations and infections, with no assurances that he would have a good quality of life.

Any potential conflicts need to be straightened out through family conferences where all parties are given the opportunity to air their views and address this ethical dilemma. A time frame of six months may not be sufficient to diagnose Mr. M with PVS. Studies have shown that there are many PVS cases that have been misdiagnosed (Andrews et al., 1996).

Considering the Law

When a patient has lost the capacity to make medical decisions for himself, there are laws that put the burden of consent to treatment on someone else. On the other hand, if the patient is aware of his current situation and has consented to discontinue the procedure of artificial feeding, the continuation of the feeding may be considered an assault or betrayal to the patient, when his interest is not being served by doing so.

According to the American Heart Association (2005), as soon as Mr. M lost the capacity to make medical decisions, a close relative or friend can become his surrogate decision maker. Surrogates should base their decisions on the patient’s previously expressed preferences if known; otherwise the justification for treating a patient who lacks the capacity to consent lies in the fact that the treatment is provided in his best interests. Surrogates should make decisions based on this, and the treatment should be discontinued where it is no longer in patient’s best interest to provide it (Mclean, 2001). The law will designate the legal surrogate decision maker for an incompetent patient who has not previously designated one through a durable power of attorney for health care. The order of priority for guardianship in the absence of a previously designated decision maker: (1) spouse, (2) adult child, (3) parent, (4) any relative, (5) person nominated by the person caring for the incapacitated patient, and (6) specialized care professional as defined by law (American Heart Association, 2005)

This order of priority makes Mr. M’s mother the legal surrogate. Her wish was to discontinue the feeding. If this was not done, she will threaten to sue on the grounds of battery and assault, because continued feeding would necessitate repeated re-insertions of the feeding tube. However, by removing the feeding tube, he will die from malnutrition and dehydration, and as a result, the hospital would have breached the duty to care for him. On the other hand, Mr. M’s brother is claiming that their mother has no right to be the legal surrogate as she did not raise them. He would sue the hospital for negligence if the hospital withdrew the feeding. According to Staunton and Chiare

One of my clients called me to complain that he had 2 episodes of fits in a day and each lasted for half a minute. He went to a hospital and had his blood tested for Phenytoin, which is an antiepileptic drug.

His blood result was normal. The doctor in the Emergency Dept, prescribed another drug for him. Keppra was ordered. Keppra is an expensive drug and my client was wondering if he should take it as he was feeling alright now.

I did a search in the cyberspace and I am glad that he did not start the drug. You will need to depend on this drug for a very long term. If you stop taking it, your episode of fit will increase. It was recommended the this drug should be taken with other antiepileptic drugs.

Unfortunately, my client is taking phenytoin now and by taking it together with keppra, he will feel very very drowsy.

I went to his house and diagnosed that phlegm was building up in his body. He told me that before he had 2 episodes of fits, after he had eaten “Chi Chong Fun” (a kind of Chinese food usually for breakfast) with sweet red bean sauce. I told him that the sauce was sweet and that will cause his body to create more phlegm.

Normally, in Chinese Medicine, a herbal formula will be prescribed for clearing the phlegm out of the meridian paths. The stagnation of the paths will reduce the good qi from circulating to his head and nourish his brain. The temporary shortage of qi in the brain may cause him to have fits. In his case, a hua tang  jian tang may help to clear the phlegm in his body.

The following is the detailed description of the western drug that the doctor prescibed to him. Nothing much was mentioned to him about the drug, except that he was told that it must be taken for long term.

Generic Name: levetiracetam(lee ve tye RA se tam)
Brand Names: Keppra

It is an anti-epileptic drug and is used to treat partial onset seizures in people with epilepsy. Do not change your doses or medication schedule without advice from your doctor, once you start the medicine.

Swallow Keppra whole, and not to break, crush, or chew before swallowing. The prescription refilled before you run out of medicine completely is important in order to get the most benefit out of this drug.

Blood may need to be tested on a regular basis that also includes the liver function. This is to ensure that the medication is not causing harmful effects. Do not stop taking Keppra suddenly as you may have increased seizures.

