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INSIDE
Groundbreaking
New Certification
Practice Change:
Let’s Feed Our
Patients!
10
16
OFFICIAL NEWSLETTER
Volume 24 – Number 5
September/October 2015
A
Cynthia W. Ward
Effective pain management is a concern for all patients having surgery and is directly related to an
individual’s comfort and well-being. Unrelieved pain may lead to postoperative complications and
patient dissatisfaction.The nurse’s role in postoperative pain management is pivotal to better patient
outcomes. Particularly, nurses’ knowledge, attitude, and skill competency about pain management are
shown to impact the patient’s pain management, as well as health outcomes. Management of postoperative pain is obtained through a combination of methods.
The postoperative care of individuals includes the challenge of managing their pain.
Postoperative pain is caused by trauma to the tissues or injury to the nerves caused by the surgical
procedure (Kodali & Oberoi, 2012). Because of the varied origins of postoperative pain, a multimodal approach to treatment is needed. This article provides a review of opioid, nonopioid, and
adjuvant medications used for pain management.
T
Opioids
Opioids are morphine-like substances that can be either natural or synthetic and are used to
treat moderate to severe pain. This class of drugs may also be referred to as narcotics; however,
more recently the word narcotic carries a stigma and is used to refer to illegal drugs that are often
abused (Adams, Holland, & Urban, 2011). Opioids act by binding to receptors, named mu, kappa,
continued on page 12
PLUS
Issues in Nursing: Bed Huddles Improve Communication and Patient Safety . . . . . . . . . . . . . . . . . 2
CNE Care of the Patient with Chronic Kidney Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Drug Update: Venous Thromboembolic (VTE) Prophylaxis: Part III. . . . . . . . . . . . . . . . . . . . . . . . . 8
Legal Nursing: Nursing Liability and Evidence-Based Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Issues
IN
Volume 24 – Number 5
September/October 2015
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2
NURSING
Bed Huddles Improve
Communication and Patient Safety
Medical error is defined as “the failure of a planned action to be completed as
intended or the use of a wrong plan to achieve an aim…[including] problems in
practice, products, procedures and systems” (HealthGrades, 2008, p. 4). In 2012, a
medical-surgical unit in an urban hospital conducted a microsystem analysis to
assess the interactions between patients, professionals, and processes to identify
barriers to providing patient care. The analysis was completed by gathering information from completed surveys including Press Ganey, HCAPS, employee satisfaction, and monitored data by the facility such as patient days, length of service,
admitting diagnosis, and quality benchmarks. Observation of staff members took
place through the day and night shift during various patient-centered cares and
job-related tasks. The microsystem analysis identified the need to revise bed huddles in order to maximize the most benefit for patient safety.
Bed huddles were originally implemented as safety huddles. Staff on the unit
used the huddles to provide information on patients related to fall risk, the risk for
skin breakdown, and any pertinent information needed to assist in patient care.
However, bed huddles only took place on the day shift and lacked information
related to patient safety.The focus of discussion was on patient discharges for the
day.The huddles would last 15-30 minutes and pulled staff off the floor. Caregivers
were away from patients longer than necessary without conveying vital patient
information. During the microsystem analysis, it was identified that neither the unit
nor patients were benefitting from the huddles on the unit. However, literature
indicated that huddles could be of significant value (Chapman, 2009; Dingley,
Daugherty, Derieg, & Persing, 2008). The unit was determined to identify the discrepancies and improve the huddles with the goal of improving health care communication and patient outcomes.
Implementation of Process Change
Bed huddles on the unit were reformatted according to literature.The following quality improvement measures were implemented after review of literature:
• A set time was established to increase attendance by management and
staff. The huddles convened at 10 a.m. and 10 p.m. throughout the trial
period.
• A whiteboard was designed to maximize communication of patient-specific information (see Figure 1) and used during bed huddles.
The whiteboard was utilized as a guide in the meetings as a reminder of
patient information to cover. The communication board was designed on a dry
erase board marked off in quadrants so that it could be updated with any change
in patient. It was to be updated prior to shift change and when there was a change
in patient status. The unit secretary would place admissions on the board during
the day shift, and the staff nurse would update pertinent information after obtaining his/her report on the patient. The responsibility of the night nurse was to
update relevant patient information throughout the shift. All members of the interdisciplinary team utilized this information (such as pharmacy, physical therapy,
social worker, case manager, etc.) as they passed through the Team Member
Center.
Huddles were timed throughout the one-month trial period and found to be
an average of 10 minutes or less. These short huddles eliminated time off of the
floor and away from patients. Management attended a majority of the huddles and
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Volume 24 – Number 5
Figure 1.
Patient Information Whiteboard
!
guided the process by providing unit updates and need-toknow information.
Summary
Evaluation and redesign of the huddle process continues,
which allows for best practice and optimal use of huddles.
Continued monitoring of fall rates and patient satisfaction
scores will provide additional opportunities for success in
the process.
Success of this process enhancement can be measured
in many ways. The number of falls may decline. Patient satisfaction scores may improve because patients will perceive
they are being cared for and their needs are being addressed.
The huddle process has guided and improved communication amongst staff. The communication board serves as a hub
of information for interdisciplinary members of the patient’s
care.
Awareness was the most significant success of this
process, bringing forth the importance of patient safety and
patient-centered care. Huddles allowed staff to disseminate
knowledge and ideas from the range of novice to expert. The
diversity incorporated views from different aspects of health
care to provide the best possible outcomes for patients.
References
Chapman, K.B. (2009). Improving communication among nurses,
patients, and physicians. American Journal of Nursing, 109(Suppl. 11),
21-25.
Dingley, C., Daugherty, K., Derieg, M., & Persing, R. (2008). Improving
patient safety through provider communication strategy enhancements.
Advances in patient safety: New directions and alternative approaches,
(vol. 3). Rockville, MD: Agency for Healthcare Research and Quality.
Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK43663/
HealthGrades (2008). The fifth annual HealthGrades patient safety in
American hospitals study. Retrieved from http://hg-article-center.s3website-us-east-1.amazonaws.com/a9/9a/3b64b168487
c86c30dc0986dc344/PatientSafetyInAmericanHospitalsStudy2008.
pdf
Melanie Davis, MSN, BSN, RN, is a Clinical Staffing
ED/Critical Care Nurse, Unity Point Health Des Moines, Des
Moines, IA.
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3
CONTINUING
CNE
NURSING
Care of the Patient with
Chronic Kidney Disease
EDUCATION
Care of the Patient with
Chronic Kidney Disease
Deadline for Submission:
October 31, 2017
MSNN1505
To Obtain CNE Contact Hours
1. For those wishing to obtain CNE contact hours,
you must read the article and complete the
evaluation through the AMSN Online Library.
Complete your evaluation online and print your
CNE certificate immediately, or later. Simply
go to www.amsn.org/library
2. Evaluations must be completed online by
October 31, 2017. Upon completion of the evaluation, a certificate for 1.0 contact hour(s) may
be printed.
Fees
Member: FREE
Regular: $20
Objectives
The purpose of this continuing nursing education
article is to increase nurses’ and other health care
professionals’ awareness of the modes of treatment
for patients in the many stages of chronic kidney disease (CKD). After studying the information presented
in this article, you will be able to:
1. Define CKD and explain its pathophysiology.
2. Discuss the classification and stages of CKD.
3. Identify methods of care for patients in each
stage of CKD.
Note: The author, editor, editorial board,
and education director reported no actual
or potential conflict of interest in relation to
this continuing nursing education article.
This educational activity is jointly provided by
Anthony J. Jannetti, Inc. and AMSN.
Anthony J. Jannetti, Inc. is accredited as a provider
of continuing nursing education by the American
Nurses Credentialing Center’s Commission on
Accreditation.
Anthony J. Jannetti, Inc. is a provider approved by
the California Board of Registered Nursing, provider
number CEP 5387. Licensees in the state of CA must
retain this certificate for four years after the CNE activity is completed.
4
Alan Garcin
In the United States, there are an estimated 25 million people who have been
diagnosed with chronic kidney disease (CKD), and the prevalence is especially high
among the elderly with approximately ten million cases in those over the age of
77 (Levey et al., 2011). It is important to note that not everybody with CKD needs
dialysis or a kidney transplant. According to Levey and colleagues (2011), there are
approximately 450,000 people in the United States who currently require dialysis.
