Pressure Ulcers

Today we're going to focus on DTI's

DTI's or Deep Tissue Injuries are the bane of nursing existence.  Although they're always categorized at the beginning of the pressure ulcer list, they're frequently not the most minor kind of pressure ulcer.  

A deep tissue injury indicates that the damage has been done at the level of the bone where the tissue well under the surface has been damaged but the surface tissue has NOT been damaged and remains intact.  

The problem is, that we're not entirely sure what causes some people to develop a deep tissue injury versus a stage one pressure ulcer in the same spot, and even worse, we're not sure what causes some peoples deep tissue injuries to "erupt" while other's heal without causing additional damage.  

When examining a patient's skin a deep tissue injury frequently shares the same appearance as a fresh bruise, but fails to begin to show signs of resolution in the next couple of days, which is the quickest way to differentiate between a bruise and a deep tissue injury.  

Deep tissue injuries, like any other pressure ulcer, are likely to appear primarily over the bony prominences, (shoulders, hips, elbows, sits bones, tail bone/sacrum, and heels). 

Because the skin is intact and still doing it's job and keeping the environment stable, there may be no medical (dressing, medicine) treatment ordered for dealing with a deep tissue injury, instead the orders usually consist of close careful monitoring, frequent turning and reposition, potentially a dry dressing if the area attracts too much moisture, and should include nutritional support. 

One of the things that we do know is that regardless of the pressure ulcer poor nutrition not only contributes to the development and progression of pressure ulcers, but that good nutrition supports healing of pressure ulcers and that good nutrition is a team effort.  

Many times in the records the nutritional support recommended by the physician and/or the nutritionist falls short in actual care, and the person then has even more to overcome in healing the pressure ulcer. 

Because deep tissue injuries can be hard to distinguish from bruising, the staff fails to put measures in place quickly once one develops and many times fails to note them.  They can also be very difficult to see in photographs of patients with non- Northern European skin tones, but they still require the same careful consistent management. 

As with most pressure ulcers an ounce of prevention is worth a pound of cure. 

Abbreviations

This week we're going to focus on our first pressure ulcer related abbreviation.  There aren't many abbreviations directly related to pressure ulcers, but this week, the abbreviation is a common one frequently seen with pressure ulcers and the treatment of those ulcers.

This week's abbreviation is

I and D or  I&D

I and D stands for incision and drainage.

This abbreviation is actually the name of a procedure and its a common procedure to help reduce or eliminate sources of infection in a wound or other infected space.  The surgeon literally makes an incision and drains the area.  But like fish 'n chips, and rock 'n roll it generally sounds when spoken like the medical professional is saying I. N. D.

Examples 

Pt. s/p I & D of the R ORIF hip
    The patient has undergone an incision and drainage of the right hip surgical site where they had previously had an open reduction internal fixation. This can happen if the surgical wound is not healing properly and is usually enough to get the wound to heal properly.

Pt to undergo I and D of left buttock pressure ulcer on Thursday.
    Usually a patient undergoes a debridement of the pressure ulcer but from time to time there are pockets of pus that need an I and D to help fix them, and this is what this type of statement is referring to.  Sometimes you see the procedures listed as debridement with I and D if necessary.

Abbreviations

Todays abbreviation describes an experience that nearly all of us have experienced at one point or another in our lives. It becomes more common to experience one half or another of today's abbreviation over the holiday season as we indulge in too much food or drink.

Without further ado:

N/V

N/V stands for nausea and vomiting.

Examples

C/o of N/V for 48 hours, demonstrates signs of dehydration.

CC: N/V per own admission drank 1 handle vodka in last 8 hours.

Pressure Ulcers

Before we can discuss the various stages of pressure ulcers, it is important to know that while everyone is at risk there are a number of populations that are at increased risk for pressure ulcers.

The reason that these particular populations are at increased risk is that they decreased ability to communicate their needs, decreased ability to feel the need to move, or decreased ability to receive assistance in moving. .

By decreased sensation I mean the person cannot feel the sensation that something is wrong or that the person needs to move, and if they cannot move on their own the patients are likely in a setting such as a broken bone where they require assistance but can tell someone they need to move.

Many times they have multiple disease processes and the lack of heath due to the multiple disease processes means that it takes longer for the wounds to heal and the patients are at increased risk for infection in the wound sites, contributing to increased wound time and starting a nasty cycle.

The primary disease processes that I see associated with pressure ulcers are diabetes, arterial disease, dementia, broken bones (both of which I've spoken briefly about), and spinal cord injuries.  Many times spinal cord injury patients can help with their own care, as most spinal cord injury patients at least in their later stages are alert and oriented enough to understand the importance of moving and repositioning regularly, but they may require assistance.  In this nursing staff preforms an important role, and when patients develop pressure ulcers it is important to have nursing staff review the records because many times nursing staff at the home fail to note that they are documenting or not documenting that they are providing care.

Next week we'll focus on the most difficult type of pressure ulcer, the DTI.

Abbreviations

Today's abbreviation is a disease process.  This particular disease process can cause patients to be at higher risk for developing pressure ulcers because it can leave them with decreased mobility and dependent on others for their care, which are two of the primary risks of pressure ulcers.