You may want to consider the consequence before taking it. Keppra can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

Avoid using together with other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxants, and medicine for seizures, depression or anxiety). These drugs can add to sleepiness that was also caused by Keppra.

Get emergency medical help if you have any of these signs of an allergic reaction like:
. hives;
. difficulty breathing;
. swelling of your face, lips, tongue, or throat.

Call your doctor at once if you have any of these serious side effects:
. unusual thoughts or behavior;
. anxiety, hallucinations;
. feeling angry, hostile, or agitated; fever, chills, body aches, flu symptoms;
. weakness, lack of coordination; or
. increasing or worsening seizures.

Other, less serious side effects may be more likely to occur, such as: dizziness; drowsiness; or depressed mood.

Remember that in the case of emergency, do carry an ID card to identify that you are taking Keppra.

Page Tags: keppra, levetiracetam, phenytoin, seizure, side effect

Chronic low back pain is among the most common chronic pain syndromes. It can cause unnecessary suffering and upset a person’s life at home and on the job. What causes the low back pain? Well, Injuries, infection or inflammation are often the origin of low back pain. Most cases result from simple sprains or strains of the muscles and ligaments. Low back pain is considered chronic if it persists for more than three months.

There is, however, a wide range of treatment options are readily available to successfully reduce or manage this type of pain. Besides the use of analgesic treatments, complementary therapy, which incorporates a wide range of practices are also thought to prompt the release of pain-relieving substances in the body.

Complementary therapies such as acupuncture, massage, meditation, herbal remedies, chiropractics and hot and cold packs are the options that anyone can apply to relieve pain. But it is important that sufferers are urged to be evaluated by a physician to rule out any serious problems. When no physical reason for the pain can be identified, treatment can be difficult to determine, and usually necessitating a multidisciplinary approach to care.

Chronic low back pain frequently affects people in their prime working years and, as a result, it is the single largest cause of lost work days and lost income. It is very frustrating. I have learnt a simple technique that can temporary help to reduce the pain. First, you must identify which side of the low back that is painful. For example, when the pain is on the left side of the low back, rub the fore head from the center toward the center of the right brow until the visible red line can be seen on the fore head. Try to rock your body slightly forward and backward while doing this. That’s it! You get quick low back pain relieved.

This is the speech that I gave in July 2005. I was told that my speech had motivated some of the audiences to choose nursing as their second career. I am say that I have no intension to deceive them as the speech was written at the time when I have really strong feeling for this career.

Unfortunately, with the injury sustained during the work, of course with no compensations and sympathies, I found myself drifted away from nursing. Although it had been a history for me now, but I am still disappointmented with the whole nursing thing here. I also feel sorry for those nurses who have been treated unfairly by their superiors and also sad that to observe that no matter how hard the nurses had try, nursing are still not perceived as a profession by many. I sincerely hope that this will change with the new NUS graduates nurses coming into this industry. Keep my finger crossed as I really not able to see that it will happen soon.

My two cents worth.

On July 2005, in the hospital auditorium:

Good afternoon,

Mr. Ng, Chief Human Resource Officer,

Directors of Nursing,

Ladies and gentlemen.

It is indeed my greatest honor to be given this opportunity to share my experiences with you.

Men that are nurses are NOT “doctor wannabes” or people who couldn’t get into a medical school; we must all get this straight: we are not failures! The fact that we chose this as our next career is because we dare to be different. Each of us is unique and we have our own noble reasons for choosing Nursing as our new career. I studied nursing because I believe that I have a lot to offer.

I had been working in the Information Technology Industry for 10 years. Although I get immense satisfaction in doing well in IT but deep inside me, I felt empty. I was contemplating a career switch but had no idea of what directions to take.

In my spare time as a licensed Traditional Chinese Medicine Practitioner, I find that I enjoy treating the sick, as well as improving the health of those who came to see me. I felt that I had not equipped myself with the adequate knowledge about Western medicine. I wanted to be more knowledgeable about the different aspects of treatments available, so as to be able to help the sick better.