A framework for the classification of CKD was first proposed by the National
Kidney Foundation (NKF) Kidney Disease Outcomes Initiative (KDOQI) in 2002,
and it was endorsed by Kidney Disease: Improving Global Outcomes (KDIGO) in
2004 (Levey et al., 2011). Staging and classification is based on kidney function using
the estimation of the glomerular filtration rate (GFR) (Winearls & Glassock, 2009).
Glomerular filtration rate is defined as the volume of fluid filtered from the
glomerular capillaries into the Bowman’s capsule per unit time. A normal GFR is
90 mL per minute or higher. Chronic kidney disease is defined as a GFR less than 60
mL per minute or kidney damage reflected by albuminuria that persists for at least
three months (Fink et al., 2012). If health care professionals are familiar with the
stages of CKD, they can provide care based on the expected condition of their
patients (Zadvinskis & Grudell, 2010).
Pathophysiology
Chronic kidney disease is usually a slow and insidious disease, with continuing
irreversible reduction in nephron number and function (Bragman & Skorecki,
2012). According to Bragman and Skorecki (2012), the destruction of the nephron
is either a result of specific underlying etiology or a set of progressive mechanisms.
Underlying etiologies include genetic abnormalities, autoimmune conditions,
glomerulonephritis, or exposure to toxins. Progressive mechanisms are often the
result of chronic inflammation associated with other medical conditions, such as
diabetes and hypertension (Bragman & Skorecki, 2012). As the nephrons are damaged, the workload of the remaining nephrons is increased to maintain renal function. The hyperfiltration of the functioning nephrons causes structural alterations
of the afferent arterioles, leading to glomerulosclerosis (Porth, 2009). As further
damage occurs, the GFR decreases, which causes progression of the disease
toward end-stage renal disease (ESRD) (Bragman & Skorecki, 2012).
Progressive mechanisms of renal dysfunction are much more prevalent than
underlying etiologies such as polycystic kidney disease. For example, excluding
those with ESRD, in 2008, 48% of Medicare patients with CKD had diabetes, 91%
had hypertension, and 46% had atherosclerotic heart disease (Fink et al., 2012).
Classification of Chronic Kidney Disease
In 2002, the National Kidney Foundation (NKF) Kidney Disease Outcomes
Quality Initiative (KDOQI) introduced a conceptual model for the definition and
classification of chronic kidney disease. Chronic kidney disease was defined based
on the presence of kidney damage, which is reflected in the glomerular filtration
rate (GFR). It was determined that a person had CKD if the GFR was less than 60
mL per minute per 1.73 m2 for more than three months.The disease was classified
into five stages based on the level of GFR. In 2004, Kidney Disease: Improving
Global Outcomes (KDIGO) endorsed this framework with minimal modifications
(Levey et al., 2011). Chronic kidney disease stages are classified in Table 1.
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Volume 24 – Number 5
Table 1.
Stages of Chronic Kidney Disease
Stage
GFR mL/min
Progression of Disease
Stage 1
greater than 90
Kidney damage
Stage 2
60-89
Kidney damage with mild or decreased GFR
Stage 3
30-59
Moderate decrease in GFR
Moderate complications
Stage 4
15-29
Severe decrease in GFR
Severe complications
Stage 5
less than 15
End-stage renal disease
Kidney failure
Source: Table adapted from NKF, 2002.
The classification of kidney disease remained unchanged
for almost a decade; however, in 2009, the leadership of
KDIGO and KDOQI convened for a “Controversies
Conference” to provide a forum to examine the validity of
the existing system and to evaluate proposed alternatives
(Levey et al., 2011).
At the conference, those present reached strong consensus that the current classification did not adequately
describe the severity of CKD and that predicting prognosis
could be improved by the following modifications to the classification:
1. Emphasize classification by cause, if known, in addition to
stage.
2. Add albuminuria stages, in addition to GFR stages (albumin
clearance rate [ACR] <30mg/g, 30-300 mg/g, and >300 mg/g).
3. Subdivide CKD Stage 3 into two stages (GFR 30-44 and 4559 mL/min/1.73 m2) (Levey et al., 2011).
A less strong consensus emerged that it would be premature to change the current definition of CKD based on
levels of GFR or presence of kidney damage. The following
recommendations were also adopted (Levey et al., 2011):
1. Make no change to the definition based on GFR (<60
mL/min/1.73 m2), irrespective of age or sex.
2. Make no change to the level of albuminuria defined as a
marker of kidney damage (urine ACR >30 mg/g).
Calculation of the Glomerular Filtration Rate
According to Myers (2008), the following calculation can
be used to determine GFR:
GFR = (140 – Age) x wt (kg)
SCr x 72
(wt = weight, kg = kilogram, SCr = Serum Creatinine level)
Many practitioners consider creatinine clearance to be a
more accurate means to determine GFR and the stage of
CKD (Myers, 2008). According to Myers (2008), the following formula is use to calculate the GFR using creatinine clearance:
CCr =
(UrineCr) x (Volume of urine per 24 h)
(SerumCr) x 1440
(C =clearance, Cr = creatinine)
Care Based on Chronic Kidney Staging
Patients who suffer from CKD have multiple comorbidities that vary from mild to severe complications, and therefore require care from multidisciplinary specialist teams.
Care teams for patients who have CKD should at minimum
include a nephrologist, oncologist, and a cardiologist to manage accompanying diseases such as diabetes mellitus and
hypertension (Dean, 2012).
Care for CKD in this article is based on the American
Association of Critical Care Nurses (AACN) Synergy Model.
The AACN Synergy Model is a conceptual framework
designed for acute and critically ill patients. “According to the
AACN Synergy Model, when patient characteristics and
nurse competencies match, patient outcomes are optimized”
(Peterson & Bredow, 2009, p. 101). Of the sixteen patient
characteristics identified by the Synergy Model, vulnerability,
complexity, and stability are highlighted by patients who
require care for CKD complications. Nursing competencies
related to the care of patient with CKD include: clinical judgment, caring practices, and systems thinking (Peterson &
Bredow, 2009). Therefore, by implementing care guided by
the clinical presentation of the patient and the stages of
CKD, the patient characteristics will be matched by the
nurses’ competencies. When synergy exists between the
nurse and patient with CKD, patient care can be tailored to
his or her individual needs and outcomes will be optimized.
The Michigan Quality Improvement Consortium (2013)
offers the following guidelines to care for adult patients
according to the stage of CKD:
Stage 1 (GFR greater than 90). Patients need to have GFR
measured annually and start smoking cessation (if they
smoke). According to current guidelines, providers need to
consider angiotensin-converting enzyme (ACE) inhibitor
5
Academy of Medical-Surgical Nurses
and/or angiotensin receptor blocker (ARB) therapy for
hypertension; set blood pressure (BP) goals less than 130/80;
and low density lipoprotein-cholesterol (LDL-C) goals less
than 100 (Michigan Quality Improvement Consortium,
2013). The KDOQI guideline for diabetes management suggests that intensive treatment of hyperglycemia prevents elevated albuminuria or delays its progression. Maintaining a
hemoglobin A1C (HA1C) less than 7% will prevent or delay
the progression of microvascular complications related to
diabetes (NKF, 2012). As stated previously, patients with diabetes need to be screened for microalbuminuria and
macroabluminuria at all stages of CKD (Levey et al., 2011).
Stage 2 (GFR 60-89). Patients should have a nephrology
referral if the GFR decline is greater than 4 mL per minute
per year. Providers should form a plan of care with patients
to maintain BP and lipid goals as above (Michigan Quality
Improvement Consortium, 2013). Nurses can educate
patients who are at risk of developing CKD if their GFR falls
below 60 mL per minute and emphasize the importance of
reducing sodium intake, maintaining a healthy diet, and being
compliant with their hypertension medication (Levey et al.,
2011).