Todays abbreviation is

CVA

CVA stands for Cerebrovascular Accident, or more commonly known as stroke.  A small stroke may leave no damage but a bad stroke can leave a patient completely bed ridden.

Examples

Pt suffered from a CVA on 12/34/56. Residual left sided weakness noted.

Dx include CVA. 


It is rare to see this in a sentence except for admission notes.  It is more likely to CVA in a list of diagnoses. It is a common reason for admission to a nursing home in someone who was previously living in an unassisted situation, unlike dementia where it is common to see them living in an assisted situation or with an extended family prior to hospitalization.

Pressure Ulcers

Last time I said we would transition from falls to pressure ulcers, and I think this week we'll start with a brief description of what a pressure ulcer is.

Nearly everyone has suffered from a  stage 2 pressure ulcer at some point in their life, but we don't call them that when we're not in the hospital.  We call them blisters.

Pressure ulcers form from a combination of factors, but two of the biggest factors are rubbing and moisture (just like when you get a blister in your shoe).  Pressure ulcers can occur everywhere on the body, but there are a few spots where they are more likely to occur.  Those spots are the hips, buttocks, and heels of the feet. They form in these spots because they're the most difficult to relieve the pressure on, and the most likely to maintain moisture if there is moisture in the environment.

Pressure ulcers when caught in the early stages can be healed without much work, much like the blister on your heel that you keep clean and dry and dressed until it heals. It is important to recognize a pressure ulcer in the early stages and work on healing the ulcer as soon as it is recognized.

There are 6 overall categories for pressure ulcers (not necessarily in order of importance)

1. DTI
2. Stage 1
3. Stage 2
4. Stage 3
5. Stage 4
6. Unstageable.

The first two stages may not be recognized in patients with dark skin as the surface skin isn't open and redness and under skin damage can be difficult to assess. This is why it's important to turn and reposition regularly and prevent skin breakdown from happening.  Over the next few weeks we'll focus on one stage at a time and discuss the importance of each stage and suggested treatments.  As always a good legal nurse consultant can make a world of difference in these cases, as they can provide insight into the specific development of pressure ulcers, and any contribution the patient may have had.

Abbreviations

After a bit of time off for the Thanksgiving holiday- its back to work with another abbreviation for Monday.

This week we'll deal with infection as it's the most serious complication that a person can experience when they're already compromised from another issue.

The test that is done on the source of the infection is our abbreviation today.

C and S or just C/S

The abbreviation is fairly straightforward. It means culture and sensitivity.  This is the lab test to show what bug is growing and how to treat the bug.  It is an important test to run. The test not only determines which bug is causing the problem but how to treat it, which cuts down on the risk of antibiotic resistance in the bug and increases the chance of returning the patient's body to normal.

Examples:

C/S ordered with urinalysis
C and S showed MRSA susceptible to vancomycin.

Abbreviations

Today's abbreviation is one of the hardest ones to recognize when dealing with medical records.  This is because like many of the difficult abbreviations it means something else outside of the medical records and it looks strange in the medical record.

Without further ado:



AKA - above the knee amputation.

It is a surgical procedure or an incident as well as a condition after the fact.  It normally is NOT something that people miss about clients, but sometimes they do, and having a nurse examine the medical record can note things like the patient coming back from a surgical procedure and the staff documenting a pulse in a non- existent leg.


Examples

Pt. with hx of AKA

Pt required AKA of left leg after traumatic injury.

Gendel Family Favorites: Turkey Cake

Today's recipe has been a Thanksgiving staple in our family since 1985.  I know the year, because I found the copy of the recipe that this is based off of.  The recipe is courtesy of Pillsbury and the little magazines that they have at the checkout counter.

This is a super simple Turkey Cake and lots of fun at a Thanksgiving Celebration. Although I've taken it out of the pan, many years, and in fact in the original recipe, you can just serve it in the pan, saving a step.

Turkey Cake

Cake
1 pkg cake mix - I use chocolate cause thats my favorite
1 c. water
1/3 c. vegetable oil
3 eggs

Frosting
1 container white frosting
2 drops red food coloring
2 drops yellow food coloring (or orange food gel instead of the above coloring)
Candy Corn
2 yellow and 1 red gumdrop
Chocolate Sprinkles
Mini Chocolate Chip
Sugar

1. Prepare the cake per the instructions on the package and allow to cool completely.
2. Reserve 2 tablespoons of the white frosting and frost the cake with the remaining frosting.
3. Using food coloring or gel color the remaining frosting and set aside.
4. Trace a turkey shape on the frosting. Usually we just draw an approximation, but for more artistic sorts email me and I'll send you a copy.
5. Frost the head with the remaining orange frosting.
6. Fill in the tail area and wing based on the picture with candy corn in overlapping layers to form the wing and tail.
7. Fill the body with chocolate sprinkles. This takes a little bit of patience but it's really not that difficult to get the sprinkles to stay in the line if you traced your turkey first. Pour them in the middle near the wing and tail and move them to the edge.
8. On a sugared surface roll out the red gumdrop in the shape of a tear drop and use for the snood. Roll out the yellow gumdrops and cut a little peace symbol out for the legs. Place both on the turkey.
9. Place the mini chocolate chip for the eye
10. ENJOY!!!