With God’s grace, I came to know about the new Accelerated Diploma in Nursing under the Strategic Manpower Conversion Programme. This was the opportunity for me to be immersed in the healthcare, so I decided to choose nursing as my next profession.

The first hurdle that I needed to overcome was to get a sponsor. I was quite pessimistic about getting one because of my age. Very fortunately, NUH and Alexandra Hospital had made me an offer. From the bottom of my heart, I am very grateful to them because at almost 40, most of the institutions would not be interested to invest in me. This is evidenced by the fact that most of my classmates are in their early thirties.

During my training stint with NYP, the biggest issue I encountered was not the number of subjects that I had to study in each semester. A lot of time was wasted tackling internal group conflicts during discussions. However, I have learnt how to agree to disagree and ways of thinking win-win. Also, my greatest satisfaction as a student was when I found more time to communicate and interact with patients. I was also happy to be able to nurse the ill back to health and render support to patients and their families.

The Accelerated Diploma in Nursing has equipped me with a basic foundation in nursing. Although, the knowledge and skills enabled me to embark on my nursing career, there are a lot of operational issues that I need to learn on the job.

I realized that beyond the facts and figures that I have learnt, I needed to have the extra 6^th sense. I had to be able to pre-empt things that may go wrong and be able to react to the situations STAT. We are not superior to the young graduates but I guess the experiences that we have under our belts do give us some advantage. Other than that, all of us have garnered similar knowledge in NYP.

Very recently, I was confronted by a patient demanding Pethidine or Marijuana injections. I explained to him that such drugs need to be prescribed by Doctors. He blew up and challenged me to give him an injection immediate if I were really a Staff Nurse. I went on to explain that I could give him the prescribed oral analgesic and only at the time stated in the inpatient medical record. He then threatened to punch me. I calmly and assertively told him to calm down as his behavior would disturb the rest of the patients in the ward. I then told him that I believe that his frozen shoulder was hurting him badly and suggested that his attending Doctor to come down and see him immediately. After listening to my explanation, he became less agitated and returned to his bed. As I have experienced confrontational scenario before in my work previously, I am able to manage them better.

When you graduated as a Staff Nurse, be prepared for the six-day work week and three rotating shifts. Do not expect red carpet treatment when you start work. You will not be automatically on a faster career track. You would not get any extra respect from your colleagues just because you are older. You have to work as a team to earn your respect. There are eyes watching your every move closely. You are expected to be able to manage and contain awkward situations. In addition, you will also be bombarded by stress.

Learn as much as possible during the clinical attachments in the hospitals. Open you hearts and minds; get yourselves immersed in the nursing culture. These are good opportunities for you to test your beliefs about choosing nursing as your next career. Ask when you are in doubt and follow the protocols that are already in place and not to deviate from the norm. Eat your humble pie and prepare to work hard. Please be thankful to the Staff Nurses who are willing to teach you. They have to put in extra energy and time to teach you on top of their routine duties.

You should keep in mind that nursing is a physically and at times emotionally demanding job. The workload can be pretty heavy. Each day, we are thriving on working in an intense atmosphere and most of us here are swimming very hard to stay afloat. We have to put in extra hours to finish the paper work and on top of that, we have to chalk up 80 to 100 hours of training per year. Although this may seem long, most of us think that such training is essential for us to acquire more skills.

After spending 2 months working as a Staff Nurse, I realize that I am in the progress of writing a colorful chapter in my life. I have embarked on a rewarding journey and have learnt to keep my chin up. This is a great profession, and I will not let any negativity get to me.

Making the mid-career switch to the healthcare sector is never easy for most of you here. You must do it for the right reasons and from within your hearts, because only then will you enjoy working with and helping people.

I wish you every success in your new career and hope that you will continue nursing for more years to come.

Thank you.

The Legal issues

Negligence is the area of the civil law where the plaintiff brings action against the defendant. As defined by Staunton and Chiarella (2004, p.36), “The cardinal principle of negligence is that the party complained of should owe to the party complaining a duty to take care, and that the party complaining should be able to prove that he has suffered damage as a consequence of a breach of duty.”. In order for a patient or the family members to be successful in a negligence action against a doctor, nurse or respective employer, there are specific elements or facts that must be established by evidence. These are: a duty of care owed to the patient, that the defendant has breached that duty, and harm or injury to the patient was caused by the breach of duty (Tingle & Cribb, 2002).