Stage 3 (GFR 30-59). In addition to the evaluation for
Stages 1 and 2, an endocrinology consultation should be considered, even if the patient is not diabetic, to rule out abnormalities of parathyroid hormone (PTH), vitamin D, calcium,
and phosphorus. At this stage, if the patient’s GFR is less than
45, a relationship with a nephrologist is recommended. Avoid
contrast, if possible. Avoid nonsteroidal anti-inflammatory
drugs (NSAIDs); low-dose aspirin (ASA) is allowed (Michigan
Quality Improvement Consortium, 2013). Patients in this
stage should be placed on a renal diet that includes limited
sodium and protein intake. Daily weight and fluid intake
should be monitored to assess for fluid overload (Myers,
2008). Patients need to be encouraged to do moderate exercise; however, vigorous exercise that will stress the body
should be avoided (Myers, 2008). Patients with Stage 3 CKD
need to be educated about the disease (Michigan Quality
Improvement Consortium, 2013). The reality of Stage 3 progressing to Stage 4 and ESRD needs to be conveyed to the
patient in the hope that he or she will make necessary
lifestyle changes to slow the progression of the disease
(Michigan Quality Improvement Consortium, 2013).
Stage 4 (GFR 15-29). In addition to the recommendations
for Stages 1, 2, and 3, patients in Stage 4 need to have their
electrolytes monitored regularly, including phosphorus, magnesium, and calcium. Due to the number and complexity of
decisions involved in treating kidney failure, a shared decision-making relationship is particularly important. During this
stage, dialysis is often part of the patient’s treatment regimen,
and they need to have open communication with all health
care providers (Renal Physicians Association [RPA], 2012).
Multidisciplinary teams should include social workers to facilitate hemodialysis treatments and psychologists/psychiatrists
to help patients cope with the psychological challenges when
newly diagnosed with ESRD related to CKD. In addition,
6
www.amsn.org
patients should also be encouraged to identify a person who
could serve as the decision-maker in the event he or she
loses decision-making capacity (RPA, 2012).
Stage 5 (GFR less than 15). Besides optimizing medical
management for ESRD, consider the available dialysis modalities and kidney transplantation, if appropriate. If the patient
chooses not to start dialysis, the continuation of medical
management must be discussed with the patient or designated legal agents (RPA, 2012). Recommendations include
that the renal care team, in conjunction with the primary
care physician, ensure that the patient or legal agent understand the benefits and burdens of dialysis before it is started
(RPA, 2012). If the patient or designated legal agent decides
not to start dialysis or chooses to stop having dialysis treatments, the patient or legal agent needs to receive appropriate end-of-life education and care. Nurses have an opportunity and a responsibility to ensure these decisions are
informed, voluntary, and implemented as requested (RPA,
2012).
Conclusion
The consensus on revising the classification of CKD
indicates the need for an update to the 2002 KDOQI clinical
practice guidelines. As stated in the KDIGO “Controversies
Conference,” there was a need for a workgroup to develop
a global guideline for the care of CKD (Levey et al., 2011).
According to Levey and colleagues (2011), the development
of global guidelines has begun.
When health care providers are able to calculate the
GFR of a patient with CKD, they can determine the stage of
the disease for their patient. Once the stage has been determined, they can better individualize and anticipate the needs
of the patient based on the expected physical and psychological manifestations. With this knowledge base, we can better
preserve the remaining kidney function, thereby improving
quality of life for the patient with chronic kidney disease.
References
Bragman, J.M., & Skorecki, K. (2012). Chronic kidney disease. In D.L.
Longo, A.S. Fausi, D.L. Kasper, S.L. Hauser, J.L. Jameson, & J. Loscalzo
(Eds.), Harrison’s principles of internal medicine (18th ed., pp. 23082321). New York, NY: McGraw Hill Medical.
Dean, J. (2012). Organising care for people with diabetes and renal disease. Journal of Renal Care, 38, 23-29. doi:10.1111/j.17556686.2012.00272.x
Fink, H.A., Ishani, A., Taylor, B.C., Greer, N.L., MacDonald, R., Rossini, D.,
... Wilt, T.J. (2012). Screening for, monitoring, and treatment of
chronic kidney disease stages 1 to 3: A systematic review for the
U.S. Preventive Services Task Force and for an American College
of Physicians Clinical Practice Guideline. Annals of Internal
Medicine, 156(8), 570-581.
Levey, A.S., de Jong, P.E., Coresh, J., El Nahas, M., Astor, B.C., Matsushita,
K., & ... Eckardt, K.U. (2011).The definition, classification, and prognosis of chronic kidney disease: A KDIGO Controversies
Conference report. Kidney International, 80(1), 17-28.
doi:10.1038/ki.2010.483
Michigan Quality Improvement Consortium. (2013). Diagnosis and management of adults with chronic kidney disease. Southfield, MI: Author.
Myers, C.M. (2008). Renal insufficiency and failure. In T.W. Barkley, Jr., &
C.M. Myers (Eds.), Practice guidelines for acute care nurse practitioners (2nd ed., pp. 415-429). St. Louis: Elsevier.
866-877-2676
Volume 24 – Number 5
National Kidney Foundation (NKF). (2002). Kidney Disease Outcomes
Quality Initiative (KDOQI) clinical practice guidelines for chronic kidney
disease: Evaluation, classification, and stratification. Retrieved from
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc
National Kidney Foundation (NKF). (2012). KDOQI clinical practice
guideline for diabetes and CKD: 2012 update. American Journal of
Kidney Diseases, 60(5), 850-886.
Peterson, S.J., & Bredow, T.S. (2009). Middle range theories: Application to
nursing research (2nd ed.). Philadelphia: Lippincott, Williams &
Wilkins.
Porth, C.M. (2009). Disorders of renal function. In C.M. Porth, & G.
Matfin (Eds.), Pathophysiology: Concepts of altered health states (8th
ed., pp. 828-829). Philadelphia: Lippincott, Williams & Wilkins.
Renal Physicians Association (RPA). (2012). Guideline recommendations and their rationales for the treatment of adult patients. In
Shared decision-making in the appropriate initiation of withdrawal from
dialysis (2nd ed., pp. 39-92). Rockville, MD: Author.
Winearls, C.G., & Glassock, R.J. (2009). Dissecting and refining the staging of chronic kidney disease. Kidney International, 75(10), 10091014. doi:10.1038/ki.2009.49
Zadvinskis, I.M., & Grudell, B.A. (2010). Clinical practice guideline appraisal
using the AGREE instrument: Renal screening. Clinical Nurse
Specialist, 24(4), 209-214. doi:10.1097/NUR.0b013e3181e36072
Alan Garcin, ACNP MSN, CCRN, is a Nurse Practitioner,
Sacred Heart Medical Center, Springfield, OR.
Acknowledgement: The author would like to give special thanks to
Sheila Melander, DSN, ACNP-BC, FCCM, FAANP, for assisting with
preparation of the manuscript.
Nutrition to Improve Outcomes
continued from page 16
greatly limits opportunities for them to receive adequate
nutrition (Barker, Gout, & Crow, 2011). Inappropriate preprocedural fasting is a concern that needs to be addressed in
order to provide the safest care possible to our patients. It is
important that nurses and physicians are aware of current
anesthesia guidelines and collaborate in order to ensure that
patients are not kept without nutrition for longer than necessary.
References
American Society of Anesthesiologists (ASA) Committee on Standards
and Practice Parameters. (2011). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the
risk of pulmonary aspiration: Application to healthy patients
undergoing elective procedures. Anesthesiology, 114(3), 495-511.
Barker, L.A., Gout, B.S., & Crowe, T.C. (2011). Hospital malnutrition:
Prevalence, identification and impact on patients and the healthcare system. International Journal of Environmental Research and
Public Health, 8(2), 514-527. doi:10.3390/ijerph8020514
Crenshaw, J.T., & Winslow, E.H. (2002). Preoperative fasting: Old habits
die hard. American Journal of Nursing, 102(5), 36-44.
Hamid, T., Aleem, Q., Lau, Y., Singh, R., McDonald, J., MacDonald, J.E., …
Balachandran, K. (2014). Pre-procedural fasting for coronary interventions: Is it time to change practice? Heart, 100(8), 658-661.
doi:10.1136/heartjnl-2013-305289
Kelsey Tirona, BSN, RN, is a Clinician II – Coronary Care
Unit, University of Virginia Health System, Charlottesville, VA.
