Monday, July 28, 2008
Wednesday, July 09, 2008
It's a good feeling knowing that this blog will be read by people in a position to consider including me in their staff. I know that whoever reads this takes nursing seriously and, therefore, wants to consider a serious, qualified new-grad. nurse. I understand that it's important to know a little bit about the person beyond statistics and credentials, and I feel that this blog presents a convenient medium for this information.
I hope the reader senses the person behind the prose after scanning this page. It' s comforting to know that nursing school is already beginning to pay off and people in charge of my future are paying attention.
Thank you for reading,
Kevin M. Kenney, SN-UNH
RESUME INFORMATION
KEVIN M. KENNEY
603.703.2185
kmu2@unh.edu
OBJECTIVE
Seeking an entry-level position as a Registered Nurse on a Medical-Surgical unit in a hospital setting after graduation in the spring of 2009. I am also interested in other available positions, particularly an entry-level RN position in the Operating Room, as I have taken a particular interest in this area through my rotations in nursing school.
•
• Community Health: Seabrook Station,
• Mental Health:
• Maternity/OB:
• Pediatrics:
• Medical/Surgical:
• Introductory Clinical Experience:
CUMULATIVE GPA as of January, 2009: 3.69
EDUCATION
[2004 – Present]
BS in Nursing in progress
Sigma Theta Tau International Honor Society of Nursing, University Scholar Award.
[2000-2004]
High School Diploma
National Honor Society, President's Education Achievement Award.
VOLUNTEER EXPERIENCE
Activity coordinator assistant for Alzheimer’s patients at SpruceWood Assisted Living Facility,
PROFESSIONAL MEMBERSHIPS
Sigma Theta Tau International Honor Society of Nursing, National Honor Society, National Technology Honor Society, American Heart Association, and National Student Nurses Association. AHA certified Basic Life Support for Healthcare Providers (CPR &
(My work history includes summer jobs that have helped me pay for nursing school)
[ January 2008 – Present ]
Substitute Teacher
• Substituted for classes in large, diverse schools in
• Learned self-confidence, leadership, and professionalism.
• Acquired strong communication and problem-solving skills.
[ May 2006 – Present ] Velcro USA, Inc.,
Machine Operator, Summer Help.
REFERENCES
1. Christine McCarthy, RN,
2. Professor Kimberly Carey, MS, RN, CNM: office phone: 603.862.2260. Email: kcarey@cisunix.unh.edu.
3.
FINAL PATIENT CARE PLAN FOR OB ROTATION AT CONCORD HOSPITAL
OB Care Plan: Clinical data gathered from 25 February 2008
Kevin Kenney, SN-UNH
Professor Kimberly Carey, MS, RN, CNM
University of New Hampshire
14 April 2008
Overview
HF is a 38 year old, married, G2P1, PPD3 mother who delivered a vigorous 8lb 2oz male infant at 0820 on 2/22/08 via repeat Cesarean section operative procedure with spinal epidural anesthesia. Client’s LMP was 5/20/07 and EDD 2/23/08. HF’s prenatal Hgb and Hct were 14.8gm/dL and 43.1% respectively. HF’s prenatal record showed B+ blood type, Rubella immunity, negative Hep B, negative GBS. Client denies alcohol, tobacco, and recreational drug use during the entirety of her pregnancy. Client has NKDA but is allergic to bee stings. Prenatal medications include Epipen, multivitamins and prenatal vitamin tablets. Client has standing orders for Motrin and Percocet PRN for pain. Prenatal chart indicates pre-existing health problems including Hx of chronic constipation, laxative abuse, anxiety and depression. HF is at risk for pregnancy complications because she is 38 years of age (Heffner, 2004, 1927). Client received prenatal education including a review of the stages and phases of labor, coping techniques and infant feeding/care. Client states that husband SF was present and supportive during pregnancy.
HF had SROM of meconium color at 0819 and delivered a vigorous male infant through the Cesarean section incision at 0820. Report indicates husband was present during delivery. Infant measured 21 ½ inches long with 35cm head circumference, weighed 8lbs 2oz, and was 39 5/7 weeks gestational age. Infant APGAR scores were 8 at 1 minute and 9 at 5 minutes and presented with mild jaundice.
PP mother and infant were stable and breastfeeding well. Low transverse abdominal incision site is clean, pink, warm, dry, well approximated and open to air. Physician removed staples on 2/25/08 and noted that incision site was clean, dry and well approximated. Client has a FF@U, light rubra as indicated by perineal pad and is voiding appropriately. HF has soft, non-tender breasts with appropriate nipple presentation and proper infant latching technique. Auscultation indicates hypoactive bowel sounds and client is on Colace. HF reports “a little sore” 3/10 pain over incision site and 1 Motrin given with good effect confirmed by reassessment of 1/10 pain. Supportive husband SF was in the room, involved in diaper changing, and verbalized enthusiasm about birth and infant. Documentation indicates that infant has voided and passed stool appropriately and effectively. Mother displays appropriate affect for PPD3 mother supported by CF’s verbalization that she is very happy with new baby.
Subjective Data
Client verbalized “a little sore” 3/10 pain over her incision. HF verbalized not having a bowel movement since before DOD on 2/21/08. Physician reported that low transverse abdominal incision looked clean, dry and well-approximated upon assessment.
Objective Data
Recent C-section (currently POD#3). Vitals: T 98.4ºF, apical P 70bpm, R 18, BP 122/84 mm/Hg, reported 3/10 pain over LTCS incision site. Staples removed from low transverse abdominal incision by physician on 2/25/08.
Assessment Data
Hypoactive bowel sounds auscultated in 4 abdominal quadrants. Lung sounds clear to auscultation. Low transverse abdominal incision site is clean, pink, warm, dry, well approximated and open to air. Physician removed staples on 2/25/08 and noted that incision site was healing appropriately. Client has a FF@U, light rubra as indicated by perineal pad and is voiding appropriately. HF has soft, non-tender breasts with appropriate nipple presentation. HF is on a normal, regular diet and her activity is Ad-lib.
Nursing Diagnoses in Order of Importance:
1. Risk for infection related to low transverse abdominal incision from Cesarean section procedure (Newfield, 2007, p. 54).
2. Acute pain related to low transverse abdominal incision manifested by verbal report of 3/10 pain scale (p. 486).
3. Risk for constipation related to
a. Decreased frequency of defecation after operative delivery.
b. PMH of chronic constipation (p. 240).
4. Risk of injury to the mother and fetus from surgical procedure (Wissman, 2007, p. 218).
5. Risk for impaired parenting related to history of depressive symptoms (Newfield, 2007, pp. 662-663).
6. Risk for perioperative-positioning injury related to low transverse abdominal incision (p. 96).
7. Risk for impaired physical mobility related to
a. Low transverse abdominal incision
b. Pain
c. Decreased strength (pp. 373-374).
8. Impaired mobility related to bed rest following the procedure (Wissman, 2007, p. 218).
9. Risk for disturbed body image related to low transverse abdominal incision (Newfield, 2007, p. 541).
10. Risk for impaired bed mobility related to major abdominal surgery (p. 304).
1st Priority Nursing Diagnosis:
Risk for infection related to incision from Cesarean section procedure.
Planning
Short term goals for HF include
a. Client will verbalize understanding of how to recognize and prevent infection.
c. Client’s temperature will remain between 97°F and 99°F.
Understanding of these goals will be measured by client verbalization and will occur by the end of the shift at 1230 or before client discharge on 2/25/08.
The long term goal for HF will be for her to develop no infection related to her low transverse abdominal incision.
Intervention
1. Assess FH’s knowledge about infection prevention and recognition. This intervention provides basis for teaching the client a plan of self-care (Newfield, 2007, p. 245).
2. Monitor client’s vital signs, paying special attention to temperature. This intervention provides clinical data needed to recognize the presence of infection (p. 57).
3. Teach the mother to take only showers (no tub baths) and to monitor and record temperature. This information teaches the patient basic information to recognize and prevent infection (p. 57).
4. Keep linens clean and changed as necessary. This intervention reduces the likelihood of nosocomial infections (p. 57).
