October 29, 2008

"Under Nursing but Over Caring"


"Over Caring or Under Nursing"

To anyone who reads this heading their first reaction will be "HOW"??, Contradictory? NO!
In the years of my professional work and especially since getting involved in mobile nursing, this apparent conflicting phenomenon disturbs me. Confirmed through a visit of a relative in a nursing home, where most of the people were fitted with a nasal tube and received liquefied nourishment.
Obviously this home was not specially for elderly persons who had a problem with swallowing, but rather an issue of convenience to the caretakers, (assisting a person by spoon feeding may be very time consuming).
This experience and that of other observations, brings me to the issue of drawing awareness of the public to the issue of what is correct and professional nursing.
Certainly not:
Over caring, a phenomenon that arises when a person is attended 24 hours by a "care taker" which is being paid to take "good care" of the sick person.. From the point of view of the family, "we want to provide the best care". However from a professional nursing concept it is wrong, because the patient will solicit the service of the "paid " care taker and for all concerned unnoticed the sick person will not be motivated to start doing things for themselves but rely on the care taker do almost everything for him/her.
Thereby loosing very fast the competences and skills to help themselves. Experience has shown that, where the sick person gets only the complementary level of assistance the motivation to regain the former abilities is much greater than for those who have a special care taker. In the long run the developing of a mutual dependency, between that care taker and the sick, will reach a stage where the sick person has lost most of the abilities to do even basic functions and the family is in a stress situation, because sooner or later the financial burden becomes to great, yet the situation has become worse instead of improved. This is also observed in institutional settings, where the patient expects that everything is being doe for him. It is a well observed fact that recovery and regaining of abilities towards self help is greatly enhanced if the person is in his own home environment and fostered to increase his owns kills and abilities to cope with daily task to care for themselves, and is stimulated to pay attention to what is happening within his/her environment, grandchildren, pets, friends, family members etc.
Under nursing, is the other side due to lack of professional nursing. Obvious there is hardly anyone who does not want to provide the best "care" for the sick family member. However the motivation and good intention by it selves, does not compensate for the professional nursing.
A professional nurse needs 3 years of training before getting a certificate of competence, and many years of experience are needed to become skilled in dealing with sick people. And additional skills are required to work in a mobile nursing system providing service in a family setting. The most common problem arise out of lack of knowledge and experience in assuring improvements of the condition, and preventing worsening of the condition. To avoid the sick a lot of suffering and anxiety, the family distress, costly medical treatment and perhaps major hospitalization fees, professional nursing is needed, at least on an advisory level.
The most common problem arising out off:
a) Dehydration; Most elderly persons do not feel thirsty and will generally not ask for liquid, giving the impression that there is also no need for intake of liquid. In many cases of hospitalization of elderly there is always the symptom of dehydration in the forefront. This may result in renal failure, and a chain reaction of complicating problems. Many people have developed temporary "mental impairment" solely due to lack of liquid intake.
b) Improper intake of Medication: No one is fond of swallowing pills. Elderly persons have an aversion to pill taking, in particular when they are insufficiently informed of the working mechanism of the same and the consequences if they are not taken regularly. People like to see medications as a symptom reliever. "I don't need to take them today I am feeling very fine"! Elderly persons are forgetful, (particularly the short term memory) they may not remember if they have taken the medication or not, resulting in double intake or missing out of a doses. Either one may have, depending on the type of medication, severe consequences. Taking medication with liquid other than water, may result in impairment of the effect of the medication or cause avoidable intestinal complications
c) Bed sore: With sick persons who are temporarily or permanently bedridden or wheel chair bound, this is perhaps one of the most frequent problems encountered, yet in most cases avoidable. Simple aids and knowledge can prevent the same development and subsequent suffering and costly treatment to the sick person.
These are just a few of the problems that a family may encounter. In my training experience (of family nurses family members) I come across that care takers are often at loss as to what to do. Having outside nursing care may be too expensive and also infringing in the family setting.

The alternative is:
a) Professional nursing counseling with case assessment;
b) On the spot nursing coaching by experienced and examined nursing staff;
c) Attending of available training in coping with sick and or handicapped family members;
d) Soliciting professional nursing help, where and when needed, on a sporadic or regular basis as may be necessary or desired.
Conclusion:
We are steering to a situation where people become elder and live longer and this includes also more impaired (naturally due to aging) persons in our society. Modern medicine is as good as the surrounding supportive nursing care is available.

