Archive for August, 2010

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Financial Repercussions of Insufficient Client Charting

August 23, 2010

In an age of electronic records and an economic recession, the nurse must be diligent about thoroughly assessing the client using a head-to-toe format and charting all findings in detail. Medicaid/Medicare has really tightened their laws on what they will and will not reimburse. For example, if a patient is admitted to the hospital and the nurse fails to chart that the client had an already present pressure ulcer, Medicare will refuse to reimburse the hospital for fees, supplies, and procedures related to the treatment of that wound. However, if the pressure ulcer is charted as being present upon arrival, the hospital is not at fault and will be reimbursed fully. Another example, separate from charting, is when a patient is discharged from the hospital following a heart failure “tune-up” and is readmitted within 30 days. The hospital in penalized for the re-admission. The problem is that there are other factors that could cause the re-admission that is not the fault of the hospital or physicians. What if the patient is non-compliant with the prescribed medication regiment? Should the hospital be a fault? Also, we care for a high risk, end stage heart failure population, so is it fair that our stats must match up to a rural hospital that only cares for mild cases of heart failure and does not perform transplants?

I agree that our government has to be careful as to how dollars are spent, but perhaps there are better ways. As healthcare professionals our voices could be beneficial and therefore need to be heard, but unfortunately I am unsure as to how this is happens. Perhaps if all master degree programs for healthcare professionals also included a Public Health component, more people would know how to be a part of healthcare reform.

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Posted in Ethics, Health Assessment, Healthcare Informatics Communication | 2 Comments »

Assessment of the Pregnant Client and Healthcare Informatics

August 23, 2010
With the assessment of the pregnant client, healthcare informatics comes quickly to mind.  The use of healthcare informatics is beneficial and necessary with the pregnant client.  The benefits of using an electronic medical record (EMR) with the pregnant client is important and necessary.  The benefits of having this record readily available and up-to-date ensures appropriate and timely health care of this client especially in an emergency or high risk situation.  This also ensures appropriate and timely health care for the fetus to also assist in producing positive health care outcomes.
With healthcare informatics and the diagnostic testing that is available to the pregnant client and fetus are concise and thorough.  Diagnostic evaluation and intervention also allows timely and accurate care of the pregnant client.  With any assessment, the pregnant client needs a complete evaluation with analysis of the fetus.  This assessment needs to be detailed with follow-up on any issues if they should arise.  With any issues, the follow-up should be quick to ensure the safety of both client and fetus.  Seek resources if needed for clinical issues with this client. This assessment ensures safety but also positive clinical outcomes.

With the assessment of the pregnant client, healthcare informatics comes quickly to mind.  The use of healthcare informatics is beneficial and necessary with the pregnant client.  The benefits of using an electronic medical record (EMR) with the pregnant client is important and necessary.  The benefits of having this record readily available and up-to-date ensures appropriate and timely health care of this client especially in an emergency or high risk situation.  This also ensures appropriate and timely health care for the fetus to also assist in producing positive health care outcomes.
With healthcare informatics and the diagnostic testing that is available to the pregnant client and fetus are concise and thorough.  Diagnostic evaluation and intervention also allows timely and accurate care of the pregnant client.  With any assessment, the pregnant client needs a complete evaluation with analysis of the fetus.  This assessment needs to be detailed with follow-up on any issues if they should arise.  With any issues, the follow-up should be quick to ensure the safety of both client and fetus.  Seek resources if needed for clinical issues with this client. This assessment ensures safety but also positive clinical outcomes.