5. Monitor low transverse abdominal incision at least every 4 hours for redness, drainage, oozing, hematoma, or loss of approximation. Monitor the patient at least every 4 hours for any signs of foul smelling lochia, uterine tenderness, or increased temperature. These interventions provide clinical data needed to recognize the presence of infection (p. 57).
Evaluation of Specific Client
Short term goals:
a. Client will verbalize understanding of how to recognize and prevent infection.
c. Client’s temperature will remain between 97°F and 99°F.
These goals were evaluated before client discharge at 1030 on 2/25/08. The client verbalized her understanding of how to recognize and prevent infection. HF’s temperature remained between 97°F and 99°F.
The long term goal for HF will be for her to develop no infection and no manifestations of infection related to her low transverse abdominal incision. Evaluation of this goal is set for 3/28/08 at 1030. HF’s short term goals have been met, which are designed to help her with understanding and eventual attainment of the desired outcome.
2nd Priority Nursing Diagnosis:
Acute pain related to low transverse abdominal incision manifested by verbal report of 3/10 pain scale.
Planning
Short term goals for HF include
a. Client will report understanding of the importance of reporting pain as soon as it starts.
b. Client’s reported 3/10 pain score will decrease to at least 2/10 and maintain at this reported level.
These goals will be measured by client verbalization and will occur by the end of the shift at 1230 or before client discharge on 2/25/08.
The long term goal for HF will be to maintain and report a 2/10 pain level or lower up until, upon, and beyond reassessment on 2/27/08.
Intervention
1. Assess FH’s understanding of the pain scale and the importance of reporting pain as soon as it starts. Pain is subjective and is more readily controlled when treated early, so this intervention promotes client understanding and compliance (Newfield, 2007, p. 487).
2. Monitor for pain at least every 2 hours or per facility policy using appropriate pain scale and behavior assessment. Only the patient can fully describe their pain, so this intervention is necessary to address pain or discomfort. Teach the patient to report pain at the onset, allowing the patient to describe the pain in detail to include aggravating factors, relieving factors, and type of pain. This intervention is essential because pain is more effectively controlled the earlier it is treated (p. 487).
3. Monitor vital signs at least every 4 hours while awake. This intervention detects early changes that might indicate pain (p. 492).
4. Provide information for pain relief such as Kegel exercises, sitz baths, or medications. This intervention provides options for the patient and nurse to consider in developing the most appropriate pain relief (p. 492).
5. Explain the etiology of “afterbirth pains” and involution of the uterus. This intervention provides an explanation of a possible source of discomfort and increases the patient’s sense of control and understanding (p. 492).
6. Administer pain medication, such as Motrin, as prescribed. Reassess and document amount of pain relief within 30 minutes after administration. This intervention is important to relieve pain and evaluate effectiveness of medication (p. 492).
7. Provide calm, quiet environment. This intervention promotes action and effect of medication by providing decreased stimuli (p. 492).
Evaluation of Specific Client
Short term goals:
Short term goals for HF include
a. Client will report understanding of the importance of reporting pain as soon as it starts.
b. Client’s reported 3/10 pain score will decrease to at least 2/10 and maintain at this reported level.
These goals were evaluated before client discharge at 1030 on 2/25/08. The client reported understanding the importance of reporting pain at the onset. Motrin was administered with good effect for reported 3/10 pain. Upon reassessment, 20 minutes after initial assessment, pain decreased to reported 1/10 pain.
The long term goal for HF will be to maintain and report a 2/10 pain level or lower up until, upon, and beyond reassessment on 2/27/08. Evaluation of this goal is set for 2/27/08 at 1030. The client has shown understanding of the importance of reporting pain at onset and she successfully met the short term goal designed to help her with understanding and eventual attainment of the desired outcome.
3rd Priority Nursing Diagnosis:
Risk for constipation related to
a. Decreased frequency of defecation after operative delivery.
b. PMH of chronic constipation.
Planning
Short term goals for HF include
a. Client will verbalize understanding of the risks of constipation.
b. Client will verbalize understanding of colace and increased fiber and water, and how these help with softening the stool and increasing the frequency of defecation.
Understanding of these goals will be measured by client verbalization and will occur by the end of the shift at 1230 or before client discharge on 2/25/08.
The long term goal for HF will be for her to defecate within 3 – 5 days postpartum and to call provider if constipation persists after 5 days postpartum. The appropriate outcome is for HF to return to normal bowel evacuation pattern for her. According to Smith (2006), “A normal and healthy bowel pattern is different for everyone. One person might have a bowel movement every three days, while another person might have more than one bowel movement every day…Generally, it is unhealthy to have your bowels open less frequently than 3 times per week or more than 3 times per day” (p. 1)
Intervention
1. Assess FH’s bowel pattern and her knowledge about bowel pattern and constipation (Wissman, 2006, p. 669). This intervention provides basis for teaching the client a plan of self-care at home and promotes the healing process (Newfield, 2007, p. 245).
2. Provide education about the changes present in the immediate postpartum period that affect the GI tract, including: Decreased abdominal muscle tone; fluid loss from perspiration, urine, lochia, dehydration during Labor and Delivery; and hunger (p. 245). This educational intervention provides a basis for teaching the client plan of self-care at home and to promote healing process (p. 245).
3. Assist in planning a high fiber, increased water diet (pp. 245-246). This intervention promotes healing, replaces lost fluids, and helps with the return to HF’s personal normal bowel evacuation pattern. This diet will promote successful lactation, good nutrition, good self-care, and will help with bowel stimulation (p.245). Administer or encourage prune juice, hot liquids, high fiber, high roughage diet and daily exercise (p. 246). This dietary intervention promotes good nutrition, bowel stimulation, and helps CF return to her normal bowel evacuation pattern (p. 245).
4. Administer Colace (ducosate sodium) as ordered (Wissman, 2006, p. 672). This medication intervention will soften the stool by increasing the amount of water the stool absorbs in the gut; thereby making it less strenuous to pass (Lilley, 2005, p. 866).
Evaluation of Specific Client
Short term goals, including
a. Client will verbalize understanding of the risks of constipation.
b. Client will verbalize understanding of colace and increased fiber and water, and how these help with softening the stool and increasing the frequency of defecation.
These goals were evaluated before client discharge at 1030 on 2/25/08. The client verbalized that she understood the risks of constipation. HF also verbalized her understanding of colace and increased fiber and water.
The long term goal for HF is to defecate within 3 – 5 days postpartum and to call provider if constipation persists after 5 days postpartum. Evaluation of this goal is set for 2/27/08 at 1030. The client has made some progress toward this goal: HF is adhering to dietary and medication suggestions which will promote outcome achievement, and she successfully met the short term goal designed to help her with understanding and eventual attainment of the desired outcome.
References
Heffner, Linda J. MD PhD. (2004). Advanced Maternal Age – How Old Is Too Old? New England Journal of Medicine, 351, 1927-1929.
Lilley, L., S. Harrington, and J. Snyder. (2005). Pharmacology and the Nursing Process. St. Louis: Mosby. p. 866.
Newfield, Susan A., et. al. (2007). Cox’s Clinical Applications of Nursing Diagnosis. Philadelphia: F.A. Davis Company. pp. 240-247.
Smith, J.J. (2006). Fibre and fluids. pp. 1-1. Retrieved April 12, 2008, from www.surginet.org/uk/patients/fibre.php.
Staff, Mayo Clinic. (2008). Fever. Infectious Disease. Mayo Foundation for Medical Education and Research. pp. 1-1. Retrieved April 12, 2008, from http://mayoclinic.com/health/fever/DS00077/DSECTION=3#
Wissmann, Jeanne PhD, RN, CNE (Ed.). (2006). Adult Medical Surgical Nursing. Overland Park, KS: Assessment Technologies Institute, LLC. pp. 669-673.
Wissmann, Jeanne PhD, RN, CNE (Ed.). (2007). Maternal Newborn Nursing. Overland Park, KS: Assessment Technologies Institute, LLC. pp. 216-218.