Duty of Care

A nurse owes a duty to a patient, where there is a nurse-patient relationship that creates that duty (Corcoran, 2000). Duty of care protects individuals from the risks and foreseeable injury resulting from factors within the organisation’s control. (Nurses Board of Western Australia, 2004). The existence of duty of care has already been established in this case study, and a nurse owes the client a special duty of care based on the establishment of a nurse-patient relationship (Mahlmeister, 1999). When Nurse Z accepted an assignment to care for Baby X, a legal duty is usually established (Ganschow, 2002). Doctor Y, by her profession, also owed a duty of care to her client.

Breach in duty of care

Breach in duty of care occurred when both Nurse Z, Nurse E, and the doctor owed the duty of care to Baby X. When suspecting that the prescription might be wrong, Nurse Z needed to fulfill the duty of care by performing nursing intervention in accordance with recognized standards of practice and within own scope of practice, consulting and clarifying any interventions that appear inappropriate with the relevant members of the health care team (ANMC, 2006). Nurse Z did not follow the protocols to check thoroughly with other health care professionals such as the pharmacist, other more experienced Doctors. When Nurse E was approached by Nurse Z to countercheck the dose of medicine, she did so by physically checking the medicine with the written order from Doctor Y. This was not the expected standard of care. When Nurse Z expressed that the treatment will endanger the patient’s life, a reasonable and prudent nurse should exercise due diligence to ensure that the order by Doctor Y was appropriate. There is a clear standard established in all health care settings to deal with disagreements with physicians’ orders, and it was not exercised. Thus, all the parties involved in this case had breached the duty of care.

Harm caused

In this case study, Baby X suffered from brain damage as a result of the infusion of Dextrose 50%. Here, there is a direct or causal relationship between the breach of duty that is claimed, and the injury that is alleged to have resulted from the breach (Ganschow, 2002). Compensation will be awarded in this case (Staunton & Chiarella, 2004). This may take into account the loss of quality of life and loss of bodily functions. According to civil law, Baby X’s parents can sue up to six years after Baby X has turned eighteen.

Q 2. Duty of care from the two nurses’ perspective

Responsibility and Accountability

Every nurse should have the knowledge and skill expected of them, to practice according to the nursing standard of care (Mahlmeister, 1999). They are legally accountable for patients in their care, and have an absolute duty to take positive action to prevent any harm to them.

In this case, there are two possible reasons that resulted in the mistake of Nurse Z giving an infusion of Dextrose 50% to baby X instead of Dextrose 5%. Firstly, it could be due to a lack of knowledge: she did not know that the dosage ordered by Doctor Y could cause fetal damage to a baby. The other reason is due to the professional hierarchy within the modern health care system. Nurses have no authority to change doctors’ orders, yet they have no legal right to refuse to carry out the medical instructions, even if they object to them (Thompson, Melia, & Boyd, 1994 as cited in Nolan & Hazelton, 1995). However, for the benefit of the patients, a nurse has a right, and a professional and legal obligation to question a doctor’s orders, if he or she believes that the treatment ordered is medically inappropriate or incorrect (Staunton & Chiarella, 2003). Any objections must be documented.

The nurse is always accountable for the outcomes of his or her actions in carrying out nursing duties (Mahlmeister, 1999). Thus both Nurse Z and Nurse E have the ultimate responsibility to ensure Baby X’s safety. By merely ensuring that the right patient was given the right drug, according to the right dose ordered by the Doctor, at the right time as to when the drug was to be given, and via the correct route, does not mean that both nurses were doing what a nurse should do. Both nurses must remember that the basis of the duty of care was to ensure that the nursing care patients received were given with autonomy, beneficence, non-maleficence and justice (Nolan & Hazelton, 1995).