Falls- The final week.

The most serious thing that can happen after a patient falls is that they die as a direct result of the fall.

In my opinion the second most serious complication that a patient can suffer after a fall doesn't usually occur right after the fall, but in the months after the fall. This is the development of pressure ulcers, and the myriad of complications that may occur as a result of the development of pressure ulcers.

Sometimes the fall is an innocent non negligent cause, such as an normally ambulatory person falling because they tripped, or had a syncopal episode.  Now the person is bed ridden and dependent on staff for their care.  This is when the person is at increased risk for pressure ulcers.

The reasons for the development of pressure ulcers are different for each client and facility.  Sometimes they're as simple as a wet diaper left on a little too long, and they heal rather quickly without any damage, but sometimes they're more complex.

That's where it becomes necessary to read the medical records to understand why a pressure ulcer had formed in a particular client and whether or not the staff is negligent in the care.

Over the next couple of weeks we'll focus first on the general causes of pressure ulcers that are non-negligent and then we'll transition into how some of the various diseases that the clients are diagnosed with affect healing.

Abbreviations

Since I've been focusing on falls for my Tuesday disease process feature, I thought I'd focus on one of the few abbreviations that occur in the medical record that can be problematic when patients are at high risk for falls.

BRP - Bathroom Privileges

Bathroom privileges means that someone has determined that the patient is not at medical risk to ambulate to and from the bathroom to their bed, but should be in bed or the chair the rest of the time. It means they should NOT be up ambulating in the hall unassisted.

This particular order is really common in the prenatal care area and in the geriatric populations. In the geriatric populations as with the prenatal populations, the patient is usually very sick or hooked up to several machines so going any distance is difficult with out assistance.

As you can see, from both populations where this is common, it is likely that they're off balance for some reason and ambulating long distances is a bad idea.

Example

Activity Level: BRP

Pt has BRP, pt has been seen ambulating several times in the hall without assistance, able to be redirected.

Gendel Family Favorites: Barb's Mac and Cheese

This is a recipe that at least 3 generations have made now.  My Grandmother made this recipe, my Mom made this recipe and now I make this recipe.

When I was growing up my Mom would make this for me and my friends.  It became an oft requested recipe, and I know at least one of  my friends has made it for visitors and she will be making it for her own child when he's old enough. When my friend's would request it, they would request it as Barb's Mac and Cheese, which is how it got its name.

Without further ado- I present you:

Barb's Mac and Cheese

Ingredients

7 oz macaroni noodles (I like Cremette)
8 oz cheddar cheese
32 oz milk (1 quart)
1 egg
salt and pepper to taste
bread crumbs (optional)

1. Preheat oven to 350 degrees.
2. While the oven is preheating boil the noodles per package instructions to al dente and drain.
3. Grease a 13x9 pan
4. Combine milk, cheddar cheese, and egg in a large bowl.
5. Add the drained noodles to the bowl, mix well, and transfer to the pan.
6. Top with bread crumbs if using
7. Bake for 1 hour or until set.
8. Slice and enjoy.

Falls

Last week I focused on an unusual fall. This week, I'll focus on a more common cause of falls.

When reviewing a record it is more likely than not that a fall will occur shortly after admission, an illness, or a readmission because these mark changes in the routine.

It is common for patients who cannot to attempt to ambulate to be found a few times before they fall half off the bed, or sitting up, or even ambulating.  Many times a bed alarm is ordered and that is the last time that the bed alarm is mentioned. The patient then falls and the note reads as below:

Nurse heard patient calling out.  Nurse went to room and found patient on the floor. Patient unable to tell nurse how patient ended up on the floor. Pt. MAE. Pt assisted back to bed and physician notified. NNO at this time.

After this the incident report will frequently record that the patient had a bed alarm in place and it was functioning, but outside of the physicians order there will be no documentation of the bed alarm in place and functioning each shift. As you can see the date of the above fall the bed alarm was not in place and functioning.

Unfortunately without the assistance of a nurse it can be hard to see all the potential problems involved in a fall.

We will focus on falls for one additional week before we move on to pressure ulcers. 

Abbreviations

There are approximately  10 abbreviations that the Joint Commission calls DO NOT USE abbreviations.  They are abbreviations that can be confusing even within the medical community and result in over doses, under doses, and/or medication administered to the wrong body part.
However, such as this week there are a number of other abbreviations that should ALWAYS be written out and many hospitals require it.

mcg-- microgram. 

The Joint Commission does not officially list this on their abbreviation list as we've gone to more computer generated writing and the latin or greek letter (mu) is not an easily accessible keyboard option. However when things are handwritten, in orders especially, this can be confused for milligrams resulting in a dose that can be over 1000x what the order was written for.

There was a recent news piece about a child in Boston who received a deadly amount of his cancer drug because of a mistake like the one described above.  It is always best to be in the habit of fully writing out the word microgram and NEVER using the abbreviation.

Best practice is to write it out EVERY time which makes it harder to misinterpret. The FDA as well as other regulatory agencies have determined this to be best practice even in non-human medical areas including veterinary medicine.