OB Care Plan: Clinical data gathered from 25 February 2008
Kevin Kenney, SN-UNH
Professor Kimberly Carey, MS, RN, CNM
University of New Hampshire
14 April 2008
Overview
HF is a 38 year old, married, G2P1, PPD3 mother who delivered a vigorous 8lb 2oz male infant at 0820 on 2/22/08 via repeat Cesarean section operative procedure with spinal epidural anesthesia. Client’s LMP was 5/20/07 and EDD 2/23/08. HF’s prenatal Hgb and Hct were 14.8gm/dL and 43.1% respectively. HF’s prenatal record showed B+ blood type, Rubella immunity, negative Hep B, negative GBS. Client denies alcohol, tobacco, and recreational drug use during the entirety of her pregnancy. Client has NKDA but is allergic to bee stings. Prenatal medications include Epipen, multivitamins and prenatal vitamin tablets. Client has standing orders for Motrin and Percocet PRN for pain. Prenatal chart indicates pre-existing health problems including Hx of chronic constipation, laxative abuse, anxiety and depression. HF is at risk for pregnancy complications because she is 38 years of age (Heffner, 2004, 1927). Client received prenatal education including a review of the stages and phases of labor, coping techniques and infant feeding/care. Client states that husband SF was present and supportive during pregnancy.
HF had SROM of meconium color at 0819 and delivered a vigorous male infant through the Cesarean section incision at 0820. Report indicates husband was present during delivery. Infant measured 21 ½ inches long with 35cm head circumference, weighed 8lbs 2oz, and was 39 5/7 weeks gestational age. Infant APGAR scores were 8 at 1 minute and 9 at 5 minutes and presented with mild jaundice.
PP mother and infant were stable and breastfeeding well. Low transverse abdominal incision site is clean, pink, warm, dry, well approximated and open to air. Physician removed staples on 2/25/08 and noted that incision site was clean, dry and well approximated. Client has a FF@U, light rubra as indicated by perineal pad and is voiding appropriately. HF has soft, non-tender breasts with appropriate nipple presentation and proper infant latching technique. Auscultation indicates hypoactive bowel sounds and client is on Colace. HF reports “a little sore” 3/10 pain over incision site and 1 Motrin given with good effect confirmed by reassessment of 1/10 pain. Supportive husband SF was in the room, involved in diaper changing, and verbalized enthusiasm about birth and infant. Documentation indicates that infant has voided and passed stool appropriately and effectively. Mother displays appropriate affect for PPD3 mother supported by CF’s verbalization that she is very happy with new baby.
Subjective Data
Client verbalized “a little sore” 3/10 pain over her incision. HF verbalized not having a bowel movement since before DOD on 2/21/08. Physician reported that low transverse abdominal incision looked clean, dry and well-approximated upon assessment.
Objective Data
Recent C-section (currently POD#3). Vitals: T 98.4ºF, apical P 70bpm, R 18, BP 122/84 mm/Hg, reported 3/10 pain over LTCS incision site. Staples removed from low transverse abdominal incision by physician on 2/25/08.
Assessment Data
Hypoactive bowel sounds auscultated in 4 abdominal quadrants. Lung sounds clear to auscultation. Low transverse abdominal incision site is clean, pink, warm, dry, well approximated and open to air. Physician removed staples on 2/25/08 and noted that incision site was healing appropriately. Client has a FF@U, light rubra as indicated by perineal pad and is voiding appropriately. HF has soft, non-tender breasts with appropriate nipple presentation. HF is on a normal, regular diet and her activity is Ad-lib.
Nursing Diagnoses in Order of Importance:
1. Risk for infection related to low transverse abdominal incision from Cesarean section procedure (Newfield, 2007, p. 54).
2. Acute pain related to low transverse abdominal incision manifested by verbal report of 3/10 pain scale (p. 486).
3. Risk for constipation related to
a. Decreased frequency of defecation after operative delivery.
b. PMH of chronic constipation (p. 240).
4. Risk of injury to the mother and fetus from surgical procedure (Wissman, 2007, p. 218).
5. Risk for impaired parenting related to history of depressive symptoms (Newfield, 2007, pp. 662-663).
6. Risk for perioperative-positioning injury related to low transverse abdominal incision (p. 96).
7. Risk for impaired physical mobility related to
a. Low transverse abdominal incision
b. Pain
c. Decreased strength (pp. 373-374).
8. Impaired mobility related to bed rest following the procedure (Wissman, 2007, p. 218).
9. Risk for disturbed body image related to low transverse abdominal incision (Newfield, 2007, p. 541).
10. Risk for impaired bed mobility related to major abdominal surgery (p. 304).
1st Priority Nursing Diagnosis:
Risk for infection related to incision from Cesarean section procedure.
Planning
Short term goals for HF include
a. Client will verbalize understanding of how to recognize and prevent infection.
c. Client’s temperature will remain between 97°F and 99°F.
Understanding of these goals will be measured by client verbalization and will occur by the end of the shift at 1230 or before client discharge on 2/25/08.
The long term goal for HF will be for her to develop no infection related to her low transverse abdominal incision.
Intervention
1. Assess FH’s knowledge about infection prevention and recognition. This intervention provides basis for teaching the client a plan of self-care (Newfield, 2007, p. 245).
2. Monitor client’s vital signs, paying special attention to temperature. This intervention provides clinical data needed to recognize the presence of infection (p. 57).
3. Teach the mother to take only showers (no tub baths) and to monitor and record temperature. This information teaches the patient basic information to recognize and prevent infection (p. 57).
4. Keep linens clean and changed as necessary. This intervention reduces the likelihood of nosocomial infections (p. 57).
5. Monitor low transverse abdominal incision at least every 4 hours for redness, drainage, oozing, hematoma, or loss of approximation. Monitor the patient at least every 4 hours for any signs of foul smelling lochia, uterine tenderness, or increased temperature. These interventions provide clinical data needed to recognize the presence of infection (p. 57).
Evaluation of Specific Client
Short term goals:
a. Client will verbalize understanding of how to recognize and prevent infection.
c. Client’s temperature will remain between 97°F and 99°F.
These goals were evaluated before client discharge at 1030 on 2/25/08. The client verbalized her understanding of how to recognize and prevent infection. HF’s temperature remained between 97°F and 99°F.
The long term goal for HF will be for her to develop no infection and no manifestations of infection related to her low transverse abdominal incision. Evaluation of this goal is set for 3/28/08 at 1030. HF’s short term goals have been met, which are designed to help her with understanding and eventual attainment of the desired outcome.
2nd Priority Nursing Diagnosis:
Acute pain related to low transverse abdominal incision manifested by verbal report of 3/10 pain scale.
Planning
Short term goals for HF include
a. Client will report understanding of the importance of reporting pain as soon as it starts.
b. Client’s reported 3/10 pain score will decrease to at least 2/10 and maintain at this reported level.
These goals will be measured by client verbalization and will occur by the end of the shift at 1230 or before client discharge on 2/25/08.
The long term goal for HF will be to maintain and report a 2/10 pain level or lower up until, upon, and beyond reassessment on 2/27/08.
Intervention
1. Assess FH’s understanding of the pain scale and the importance of reporting pain as soon as it starts. Pain is subjective and is more readily controlled when treated early, so this intervention promotes client understanding and compliance (Newfield, 2007, p. 487).
2. Monitor for pain at least every 2 hours or per facility policy using appropriate pain scale and behavior assessment. Only the patient can fully describe their pain, so this intervention is necessary to address pain or discomfort. Teach the patient to report pain at the onset, allowing the patient to describe the pain in detail to include aggravating factors, relieving factors, and type of pain. This intervention is essential because pain is more effectively controlled the earlier it is treated (p. 487).
3. Monitor vital signs at least every 4 hours while awake. This intervention detects early changes that might indicate pain (p. 492).
4. Provide information for pain relief such as Kegel exercises, sitz baths, or medications. This intervention provides options for the patient and nurse to consider in developing the most appropriate pain relief (p. 492).
5. Explain the etiology of “afterbirth pains” and involution of the uterus. This intervention provides an explanation of a possible source of discomfort and increases the patient’s sense of control and understanding (p. 492).