Nurse Z and Nurse E must also be able to recognise the signs and symptoms in the baby that signaled that something was wrong when Dextrose 50% was infused. There should be regular monitoring of Baby X’s condition and the Doctor must be alerted when the baby’s condition was deteriorating. In this case study, no one realized that anything was wrong until Baby X had a cardiac arrest and subsequently suffered brain damage from the incorrect infusion of Dextrose 50%.

Principle of Beneficence

Nurse Z should be assertive when clarifying the dosage, and in obtaining additional medical advice. Doctor Y told her that she has checked with Doctors A, B, and C. To avoid being negligent, and to check if Doctor Y was lying, Nurse Z could check again with Doctors A, B, or C whether Doctor Y had consulted with them about administering Dextrose 50% to a baby. She could also escalate the matter to more experienced doctors. Alternatively, Nurse Z could consult the pharmacist to clarify and resolve the conflict over the drug dosage. If the conflict is still unresolved, her supervisor or senior nurses could be the best people to help Nurse Z.

Nurse E had re-checked the dose of Dextrose 50% with Nurse Z. She should not just look at the order form, and check against the medicine ordered. Nurse E should not countersign without understanding the patient’s condition. Although there may have been a lack of communication between Nurse E and Nurse Z, the question was whether Nurse E was accountable for her colleague’s actions. According to Gray and Pratt, (1989), as cited in Nolan & Hazelton, (1995), nurses are accountable for exercising their power in the interests of nursing. Their actions will affect the profession’s destiny.

Reference

ANMC (2006). ANMC national competency standards for the registered nurse. Canberra: ANMC.

Corcoran, M. (2000). What is negligence? BJU International, 86(3),280-285.

Ganschow, J. R. (2002). Introduction to the law. Seminars in Oncology Nursing, 18(2), 99-104.
Mahlmeister, L. (1999). Legal issues in nursing and health care. In B. Cherry, and S, Jacob. Contemporary nursing: issues, trends and management. St Louis: Mosby.

Nolan, A., & Hazelton, L. (1995). Responsibility and accountability. The practicing nurse. Sydney: WB Saunders.

Nurses Board of Western Australia. (2004). Scope of Nursing Practice Decision-Making Framework Learning Guide. Retrieved March 28, 2007, from http://www.nbwa.org.au.
Staunton, P., & Chiarella, M. (2003). Nursing and the Law. (5th ed.) Sydney: Churchill Livingston.

Tingle, J. & Cribb, A. (2002). Nursing law and ethics (2nd ed.). Oxford: Blackwell Publishing Company

History does repeat itself. My friend was telling me about the uncertainty of life and health. When we reach 40 health is most vulnerable. There are unknown changes in our bodies and disease creeping in and causing lots of inconvenience to our lifestyle.

It does not help my friend to feel relief when I told him that certain ethnic groups, overweight and those with family history of diabetes mellitus (DM) are more likely to have DM. In an article written by Liaw (2008), on 14^th January, 2008, he said that “Indians are 2 to 3 times more likely than Chinese to contract Type II diabetes, and Asians on the whole are about twice as likely as Caucasians to get it”.

In my opinion, DM is a metabolic disease and is linked with obesity. Metabolic syndrome is when the body’s system failed to convert food into energy. When there is too much sugar, which will eventually break down into glucose, in the blood and the insulin produced by the pancreas cannot help glucose to enter the cells.

DM does not kill, but it is the 7^th principal cause of death in Singapore in 2006 (Liaw, 2008). Most of the patients are dying or died from the complications caused by DM. Peter Gluckman pointed to the Straits Times that there are growing numbers of young people – some not even fat- are contracting DM. He said that even you are thin on the outside, but there may be a lot of fat inside you which made you susceptible to diabetes.

Liaw (2008) made an interesting point about the food we get as a child when we were born. He had made a good point here and I strongly believe that DM is related to your diet. Liaw (2008) said that “The traditional confinement diet Chinese mothers follow in the first month after child-birth might hold a key to lowering their babies’ risk of diabetes later in life”. What Liaw was trying to say is that what you feed your babies with is very important and I do not think that it is necessary be within the confinement period. It should be an on-going thing.