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Dehydration and illness in elderly persons

Dehydration and illness in elderly persons

The problem of dehydration is in general not receiving the attention that is deserves.
Approximately 70% to 75 % of our body mass consists of liquid. The reduction of 5% can cause problems and above 10% can lead to a life threatening situation. The Emergency Rooms of Hospitals are meeting this issue day by day. But ones the patient is discharged to home little attention is given to the original cause of the hospitalization, which is dehydration.
Most people are not aware of what is the correct amount of liquid a person should consume a day.
That is because there is no "correct amount" that would apply to all individuals equally.
The amount could vary from between 1 ½ liters to 6 liters in 24 hours depending on the individual and his/her special circumstance.

Factors that influence the need of liquid are;
Physical size
Physical activity
Age
Exposure to temperature
Health condition, such as fever
Medication (diuretics)
Intestinal infection with diarrhea
Endocrinological conditions such as diabetes
And other factors.

To know if a person has the correct amount of liquid consumed is when the urine has a color close to fresh pressed lime water. However most people will be far away from the ideal condition inviting long term consequences; such as
Confusion
Disorientation
Strokes
Kidney stones
Constipation
Fatigue
Wrinkles in the face (There is no cream that can substitute the water)
Cardiovascular problems
And many others………


Elderly people have a less significant feeling of thirst and hence tend to drink less. This can be easily compensated in that they have fresh fruits at their reach ready for consumption. Fruit juices are also more palatable to the elderly. Nutrients with added water such as porridge, jellys etc. are helpful to prevent dehydration. Liquid should be in such a place to be easily senn and available to the elderly.

If you have questions about care taking of elderly,
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When a nurse is not a nurse

When a nurse is not a nurse!
In recent time we have come across a series of situation where we noticed that so called "nurses" are offering medical, as well as general nursing to the ignorant public.
These "nurses" have at times not more than some vague practical experience often only from observation from nurses, in care taking. These "nurses" are offered by various agencies as well as hospitals to take care of patients in Hospitals and private homes as "private nurse" or a sent to people’s houses to take care of sick people.

Since the word NURSE is not a protected term (only State Registered Nurse =SRN) these people give the impression to the public that they are trained nurses, and competent to do nursing.

We have also come across cases were foreigners on visit passes who do not have certificates of Nursing training from their home country, but do privat nursing They are not registered with the Nursing Board of Malaysia, but working in various institutes and privately as nurses.
The public is often in a situation where they are in urgent need of nursing assistance for their sick family member. They do not dare to ask if these persons are really trained and qualified. They are also not requesting to view the certificate of nursing registration by the Nursing Board of Malaysia.

One does not needs to have a vivid fantasy to imagine what can happen to a sick person, who is attended by such fake nurses who performs various medical nursing tasks without academically qualification or professional training and are lacking skill and knowledge of the task they are performing.

These persons even perform tasks which in developed countries are usually performed by medical doctors only, or specially qualified nurses such as setting of feeding tubes, urethral catheterization etc.

The public is most of the time relying on the words of the referring agency, which just uses the term "they are qualified" or they are "nurses with experience" insinuating that they have a formal training and qualification.

It will not be surprising if such cases will increase in the near future as the need for qualified nurses is constantly increasing, and the supply can not meet the demand.
Genuine qualified foreign nurses are in a predicament, as they will only get a visa if they have an employer. How to get an employer without registration and certification by the Nursing Board? How is the Nursing Board registering a nurse who can not submit her application for registration without a registered employer. How is the Mobile nursing agency getting registered if there are no legal provision for such a registration? A vicious cycle that is difficult to be solved.
The public in the mean time is at the mercy of such unscrupulous practices by fake "Nurses" which not only tarnish the name of the nursing profession, but place the patient in an unpredictable danger as nursing is a professional job which takes 3 years of training and many more years of experience.

No one would send his car to a carpenter for repair. But exactly this is what happens in cases of hiring an unprofessional person to nurse a sick family member.
We can only appeals to the public, to be on guards when hiring "private nurses", and ensure that they can show prove of their qualification.
"Better to be safe than sorry"!

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October 24, 2008

The Wrong System Breeds the Wrong Product we should not be supprised with the results


The Wrong System Breeds the Wrong Product

I have written several critical comments about the quality of nursing in the country. It is essential to have a look and try to analyse the causes for the ‘poor’ products. To do so we have to look at the way our nursing system is being managed.