6. Administer pain medication, such as Motrin, as prescribed. Reassess and document amount of pain relief within 30 minutes after administration. This intervention is important to relieve pain and evaluate effectiveness of medication (p. 492).
7. Provide calm, quiet environment. This intervention promotes action and effect of medication by providing decreased stimuli (p. 492).
Evaluation of Specific Client
Short term goals:
Short term goals for HF include
a. Client will report understanding of the importance of reporting pain as soon as it starts.
b. Client’s reported 3/10 pain score will decrease to at least 2/10 and maintain at this reported level.
These goals were evaluated before client discharge at 1030 on 2/25/08. The client reported understanding the importance of reporting pain at the onset. Motrin was administered with good effect for reported 3/10 pain. Upon reassessment, 20 minutes after initial assessment, pain decreased to reported 1/10 pain.
The long term goal for HF will be to maintain and report a 2/10 pain level or lower up until, upon, and beyond reassessment on 2/27/08. Evaluation of this goal is set for 2/27/08 at 1030. The client has shown understanding of the importance of reporting pain at onset and she successfully met the short term goal designed to help her with understanding and eventual attainment of the desired outcome.
3rd Priority Nursing Diagnosis:
Risk for constipation related to
a. Decreased frequency of defecation after operative delivery.
b. PMH of chronic constipation.
Planning
Short term goals for HF include
a. Client will verbalize understanding of the risks of constipation.
b. Client will verbalize understanding of colace and increased fiber and water, and how these help with softening the stool and increasing the frequency of defecation.
Understanding of these goals will be measured by client verbalization and will occur by the end of the shift at 1230 or before client discharge on 2/25/08.
The long term goal for HF will be for her to defecate within 3 – 5 days postpartum and to call provider if constipation persists after 5 days postpartum. The appropriate outcome is for HF to return to normal bowel evacuation pattern for her. According to Smith (2006), “A normal and healthy bowel pattern is different for everyone. One person might have a bowel movement every three days, while another person might have more than one bowel movement every day…Generally, it is unhealthy to have your bowels open less frequently than 3 times per week or more than 3 times per day” (p. 1)
Intervention
1. Assess FH’s bowel pattern and her knowledge about bowel pattern and constipation (Wissman, 2006, p. 669). This intervention provides basis for teaching the client a plan of self-care at home and promotes the healing process (Newfield, 2007, p. 245).
2. Provide education about the changes present in the immediate postpartum period that affect the GI tract, including: Decreased abdominal muscle tone; fluid loss from perspiration, urine, lochia, dehydration during Labor and Delivery; and hunger (p. 245). This educational intervention provides a basis for teaching the client plan of self-care at home and to promote healing process (p. 245).
3. Assist in planning a high fiber, increased water diet (pp. 245-246). This intervention promotes healing, replaces lost fluids, and helps with the return to HF’s personal normal bowel evacuation pattern. This diet will promote successful lactation, good nutrition, good self-care, and will help with bowel stimulation (p.245). Administer or encourage prune juice, hot liquids, high fiber, high roughage diet and daily exercise (p. 246). This dietary intervention promotes good nutrition, bowel stimulation, and helps CF return to her normal bowel evacuation pattern (p. 245).
4. Administer Colace (ducosate sodium) as ordered (Wissman, 2006, p. 672). This medication intervention will soften the stool by increasing the amount of water the stool absorbs in the gut; thereby making it less strenuous to pass (Lilley, 2005, p. 866).
Evaluation of Specific Client
Short term goals, including
a. Client will verbalize understanding of the risks of constipation.
b. Client will verbalize understanding of colace and increased fiber and water, and how these help with softening the stool and increasing the frequency of defecation.
These goals were evaluated before client discharge at 1030 on 2/25/08. The client verbalized that she understood the risks of constipation. HF also verbalized her understanding of colace and increased fiber and water.
The long term goal for HF is to defecate within 3 – 5 days postpartum and to call provider if constipation persists after 5 days postpartum. Evaluation of this goal is set for 2/27/08 at 1030. The client has made some progress toward this goal: HF is adhering to dietary and medication suggestions which will promote outcome achievement, and she successfully met the short term goal designed to help her with understanding and eventual attainment of the desired outcome.
References
Heffner, Linda J. MD PhD. (2004). Advanced Maternal Age – How Old Is Too Old? New England Journal of Medicine, 351, 1927-1929.
Lilley, L., S. Harrington, and J. Snyder. (2005). Pharmacology and the Nursing Process. St. Louis: Mosby. p. 866.
Newfield, Susan A., et. al. (2007). Cox’s Clinical Applications of Nursing Diagnosis. Philadelphia: F.A. Davis Company. pp. 240-247.
Smith, J.J. (2006). Fibre and fluids. pp. 1-1. Retrieved April 12, 2008, from www.surginet.org/uk/patients/fibre.php.
Staff, Mayo Clinic. (2008). Fever. Infectious Disease. Mayo Foundation for Medical Education and Research. pp. 1-1. Retrieved April 12, 2008, from http://mayoclinic.com/health/fever/DS00077/DSECTION=3#
Wissmann, Jeanne PhD, RN, CNE (Ed.). (2006). Adult Medical Surgical Nursing. Overland Park, KS: Assessment Technologies Institute, LLC. pp. 669-673.
Wissmann, Jeanne PhD, RN, CNE (Ed.). (2007). Maternal Newborn Nursing. Overland Park, KS: Assessment Technologies Institute, LLC. pp. 216-218.
SOME BACHELOR'S WORK
FINAL SCHOLARLY RESEARCH PAPER FOR NURSING 622: CLINICAL DECISION MAKING II
Running head: TEMPERATURE
Temperature Measurement: What is the “Gold Standard?”
Kevin Michael Kenney, SN-UNH
PICO Paper, NURS 622
Professor Raelene Shippee-Rice, Ph.D., RN
University of New Hampshire
20 April 2008
I. Issue
The ideas and questions that fuel the main thrust of this paper evolved from questions developed in a previously written essay. In this essay, I described a clinical situation that involved me, my patient, the primary nurse, and my instructor. This particular shift, I was assigned a two-month-old child admitted for dehydration and an upper respiratory infection. The primary nurse asked me to take a rectal temperature with my assessment, and I hesitated; I had read that rectal thermometers can damage the sensitive tissue of the rectum and I felt that I was not adequately experienced in this area, especially with a two-month-old child. I told the nurse that I wasn’t familiar with the intervention and that I would watch her do it so I could learn. She responded with aversion because I wasn’t comfortable doing a rectal temperature on an infant, “as a junior nursing student.”
II. Clinical Bottom Line
A faculty member explained that UNH nursing students are not supposed to do rectal temperatures because of the risk involved with damaging sensitive rectal tissue. During the next scheduled set of vitals for the patient in discussion, I used the temporal artery scan method and got exactly the same temperature that the primary nurse attained rectally. What did that finding mean, if anything? Would this occurrence become significant upon further exploration? How dangerous is rectal thermometry? Before researching these questions, I predicted that the overall evidence would prove that rectal thermometry was clinically unnecessary and unsafe. I wasn’t aware of it then, but the questions I asked myself would evolve into the basis of this paper.
III. Case and clinical question
I was interested in finding research evidence that showed the best practice standard for rectal temperatures versus other assessment methods, and this paper offered me the appropriate medium to appease my own curiosity and hopefully provide useful information for my peers and other members of the practicing community. So, the question remains: Is rectal thermometry the most clinically appropriate method of temperature measurement in the Pediatric setting? This paper will analyze five different routes of temperature attainment used in the clinical setting: Rectal, tympanic, axillary, oral, and temporal. Each method of thermometry will be described in brief to preface the body of the paper.