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Posted in Electronic Medical Record, Health Assessment | 1 Comment »

Informatics and the Ventilated Patient

August 23, 2010

ICU nursing frequently involves caring for the patient who is artificially ventilated.  This could be for numerous reasons: i.e. failure to wear off ventilator following surgery, respiratory failure, PE, pneumonia, etc.  Without advances in informatics, care of this difficult patient would be made even more difficult.  Assist controlled ventilation is the most often used.  In this mode, tidal volume and rate are pre-set.  In other words the ventilator is taking over the work of breathing, filling the lungs with air and enabling gas exchange to occur so the patient remains well-oxygenated.  If the patient does indicate respiratory effort, the ventilator is programmed to respond though it still delivers the preset tidal volume.  Nurses must be attentive to the patient’s respiratory rate and the ventilator’s assistance in order to avoid hyperventilation and subsequent respiratory alkalosis.  Generally, the nurse checks and records ventilator settings and respiratory effort frequently throughout the shift.  The patient will be monitored with vital signs, cardiac rate and rhythm, respiratory rate and pulse oximetry, via electronic monitors which transmit information directly to nurses in preset intervals (often as frequently as 2-5 minutes) and alarm when abnormals occur.  Without this form of monitoring, care of this patient would be much more difficult.  If the ventilator is alarming, the nurse attends to the patient first, then, if all is well, attends to the alarms which may indicate water in the tubing or a loose connection.  The patient should be assessed for skin color (nail beds and lips particularly), lung sounds, bilateral chest expansion, need for suctioning and respiratory effort.  The physician may order labs, arterial blood gases, chest x-ray or alteration of settings.  Again, thanks to computerized information retrieval continuity of care on a multi-disciplinary level is more accessible than in the past.  In most ICUs, physicians, nurses and respiratory therapists have access to electronic bedside charting to allow for continuous monitoring.  This form of charting makes the work of documentation and information retrieval safer for the patient.  Simply put, breathing supplies the human anatomy with life-giving oxygen a necessity for every cell in the human body; thus the “A” in ABCs.  Nurses always must attend to airway first, for without a patent airway, no other intervention could help the patient achieve homeostasis.

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Posted in Electronic Medical Record, Health Assessment, Nursing Physiology, Telemedicine | Leave a Comment »

Health Informatics and the Cardiovascular System-Health Assessment

August 18, 2010

In blending in healthcare informatics and the cardiovascular system, there are many opportunities to explore.  For instance, informatics can provide a detailed patient care record (EMR) that contains valuable health information that can be shared amongst healthcare providers. Next, with informatics, there are numerous cardiovascular diagnostic tests that are available to individuals seeking care.  Some of these tests include electrocardiogram (EKG), echocardiogram, and cardiovascular catherization technology.  These diagnostic tests provide information for preventive medicine and health care practices as well as current diagnostic interventions to prevent injury or further injury to the cardiac muscle.  Finally, the use of informatics to provide an updated electronic medical record and technology to perform comprehensive cardiovascular diagnostic evaluation allows healthcare to be concise and proficient, contributing to positive patient outcomes.  With this technology, an individual with chest pain entering an emergency department can gain access to care quickly to diagnose his condition that can provide interventions to save muscle as well as his life.  This can be accomplished by using efficient diagnostic technology and an up-to-date electronic medical record.  In this situation, time is muscle, and healthcare informatics can minimize this time to reach a diagnosis and quickly provide appropriate health care interventions to promote positive patient care outcomes.

Thank you.

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Posted in Health Assessment | 5 Comments »

Healthcare Informatics and the Reproductive System-Heath Assessment

August 18, 2010

The advances of healthcare informatics with the reproductive system are numerous.  With the female reproductive system, ultrasonography can detect such conditions as fibroids in the uterus causing abnormal vaginal bleeding as well as advances in laser surgical procedures to perform an abdominal hysterectomy.  The use of robotic surgical intervention is becoming more  popular especially in minimizing surgical risks.

With obstetrics, the advances of ultrasonography are tremendous and especially useful with problematic pregnancies.  The use of 3D ultrasound technology can detect fetal abnormalities and allow appropriate interventions.  With informatics, health care data can be shared with healthcare providers to assist with providing seamless care especially for the delivery of a newborn with specific health conditions.

With the male reproductive system, laser technology is utilized to perform many surgical procedures including surgical procedures on the prostate gland.  Diagnostic testing can detect many conditions including BPH and certain cancers.  With prostate cancer, there has been many advancements in the treatment regimen to improve the survival rate with early diagnosis using labwork and diagnostic testing such as ultrasound.

