AMERICAN NURSE O FFICIAL J OURNAL An Publication July 2020 Volume 15 • Number 7 MyAmericanNurse.com Bedside mobility assessment tool Palliative care FAQs Mindfulness for medication safety Learning to let go CNEJoin the Challenge! CONNECT. ENGAGE. CHALLENGE YOURSELF! HNHN.ORG #HEALTHYNURSEMyAmericanNurse.com July 2020 American Nurse Journal 1 Editor-in-Chief Lillee Smith Gelinas, MSN, RN, CPPS, FAAN Senior Fellow and Nurse Executive, Institute for Patient Safety University of North Texas Health Science Center, Fort Worth, Tex. Editorial Board AMERICAN NURSE O FFICIAL J OURNAL Editorial mission: American Nurse Journal is dedicated to integrating the art and science of nursing. It provides a voice for today’s nurses in all specialties and practice settings. As the official journal of the American Nurses Associ- ation, it serves as an important and influential voice for nurses across the country. The journal is committed to de- livering authoritative research translated into practical, evidence-based literature and relevant content to keep nurses up-to-date on best practices, help them maximize patient outcomes, advance their careers, and enhance their pro- fessional and personal growth and fulfillment. E DITOR E MERITUS Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN Research Associate Professor Sadie Heath Cabaniss Professor and Dean University of Virginia School of Nursing Charlottesville, VA Jose Alejandro, PhD, RN-BC, MBA, CCM, FACHE, FAAN President (2018-2020), Case Management Society of America 12th President (2012-2014), National Association of Hispanic Nurses Director, Care Management, UC Irvine Health Orange, CA Danielle (Dani) Bowie, DNP, RN, NE-BC Vice President of Nursing Workforce Development Bon Secours Mercy Health Cincinnati, OH Thomas R. Clancy, PhD, MBA, RN, FAAN Clinical Professor, School of Nursing University of Minnesota Minneapolis Danette Culver, MSN, APRN, ACNS-BC, CCRN-K, RN-BC Clinical Nurse Specialist Norton Healthcare Louisville, KY Amina Dubuisson, MSN, MBA/HCM, RN, LNHA Vice President of Clinical Services Ventura Services Florida Fort Lauderdale, FL Michael L. Evans, PhD, RN, NEA-BC, FACHE, FAAN Dean and Professor Texas Tech University Health Sciences Center School of Nursing Lubbock, TX Margaret A. Fitzgerald, DNP, APRN, BC, NP-C, FAANP, CSP President, Fitzgerald Health Education Associates, Inc. North Andover, Mass. FNP, Adjunct Faculty, Family Practice Residency Greater Lawrence Family Health Center, Inc. Greater Lawrence, MA Melissa A. Fitzpatrick, MSN, RN, FAAN President Kirby Bates Associates and Tyler & Company Chapel Hill, NC Christine Hedges, PhD, RN, NE-BC Adjunct Assistant Professor UNC School of Nursing Chapel Hill, NC Tiffany Kelley, PhD, MBA, RN-BC DeLuca Foundation Visiting Professor for Innovation & New Knowledge UCONN School of Nursing Storrs, CT Founder/CEO Nightingale Apps & iCare Nursing Solutions Boston, MA Linda J. Knodel MHA, MSN, NE-BC, CPHQ, FACHE, FAAN Senior Vice President/Chief Nurse Executive Kaiser Permanente Oakland, CA Eileen T. Lake, PhD, RN, FAAN Jessie M. Scott Endowed Term Chair in Nursing and Health Policy Professor of Nursing and Sociology Associate Director, Center for Health Outcomes and Policy Research University of Pennsylvania School of Nursing Philadelphia Norma M. Lang, PhD, RN, FRCN, FAAN Professor and Dean Emeritus School of Nursing University of Pennsylvania, Philadelphia Wisconsin Regent Distinguished Professor and Aurora Professor of Health Care Quality and Informatics Professor Emerita College of Nursing University of Wisconsin, Milwaukee Tina Marrelli, MSN, MA, RN, FAAN Marrelli and Associates, Inc. Health Care Consultants and Publishers e-Caregiving Solutions Venice, FL Bernadette Mazurek Melnyk, PhD, RN, CRNP, FAANP, FNAP, FAAN Vice President for Health Promotion University Chief Wellness Officer Dean and Professor, College of Nursing Professor of Pediatrics & Psychiatry, College of Medicine The Ohio State University Columbus Sally Miller, PhD, APRN, FNP-BC, AGACNP-BC, AGPCNP- BC, PMHNP-BC, FAANP Associate Professor, Associate Dean for Graduate Affairs University of Nevada Las Vegas Las Vegas, NV Jack Needleman, PhD, FAAN Fred W. and Pamela K. Wasserman Professor Chair, Department of Health Policy and Management UCLA Fielding School of Public Health Los Angeles Christine Pabico, MSN, RN, NE-BC Director, Pathway to Excellence Program American Nurses Credentialing Center Silver Spring, MD Rebecca M. Patton, DNP, RN, CNOR, FAAN Former President, American Nurses Association Lucy Jo Atkinson Professorship in Perioperative Nursing Frances Payne Bolton School of Nursing at Case Western Reserve University Cleveland, OH Mark Pelletier MS, RN Chief Operating Officer Chief Nurse Executive The Joint Commission Oakbrook Terrace, IL Joseph Potts, MSN, RN Assistant Nurse Manager, Resource Pool Northeast Georgia Medical Center Gainesville, GA Staci Reynolds PhD, RN, ACNS-BC, CCRN, CNRN, SCRN