NEW and UPDATED
PREPARE
STAY CURRENT
ENSURE
7
Drug Update
www.amsn.org
Venous Thromboembolic (VTE) Prophylaxis: Part III
General Considerations in Reducing and Preparing for Unexpected Bleeding Events with the NOACs
Recap of Parts I & II
Parts I and II of this series on VTE prophylaxis
(Goldstein, 2014, 2015) have focused on reviews of new
medications available for prevention of coagulopathies following orthopedic surgeries and diagnoses of non-valvular
atrial fibrillation, drug interactions leading to increased bleeding risks with these medications, and new antidotes under
study to treat acute bleeding events for patients taking the
new anticoagulant medications. This final installment of the
three-part update will address easily used screening checklists for nurses to use at the bedside that assess bleeding risk
and stroke risk for patients, as well as emergency responses
for patients who are observed to have uncontrolled, acute
bleeding events while taking any of the anticoagulant medications we have reviewed.
Assessing Patients at Risk
In some cases, as rare as they may be, patients may be
admitted to a med-surg floor with an unreported history of
atrial fibrillation (afib) or prior warfarin use.A simple and easily completed bedside checklist for stroke risk among those
with afib is the CHADS-2, a scale originally developed in
2001 in order to assign risk scores for stroke based upon
clinical history and risk factors present (Gage et al., 2001;
Levine, 2014).
Readers may see reference to a newer, updated CHADS
scale (the CHA2DS2-VASc system), developed by the
European Society of Cardiology (ESC), which adds three
additional measures for predicting stroke risk and appears to
add greater sensitivity in predicting strokes (Lip, Nieuwlaat,
Pisters, Lane, & Crijns, 2010). An online version of the
CHA2DS2 score calculator (widely accepted in Europe and
the United Kingdom) is available at http://www.qxmd.
com/calculate-online/cardiology/chads2-stroke-risk-in-atrialfibrillation to assist in determining percentage of stroke risk.
However, in the United States, the 2012 update of practice recommendations by the American College of Chest
Physicians (Guyatt et al., 2012) recommends the original
CHADS-2 scoring system for assessment and treatment of
patients at risk. On the CHADS-2, anyone scoring 2 or more
is considered high risk for stroke within the next year.
Clinicians may also wish to familiarize themselves with
bleeding risk assessment tools in the medical literature. One
helpful and simple assessment tool is the HAS-BLED assess-
ment, which yields a 1-year bleeding risk score based upon
clinical history (Pisters et al., 2010). Anyone who scores a
total of 3 or greater on the HAS-BLED Scale is at high risk
for a bleeding event over the next year (Coagulation Center,
2015). An online HAS-BLED score calculator can be found at
http://www.qxmd.com/calculate-online/cardiology/has-bledscore-bleeding-in-atrial-fibrillation and may be used to evaluate bleeding risk percentage.
If physicians are not aware of a risk assessment of 3 or
more on a given patient, they need to be informed and
nurses should be cautious in the use of any NSAIDs with
such patients, even if NSAIDS have been approved on the
patient electronic MAR. It is the experience of this writer
that such medication interactions are often missed or overlooked during pharmacy reconciliations.
Treating Unexpected Bleeding Events
Some facilities have developed emergency protocols for
acute or life- or limb-threatening bleeding events for patients
taking any Factor IIa or Factor Xa oral anticoagulant, which
involves the following step-wise treatment approach (Kumar,
Smith, & Henry, 2015; Vílchez, Gallego, & Lip, 2014).
Step 1: Withhold anticoagulant; start timed monitoring of
PT, aPTT, and TT (Thrombin Time).
Step 2: Transfuse blood products high in plasma.
Step 3: Consider need for surgery or embolization.
Step 4: Activate charcoal to reduce additional absorption if
dabigatran or rivaroxaban taken within 2 hours or
apixaban within 3 hours.
Step 5: Consider hemodialysis with dabigatran only.
Step 6: Consider antifibrinolytic therapy.
Step 7: Consider PCCs (rivaroxaban/apixaban) (Perlstein
et al., 2014).
Nursing staff also need to be aware of drug-drug interactions with the NOACs. By examining Table 5, readers will
notice that all of the NOACs, excluding warfarin, are substrates for the P-glycoprotein (P-gp) transport system. This
makes all of these drugs susceptible to influences of P-gp
inhibitors. These inhibitors will decrease elimination of the
medication, prolonging half-lives and increasing plasma concentrations. Specific P-gp inhibitors nurses need to be wary
of (especially with impaired renal function) include: ketoconazole, dronedarone, amiodarone, verapamil, dilitiazem, clarithromycin.
Note: Tables 1 and 2 can be found with Part I of this series, which appeared on pages 14-15 of the September/October 2014 issue
of MedSurg Matters! Tables 3 and 4 can be found with Part II, which appeared on pages 9-13 of the July/August 2015 issue.
8
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Volume 24 – Number 5
Table 5.
Pharmacokinetics (PK) and Pharmacodynamics (PD) of the NOACs
Compared to Warfarin
Characteristics
Warfarin
Dabigatran
Apixaban
Rivaroxaban
Edoxaban
99
35
87
95
54
20-60
7-17
8-15
7-13
9-11
¹Reversal of Bleeding Events
FFP/PCC
Vitamin K+
PCC Idarucizumab
Dialysis+
PCC
PCC
Andexanet
PCC
Aripazine
Metabolism/elimination
100% liver
80% renal
20% liver
25% renal
75% fecal
33% renal
67% liver
35% renal
65% liver
Yes
No
No
No
NR
2C9, 3A4
No
3A4
3A4, 2J2
3A4
No
Yes
Yes
Yes
Yes
Protein binding (%)
Half-life: [t1/2 (hours)]
Food interaction
Liver Substrates CYP
Substrate P-gp
Key: CYP = cytochrome P proteins. Human CYPs are primarily membrane-associated proteins located either in the inner membrane of mitochondria or in the
endoplasmic reticulum of cells. CYPs metabolize thousands of endogenous and exogenous chemicals including medications. FFP = fresh frozen plasma. NR = not
researched. PCC = prothrombin complex concentrate. P-gp = permeability glycoprotein, also known as multidrug resistance protein 1, an important protein of the
cell membrane that pumps foreign substances out of cells.
¹As of January 6, 2015, there are no licensed, FDA approved medications for reversal of Factor IIa and Factor Xa oral anticoagulants. The suggestions for reversal
of acute bleeding events listed above are based upon preliminary available data from Phase II/III studies and case reports in the medical literature, based on physician
clinical judgment. Refer to references above and also Table 3 in Part II.
Sources: Adapted from Dager, 2011; Kumar, Smith, & Henry, 2015; Patanwala, Acquisto, & Erstad, 2011; Vílchez, Gallego, & Lip, 2014.
Hepatic metabolism occurs primarily via the
cytochrome P-450 system (CYP) and includes both the 3A4
and 2J2 families of enzymes. Due to the involvement of
CYP3A4 in all of the NOACs except dabigatran, plasma concentrations of apixaban, edoxaban, and rivaroxaban can
become elevated in the presence of strong inhibitors. These
strong inhibitors include: ketoconazole, itraconazole, conivaptan, HIV protease inhibitors, and clarithromycin.There are
other weaker inhibitors and inducers that were also examined by Mohrien, Oliphant, and Self (2013) in an excellent
review of these important drug interactions.
Increased bleeding risks due to aspirin and NSAID use
were reviewed in Part I of this series (Goldstein, 2014).
Conclusion
The use of Factor IIa and Factor Xa oral anticoagulants
will likely increase and continue over the next several years.
Nurses need to be aware of drug interactions that directly
affect the bleeding risks of their patients. In addition, nurses
also need to prepare for possible adverse bleeding events
associated with these medications. Identifying unexpected
bleeding in any patient prescribed these medications is the
first step in reversing the event. Being aware of research on
specific antidotes and specific procedures, such as the use of
hemodialysis and PCCs, can help save lives. Unfortunately,
there are no FDA approved or licensed antidotes for the
Factor IIa or Factor Xa oral anticoagulants at this time.
Questioning dosing and use of these medications in patients
with moderate to severe renal or hepatic impairment is also
an important nursing intervention to prevent adverse drug
events associated with all anticoagulant medications.