From my observation promotions are not based on quality, qualification and competency but rather merely on the automatic promotion based on years in service in the system.
This means that as times goes by even mediocre staff will get promoted to supervisory levels. In that a mediocre supervisor cannot deliver superior service is the logical conclusion. Not only are the staff working under such supervisors being poorly supervised and quided, even the patients have to be subjected to the same system. Little can be done by the more efficient and skillfull subordinates as the system will act as a blockade against the ‘smart ones’. These more efficient nurses would be marked as ‘acting smart‘ and most likely isolated and regarded as ‘revolts‘ by their superiors.

The real ‘good nurses’ will obviously and with merit be chosen for further education and subsequently promoted to higher levels of mainly administrative functions. This in return deprives the clinical sector of excelling skillful superiors. In other words, the skillful and competent nurses will not stay too long in the clinical ward service but will go up to the administrative sector, into works that at time could be done more effectively and efficiently by trained secretaries, instead of a promoted nurse. Here such a nurse will be wasting her nursing knowledge and skills, and struggle with administrative assignments just because the system is such.

Why can‘t the system be redesigned to provide ample promotional opportunities within the clinical nursing section? Why does a horde of highly qualified nurses have to man the nursing board, where most of the work is administrative? Does it need a nurse to prepare for the issuing of adninistrative work such as registration of nurses with the board?

Why not design a system where all nurses have to undergo continues learning particular in the field of patient management. This would prevent the practices of bygone times e.g. use of zinc oxide cream for bedsore etc. Why are the specially trained nurses not assigned to pass on the skills to the clinical staff in their practice of nursing. With the passing of nursing examination a nurse has indeed just begun to learn and develope her skills.

May I suggest that prior to the annual renewal of their licence nurses have to show proof of having attained the required number of hours in attending lectures and/or seminars to update and upgrade themselves. This is a way to ensure competence in nurses and upgrade the quality of nursing for the bebefits of patients.

On the other hand, each nurse must be sufficiently motivated to acquire additional skills and knowledge in the nursing field. Personal/job satisfaction in nursing depends, to a great degree, on the competence one has and can apply. The patient-care and communication can be so rewarding they act as a motivation to continuosly improve one‘s skills and competence.
We are faced with a peculiar situation in nursing that to my observation the nurses see themselve as assistants to the doctors whose directives are to be executed and instructions to be followed. Many a time I got the response: ‘the doctor did not give instruction’. But the issues of oral care, fungus prevention on the private parts of patients, decubitus prevention and dehydration are primarily the duties of nurses and only secondary to the doctors.
It is not supprising therefore that the nurses suffer from an inferiority complex due to lack of self confidence and competence. Nurses do not see themself as professionals working side by side with the other medical professionals but subservient to them. This obviously has to do with the lack of knowledge and skills the nurse is able to display. I have never felt that way but see the management of a patient as the combined role of a doctor and a nurse. No one is superior or inferior to the other, but each has the specific duties for which they are trained and skilled.
Perhaps it is time for the respective authorities to address this phenomena and act quickly on the shortcomings as abserved before the nursing profession takes a plunge into dangerous and criminally neglegent state.

I know of many concerned nurses in the country who are vocal and energetic in search for an answer to the problem. But do they get the necessary support, or are they running against a wall?

Let all concerned nurses in the country get together and have a "no barrier", frank and honest analysis with the authorities. Hopefully the authorities will implement the necessary changes without any delay or before it is too late.

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October 19, 2008

decubitus(bedsore) a criminal nursing neglecience

Bed sore a criminal nursing neglicience

By writing this article I am responding to my professional conscience.
Despite various and numerous approaches to reach the target groups I have not been able to activate or receive any response or echo.
Perhaps someone will stumble over this article and her/his nursing conscience gets activated.
Decubitus/Bedsore - a crime in the nursing profession!

Yes I am standing by this. Bedsore or decubitus as it is called in the professional language is a criminal negligence in the nursing process.

No matter how often it occurs in our hospitals, nursing homes and rehabilitation centers, or also in the private settings in patients’ homes it does not make it a non-preventable, painful and horrifying condition. Bedsores are in general preventable provided one understands the processes and conditions that contribute to its development.