Example:
Forteo 20mcg SQ QD -- Forteo 20 micrograms sub-q every day

Drug X to be administered at 50 micrograms/kg/day

Gendel Family Favorites: Blueberry Muffins

The first Gendel Family Favorite is a breakfast Recipe.  Next week we'll have a side, then a Thanksgiving themed dessert, and finally a holiday season drink.

This is my all time favorite recipe.  For those of you who don't know, I normally don't like blueberries. I don't know why I just don't like them. But I go out of my way for these. These muffins have been part of our Thanksgiving, Christmas, and New Year's Day breakfasts for all but a few years (when the cookbook went briefly missing) for most of my life.

Because these are so unique I had to take all the pictures.

 From Muffins by Elizabeth Alston
The Best Blueberry Muffin 

Elizabeth says- Bursting with berries, these are the best blueberry muffins of all. The secret is an extra half cup of blueberries which are mashed, and then added to the batter.

My mom and I were discussing these ahead of this post and we agreed. These are muffins that remind of us of Smurfs. Smurf muffins. A couple of things to know- we at our house to my knowledge have NEVER made these with fresh blueberries, we've always used frozen so we've always used the full amount of sugar.

Ingredients:

1/2 cup (1 stick) butter at room temperature
1 cup granulated sugar or slightly less depending on the tartness of the berries
2 large eggs
1 teaspoon vanilla extract
2 teaspoons baking powder
1/4 teaspoon salt
2 1/2 cups blueberries (mash 1/2 cup with a fork) Thaw the half cup- makes mashing easier. 
2 cups all purpose flour
1/2 cup milk
1 tablespoon sugar mixed with 1/4 teaspoon ground nutmeg we usually leave this part off but it can add a nice touch. 

Instructions:

1. Heat oven to 375 degrees. Grease 12 regular muffin cups, including the area between each cup, or use foil baking cups.

2.  In a medium size bowl, beat butter until creamy. Beat in the sugar until pale and fluffy. Beat in eggs, one at a time. Beat in vanilla, baking powder and salt.

3. Mix mashed berries into batter.

4. Fold in half the flour with a spatula then half the milk. Add the remaining flour and milk. Fold in remaining blueberries.

5. Scoop batter into muffin cups. Sprinkle with nutmeg sugar.

6. Bake 25 to 30 minutes, or until golden brown (They will turn golden brown). Let muffins cool at least 30 minutes in the pan before removing. Enjoy slightly warm.

Falls STILL (There's lots to say on this)

I could have written one very long blog post on falls, but I wasn't particularly interested in overwhelming you with all of the information rather I was interested in providing short bites about falls that can be processed each week.  

I was gonna take a break from falls but can't remember what I was going to talk about so we'll keep going on falls anyway. 

Today we're going to focus on falling out the window.  Another story that's stuck with me.  The woman suffered from a diagnosis of dementia.  She resided on a locked second floor unit of a local nursing home.  She had decided that she needed to go to the grocery store.  She couldn't get off the unit through the door, so she went to her room to attempt to open the window.  The window opened so she climbed out the window, falling to the bushes below. 

Thankfully she only suffered a broken arm. 

When the state investigated what happened they found that the unit was in disrepair.  The little device that stops the window from opening at 4 inches was missing.  It was found that the staff knew that the window opened wider than four inches and failed to repair the window to prevent the client from leaving via the window and harming herself. 

In this case the staff was very lucky that the client did not hurt herself more severely than a broken arm, but it is clear that they failed to provide a safe environment.  

This would have been a difficult case, except for the reporting to the state and the state doing a thorough investigation.  Because they did the investigation it was found that the cause of the fall was the window being in disrepair, and that the staff knew the window was in disrepair, yet failed to do anything about it. Further the nursing staff failed to report up the chain of command that the maintenance staff failed to fix the window. 

After the state came in the window was fixed the next day but the damage was done. 

This is an uncomplicated fall out the window.  Usually they are more complicated than that and a nurse is needed to investigate the whys of a fall out the window.  Was there psychosis due to medication errors prior to the fall, or was there suicidal ideations (the expression of the desire to commit suicide and a concrete plan) without close and appropriate medical supervision before the fall. What was the outcome?  Nursing helps with all of these. 

Abbreviations

Today we have an abbreviation that is very common in medicine and really saves a lot of time for medical professionals.

S/P 

S/P stands for status post.  It means after. The information after the s/p in note indicates what kind of thing the patient is is after.


Examples:

S/P ORIF on 9/22. (Status post open reduction internal fixation on 9/22).

S/P colonoscopy with complications.

Falls Continued

We've focused on some of the more general reasons for falling that may not involve a lawsuit, but now we'll begin to look at some of the causes of falls that are usually caused by negligence or a lack of awareness by others. 

For the next couple of weeks we will focus on patients that reside in a skilled nursing setting or an assisted living setting. 

Another story.  This client was admitted to the nursing home after a hospitalization. She was in the nursing home for rehabilitation.  While the staff was admitting the client to the nursing home she attempted several times to climb out of bed, and ambulate.  At that time it was clear that the client was at high risk for falls.  However the nurse left the client alone without any safety precautions in place.  A few hours later the client was found on the floor by the nursing staff. When the client arrived at the hospital it was discovered that she had broken her hip. 