References
Coagulation Center. (2015). HAS-BLED risk assessment pocket guide.
Retrieved June 1, 2015, from http://www.coagulationcenter.com/
assets/pdf/HAS-BLED_Pocket_Guide.pdf
Dager,W.E. (2011). Using prothrombin complex concentrates to rapidly
reverse oral anticoagulant effects. The Annals of Pharmacotherapy,
45(7-8), 1016-1020.
Gage, B.F., Waterman, A.D., Shannon, W., Boechler, M., Rich, M.W., &
Radford M.J. (2001). Validation of clinical classification schemes for
predicting stroke: Results from the National Registry of Atrial
Fibrillation. Journal of the American Medical Association, 285(22),
28642870.
Goldstein, P.C. (2014).Venous thromboembolic (VTE) prophylaxis: Part
I – NSAIDs found to significantly increase bleeding risk with traditional and newer oral anticoagulant drugs. MedSurg Matters!,
23(5), 14-15.
Goldstein, P.C. (2015).Venous thromboembolic (VTE) prophylaxis: Part
II – Challenges in the treatment of acute bleeding events and
development of new thrombin and Factor Xa inhibitor antidotes.
MedSurg Matters!, 24(4), 9-13.
Guyatt, G.H., Akl, E.A., Crowther, M., Gutterman, D.D., Schuunemann,
H.J., & American College of Chest Physicians Antithrombotic
Therapy and Prevention of Thrombosis Panel. (2012). Executive
summary: Antithrombotic therapy and prevention of thrombosis
(9th ed.): American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines. Chest, 141(Suppl. 2), 7S-47S.
continued on page 15
9
www.amsn.org
• Decide what treatment is needed based on prior
Legal Nursing
Nursing Liability and
Evidence-Based Practice
Have you ever been told, “We always do it that way?”
Are you liable if you follow an outdated policy? Are you liable
if a physician is unwilling to change or even discuss a patient’s
plan of care? As nurses, we are responsible to ensure safe
care for the patient that it is evidence-based and is within the
standard of care.A poor patient outcome could result in legal
action by the patient/family against the physician, facility,
nurses, and staff. Numerous studies have indicated that an
evidence-based approach to practice versus the implementation of clinical care that is steeped in tradition or based upon
outdated policies results in a multitude of improved health,
safety, and cost outcomes, including a decrease in patient
morbidity and mortality (McGinty & Anderson, 2008;
Williams, 2004).
The Academy of Medical-Surgical Nurses (AMSN)
website (www.amsn.org) provides an excellent example of
an evidence-based practice (EBP) process that can assist in
making decisions on how to care for a patient:
• Help determine what’s wrong (formulate a question).
A new nursing role.
A groundbreaking certification.
knowledge (evidence review).
• Administer the medicine (implement).
• Reassess the patient the next morning (evaluate your
plan).
According to Melnyk and Fineout-Overholt (2011),
when clinicians know how to find, critically appraise, and
use the best evidence in clinical practice, and when patients
are confident that their health care providers are using evidence-based care, optimal outcomes are achieved for all.
EBP is now widely recognized throughout the globe as the
key to delivering the highest quality of health care and
ensuring the best patient outcomes (Melnyk & FineoutOverholt, 2011). Current trends in medical malpractice lawsuits suggest that the gold standard is evidence-based practice. Therefore, standards of care must be evidence-based
and not based on what is customary.
Standard of Care
It is important to understand how the legal system
defines the standard of care, and to what standards health
care providers are being held. Negligence, in general, is “the
doing of something which a reasonably prudent person
would not do, or the failure to do something which a reasonably prudent person would do, under circumstances
similar to those shown by the evidence” (Ashley, 2003, p.
72). In law, medical malpractice is considered a specific area
within the general domain of negligence. It requires four
conditions (elements) be met for the plaintiff to recover
damages: duty, breach of duty, harm, and causation. The second element, breach of duty, is synonymous with the standard of care. Prior to several important cases in the 1900s,
the standard of care was defined by the legal concept of
“custom” meaning, “That’s the way we have always done it.”
In addition, in 1934, the case of Garthe v. Ruppert cited
“certain dangers have been removed by a customary way of
doing things safely, this custom may be proved to show that
[the one charged with the dereliction] has fallen below the
required standard” (Moffett & Moore, 2011, p. 3). Simply
put, if other health care providers can demonstrate that
practicing a certain way can eliminate risk of harm, then the
practice with the least amount of risk is used to define the
standard of care. However, a jury still has the burden of
determining that a deviation from the original custom
caused reasonable harm.
Evidence-Based Practice
CCCTM is the result of a collaboration of theMedical-Surgical Nursing Certification Board (MSNCB; msncb.org)
and the American Academy of Ambulatory Care Nursing (AAACN; aaacn.org).
An evidence-based practice is considered any practice
that has been established as effective through scientific
research according to a set of explicit criteria (Drake et al.,
2001). In 2000, Sackett, Straus, Richardson, Rosenberg, and
Haynes defined EBP as the conscientious use of current
best evidence in making decisions about patient care. In
other words, the best nurses use both individual clinical
If you have any questions or comments regarding the “Legal Nursing” column, or if you are interested in writing, please contact Column Editor
Helen P. Neil at [email protected].
10
866-877-2676
expertise and the best available evidence; it takes both to
provide the optimum quality of care. How do we know if a
systemic approach as well as critical appraisal and synthesis
of the most relevant and best research were utilized to
establish treatment practices? In 2001, Torrey and colleagues determined that treatment practices must meet
four selection criteria to be considered evidence-based
practice:
• The treatment practices had been standardized
through manuals or guidelines.
• They had been evaluated with controlled research
designs.
• Through the use of objective measures, important
outcomes were demonstrated.
• The research was conducted by several research
teams.
The time has come for health care providers to incorporate EBP into daily activities to increase confidence in the
care that is delivered and ensure the best outcomes for
patients.
“Knowing is not enough; we must apply. Willing is not
enough; we must do” (Goethe Society, 1998).
In addition, applying evidence-based practice to making
important decisions in combination with clinical expertise,
astute assessment, and respect for patient values decreases
the risk of causing harm and provider liability. EBP utilizes
the most up-to-date methods of providing care and the
most up-to-date appropriate state laws and regulations.
Appropriate use of EBP is imperative in reducing vulnerability to legal action, injury, or harm to a patient.The first medical legal case against a physician that addressed “customary
actions” occurred in 1974 in the case of Helling v. Carey.
The plaintiff (Helling) sued her ophthalmologist (Carey) for
the loss of her eyesight due to glaucoma.The case of Helling
v. Carey set a worrisome precedent for medical malpractice
cases (Moffett & Moore, 2011). The court essentially ruled
that even though the customary practice at the time was
followed, the ophthalmologist was still liable because he
failed to provide care that was based on evidence-based
practice.
Volume 24 – Number 5
Drake, R.E., Goldman, H.H., Leff, H.S., Lehman, A.F., Dixon, L., Mueser,
K.T., & Torrey, W.C. (2001). Implementing evidence-based practices in routine mental health service settings. Psychiatric Services,
52(2), 179-182.
Goethe Society of North America (GSNA), The. (1998). Popular
quotes: Commitment. Retrieved from http://www.goethe
society.org/pages/quotescom.html
McGinty, J., & Anderson, G. (2008). Predictors of physician compliance
with American Heart Association guidelines for acute myocardial infarction. Critical Care Nursing Quarterly, 31(2), 161-172.
Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-based practice in
nursing & healthcare: A guide to best practice (2nd ed.). Philadelphia:
Lippincott, Williams, & Wilkins.
Moffett, P., & Moore, G. (2011). The standard of care: Legal history and
definitions: The bad and good news. Western Journal of Emergency
Medical, 12(1), 109-112.
Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W., & Haynes,
R.B. (2000). Evidence-based medicine. How to practice and teach
EBM (2nd ed.). London: Churchill Livingstone.
Torrey, W.C., Drake, R.E., Dixon, L., Burns, B.J., Flynn, L., Rush, A.J., …
Klatzker, D. (2001). Implementing evidence-based practices for
persons with severe mental illnesses. Psychiatric Services, 52(1),
45-50.