In the years of my profession as a nurse the most striking observation I made is the total apathy and ‘tidak apa’ (could not be bothered) attitude of the nursing profession. This unfortunately is being accepted by the medical profession which does seemingly have equally little understanding of this problem. Perhaps understandably, the prevention of bedsore is mainly a nursing issue.
Why is it that so many patients irrespective of the place of care are afflicted with single or multiple bedsores? The maximum spots of skin abrasions and lacerations we ever come across were counted as 15 spots. The hospital staff claimed that this was due to the complexity of her illness. However this was countered as the sores receded and healed within weeks of proper skin care and proper sore management.

With the necessary cooperation of the family we have been managing to heal all bedsores we were given the responsibility of management.
When the family members inquired how the bedsores developed they were told by the hospital nurses that it was ‘BIASA’ (usual state) as the patient was elderly and bed-ridden. What they did not tell the families was that they did not even know that bedsores were developing on the patient.

It is a common practice that the body care of many patients is taken care of by relatives or maids. Apparently with the noble intention of the Health Ministry that the family learn how to manage the patient once he is discharged home. However the teaching aspect by the nurses in the ward is nil. So how is the family or the maid able to detect early signs of bedsore development or prevention when there is no coaching? But rather brushed off as menial work on the patient?! How does a nurse know that the patient is at risk to develop bedsore if she does not even know the contributory factors that lead to the development of bedsores. In one case the nurse was informed of an abrasion at the buttock. The nurse did not even inspect the buttock but just passed zinc oxide cream to the maid to apply.

Do our nurses understand:
proper skin care?
pressure and counter pressure?
interference of gas-exchange (diffusion-interference)?
metabolism in cells?
damage to cell-walls?
nutritional requirements?
impaired mobility?
spinal cord injury?
para/hemi/tetraplegia (quardraplegia)?
coma?
friction/rubbing?
unsanitary conditions?
sedation?
anaemia?
exicosis (dehydration)?
moisture of the skin?
And many other aspects that contribute to the prevention or development of bedsore?

I am willing to challenge any of our nurses currently taking care of patients particularly of geriatric patients of the knowledge and skills in the prevention of bedsores.
In most hospitals that I visited the patients were placed on incorrect mattresses, diapers were changed according to schedule, not as to the need of the patients, knowledge of skin care was close to nil, nutrition seemed to be unimportant and much more.

Ironically my offer to provide seminars on the issue of bedsores to approximately 15 hospitals and nursing schools in the Klang Valley did not get even an enquiry response.
Perhaps only legally criminalizing of the negligence of nurses responsible for a patients’ development of bedsores would wake up the nursing fraternity and the medical sector.

It’s time that we get rid of the lackadaisical attitude of bedsores are ‘BIASA’!

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October 14, 2008

Care and Management of Bedsore/pressure sore awailable in Malaysia





Pictures show improvement after professional treatment
Photos taken by treating nurse; Mona Hassan
Care and Management of Bedsore/pressure sore (decubitus)

It is surprising that the majority of the public and the medical/nursing profession is not aware of the fact that decubitus/bedsore wounds can be successfully treated.

This perhaps results the attitude and/or impression that if a bedsore develops the condition of the person must be so serious that it is not treatable or regard as time wasting in attempting to treat it.

Unfortunately many people are having the notion that the development of bedsore is an early sign of impending demise of the patient. I have heard people say, ”Oh, he already has bedsore so he will die very soon”

Ignorance and apathy are the main reasons for people to let their beloved die without attending to the sore, which in almost 100% of cases can be successfully rehabilitated.

In the first Instance it is imperative that a nursing assessment of the patient’s condition is being taken.

A bedsore can encompass many causes and until the main causes are identified by an experienced nurse in the management of bedsores it will be difficult to make a treatment/management plan.

A treatment and management plan must include the following points:

overall health condition of the patient
bed and beddings
nutritional aspect
hygiene of the patient
skin care
medication

After that the nurse will then be able to make recommendations for the care taking person.
The family will be informed of what dressing materials are required and how often the dressing has to be changed. In the early stages this should be done by the nurse to ensure that proper hygiene and monitoring of the wound is adhered to. At the later stage when the wound has improved and become superficial, dressings can be left in-situ for 3-5 days and the care taker may be able to renew the dressings.
Not every wound is the same, so the conditions of the patient and in any case even the patient’s condition may change, high temperature, exicosis, sepsis etc. and require medical intervention.

The family must have a lot of patience and cannot expect a quick healing process particularly if the sore is deep and ‘pockets’ have developed.
Paramount in the healing process is that the nurse’s recommendations are being followed as these are aimed to improve the general condition of the patient and subsequently expedite the healing process.

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