The story is a bit dramatic (and I imagine that's why it has stuck with me), but it clearly outlines the potential for negligence in a skilled nursing or assisted living setting. 

What struck me the most when I reviewed this client's medical record, was that the nursing staff was so clearly aware that the client was at risk for falls yet failed to put ANY preventative measures in place. There were no bed alarms, side rails, or floor mats in place.  There was no close monitoring of the patient.  The fall risk assessment when it was completed showed that the client was at high risk for falls. 

This is pure negligence by the nursing staff.  They failed to do their job.  They did not set out to harm her, but managed to by failing to provide her with safe, adequate, and appropriate care.  This incident left the client permanently bedridden.  

I know its a very brief overview, but if you use a legal nurse consultant you can get this and so much more. 

Abbreviations

Since it's Halloween on Saturday I though we'd focus on an abbreviation that is both "spooky" and a good reminder to drive safe and drive sober.  Call for a ride if you've had too much to drink. This is an abbreviation that NO medical professional wants to use.

DOA

DOA is dead on arrival

You can see why this is an abbreviation that no medical professional wants to use.  It means that there was no chance to save the patient.

Because of the nature of the abbreviation, there are three primary groups of users - police officers, first medical responders (paramedics, EMTs, firefighters), and ER staff. Rarely is the abbreviation used in other areas.

Examples:


When EMS arrived at the scene of the accident pt was unresponsive without a pulse. Pt was cool to the touch and after consultation with physician no other emergency measures were taken. Pt declared DOA.

This is a bit of an extreme example.

Pt arrived with CPR in progress. Rhythm assessed. Pt was determined to be without a heartbeat.  Pt declared DOA.

This is a more likely example because it is uncommon for first responders to arrive in a situation where the patient is clearly deceased upon their arrival.

Before I end today's post and get back to helping attorneys with their complex medical record needs- I want to note one thing. DOA is a declaration.  It's a status- not just an abbreviation used in the middle of the sentence.  If you note in my above examples, its the end of a sentence.

Tuesday October 20, 2015 Falls (Slip and Fall)

This is a favorite story.  I related it the other night at a party. (As seen on CCTV)

A woman was in a big box store shopping with her young child in the cart. She stopped in the middle of the aisle to look at something. She pulled the cart off to one side as many of us do.  This left her small child within reach of a number of bottled hair care products.  The child proceeded to grab one and squeeze it all over the floor while his mother was not looking. The mother and child then went off. I like to think to inform an employee of what had just happened but we don't know. Within a minute- another customer walked by the same aisle, looked down the aisle and saw the spill. He then strode down the side of the aisle without the spill, disappeared off camera momentarily, came back and purposefully walked through the spill. He fell. He attempted to sue the big box store.

The point of this story is that sometimes falls happen, and sometimes the person falling creates a situation where common sense and safety sense seem to have evaporated.

The above story took place in public, but the same thing can happen in a nursing home.  In the nursing home, it is more likely that the person tripped over their own two feet, failed to watch where they were going, or dropped something, and bent to pick it up.

When accidental falls happen in the nursing home, the best way to prove them to be accidental falls short of the CCTV (which is now somewhat available in Illinois), is a consistent story.  This comes from clients who are alert and oriented x3, and when the client and the staff have a consistent story that fails to change when the client moves from the nursing home to the hospital, and from one caregiver to the next.  The thing is that falls happen. Not all falls can be prevented, and sometimes, clients just slip and fall.

In Illinois, cameras are going to go a long way for nursing homes, and for families, in demonstrating what happens. The camera observes what happened before and after the fall. It can see things, like a person looking at a spill, walking by it, and coming back to see a spill. I am watching for with eager anticipation the first court case with these cameras, and how it plays out.  In the mean time, a nurse can help determine if a fall was truly accidental, or if the fall was consistent with negligence and poor safety behavior on the part of the nursing home.

October 19, 2015 Abbreviations

Today we're just going to dive right in.  There isn't a lot to say about this abbreviation except that it's not a common abbreviation. Because this is not a common abbreviation it can be missed by staff and cause follow up appointments to be missed. This is the importance of having a nurse involved in care. 

Next week I'll do the more common abbreviation. 

This week's abbreviation is:

RTC

RTC means return to care.  Its a very straightforward abbreviation that means when the medical staff wants to see the patient again.  

Example:

RTC in one week for VS monitoring. (Return to care in one week for vital sign monitoring). 

RTC PRN (Return to care as needed). 

Tuesday October 13, 2015 Falls Continued (Falls due to Fainting)

Today I thought we'd focus on the first cause of falls.  I won't ever be able to cover all of the various causes of falls that one can have but I can give some insight into some of the biggest causes of falls.

The first cause of falls that we'll explore is syncapol episode (or fainting).

The causes of fainting can be many and varied but the reason we'll focus on today is a sudden change in blood pressure, usually a sudden drop. It is up to a physician to determine the cause. Causes frequently include illness, sudden change in position (called orthostatic hypotension), or even bearing down to use the washroom and stopping. Another reason for fainting is holding your breath.  You won't kill yourself holding your breath but you will pass out, causing you to start breathing again. It's the body's defense mechanism.