Williams, D. (2004). Treatment delayed is treatment denied. Circulation,
109(15), 1806-1808.
Helen P. Neil, MSN, RN, CLNC, is President and Owner,
Neil Nurse Consulting, LLC, New Orleans, LA. She is the “Legal
Nursing” Column Editor.
A
Conclusion
The topic of evidence-based practice versus customary
actions is currently being dealt with on a case-by-case basis.
It is important for every health care provider to understand
and provide care that any minimally competent provider in
the same position would give in the same situation, with the
same resources. Although the concept of applying best evidence in a clinical decision sounds easy, it is very difficult to
apply during day-to-day activities. When making difficult
clinical decisions, ask yourself, “Would I rather my provider
give customary care or evidence-based care?”
discover new directions for your practice
make career-changing connections
enjoy our nation’s capitol
References
Ashley, R.C. (2003). Understanding negligence. Critical Care Nurse,
23(5), 72-73.
11
Academy of Medical-Surgical Nurses
www.amsn.org
Table 1.
Opioid Medications
Medication
Dosage
Type of Pain
Recommended for
Onset of
Action
Peak of
Action
Duration
Morphine
2-5 mg IV
Nociceptive pain
Neuropathic pain
5-10 minutes
15-30 minutes
3-4 hours
Hydromorphone
0.5-1 mg IV
Nociceptive pain
5 minutes
8-20 minutes
4 hours
Hydrocodone
5-10 mg PO
Mild to moderate intermittent
pain
30-60 minutes
60-90 minutes
4-6 hours
Oxycodone
5 mg PO
Persistent pain
30-60 minutes
60-90 minutes
3-4 hours
Sources: Adapted from Arnstein, 2010; Pasero, Quinn, et al., 2011.
Postoperative Pain Management
continued from page 1
sigma, delta, and epsilon. Of the receptors, mu and kappa are
the most important for pain management (Adams et al.,
2011). Opioid receptors are mainly located in the brain, dorsal horn of the spinal cord, brainstem, thalamus, and cortex.
Opioid medications are thought to cause analgesia primarily
through their interaction with the receptors in the central
nervous system. Recently, however, receptors have been
found peripherally in the nerve and immune system cells,
indicating that opioids may also provide peripheral analgesia
(Pasero, Quinn, Portenoy, McCaffery, & Rizos, 2011). When
opioid medications attach to the receptor sites, they block
the transmission phase of the nociceptive pain transmission
process, causing analgesia.
Opioids are divided into groups based on their mechanism of action: mu agonist, partial agonist, and mixed agonistantagonist. Mu agonist is defined as “any opioid that binds to
the mu opioid receptor subtype and produces effects”
(Pasero, Quinn, et al., 2011). Mu receptor opioids, also known
as full agonists or pure agonists, include morphine,
methadone, hydromorphone, fentanyl, sufentanil, alfentanil,
oxycodone, and leverphanol (Pasero, Quinn, et al., 2011).
Pure mu agonists have a greater analgesic effect because they
bind with two receptors (Adams, Holland, & Urban, 2011).
Partial agonists are mu agonists but kappa antagonists. An
example is buprenorphine, which has limited use as an analgesic, and is most often used in the treatment of opioid
addiction (Pasero, Quinn, et al., 2011).Agonist-antagonists are
opioids “that bind to the kappa opioid receptor site acting as
an agonist (capable of producing analgesia) and simultaneously to the mu opioid receptor site acting as an antagonist
(reversing mu agonist effects)” (Pasero, Quinn, et al., 2011, p.
277). Examples are butorphanol, nalbuphine, and pentazocine.The benefit of mixed agonist-antagonists is the lack of
physical dependency, with little or no withdrawal symptoms
if abruptly discontinued (Adams, Holland, & Urban, 2011a).
Their use as analgesics may be limited due to undesirable
side effects, such as dysphoria, and because they can cause
withdrawal in individuals who are opioid dependent (Pasero,
12
Quinn, et al., 2011). These drugs also have an upper limit,
above which there is no further analgesic effect (Arnstein,
2010).
Opioids are recommended for moderate to severe pain
and are most effective for continuous, dull pain (Layzell,
2008), such as the somatic nociceptive pain associated with a
surgical incision. Opioids given by epidural or patient controlled analgesia (PCA) are preferable to as-needed dosing
(American Society of Anesthesiologists Task Force on Acute
Pain Management, 2012). The commonly used opioids for
post-surgical pain include morphine and hydromorphone for
severe pain and hydrocodone and oxycodone for mild to
moderate pain. Refer to Table 1 for a comparison of the
dosage, type of pain the medication is recommended for,
onset of action, peak of action and duration for the commonly used opioid medications.
Opioid Adverse Effects
Common adverse effects of opioids include nausea, constipation, respiratory depression, sedation or urinary retention (Pasero, Quinn, et al., 2011). Itching and mental changes
such as delirium may also occur (Arnstein, 2010). Measures
must be taken to prevent the adverse effects of opioids. The
prevention of constipation is of particular concern in a postoperative patient. Constipation may be prevented by routine
administration of a laxative and stool softener beginning as
soon as permissible after surgery. Early ambulation, adequate
hydration and dietary fiber may also aid in the prevention of
constipation. Nausea, itching and sedation may decrease the
longer the individual is taking the opioid; if not, reducing the
opioid dose may provide relief. A non-sedating anti-emetic,
such as ondansetron may be used to help control nausea.
Delirium may be relieved with a reduction in the opioid dose
or changing to a different opioid (Arnstein, 2010; Pasero,
Quinn, et al., 2011).
Morphine
Morphine is known as the “gold standard” against which
all other opioids are compared. Morphine is hydrophilic, contributing to its slow onset and long duration of action. It is
metabolized in the liver. Morphine is primarily effective for
nociceptive pain; however, it has been found to be effective
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Volume 24 – Number 5
Table 2.
Nonopioid Medications
Medication
Dosage
Type of Pain
Recommended for
Onset of
Action
Peak of
Action
Duration
Acetaminophen
650 mg PO
650-1,000 mg IV
Mild to moderate
nociceptive pain
30-60 minutes
5 minutes
0.5-2 hours
1-3 hours
Ibuprofen
400-800 mg PO
Somatic nociceptive pain
associated with inflammation
30-60 minutes
1-2 hours
4-6 hours
Ketorolac
15-30 mg
Somatic nociceptive pain
associated with inflammation
2-5 minutes
2-3 hours
6 hours
Sources: Adams, Holland, & Urban, 2011; Drugs.com, 2014; Pasero, Portenoy, & McCaffery, 2011.
for neuropathic pain particularly when combined with the
gabapentinoids and analgesic antidepressant adjuvants
(Pasero, Quinn, et al., 2011). A suggested starting dose of IV
morphine for an opioid-naïve individual is 2-5 mg every three
or four hours (Arnstein, 2010).
Hydromorphone
Hydromorphone is the second choice opioid for postoperative pain management. When given intravenously the
onset of action is five minutes, the peak effect occurs in 8-20
minutes and the duration is four hours. It is metabolized in
the liver and eliminated by the kidneys. Hydromorphone is
five or more times more potent than morphine which must
be taken into account if converting from one drug to the
other in order to prevent over-dosage (Pasero, Quinn, et al.,
2011). A suggested starting dose of IV hydromorphone for
opioid-naïve individuals is 0.5-1.0 mg every three or four
hours (Arnstein, 2010).
Hydrocodone
Hydrocodone is only available in combination with acetaminophen, aspirin or ibuprofen. The amount of the nonopioid component must be considered when hydrocodone is
prescribed or administered. Hydrocodone is best used for
mild to moderate intermittent pain in opioid-naïve individuals. The onset of action of hydrocodone is 30 minutes, the
peak effectiveness is 60 minutes, and the duration is 4-6
hours. It is metabolized by the CYP450 enzyme (Pasero,
Quinn, et al., 2011).
Oxycodone
Oxycodone is used to treat persistent pain. It is available
either alone or in combination with nonopioid medications.