IV. Search and Studies
To find the articles for this paper, I explored many different databases and found applicable articles from sources including CINHAL, PubMed, EBSCOhost, Medline, Sage Premier, and Ovid. To illustrate one example of my strategy for finding articles, I will explain how I found Dew’s (2006) article, Is Tympanic membrane thermometry the best method for recording temperature in children?: First, I logged on to the University of New Hampshire Library website (library.unh.edu), then dropped down the “Library quick find” field and opened the “Databases” web page. From there I clicked on the “Health/Medicine/Sports” section and scrolled down to find the Sage Premier database. In Sage Premier, I typed, “Tympanic Membrane Thermometry” into the search box and selected the full text version of Dew’s article, Is Tympanic membrane thermometry the best method for recording temperature in children?, from the results list. I used similar search strategies for all eight retrieved articles, using search terms such as: Rectal temperature, rectal thermometry, temporal thermometry, axillary temperature, temperature measurement, pediatric, and children. After reviewing the eight retrieved articles, six were included in my paper and two were discarded due to deviation from relevant material.
V. Overview of temperature assessment
Rectal temperatures are taken with a rectal thermometer or probe which is usually designated with a red tip or cap (Altman, 2004, p. 36). The thermometer or probe is lubricated then inserted ½ inch into the anus for newborns, ¾ inch for infants, and 1 inch for preschoolers and older children (Potts, 2007, p. 390) and held in place for 2 minutes to obtain a reading (Altman, 2004, p. 37). Rectal thermometry is an invasive measurement (Moran, 2002, p. 882) but is the most accurate for children of all ages (Potts, 2007, p. 389) and is considered the “gold standard” for obtaining core (deep tissue) temperatures (Wilshaw, et al., 1999, p. 88).
Tympanic temperatures are taken with a Tympanic infrared thermometer which uses a sensor probe inserted into the opening of the ear canal. The infrared sensor measures the amount of infrared heat produced by the tympanic membrane (Dew, 2006, pp. 96-97) and usually provides a result within two seconds (Altman, 2004, p. 33). According to Dew, tympanic thermometry is indicated because temperature within the hypothalamus is accepted as the most accurate measure of core temperature and the tympanic membrane shares its blood supply with the hypothalamus. Although the tympanic membrane supposedly reflects core body temperature, Dew also describes literature that points out possible inaccuracy of this method because the sensor reads heat from the external rather than the internal carotid artery (p. 97).
Axillary temperature is attained by placing a thermometer within the center of the child’s axilla for about six to eight minutes (Altman, 2004, p. 37). Axillary thermometry reflects “shell temperature” (Lanham, 1999, p. 2) and is only accurate when placed directly over the axillary artery (Dew, 2006, p. 98). Dew explains that accurate placement of the axillary thermometer is usually unfeasible with children and the placement times are impractical (p. 98).
Oral temperature readings are obtained with an oral thermometer placed in the sublingual pocket of the child’s mouth for between one and ten minutes. Temperature readings can be affected by beverages, mouth breathing, or tachypnea (p. 98) and smoking; potentially applicable to the adolescent pediatric population (Moran, 2002, p. 881). Similar to problems with the axillary method, Dew finds a potential unfeasibility with the placement location and result times of the oral thermometer in children (p. 98).
Finally, temperatures are obtained with a temporal thermometer by assessing the temporal artery. The thermometer is scanned over the temporal artery, producing a result almost instantly. Temporal thermometry provides a relatively new and non-invasive method of temperature assessment that is tolerated well by infants (Greenes & Fleisher, 2001, p. 2).
VI. Evidence
Why is discovering the most appropriate method of temperature assessment important? Why should healthcare providers care about answers to the questions posed in this paper? In, A Comparison of the Use of Tympanic, Axillary, and Rectal Thermometers in Infants, authors Russell Wilshaw, et.al. provide a concise answer to “why” these questions matter. The authors (1999) write, “If a tympanic…or axilla thermometer demonstrates an ability to be as precise, rapid, safer, easier, and cleaner than a rectal thermometer, it would benefit clients, families, and nurses who assess infants” (p. 89). So, are these alternate methods more beneficial to clients, families and the nurses who assess infants? In, Is Tympanic membrane thermometry the best method for recording temperature in children, author Paula L. Dew provides some answers to this question.
In her research, Dew included an analysis of children’s (client’s), parents’, and nurses’ preferences regarding tympanic versus rectal thermometry. Dew (2006) found that 79.4 percent of parents preferred tympanic versus rectal temperature assessment, and 88 percent of nurses preferred the tympanic approach (pp. 104-105). Although the results are less specific, Dew reports that tympanic thermometry was the preferred method in children older than six years of age. Dew explains the importance of considering the children’s preferences regarding thermometry methods, but this is only one of many factors to consider when choosing the appropriate intervention for these children. Families and nurses may be content with the tympanic method, but the purpose of this paper is to decide what is best from all angles of the dynamic patient.
In Accuracy of a Noninvasive Temporal Artery Thermometer for Use in Infants, Greenes and Fleisher (2001) compare temperature assessments using temporal, tympanic, and rectal thermometers. Based on their linear regression analysis of the relationship between temporal and rectal temperatures, the authors write that “neither tympanic nor [temporal] temperature was equivalent to rectal temperature” (pp. 376-381). When comparing temporal with tympanic methods, the authors explain that temporal thermometry is significantly more accurate than tympanic thermometry and significantly more sensitive at detecting rectal fever in infants. However, Greenes and Fleisher report that the temporal thermometer failed to detect 35 percent of rectal fever cases and 6 percent of high-grade rectal fever cases. The authors conclude that “rectal thermometry should still be considered the preferred method for temperature measurement in infants” (pp. 376-381). While this study further solidified the existing acceptance of the rectal temperature as the “gold standard,” (Wilshaw, et al., 1999, p. 88) the authors created a hierarchy of clinically appropriate temperature measurement interventions: The most accurate method is still rectal thermometry, followed by temporal, and then tympanic.
Based on her research, Dew (2006) concluded that “tympanic thermometry provides the best means of measuring temperature in children aged two months to 16 years both in and out of hospital…” (p. 106). Since the hypothalamus is considered the most accurate measure of core temperature, and the tympanic membrane shares its blood supply with the hypothalamus, Dew argues that a tympanic temperature most accurately reflects core body temperature (p. 97). Dew explains that rectal thermometry was withdrawn from general pediatric use because of emotional distress and the possibility of rectal perforation (p. 98). The author also considers sexual abuse litigation as a factor and highlights the idea that “we live in an era of increasing litigation” (p. 107). Dew positions herself as a clear opponent to rectal thermometry by writing, “future research should not include this method” (p. 107).
In, Axillary and rectal temperature measurements in infants, Morley, et al. address the issue of rectal perforation related to rectal thermometry with a powerful statistic: Morley (1992) writes, “…Perforation has occurred in less than one in two million measurements. If an infant’s temperature needs to be taken, rectal temperature should be used” (p. 122). The authors (1992) explain that there have been twenty cases of infant rectal perforation reported in the last thirty years and all cases occurred in neonates. Morley, et al. stress that after reviewing the literature, they conclude that the complication of rectal perforation has been “over-emphasized” and is too rare to be banned (p. 124). Considering Morley’s findings, it appears that Dew’s (2006) rectal perforation angle might warrant reconsideration.
Morley, et al. (1992) provides two evidence-based reasons for why rectal temperature is the more precise measurement of body temperature. First, the authors explain that the higher temperature is more likely to reflect actual body temperature when compared to a lower temperature; and they found rectal temperatures to be higher than axillary temperatures in 917 out of 938 (98%) of the babies included in the study. Second, rectal temperature was a more precise measurement than axillary as evidenced by having a smaller standard deviation than axillary temperature (p. 123).
VII. Comments
Based on analysis and evaluation of six scholarly studies chosen for review, the most clinically appropriate method for assessing temperature in pediatric patients (and the answer to the original question) is through rectal thermometry. In, A Comparison of the Use of Tympanic, Axillary, and Rectal Thermometers in Infants, Wilshaw, et al. explain that “nurses need to know that speed and convenience do not necessarily mean accuracy when dealing with febrile infants” (p. 93). Greenes and Fleisher (2001) report the inaccuracy and inadequacy of axillary, supralingual, tympanic, and temporal thermometry, but also mention the disadvantages of rectal thermometry, including: Patient discomfort, emotional upset for the patient and parent, risk for injury and transmission of stool-borne pathogens.