A patient who is otherwise healthy may sit up suddenly in the middle of the night needing to go to the washroom, and the sudden change in position (from lying flat to standing up), which isn't so common during the day (as we're not usually changing positions suddenly during the day) causes the blood pressure to drop as the person has moved too fast for the body to compensate for the change in position and the patient faints and falls. In this case you may hear the thud, but it is uncommon for this patient to have or need safety measures prior to or even after the fall.

In my personal experience this particular patient may have no reason for the episode or it may turn out that they have orthostatic hypotension (their blood pressure drops when they change position) and this may just be the first time that anyone is aware of the condition.  After this initial fall, preventative measure should be taken to prevent additional falls if this is the case.

If the reason is illness, or if there is another reason for the fainting episode, the cause needs to be determined before proper precautions can be put in place.

These patients, like those who may just slip and fall- next weeks focus- may not have precautions in place prior to their falls. This is because many times these clients are at lowest risk for falls prior to their incident. Like any fall, it is important to evaluate the whole record and not the specific incident to find out what happened.

It is especially important for attorneys to work with the medical community, a nurse and physician, to help determine if there is negligence in this type of fall.

Monday October 12, 2015 Abbreviations

We've covered some of the more significant abbreviations in the medical world that are not necessarily understood by the non-medical community.  Today I thought we'd discuss one that most of the non-medical community would know but see if I could shed some more light on in.

Lets get to work.

Today's abbreviation is

VS 

VS- Vital Signs

This is one of the most understood by the "lay person" because it is not only discussed in the media, but it appears on medical shows (ER, Scrubs), and it is something that medical personnel discuss with their clients.

Everyone has had their vital signs checked at some point in their life.  Every time that someone goes to their primary care physician, walk in clinic, or ER, their vital signs are taken.

Vital signs include the following five areas of measurement:

1. Blood Pressure- Ideal 120/60
2. Respiratory Rate- I like to see 14 or 16 breaths per minute, but 12 or 20 breaths per minute can be normal for some clients
3. Heart Rate - Normal is considered 60-100
4. Temperature-- 98.6 is ideal
5. Pain - 0 pain is the goal.

6. Sometimes pain isn't assessed and sometimes also pulse oximetry (the amount of oxygen in the blood) is assessed as part of the vital signs  For pulse oximetry 100% is ideal.


Example:

Pt's. VS are 120/60, 14, 82, 98.6, 100% on RA at 9 am . (RA- room air).  In this example the patient's vital signs would be considered normal.

Pt's VS after treatment 150/80, 110, 99.5, 95% pain 8/10. This patient's vital signs would be considered abnormal.  Because the patient received treatment the abnormal vital signs could be a result of the treatment, but the nurse did not indicate what treatment was given.

Wednesday October 7, 2015 Falls Part 2

Last week we talked about what happens after a patient falls and the nurse finds the patient.  This week we're going to deal with the same scenario, but this time unlike last week the patient will not be ok.

The nurse's note reads as follows

Nurse heard patient call out.  Went to check on patient. Patient found lying on the floor.  Patient's left leg clearly shortened and internally rotated. Vital Signs WNL. Patient complaining of pain of 10/10 in left leg.  Patient made comfortable and 911 called. Patient transferred to the hospital via EMS, physician notified.


Again, this note is not ideal, but there are a number of key elements here that make this a very good note.  While the it is still not clear why the client fell, or if they were a fall risk prior to the fall, the nurse did some very important things.

First the nurse noted that the client was injured (left leg clearly shortened and internally rotated). This is a very clear sign of a hip fracture. Likely of the femur area of the joint.  The hip is three bones, and a break like this is the top of the femur.

The second thing this nurse clearly did right is that she called 911.  A fractured bone after a fall is an emergency.  In the hospital assistance would be called for and the patient would be transferred back to bed where the leg would be stabilized. But in the community, the nurse needed to contact emergency services to transfer the patent to the hospital. Because this is a medical emergency the physician has to be notified but not until after 911 has been notified.

Although it says that the patient was made comfortable while waiting for 911 it would be ideal if it said that the patient was made comfortable on the floor, rather the more ambiguous made comfortable.  The reason for this is that a break can be made worse if the bone/extremity that is broken is moved prior to emergency medical services. But at the same time a pillow for the head and a blanket to help prevent shock, and to keep the patient comfortable is a perfectly acceptable treatment while waiting for EMS services.

Next week we'll focus on what an incident report includes.

October 5, 2015 Abbreviations

Today's abbreviation is very common in the medical world and can mean different things depending on the context it is used in.

Today's abbreviation is

WNL 

WNL means within normal limits.

Like a lot of abbreviations in the medical world, the meaning of this depends on the context in which it is used.

The two examples below show the difference in the abbreviation's use.  WNL when the person doing the documentation does not clarify that it is for the patient, means that it applies to what is normal for the population as a whole.

Sometimes the person documenting clarifies that the behavior, range of motion, or something else is WNL for the client or patient, by stating WNL for patient. This is especially important if the person's mobility is concerned. If the person had limited range of motion, it is likely that the documentation would reflect that is is normal for the person but not normal for the population. With skin color, it is normal to say that it is WNL for clients, because not all patients have the same color skin.