The advancements of healthcare technology and informatics greatly improves diagnostic evaluation of the male and female reproductive system.  This advancement assists in evaluating a patient in an obstetric emergency or a patient that is having hematuria which is a concise, efficient diagnosis which impacts patient outcomes.

Thank you.

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Cardiac Care and Informatics Technology

August 16, 2010

The human heart is an amazing structure.  Serving as a pump for the approximately 5.5 liters of blood, it sends nutrients, oxygen electrolytes, and blood cells throughout the body and removes carbon dioxzide and wastes, beating approximately 60-100 beats per minute, every minute of our lifetime starting at about the fourth week after conception – all this without us ever having to think about it!  Technology has given us insight as to the normal and abnormal function of the heart.  When someone comes into the ER with crushing chest pain, we immediately think IV, O2, monitor – and proceed, if appropriate, with MONA – morphine, oxygen, nitroglycerin and aspirin.  The monitor can give us information on rate and rhythm, conduction, angina or AMI,  indigestion, anxiety or cardiac event. Without the monitor, we would just be guessing and perhaps delay treatment which would increase  progression of cardiac damage (i.e. time=muscle).  Other studies we can expect the physician to order are CBC, CMP, PT/INR, chest xray, possibly CT or prep for cardiac cath.  All these studies are based on technology and informatics with the promise of rapid retrieval of information, therefore preserving cardiac function and life.  Bedside charting via electronics in the ER can also help maintain cardiac function.  While waiting for labs and further orders, the nurse can remain at the bedside and not be fumbling through papers, therefore monitoring the patient and cardiac monitor constantly.  Some technological programs are checklists, which can also serve as cues for the nurse, plus allow easy access to information as needed.   If the MI progresses to Vtach or Vfib, the nurse is at the bedside and can initiate defibrillation immediately.  If it progresses to asystole, the nurse can start CPR without delay.  It is both calming and reassuring to the patient and family to have the nurse present continuously.  Prior to advances in technology, delay in care was a major contributing factor to cardiac loss and death.  While delays in care still occur, medical technology has definitely improved the outcome of cardiac events.  Many patients proceed to rapid cardiac cath with subsequent bypass surgery if appropriate and are discharged within several days with a much more positive prognosis than in the past.  While AMI is still a very serious health problem, informatics and technology have improved the outcome both in the acute phase and the post MI period.

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Posted in Disease Prevention, Health Assessment | Leave a Comment »

Physical therapy in the ICU

August 16, 2010

Working in the ICU many of our patients are on bedrest for an average minimum of 2 days, with many as long as weeks and months. As a critical care RN, my main focus is keeping the patient hemodynamically stable and thus the musculoskeletal system takes a back seat. However, eventually once the patient is more stable, physical reconditioning takes place. When is the right time?

I think the answer is as soon as possible! I read a research study that stated one day of muscle atrophy from bedrest can take a week of physical therapy to regain. This statistic shocked me and as a result I have tried to be more cognizant of the need for physical therapy for my patients. As an advocate for my patients I try to discuss the need for physical therapy during interdisciplinary rounds as early as possible. Also, when the physical therapist is working with patients I listen so I can learn ROM exercises that I can help them perform. For our chronically ill patients that have been on bedrest for weeks or months, I attempt to do simple exercises with them such as resistance or stretching as they can tolerate. However, there are times when I simply do not have time to consistently work with them, and the physical therapists are usually stretched thin and can only visit once a day. With this said, how can the void be filled?

I feel that family is the best option. As nurses and physical therapists we need to include the family in learning and teaching exercises. Research shows that families cope better when they are involved in their loved one’s care. They are at the bedside often times most of the day and it has been my experience that they are more than happy to assist in patient care.  Involving the family early in bedside care can also help with the transition home.

I would be interested to hear what others think and what interventions they implement to help their patients recondition. I also want to know what healthcare informatics resources are available for the nurses and the families.