Caution must be taken when prescribing or administering
the combination. Oxycodone is more potent when compared to morphine at a 2:3 ratio. The onset of action of oxycodone is in 30-60 minutes, the peak effectiveness is 60 minutes and the duration is 3-4 hours. It is metabolized in the
liver by the CYP450 enzyme and eliminated by the kidneys
(Pasero, Quinn, et al., 2011).
Nonopioids
Nonopioid medications are useful for mild to moderate
nociceptive pain, such as the pain from trauma or surgery, as
well as pain caused by damage to the bones, joints, or soft tissue. Aspirin or other non-steroidal anti-inflammatory drugs
(NSAIDs) are effective for somatic nociceptive pain associated with inflammation, such as musculoskeletal pain.The use
of acetaminophen or NSAIDs are recommended as part of a
multimodal analgesic plan to treat postoperative pain.
Multimodal analgesia refers to the combination of a nonopioid medication with an opioid medication. It is thought that
this combination decreases the amount of each medication
required and provides more effective pain management than
if the medications were given separately. There may also be
an opioid sparing effect, which reduces the side effects of the
opioids and improves their tolerability. Nonopioids should be
given at the lowest effective dose for the shortest period of
time necessary (Pasero, Portenoy, & McCaffery, 2011). Refer
to Table 2 for a comparison of the dosage, type of pain the
medication is recommended for, onset of action, peak of
action, and duration for the commonly used nonopioid medications.
Acetaminophen
Acetaminophen use does not result in tolerance or
dependence, and there is no risk of respiratory depression. It
does not provide an anti-inflammatory effect like a nonsteroidal anti-inflammatory drug; however, it has a benefit
over NSAIDs in that it does not interfere with platelet function or skin or bone healing and generally does not produce
gastrointestinal problems (Arnstein, 2010). The recommended oral starting dose is 650 mg every four hours, not
to exceed a total of 4,000 mg in a 24-hour period.
Acetaminophen is also available in an IV form (Pasero &
Stannard, 2012). IV acetaminophen does not cause any of the
gastrointestinal, renal or bleeding side effects that may be
associated with NSAIDs. It has a faster onset of action than
when given orally. It also bypasses the liver which helps
reduce the potential of liver injury. The usual dose is 6501,000 mg given every 4-6 hours. The maximum daily dosage
of acetaminophen is 4,000 mg. Acetaminophen given by all
routes must be accounted for in the maximum daily dosage
(Pasero & Stannard, 2012).
The most severe complication of acetaminophen is
hepatotoxicity related to over-dosage. Over-dosage most
often occurs when the maximum daily dosage exceeds 4
13
Academy of Medical-Surgical Nurses
grams. This is a serious consideration in individuals taking
acetaminophen on a regular basis or who have preexisting
liver disease or regular alcohol use. No more than 2.5 grams
per day is recommended in individuals who drink more than
two ounces of alcohol daily. There may also be an increased
risk of chronic renal failure with long-term use of acetaminophen (Pasero, Portenoy, et al., 2011).
NSAIDs
The starting dose of an NSAID should be the lowest
recommended dose. Ketorolac and ibuprofen are the only
NSAID medications for IV use that are available in the United
States. Both are effective for moderate postoperative pain,
and in combination with opioids for severe pain. The usual
recommended dose for ibuprofen is 400-800 mg every four
hours. The dose can be titrated to effect. A 30 mg dose of
ketorolac is equianalgesic to 10 mg of morphine. The usual
dose of ketorolac is 15-30 mg given every six hours around
the clock. Ketorolac should not be given for more than five
days (Pasero, Portenoy, et al., 2011).
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The most common adverse effect related to NSAID use
is gastrointestinal (GI) irritation which can lead to ulceration
and associated bleeding. The mechanism of ulceration is due
to non-selective inhibition of COX-1 which has a protective
effect to the GI tract, while NSAID inhibits COX-2, providing
anti-inflammatory effects. This effect is systemic and can
occur regardless of the route of administration of the
NSAID. The risk of GI adverse effects increases with higher
doses and longer treatment and in individuals with previous
GI disease (Pasero, Portenoy, et al., 2011). GI complications
can be minimized by having the patient take the medication
with a full glass of water and sit upright for 20-30 minutes
and taking the medication with food (Arnstein, 2010).
Adjuvants
Adjuvant analgesics are medications whose primary indication is something other than pain, but act as an analgesic
for some conditions.They are often given in addition to analgesic medications, but may be given alone for some conditions, such as diabetic neuropathy and postherpetic neuralgia.
Adjuvant analgesics are chosen based on the type of pain the
patient has along with the type of other symptoms and comorbidities that are present. Adjuvant medications are most
often given to treat neuropathic pain, although some are also
effective for nociceptive pain (Pasero, Polomano, Portenoy, &
McCaffery, 2011). There are many classes of drugs used as
adjuvants. Antidepressants and anticonvulsants will be discussed here.
Antidepressants
Antidepressants are helpful to treat neuropathic pain
and other types of persistent pain states. Antidepressants are
considered first-line or second-line treatment for many types
of persistent neuropathic pain.Tricyclic antidepressants work
by inhibiting presynaptic neuronal reuptake of norepinephrine and serotonin. Their exact mechanism of pain management is unknown. Side effects such as orthostatic hypotension are common with tricyclic antidepressants. The serotonin norepinephrine reuptake inhibitors (SNRIs) cause less
side effects than the tricyclic antidepressants and are recommended as the first choice (Pasero, Polomano, Portenoy, &
McCaffery, 2011).
Anticonvulsants
Anticonvulsants are used to treat persistent neuropathic
pain. The specific mechanism of action in treating pain is not
known, but is thought to be through the blocking sodium
channels and reducing excitability in sensitized C-nociceptors (Ghafoor & St. Marie, 2010). Gabapentin and pregabalin
are considered first-line treatments for neuropathic pain
along with antidepressants (Pasero, Polomano, et al., 2011).
Recently, these drugs are also being used to treat postoperative pain (Wu & Raja, 2011). Anticonvulsants are generally
well-tolerated, with dizziness and sedation the most common side effects. Doses of anticonvulsants are individualized
to the patient’s response (Pasero, Polomano, et al., 2011).
866-877-2676
Conclusion
Pain management is an essential function of the medicalsurgical nurse. Effective postoperative pain management can
improve patient outcomes and aid in the prevention of postoperative complications (Pasero, Quinn, & Portenoy, 2011).
Thorough knowledge of the medications used for pain management is essential for safe, effective pain management.
References
Adams, M.P., Holland, L.N., & Urban, C.Q. (2011). Drugs for the control
of pain. In M.P. Adams, L.N. Holland, & C.Q. Urban (Eds.)
Pharmacology for nurses: A pathophysiologic approach (3rd ed., pp.
218-238). Upper Saddle River, NJ: Pearson Education, Inc.
American Society of Anesthesiologists Task Force on Acute Pain
Management. (2012). Practice guidelines for acute pain management in the perioperative setting: An updated report by the
American Society of Anesthesiologists Task Force on Acute Pain
Management. Anesthesiology, 116(2), 248-273.
Arnstein, P. (2010). Clinical coach for effective pain management.
Philadelphia: F.A. Davis Company.
Drugs.com. (2014). Ketorolac injection. Retrieved August 27, 2015, from
http://www.drugs.com/pro/ketorolac-injection.html
Ghafoor,V.L., & St. Marie, B. (2010). Overview of pharmacology. In B. St.
Marie (Ed.), Core curriculum for pain management nursing (2nd ed.,
pp. 235-305). Dubuque, IA:American Society for Pain Management
Nursing.
Kodali, B., & Oberoi, J.S. (2012). Management of postoperative pain.
UpToDate, Inc.
Layzell, M. (2008). Current interventions and approaches to postoperative pain management. British Journal of Nursing, 17(7), 414-419.
Pasero, C., Polomano, R.C., Portenoy, R.K., & McCaffery, M. (2011).
Adjuvant analgesics. In C. Pasero, & M. McCaffery (Eds.), Pain
assessment and pharmacologic management (pp. 623-818). St. Louis,
MO: Mosby Elsevier.
Pasero, C., Portenoy, R.K., & McCaffery, M. (2011). Nonopioid analgesics. In C. Pasero, & M. McCaffery (Eds.), Pain assessment and
pharmacologic management (pp. 177-276). St. Louis, MO: Mosby, Inc.