Research is needed to establish additional clinically appropriate methods of temperature measurement for future practice. Greenes and Fleisher conclude that “a continued need exists for a form of thermometry that is as well tolerated as the tympanic technique but gives results that closely agree with rectal temperature” (pp. 376-381). The outcome of this paper is significant because while clarifying the accuracy of rectal temperatures, it also reveals the need for a more comfortable approach. As nurses, we need to blend comfort with accuracy because we are responsible for every element of the patient.
VIII. References
Altman, Gaylene B. (2004). Delmar’s Fundamental and Advanced Nursing Skills. New York: Thomson Delmar Learning. pp. 29- 42.
Dew, Paula L. RN, DipHE(Child), BSc(Hons). (2006). Is Tympanic membrane thermometry the best method for recording temperature in children? Journal of Child Health Care, 0(96): pp. 96-110. Greenes, David S. MD, Gary R. Fleisher, MD. (2001). Accuracy of a Noninvasive Temporal Artery Thermometer for Use in Infants. Archives of Pediatrics & Adolescent Medicine, 155(3): pp. 376-381.
Lanham, DM, B. Walker, E. Klocke, and M. Jennings. (1999). Accuracy of Tympanic Temperature Readings in Children Under 6 Years of Age. Pediatric Nursing, 25(1): pp. 39-42.
Moran, Daniel S., and Liran Mendal. (2002). Core Temperature Measurement: Methods and Current Insights. Sports Medicine, 32(14): pp. 879-885.
Morley, CJ, PH Hewson, AJ Thornton, and TJ Cole. (1992). Axillary and rectal temperature measurements in infants. Archives of Disease in Childhood, 67: pp. 122-125.
Potts, Nicki L., and Barbara L. Mandleco (2007). Pediatric Nursing: Caring for Children and Their Families. New York: Thomson Delmar Learning. pp. 389-391.
Wilshaw, Russell RN, MS, CEN, Renea Beckstrand, RN, MS, CCRN, Dawn Waid, RN, BSN, and G. Bruce Schaalje, PhD. (1999). A Comparison of the Use of Tympanic, Axillary, and Rectal Thermometers in Infants. Journal of Pediatric Nursing, 14(2): pp. 88-93.
FINAL SCHOLARLY RESEARCH PAPER FOR NURSING 622: CLINICAL DECISION MAKING II
Running head: TEMPERATURE
Temperature Measurement: What is the “Gold Standard?”
Kevin Michael Kenney, SN-UNH
PICO Paper, NURS 622
Professor Raelene Shippee-Rice, Ph.D., RN
University of New Hampshire
20 April 2008
I. Issue
The ideas and questions that fuel the main thrust of this paper evolved from questions developed in a previously written essay. In this essay, I described a clinical situation that involved me, my patient, the primary nurse, and my instructor. This particular shift, I was assigned a two-month-old child admitted for dehydration and an upper respiratory infection. The primary nurse asked me to take a rectal temperature with my assessment, and I hesitated; I had read that rectal thermometers can damage the sensitive tissue of the rectum and I felt that I was not adequately experienced in this area, especially with a two-month-old child. I told the nurse that I wasn’t familiar with the intervention and that I would watch her do it so I could learn. She responded with aversion because I wasn’t comfortable doing a rectal temperature on an infant, “as a junior nursing student.”
II. Clinical Bottom Line
A faculty member explained that UNH nursing students are not supposed to do rectal temperatures because of the risk involved with damaging sensitive rectal tissue. During the next scheduled set of vitals for the patient in discussion, I used the temporal artery scan method and got exactly the same temperature that the primary nurse attained rectally. What did that finding mean, if anything? Would this occurrence become significant upon further exploration? How dangerous is rectal thermometry? Before researching these questions, I predicted that the overall evidence would prove that rectal thermometry was clinically unnecessary and unsafe. I wasn’t aware of it then, but the questions I asked myself would evolve into the basis of this paper.
III. Case and clinical question
I was interested in finding research evidence that showed the best practice standard for rectal temperatures versus other assessment methods, and this paper offered me the appropriate medium to appease my own curiosity and hopefully provide useful information for my peers and other members of the practicing community. So, the question remains: Is rectal thermometry the most clinically appropriate method of temperature measurement in the Pediatric setting? This paper will analyze five different routes of temperature attainment used in the clinical setting: Rectal, tympanic, axillary, oral, and temporal. Each method of thermometry will be described in brief to preface the body of the paper.
IV. Search and Studies
To find the articles for this paper, I explored many different databases and found applicable articles from sources including CINHAL, PubMed, EBSCOhost, Medline, Sage Premier, and Ovid. To illustrate one example of my strategy for finding articles, I will explain how I found Dew’s (2006) article, Is Tympanic membrane thermometry the best method for recording temperature in children?: First, I logged on to the University of New Hampshire Library website (library.unh.edu), then dropped down the “Library quick find” field and opened the “Databases” web page. From there I clicked on the “Health/Medicine/Sports” section and scrolled down to find the Sage Premier database. In Sage Premier, I typed, “Tympanic Membrane Thermometry” into the search box and selected the full text version of Dew’s article, Is Tympanic membrane thermometry the best method for recording temperature in children?, from the results list. I used similar search strategies for all eight retrieved articles, using search terms such as: Rectal temperature, rectal thermometry, temporal thermometry, axillary temperature, temperature measurement, pediatric, and children. After reviewing the eight retrieved articles, six were included in my paper and two were discarded due to deviation from relevant material.
V. Overview of temperature assessment
Rectal temperatures are taken with a rectal thermometer or probe which is usually designated with a red tip or cap (Altman, 2004, p. 36). The thermometer or probe is lubricated then inserted ½ inch into the anus for newborns, ¾ inch for infants, and 1 inch for preschoolers and older children (Potts, 2007, p. 390) and held in place for 2 minutes to obtain a reading (Altman, 2004, p. 37). Rectal thermometry is an invasive measurement (Moran, 2002, p. 882) but is the most accurate for children of all ages (Potts, 2007, p. 389) and is considered the “gold standard” for obtaining core (deep tissue) temperatures (Wilshaw, et al., 1999, p. 88).
Tympanic temperatures are taken with a Tympanic infrared thermometer which uses a sensor probe inserted into the opening of the ear canal. The infrared sensor measures the amount of infrared heat produced by the tympanic membrane (Dew, 2006, pp. 96-97) and usually provides a result within two seconds (Altman, 2004, p. 33). According to Dew, tympanic thermometry is indicated because temperature within the hypothalamus is accepted as the most accurate measure of core temperature and the tympanic membrane shares its blood supply with the hypothalamus. Although the tympanic membrane supposedly reflects core body temperature, Dew also describes literature that points out possible inaccuracy of this method because the sensor reads heat from the external rather than the internal carotid artery (p. 97).
Axillary temperature is attained by placing a thermometer within the center of the child’s axilla for about six to eight minutes (Altman, 2004, p. 37). Axillary thermometry reflects “shell temperature” (Lanham, 1999, p. 2) and is only accurate when placed directly over the axillary artery (Dew, 2006, p. 98). Dew explains that accurate placement of the axillary thermometer is usually unfeasible with children and the placement times are impractical (p. 98).
Oral temperature readings are obtained with an oral thermometer placed in the sublingual pocket of the child’s mouth for between one and ten minutes. Temperature readings can be affected by beverages, mouth breathing, or tachypnea (p. 98) and smoking; potentially applicable to the adolescent pediatric population (Moran, 2002, p. 881). Similar to problems with the axillary method, Dew finds a potential unfeasibility with the placement location and result times of the oral thermometer in children (p. 98).
Finally, temperatures are obtained with a temporal thermometer by assessing the temporal artery. The thermometer is scanned over the temporal artery, producing a result almost instantly. Temporal thermometry provides a relatively new and non-invasive method of temperature assessment that is tolerated well by infants (Greenes & Fleisher, 2001, p. 2).