Example

ROM WNL (range of motion within normal limits).

Vital signs WNL 

Tuesday September 29, 2015 Falls Week 1

Falls-

Yesterday I introduced an abbreviation important to falls MAE.  Because I started with that abbreviation we're going to work backwards from the abbreviation and the after affects of a fall to the causes.

So the client is already on the floor. They've fallen. Too late to prevent the fall, cause it's happened. What needs to happen next.

For today the following scenario is going to be discussed:

Nurse heard patient calling out.  Nurse went to room and found patient on the floor. Patient unable to tell nurse how patient ended up on the floor. Pt. MAE. Pt assisted back to bed and physician notified. NNO at this time.

What happened, or what happens:

The nurse heard the patient call out, she went into the room to check on the patient. The nurse asked the patient what happened.  The nurse should have assessed the patient to ensure that the patient could move all extremities (MAE) within normal limits for the patient. It appears that she saw evidence of that, but did not necessarily assess for the ability to move all extremities. After she saw that the patient had not been visibly injured at this time, the patient was assisted back to bed.

This is a fairly straight forward version of what I see when a patient falls.  There are a ton of things that could go wrong with this scenario, even in my little note. Using a Certified Legal Nurse Consultant can help identify those things.

Monday September 28, 2015 Abbreviations

Today we have a simple but important abbreviation. And as a result a short post. This abbreviation is especially important when clients fall.  We'll discuss falls briefly tomorrow, and give a brief overview of some of the reasons that people fall.

Todays abbreviation is

MAE

MAE stands for moves all extremities.  Extremities are limbs. Being able to move all extremities after a fall is important. 

Examples

Pt. able to MAE.  

The reason that there are not two examples is that is usually the only way that this particular abbreviation is used. Sometimes it is used in physical therapy notes but usually in the same context.  Tune in tomorrow for more on falls. 

Tuesday September 21 2015 SOB

First off, for my Jewish readers I hope that the fast tonight and tomorrow is easy and meaningful and to my Muslim readers a happy Eid Mubark.

Lets talk about SOB. Yesterday I related (poorly) a joke told to me by my father about a client who was demonstrating SOB (shortness of breath) and confused it with another meaning for the same abbreviation.

Shortness of breath is a big concern for medical staff and when patients are complaining of shortness of breath staff acts quickly.  The causes are many and numerous. Shortness of breath can be caused by anything from a panic attack to a heart attack or stroke.

Not only is shortness of breath something a client can report feeling without measurable symptoms but it can also be measured.  Clients experiencing shortness of breath may have decreased oxygen levels in their blood (measured with a small device placed over the finger, toe, or ear). Their respiratory rate is usually INCREASED, because they're trying to get more oxygen in, and they look uncomfortable.

The best way to resolve shortness of breath is to resolve the cause of it. If the patient is having a panic attack, applying oxygen may not help but giving Ativan and easing the symptoms may help, but if the patient is having a heart attack, oxygen will help.  If the patient is experiencing an asthma attack medication to open the airway through inhalation will help.

In short- shortness of breath is a dangerous situation, and the cause needs to be diagnosed quickly to help guide treatment. It is not a cause, but is a symptom of a more serious medical condition, and should be treated with respect.

Monday Sept 21, 2015 Abbreviations

A Joke: (badly told because I can only tell jokes badly)

There was a gentleman who became very sick. He headed to the local hospital and soon became critically ill. He began to recover, and as part of his recovery he began to review his medical records. As he was reviewing his medical records he quickly became concerned. His nurse came in.  The gentleman apologized profusely to the nurse, and said I am so sorry for my behavior while I was sick.  The nurse looked at him confused. The gentleman pointed to a spot in the medical records. The nurse laughed. SOB she said stands for Short of Breath. 

Like I said a badly told joke. 

But this week's abbreviation is 

SOB

SOB stands for short of breath or shortness of breath. This is a pretty common abbreviation. It is seen in lots of places and tomorrow I'll discuss some of the common causes of SOB that are seen in the medical record. 

Examples

Chief Complaint: SOB

Pt. appeared SOB with use of accessory muscles and rapid respiratory rate. 

Tuesday September 14 2015 DVT

For the second topic that I want to add to the blog, I think we'll discuss various disease processes (which are just diseases) that are featured in the media.

My mom is the inspiration for this particular post. She was watching TV the other night when I wandered into the kitchen. I heard the end of a Xaralto commercial and she asked me about risk for DVT.

A DVT (deep vein thrombosis) is a type of blood clot.  Everyone can get blood clots, and everyone can get DVT's. There are certain people who are more at risk for DVT's than others. People in situations where blood is more likely to stay in your legs (which is the most common site for DVT's) are more at risk than the general population. Some of those populations include people sitting on airplanes for long periods of time, women over 35 on birth control, and those with abnormal heart rhythms. These are the people that the advertisements for medication on TV are aimed at.

People in hospitals and nursing homes are also at risk for DVT's, but we know what to do to try and prevent DVT's. Its not a perfect science, but encouraging early mobility, the use of SCD (sequential compression devices) and medication (heparin) helps.