Pasero, C., Quinn, T.E., Portenoy, R.K., McCaffery, M., & Rizos, A. (2011).
Opioid analgesics. In C. Pasero, & M. McCaffery (Eds.), Pain assessment and pharmacologic management (pp. 277-622). St. Louis, MO:
Mosby, Inc.
Pasero, C., & Stannard, D. (2012).The role of intravenous acetaminophen in
acute pain management: A case-illustrated review. Pain Management
Nursing, 13(2), 107-124. doi: 10.1016/j.pmn.2012.03.002
Wu, C.L., & Raja, S.N. (2011).Treatment of acute postoperative pain. The
Lancet, 377(9784), 2215-2225.
Cynthia W. Ward, DNP, RN-BC, CMSRN, ACNS-BC,
is a surgical clinical nurse specialist at Carilion Roanoke
Memorial Hospital in Roanoke, VA.
Volume 24 – Number 5
Drug Update
continued from page 9
Kumar, R., Smith, R.E., & Henry, B.L. (2015). A review of and recommendations for the management of patients with life-threatening dabigatran-associated hemorrhage: A single-center university hospital
experience. Journal of Intensive Care Medicine, (epub ahead of
print). doi:10.1177/0885066614527417
Levine, E. (2014). CHADS2 score for stroke risk assessment in atrial fibrillation. Retrieved June 1, 2015, from http://emedicine.medscape.com/
article/2172597-overview
Lip, G.Y., Nieuwlaat, R., Pisters, R., Lane, D.A., & Crijns, H.J. (2010).
Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based
approach:The euro heart survey on atrial fibrillation. Chest, 137(2),
263-272.
Mohrien, K., Oliphant, C.S., & Self, T.H. (2013). Drug interactions with
novel oral anticoagulants: gp and CYP3A4 effects. Consultant,
53(12), 918-919.
Patanwala, A.E., Acquisto, N.M., & Erstad, B.L. (2011). Prothrombin complex concentrate for critical bleeding. Annals of Pharmacotherapy,
45(7-8), 990-999.
Perlstein, I., Wang, Z., Song, Y., Wang, J., Bedford, B., Chang, M., … Frost,
C. (2014, December 8). Reversal of apixaban anticoagulation by 4Factor Prothrombin Complex Concentrates (PCC) in healthy subjects.
Paper presented at the 56th Annual Meeting of the American
Society of Hematology, San Francisco, CA (Session 332).
Retrieved December 10, 2014, from https://ash.confex.com/
ash/2014/webprogram/start.html
Pisters, R., Lane, D.A., Nieuwlaat, R., de Vos, C.B., Crijns, H., & Lip, G.Y.
(2010). A novel user-friendly score (HAS-BLED) to assess 1-year
risk of major bleeding in patients with atrial fibrillation: The Euro
Heart Survey. Chest, 138(5), 1093-1100. doi:10.1378/chest.100134
Vílchez, J.A., Gallego, P., & Lip, G.Y. (2014). Safety of new oral anticoagulant drugs: A perspective. Therapeutic Advances in Drug Safety, 5(1),
8-20
Perry C. Goldstein, MSN, RN, CMSRN, PCCN,TNCC, is
a Staff Nurse, Critical Care Unit (CCU), Sumner Regional
Medical Center, Gallatin, TN. He is a member of the MedSurg
Matters! Editorial Committee.
Heather D. Hale, BSN, RN, CCRN, is a Staff Nurse, Critical
Care Unit (CCU), Sumner Regional Medical Center, Gallatin,
TN.
Apply for CMSRN®
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15
Volume 24 – Number 5 • September/October 2015
AMSN BOARD OF DIRECTORS
President
Jill Arzouman, DNP, RN, ACNS, BC, CMSRN
Immediate Past President
Kathleen Lattavo, MSN, RN, CNS-MS, CMSRN,
RN-BC, ACNS-BC
Treasurer
Jane E. Lacovara, MSN, RN, CMSRN, CNS-BC
Secretary
Robin Hertel, EdS, MSN, RN, CMSRN
East Holly Avenue, Box 56, Pitman, NJ 08071-0056 • 866-877-AMSN (2676)
[email protected] • www.amsn.org
Director
Gloria J. Hurst, BSN, RN, CMSRN
Nutrition to Improve Outcomes
Director
Michele George, MBA, BSN, RN
Director
Cynthia C. Barrere, PhD, RN, AHN-BC, RCNS, FAAN
Chief Executive Officer
Cynthia Hnatiuk, EdD, RN, CAE, FAAN
Practice Change: Let’s Feed Our Patients!
Director, Association Services
Suzanne Stott, BS
MedSurg Matters!
Patients are routinely kept “NPO (nil
per os, or nothing by mouth) after midnight” on the day of surgery or any procedure requiring anesthesia or sedation.
Although current research and anesthesia
guidelines no longer support this practice,
prolonged fasting is still the standard in
many heath care facilities.
In 1999, the American Society of
Anesthesiologists (ASA) revised their
practice guidelines, recommending that
patients may have clear liquids up to two
hours before procedures requiring general
anesthesia, regional anesthesia, or sedation/analgesia (ASA, 2011). Patients may
even have a small meal six hours prior to
the procedure, such as toast and tea and a
heavier meal eight hours prior (ASA,
2011). These guidelines suggest patients
should be kept NPO for approximately
two hours, while research suggests that
patients tend to remain NPO for an average of 12-14 hours, with some patients
fasting as long as 20 hours (Crenshaw &
Winslow, 2002).
Although there is little evidence about
the benefits of pre-procedural fasting, the
rationale behind this practice is the belief
that patients who eat or drink before
receiving anesthesia will likely aspirate dur-
ing the procedure.ASA revised their guidelines based on newer studies that suggest
modern anesthesia poses a low risk of pulmonary aspiration. One recent study
demonstrated that patients undergoing
percutaneous coronary catheterization do
not require any fasting prior to the procedure. Patients were observed after undergoing percutaneous coronary intervention
(PCI) with moderate sedation without
fasting prior to the procedure. There were
no occurrences of intra-procedure or
post-procedure aspiration pneumonia
(Hamid et al., 2014).
Not only is it unnecessary to keep
patients NPO after midnight, it is actually
more harmful than beneficial. Patients who
are kept NPO for an extended period of
time are at a higher risk of irritability,
headache, dehydration, hypovolemia, and
hypoglycemia (Crenshaw & Winslow,
2002). In the case of invasive cardiac procedures, patients who are fasted are
potentially at risk for contrast-induced
nephropathy (acute kidney injury), dehydration, and poorly controlled hypertension (Hamid et al., 2014). Additionally,
about 40% of patients in the hospital are
malnourished; keeping patients NPO
Editor
Molly McClelland, PhD, MSN, RN, CMSRN, ACNS-BC
Editorial Committee
Barbara Chamberlain, PhD, APRN, MBA, CCRN, WCC
Millicent G. De Jesus, MSN, RN-BC
Deidra B. Dudley, MN, MS, RN-BC, NEA-BC
Michael M. Evans, MSN, MSEd, RN, ACNS, CMSRN, CNE
Dianne J. Gibbs, MSN, RN
Perry C. Goldstein, MSN, RN, CMSRN, PCCN
Stephanie Huckaby, MSN, RN-BC
Elizabeth Miller, DNP, RN, CMSRN, CCM
Sally S. Russell, MN, RN, CMSRN
Catherine A. Santori, RN, CMSRN
Elizabeth Thomas, MSN, RN, ACNS-BC
Managing Editor
Katie R. Brownlow, ELS
Editorial Assistant
Linda Alexander, BA
Layout and Design Specialist
Robert Taylor, AS
Education Director
Rosemarie Marmion, MSN, RN-BC, NE-BC
The purpose of MedSurg Matters! is to disseminate
information that will provide or enhance nursing
knowledge, practice, and professional development
related to medical-surgical nurses.
continued on page 7
If you have any questions or comments regarding the "Nutrition to Improve Outcomes" column, or
if you are interested in writing, please contact Column Editor Beth Quatrara at
[email protected].
The mission of AMSN is to promote
excellence in medical-surgical nursing.
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