VI. Evidence
Why is discovering the most appropriate method of temperature assessment important? Why should healthcare providers care about answers to the questions posed in this paper? In, A Comparison of the Use of Tympanic, Axillary, and Rectal Thermometers in Infants, authors Russell Wilshaw, et.al. provide a concise answer to “why” these questions matter. The authors (1999) write, “If a tympanic…or axilla thermometer demonstrates an ability to be as precise, rapid, safer, easier, and cleaner than a rectal thermometer, it would benefit clients, families, and nurses who assess infants” (p. 89). So, are these alternate methods more beneficial to clients, families and the nurses who assess infants? In, Is Tympanic membrane thermometry the best method for recording temperature in children, author Paula L. Dew provides some answers to this question.
In her research, Dew included an analysis of children’s (client’s), parents’, and nurses’ preferences regarding tympanic versus rectal thermometry. Dew (2006) found that 79.4 percent of parents preferred tympanic versus rectal temperature assessment, and 88 percent of nurses preferred the tympanic approach (pp. 104-105). Although the results are less specific, Dew reports that tympanic thermometry was the preferred method in children older than six years of age. Dew explains the importance of considering the children’s preferences regarding thermometry methods, but this is only one of many factors to consider when choosing the appropriate intervention for these children. Families and nurses may be content with the tympanic method, but the purpose of this paper is to decide what is best from all angles of the dynamic patient.
In Accuracy of a Noninvasive Temporal Artery Thermometer for Use in Infants, Greenes and Fleisher (2001) compare temperature assessments using temporal, tympanic, and rectal thermometers. Based on their linear regression analysis of the relationship between temporal and rectal temperatures, the authors write that “neither tympanic nor [temporal] temperature was equivalent to rectal temperature” (pp. 376-381). When comparing temporal with tympanic methods, the authors explain that temporal thermometry is significantly more accurate than tympanic thermometry and significantly more sensitive at detecting rectal fever in infants. However, Greenes and Fleisher report that the temporal thermometer failed to detect 35 percent of rectal fever cases and 6 percent of high-grade rectal fever cases. The authors conclude that “rectal thermometry should still be considered the preferred method for temperature measurement in infants” (pp. 376-381). While this study further solidified the existing acceptance of the rectal temperature as the “gold standard,” (Wilshaw, et al., 1999, p. 88) the authors created a hierarchy of clinically appropriate temperature measurement interventions: The most accurate method is still rectal thermometry, followed by temporal, and then tympanic.
Based on her research, Dew (2006) concluded that “tympanic thermometry provides the best means of measuring temperature in children aged two months to 16 years both in and out of hospital…” (p. 106). Since the hypothalamus is considered the most accurate measure of core temperature, and the tympanic membrane shares its blood supply with the hypothalamus, Dew argues that a tympanic temperature most accurately reflects core body temperature (p. 97). Dew explains that rectal thermometry was withdrawn from general pediatric use because of emotional distress and the possibility of rectal perforation (p. 98). The author also considers sexual abuse litigation as a factor and highlights the idea that “we live in an era of increasing litigation” (p. 107). Dew positions herself as a clear opponent to rectal thermometry by writing, “future research should not include this method” (p. 107).
In, Axillary and rectal temperature measurements in infants, Morley, et al. address the issue of rectal perforation related to rectal thermometry with a powerful statistic: Morley (1992) writes, “…Perforation has occurred in less than one in two million measurements. If an infant’s temperature needs to be taken, rectal temperature should be used” (p. 122). The authors (1992) explain that there have been twenty cases of infant rectal perforation reported in the last thirty years and all cases occurred in neonates. Morley, et al. stress that after reviewing the literature, they conclude that the complication of rectal perforation has been “over-emphasized” and is too rare to be banned (p. 124). Considering Morley’s findings, it appears that Dew’s (2006) rectal perforation angle might warrant reconsideration.
Morley, et al. (1992) provides two evidence-based reasons for why rectal temperature is the more precise measurement of body temperature. First, the authors explain that the higher temperature is more likely to reflect actual body temperature when compared to a lower temperature; and they found rectal temperatures to be higher than axillary temperatures in 917 out of 938 (98%) of the babies included in the study. Second, rectal temperature was a more precise measurement than axillary as evidenced by having a smaller standard deviation than axillary temperature (p. 123).
VII. Comments
Based on analysis and evaluation of six scholarly studies chosen for review, the most clinically appropriate method for assessing temperature in pediatric patients (and the answer to the original question) is through rectal thermometry. In, A Comparison of the Use of Tympanic, Axillary, and Rectal Thermometers in Infants, Wilshaw, et al. explain that “nurses need to know that speed and convenience do not necessarily mean accuracy when dealing with febrile infants” (p. 93). Greenes and Fleisher (2001) report the inaccuracy and inadequacy of axillary, supralingual, tympanic, and temporal thermometry, but also mention the disadvantages of rectal thermometry, including: Patient discomfort, emotional upset for the patient and parent, risk for injury and transmission of stool-borne pathogens.
Research is needed to establish additional clinically appropriate methods of temperature measurement for future practice. Greenes and Fleisher conclude that “a continued need exists for a form of thermometry that is as well tolerated as the tympanic technique but gives results that closely agree with rectal temperature” (pp. 376-381). The outcome of this paper is significant because while clarifying the accuracy of rectal temperatures, it also reveals the need for a more comfortable approach. As nurses, we need to blend comfort with accuracy because we are responsible for every element of the patient.
VIII. References
Altman, Gaylene B. (2004). Delmar’s Fundamental and Advanced Nursing Skills. New York: Thomson Delmar Learning. pp. 29- 42.
Dew, Paula L. RN, DipHE(Child), BSc(Hons). (2006). Is Tympanic membrane thermometry the best method for recording temperature in children? Journal of Child Health Care, 0(96): pp. 96-110. Greenes, David S. MD, Gary R. Fleisher, MD. (2001). Accuracy of a Noninvasive Temporal Artery Thermometer for Use in Infants. Archives of Pediatrics & Adolescent Medicine, 155(3): pp. 376-381.
Lanham, DM, B. Walker, E. Klocke, and M. Jennings. (1999). Accuracy of Tympanic Temperature Readings in Children Under 6 Years of Age. Pediatric Nursing, 25(1): pp. 39-42.
Moran, Daniel S., and Liran Mendal. (2002). Core Temperature Measurement: Methods and Current Insights. Sports Medicine, 32(14): pp. 879-885.
Morley, CJ, PH Hewson, AJ Thornton, and TJ Cole. (1992). Axillary and rectal temperature measurements in infants. Archives of Disease in Childhood, 67: pp. 122-125.
Potts, Nicki L., and Barbara L. Mandleco (2007). Pediatric Nursing: Caring for Children and Their Families. New York: Thomson Delmar Learning. pp. 389-391.
Wilshaw, Russell RN, MS, CEN, Renea Beckstrand, RN, MS, CCRN, Dawn Waid, RN, BSN, and G. Bruce Schaalje, PhD. (1999). A Comparison of the Use of Tympanic, Axillary, and Rectal Thermometers in Infants. Journal of Pediatric Nursing, 14(2): pp. 88-93.
CLINICAL DECISION MAKING PAPER
Decision Analysis II
This particular situation involved me and my patient, “AG,” in OB clinical on 14 April 2008 at Concord hospital. AG is a 31year-old, PPD3 mother who gave birth to a healthy baby boy via primary Cesarean section procedure on 11 April 2008. We were planning on discharging AG sometime around noon. AG’s history (Hx) includes: Fibroids on her uterus, abnormal Pap smear, STDs, and family Hx of cystic fibrosis. There were no medical complications of AG’s pregnancy and no neonatal complications at birth. On 14 April 2008, AG presents with a clean, dry, well-approximated low transverse abdominal incision with staples intact from the primary C-section procedure.
I was just beginning my postpartum assessment of AG when the doctor came in to remove the staples from AG’s low transverse abdominal incision and I stopped what I was doing to observe the procedure. After removing the staples, the doctor had me feel the fibroids on CG’s uterus, which were all easily palpable. We noted that the client’s uterus was firm, and about four fingerbreadths (cm) above the umbilicus. The doctor explained to me and our patient how this finding was appropriate with a client presenting with fibroids.