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Posted in Healthcare Informatics Resources | 1 Comment »

Telecardiology

August 16, 2010

In an era with a shortage of nurses and primary care providers in rural areas, telemedicine is a innovative way to reach out to and underserved population. Within the umbrella of telemedicine, we also have telecardiology specifically, which is a new concept for most. However, the first major use of telecardiolgy was in 1975 in India where EKG’s were sent via phone lines for evaluation. In North Carolina many patients must travel hours to reach a city equipped to manage their cardiac disease. This creates physical and often times financial strain on the patients resulting in lack of follow up care.

This is where modern health care and brilliantly engineered cardiac devices come into play. Patients can now send information via their pacemakers or internal cardiac defibrillators (ICD) directly to their physician for evaluation, all of which is done over phone or internet. The physician can monitor heart rate, rhythm changes, or see if their ICD has implemented a shock. The physician can then change settings on their pacemaker or ICD from a computer that will better help the patient’s cardiac arrhyhmias. Medications can also be prescribed or changed based the transmitted data. This is a major benefit for patients who live far from their physician’s hospital or office.

I get excited to think how modern medicine will continue to grow and how it will continue to benefit disadvantaged patients.

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Posted in Telemedicine | 1 Comment »

Increased nurse responsibility and the effects on bedside care

August 13, 2010

The role of the nurse is an ever increasing scope. I am close to entering only my fourth year as an RN and in this short time have seen numerous responsibilities placed upon our RN’s that were not previously there. Unfortunately, the fore mentioned responsibilities mainly consist of documentation that keep the hospital in compliance with JACHO, OSHA, and maintain Magnet status, NOT bedside nursing interventions. Most of these committees are present to keep hospitals in check and make sure they adhere to patient safety guidelines. However, as we add these additional items that require daily documentation (ie: falls risk, elopement risk, etc), we are pulling the RN farther and farther from the bedside! I pose the question, how does this increase patient safety?

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Posted in Accreditation | 3 Comments »

Nurse charting in the hospital setting: Does electronic charting win?

August 13, 2010

Two years ago my hospital transitioned to electronic nurse charting. Adapting this new form of documentation caused a rumble amongst much of the staff. It seems there is always a natural fear that arises when something so new in form is implemented. At that time I had only been a nurse for a little over a year, so I was open to just about anything as I was not too set in my ways. I continue to hear the occasional comment reflecting back to the good ol’ days when charting involved nothing more than a pen and paper. Last week our computer system was out of service for three hours for upgrades and as I was charting, once again on paper, I began to contrast and compare the two different styles of documentation in my mind.

Electronic charting has many benefits. It’s legible, finite, organized, and consistent. For example, intake and output are entered and it automatically gives the nurses and doctors a net positive or negative daily fluid balance. With paper charting we had to painstakingly calculate intake and output hourly, which is basic math, but still remains time consuming. Patients’ lab values are automatically uploaded to their e-chart which also saves time. Vital signs automatically flow from the bedside monitor to the e-chart and simply need confirmation to be permanent. No longer are the days of placing triangles and dots for graphical depiction of vital signs.

There are some negatives to electronic charting. As stated above, down time for upgrades is always an annoyance. It causes inconsistencies in the patent record and is a hurdle for newer staff that never used our paper flowsheets. Some aspects are actually more time consuming than that of paper charting. Lags in servers and computer glitches often time cause sluggish operating systems. And of course there are always times when you have almost finished charting a long, detailed note, when the whole system crashes!

Grievances aside, I guess at the end of the day we all know that patient safety is the most important concern. With that said, I must admit that electronic charting is much safer than that of paper, therefore it wins my vote. As stated earlier, there is little room for misinterpretation. There is consistency among all staff, and patient records can be accessed by physicians anywhere in the hospital. Perhaps we are in the initial stages of developing a universal system that can be accessed by all institutions across the country. Wouldn’t that be nice!

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Posted in Electronic Medical Record | Leave a Comment »

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