When I was working as a Medical Nurse in a chronic management ward, I observed that most patients with DM like one particular food. It is the cheapest that you can get and most convenient for anyone to put such item at home for treating hungry any time of the day. Yes, I mean the notorious BREAD!!!

Most of the breads are processed carbohydrates. Unless you are eating those expensive and hard to swallow full wholemeal and wholegrained bread, if not, most of them will give you more glucose in your blood. If you do not believe me, why not try to monitor your blood glucose level after taking the processed carbohydrates? You will know what I mean.

In Traditional Chinese Medicine therapy, most of treatments are focused on the 3 burners or on Ying deficiency. With my understanding on the formation of DM, my treatment will generally focuse on digestion problems, strengthening the function of the heart and restrict the consumption of processed carbohydrates.

Refernce

Liaw, W. C. (2008). S’pore And NZ Researches To Study Diabetes, Obesity In Asian. The Straits Times, Singapore, H5.

Tag: 

metabolic syndrome, diabetes, overweight, obesity, carbohydrates, bread, glucose, principal cause, confinement, diet, chinese mother, traditional chinese medicine therapy,

Wondering why I join nursing? I managed to retrieve my interview notes with the Straits Times in 2005. Sound very persuasive but the truth about nursing can be very “cruel”. It was unfortunate that I injured my hand and my dreams were crashed (including my migration dream)….sigh.However, I have learnt a lot from the job and it is indeed an eye opening experience for me. I always encourage the student to take up the challenges but not to stay in nursing just because you have no where to go after your GCE ‘O’ levels. There were some students who were discouraged by me along the way but I think it is good as nursing is not for everyone, include myself. You must be flexible and agile to switch your career in order to adopt to the environment. I am just doing that.

Thanks to my nursing experience, I have learnt how to be more flexible in life.

My interview questions:

1. What makes you decide to change your career path at that stage of your life?

I have always been interested in healthcare and believe that knowing more about healthcare will benefit those around me, like my family, my relatives and my friends. That is why, I have spent majority of my IT career in healthcare industry. In my spare time as a full licensed Traditional Chinese Medicine Practitioner, I find that I enjoy treating the sick, as well as improving the health of those who came to see me. I felt that I had not equipped myself with the adequate knowledge about Western medicine. I wanted to be more knowledgeable about the different aspects of treatments available, so as to be able to help the sick better. I believe Nursing will be a great complement to it.Making the mid-career switch to the healthcare sector is never easy for me. One must do it for the right reasons and from within your heart, because only then will you enjoy working with and helping people.

2. How are you adjusting with the new working environment & job scope?

   As a Staff Nurse, I need to be prepared for the six-day work week and three rotating shifts. I realized that beyond the facts and figures that I have learnt from NYP, I am expected to work hard and to learn from my colleagues as much as possible of all the things I need to know in order for me to be productive as a Staff Nurse. Nursing is indeed a physically and at times emotionally demanding job. The workload can be pretty heavy. Each day, I am thriving on working in an intense atmosphere. There are eyes watching your every move closely and is constantly bombarded by stress.

3. What are the views & reactions of your family & friends when they know of your decision?

My parents are supportive of my decision to make such career a change. They know that I am interested in Healthcare. They had given me the same support that they had given me many years ago when I took up the Traditional Chinese Medicine.

However, my friends were looking at me in disbelief. While a few of them were very kind to help me to get another job, another of my friend recommended me a psychiatrist.

4. How have your previous working experiences helped you now?

I can speak a few dialects and that enables me to be better connected to patients, especially the elderly patients who do not speak English and Mandarin. It is not uncommon for a nurse to encounter patients who are confrontational. As I have experienced confrontational scenario before in my work previously, I am able to manage them better.

I am hoping that in future I could make use of my previous experiences in IT to suggest an effective Nursing system. Such system could help to enhance the professional image of nursing and also enables nurses to provide better healthcare services for the patients.

Tag: change, career,  health, nurse, professional, tcm, interview, traditional chinese medicine, mid-career, NYP, Staff nurse, stress, healthcare, psychiatrist.