When the doctor left, I resumed my assessment of AG. I palpated her fundus and noted, again, that the fundus was firm and four fingerbreadths above the umbilicus. I was content with my finding of a firm fundus, but not satisfied with the fundal height; even considering her fibroids. The fundal height is supposed to descend to the level of the umbilicus immediately postpartum, and only ascend about about 1-2cm after 12hrs, then descend 1cm each postpartum day until it reaches halfway between the symphysis pubis and umbilicus by the sixth postpartum day. Since my client was on her third postpartum day, she should be no higher than the level of umbilicus, which is a recurrent finding in my experiences in the clinical setting (Wissman, 2007, p.273).
At this point, I made a decision based my own personal knowledge and experience gained from teachers and other resources. I remember learning about one simple primary nursing intervention to implement upon palpating a fundus that is too high: Ask the client to empty her bladder. If the uterus is not descending appropriately (manifested by assessing an inappropriate fundal height), especially in combination with a boggy fundus, this can be an indication of uterine atony and risk for hemorrhage. However, before “jumping to conclusions,” I was taught to think about step one: Ask the client to urinate. A full bladder can displace the uterus and alter the fundal height upon assessment. So, with this in mind, I asked my client to urinate. I came back 15 minutes later and reassessed the fundal height which had descended a significant four centimeters to the appropriate level of umbilicus.
If I was faced with this situation again, I might have suggested the possibility of a full bladder affecting my client’s fundal height during the doctor’s assessment. My patient’s fibroids might have played a role in her fundal height, but a full bladder definitely played a central role. When I reflect on the fact that the doctor never explained the link between the client’s full bladder and her uterus; only focusing on the fibroids, it seems that the doctor overlooked a simple intervention.
I used a combination of clinical decision making, problem solving, judgment, and clinical reasoning to reach my decision and deal with the presented issue. It was an incredible feeling to connect theory with practice in the clinical setting and see it “work out” with a real patient. The primary nurse commended me on being able to connect the “pieces” and make that kind of a decision as a young nursing student. She informed Kim (my clinical instructor) about the decision that I had made based on my assessment findings and Kim was pleased. In retrospect, I am happy with my decision and thankful to my teachers.
References
Wissmann, Jeanne PhD, RN, CNE (Ed.). (2007). Maternal Newborn Nursing. Overland Park, KS: Assessment Technologies Institute, LLC. pp. 270-274.
Decision Analysis II
This particular situation involved me and my patient, “AG,” in OB clinical on 14 April 2008 at Concord hospital. AG is a 31year-old, PPD3 mother who gave birth to a healthy baby boy via primary Cesarean section procedure on 11 April 2008. We were planning on discharging AG sometime around noon. AG’s history (Hx) includes: Fibroids on her uterus, abnormal Pap smear, STDs, and family Hx of cystic fibrosis. There were no medical complications of AG’s pregnancy and no neonatal complications at birth. On 14 April 2008, AG presents with a clean, dry, well-approximated low transverse abdominal incision with staples intact from the primary C-section procedure.
I was just beginning my postpartum assessment of AG when the doctor came in to remove the staples from AG’s low transverse abdominal incision and I stopped what I was doing to observe the procedure. After removing the staples, the doctor had me feel the fibroids on CG’s uterus, which were all easily palpable. We noted that the client’s uterus was firm, and about four fingerbreadths (cm) above the umbilicus. The doctor explained to me and our patient how this finding was appropriate with a client presenting with fibroids.
When the doctor left, I resumed my assessment of AG. I palpated her fundus and noted, again, that the fundus was firm and four fingerbreadths above the umbilicus. I was content with my finding of a firm fundus, but not satisfied with the fundal height; even considering her fibroids. The fundal height is supposed to descend to the level of the umbilicus immediately postpartum, and only ascend about about 1-2cm after 12hrs, then descend 1cm each postpartum day until it reaches halfway between the symphysis pubis and umbilicus by the sixth postpartum day. Since my client was on her third postpartum day, she should be no higher than the level of umbilicus, which is a recurrent finding in my experiences in the clinical setting (Wissman, 2007, p.273).
At this point, I made a decision based my own personal knowledge and experience gained from teachers and other resources. I remember learning about one simple primary nursing intervention to implement upon palpating a fundus that is too high: Ask the client to empty her bladder. If the uterus is not descending appropriately (manifested by assessing an inappropriate fundal height), especially in combination with a boggy fundus, this can be an indication of uterine atony and risk for hemorrhage. However, before “jumping to conclusions,” I was taught to think about step one: Ask the client to urinate. A full bladder can displace the uterus and alter the fundal height upon assessment. So, with this in mind, I asked my client to urinate. I came back 15 minutes later and reassessed the fundal height which had descended a significant four centimeters to the appropriate level of umbilicus.
If I was faced with this situation again, I might have suggested the possibility of a full bladder affecting my client’s fundal height during the doctor’s assessment. My patient’s fibroids might have played a role in her fundal height, but a full bladder definitely played a central role. When I reflect on the fact that the doctor never explained the link between the client’s full bladder and her uterus; only focusing on the fibroids, it seems that the doctor overlooked a simple intervention.
I used a combination of clinical decision making, problem solving, judgment, and clinical reasoning to reach my decision and deal with the presented issue. It was an incredible feeling to connect theory with practice in the clinical setting and see it “work out” with a real patient. The primary nurse commended me on being able to connect the “pieces” and make that kind of a decision as a young nursing student. She informed Kim (my clinical instructor) about the decision that I had made based on my assessment findings and Kim was pleased. In retrospect, I am happy with my decision and thankful to my teachers.
References
Wissmann, Jeanne PhD, RN, CNE (Ed.). (2007). Maternal Newborn Nursing. Overland Park, KS: Assessment Technologies Institute, LLC. pp. 270-274.
Sunday, October 29, 2006
Nursing Philosophy, etc...
Any profession comes with a certain level of responsibility, but nursing comes with one of the highest. According to recent Gallup polls, nursing is considered the number one most trusted profession in the United States. Obviously, this is a high standard to maintain.
Being a professional "anything" usually means that your position in society is one deserving of respect. This respect comes from the fact that your position was gained through some kind of hard work, usually some education, and the possession of some kind of skill or skills that set you apart from others. For example, not everyone can become a professional baseball player, mountain climber, musician, or chef; and not everyone can become a professional nurse. Part of being a professional nurse means that this nurse has been well-educated and is fully competent and skilled in his/her practice. I think that in the eyes of the public, professionals should be trustworthy. The word, "professional" may have a nice ring to it and provide a certain level of importance and confidence, but carrying this word as part of your title is also an enormous responsibility. Professional nurses are respected, but with respect comes the responsibility to consistently provide the best quality care, worthy of "professional" status. If a waiter serves the wrong order, the guest might be upset with his meal. If a professional nurse gives his patient the wrong medication, or the wrong amount of medication, that client's health is in jeopardy. A professional nurse is trustworthy, competent, intelligent, confident, empathetic, and accountable.
Nurses can develop a sense of commitment and meaning to the nursing profession fairly easily - in my opinion. My Dad told me that one of the best things about being a nurse is how he is treated by patients and their families. Everybody is usually so grateful, and this can really create a deep sense of meaning. You go to work and you are needed - literally NEEDED - for human lives. This can bring a tremendous amount of pressure, but it can also give you a deep sense of purpose in the nursing profession.
Health is a relative term. A measurement of health is different for everybody depending on the circumstances; there is no standard of health that applies to everybody. I believe health refers to the mind, body and soul of a person. Nursing, in theory, deals with every aspect of an individual; nurses don't just see patients as an organization of cells interacting with the environment, but rather a complex, dynamic individual with layers upon layers of factors worthy of consideration.
Obviously, the patient or "client" is the nurse's number one responsibility. But when you think about it, everybody in society is a client. If the nurse really believes in helping people, he/she will know that this is not limited to a bedside. A nurse can educate families of patients, the public, and his/her own families about pertinent issues to improve and protect their health. I am also my own client, because I will definitely use my nursing education to benefit my own health and well-being.
A little more about me:
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