The medications advertised on TV (Xaralto, etc) are designed for active adults who are unlikely to suffer complications from bleeding.  The way that all of the medications work (Xaralto, etc and Heparin and Warfarin) is by decreasing the clotting factor in the blood. The older medications (Heparin, Warfarin) can be reversed by administration of Vitamin K. The newer medications (Xaralto, etc.) can only be reversed by administration of Fresh Frozen Plasma or clotting factor.

This is the reason that all medication should be discussed with the prescribing physician including risk factors.  Sometimes, the newest medication isn't always best for treating the disease.

DVT's are usually diagnosed when patients have pain in their calf along with warmth and redness. The patient undergoes a Doppler of the painful extremity, where like the weather radar, changes in the blood flow in the leg can seen. DVTs when treated quickly resolve without complications and patients can discontinue their medication. A DVT that goes untreated can kill. It "breaks free" from its location and can travel to the lungs where the blood vessels are much smaller. When the blood vessels in the lungs are blocked, it becomes difficult to breath, and if the blood clot is big enough, it unfortunately will kill the person. When the DVT "breaks free" and travels to the lungs it is called a pulmonary embolism and can constitute a medical emergency.

Please don't hesitate to contact your medical professional for more information, including diagnosis and treatment. Medical professionals are trained to diagnose and treat diseases. This is designed to be supplementary information ONLY!

Sunday September 13, 2015 Holiday Tomorrow Abbreviation Today

We have one more abbreviation to cover in our short related abbreviations series. This, like many other abbreviations is difficult to produce in computer short hand, and that accounts for some of the variation in the way that it is written today in electronic documentation.  This is the version I demonstrate below.

Here's this week's abbreviation:

2nd to

This abbreviation means related to or due to depending on the circumstance of the sentence structure. In electronic records it is written as 2nd or just 2.  In handwritten text it is seen as 2 followed by the degree symbol (2º) Most people don't know that you can do that with simple computer commands and don't have the time to do it.

This is a much more common abbreviation for physicians to use than it is for nurses to use. This is also a common physical therapy abbreviation.


Examples

Client unable to ambulate 500 ft 2º complaints of shortness of breath and fatigue.

Final Diagnosis: Syncope 2nd to transient hypotension.
   This means fainting due to a brief episode of low blood pressure.

Sunday September 6th. Holiday Tomorrow Abbreviation Today

Because tomorrow is the Labor Day Holiday in the US, I, like most of America will be taking the day off and avoiding labor. So I decided I'd post the weekly abbreviation today.  

Last week I started out with the first in a series of abbreviations (r/t) that mean very similar things. 

The next in this list of important abbreviations is as follows:

D/T-- due to

Like related to this particular abbreviation links together like objects.  This focuses on cause and effect where related to is more likely to be used when things are less clearly linked. 

Example

Pt had syncopal episode d/t transient hypotension.  (Patient fainted due to a brief episode of low blood pressure). 

Pressure ulcer worsened d/t lack of repositioning by staff in the previous week. 

Monday August 31, 2015 Abbreviations

Today we're going to tackle an abbreviation that many non medical professionals find difficult. It's one of a series of abbreviations that are sometimes used interchangeably. I'll focus on each individually but its normal to feel confused about them.

r/t-- related to

Because each of a number of assorted abbreviations mean approximately the same thing it is really hard to remember, also this is the least common of the abbreviations, and most commonly used by the physicians and physical therapists and not the nurses. It will appear a few times in a medical record, and just uncommonly enough to be difficult to remember.

These examples are here for reference but if you have specific questions to meaning please contact me and I'll be happy to help you out.

Examples:

The wound on her left foot is r/t diabetes

Alteration in nutrition r/t the presence of a g-tube

Monday August 24, 2015 Abbreviation

This week's abbreviation is the opposite of last week's abbreviation.

PO

This abbreviation literally means Per Os, which stands for by mouth.  This abbreviation can also mean orally. Although it is not common to see it written out, the place where you most likely see this in in the vital signs chart.  When temperature is taken and recorded, to save space many charts use PO to indicate that the temperature was taken orally. In this way it's really just a space saver, and about the only place I have regularly seen it mean orally.

Unlike NPO, this is more commonly seen in notes, but it can also be an order.  As an order it is usually used with medication to indicate the way the medication should be administered.

Examples:

She took all of her medicines PO without any difficulty.

Amoxicillin 500mg PO daily

Monday August 17 2015 Abbreviations

Goodness gracious.  I think I've figured out this blog thing. If I've figured it out I'll start adding categories until there's new content Sunday through Thursday each week.

But since I'm still figuring it out Monday is still the only day with information.

On to today's abbreviation.

I've decided to focus on a personal favorite today. This is the first abbreviation that I learned.

NPO

It literally means Nil Per Os. Which is Latin for nothing by mouth.  

Nothing by mouth is both a dietary status and a physician order.  The reasons for nothing by mouth are different depending on the client. Sometimes the client's diet is NPO because they're at risk for aspiration or choking on their food, and sometimes the order is NPO because the person is going for a test the next morning. 

NPO is almost always in capital letters in the sentence. 

Example Sentences

Patient was made NPO at midnight for his test tomorrow morning. Patient was aware of his status. 

Patient is NPO due to her high risk for aspiration.