Assistant Clinical Professor/DANCE Coordinator Duke University School of Nursing Infection Prevention Clinical Nurse Specialist Duke University Hospital Durham, NC Stephanie Schulte, MLIS Associate Professor, Health Sciences Library The Ohio State University, Health Sciences Library Columbus Franklin A. Shaffer, EdD, RN, FAAN Chief Executive Officer CGFNS International Philadelphia, PA Roy L. Simpson, DNP, RN, DPNAP, FAAN, FACMI Clinical Professor, Assistant Dean for Technology Management Nell Hodgson Woodruff School of Nursing Emory University Atlanta, GA Marla J. Weston, PhD, RN, FAAN CEO Weston Consulting, LLC Washington, DC July 2020 • Volume 15 • Number 7 MyAmericanNurse.com Editorial Staff Editor-in-Chief Lillee Smith Gelinas, MSN, RN, FAAN Executive Editor, Professional Outreach Leah Curtin, RN, ScD(h), FAAN Editorial Director Cynthia Saver, MS, RN Managing Editor Julie Cullen Copy Editor Jane Benner Publishing Staff Group Publisher Gregory P. Osborne Executive Vice President Steve Ennen Director of Professional Partnerships Tyra London Associate Publisher John J. Travaline Account Managers Mary Chris Schueren, Cara Sosnoski 215-489-7000 Production Director Christian Evans Gartley Art Director David Beverage Designer Christy Carmody American Nurses Association Staff Joan Hurwitz Vice President, Communications Susa McCutcheon Editorial Director, Communications Susan Trossman, RN Writer-Editor, Communications P UBLISHED BY HealthCom Media 259 Veterans Lane, Doylestown, PA 18901 Telephone: 215-489-7000 www.healthcommedia.com Chief Executive Officer Gregory P. Osborne Executive Vice President Steve Ennen Finance Director/Operations MaryAnn Fosbenner Business Manager Jennifer Felzer Director of Marketing John Grdinich Project Manager Meredith Haywood Website Developer Brian Jones Digital Content Editor Lydia L. Kim Database Administrator Parvathi Bellamkonda Editorial Intern Riley Kleemeier American Nurse Journal is the official journal of the American Nurses Association, 8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910-3492; 800-274-4ANA. The journal is owned and published by HealthCom Media. American Nurse Journal is peer reviewed. The views and opinions expressed in the editorial and advertising material in this issue are those of the authors and advertisers and do not necessarily reflect the opinions or recommendations of the ANA, the Editorial Advi- sory Board members, or the Publisher, Editors, and staff of American Nurse Journal. American Nurse Journal attempts to select authors who are knowledgeable in their fields. However, it does not warrant the expertise of any author, nor is it responsible for any statements made by any author. Certain statements about the uses, dosages, efficacy, and characteristics of some drugs mentioned here reflect the opinions or investigational experience of the au- thors. Nurses should not use any procedures, medications, or other courses of diagnosis or treatment discussed or suggested by authors without evaluating the patient’s conditions and pos- sible contraindications or dangers in use, reviewing any appli- cable manufacturer’s prescribing or usage information, and comparing these with recommendations of other authorities. Edited, designed, & printed in the USA AMERICAN NURSE O FFICIAL J OURNAL 2 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com 4 Editorial By Lillee Gelinas, Editor-in-Chief Take time to appreciate yourself and your colleagues every day. 6 CNE Frequently asked questions about palliative care By Kaveri M. Roy Learn how to serve as a leader as patients and families navigate serious illness. 18 The Bedside Mobility Assessment Tool 2.0 By Teresa Boynton, Dee Kumpar, and Catherine VanGilder Use this tool to identify patient mobility function deficits and guide the healthcare team in selecting equipment to safely move patients. W EB EXCLUSIVE ! Preventing postoperative pulmonary complications By Cindy Paradiso Implementing ERAS and I COUGH protocols can help increase successful surgical outcomes. myamericannurse.com/?p=67027 R APID R ESPONSE 12 Stroke: Act FAST By Alysia D. Adams Quick symptom identification and action ensures timely therapy. W EB EXCLUSIVE ! Lead toxicity in children By Shermaine Payne, Myriam Jean Cadet, and Kenya Harris This case study demonstrates the assessment, diagnosis, and treatment of lead toxicity. myamericannurse.com/?p=67254 W EB EXCLUSIVE ! Be alert for Kawasaki disease By Beth McVey Your strong assessment skills may be the key to early diagnosis. myamericannurse.com/?p=66960 W EB EXCLUSIVE ! Drugs and devices today Access an update of drug news, including alerts, approvals, and removals, at myamericannurse.com/ article-type/drugs-and-devices 14 Year of the Nurse By Ernest J. Grant Nursing’s perspective and knowledge is critical during the current pandemic and to how we move forward. American Nurse Journal (ISSN 1930-5583 [print], ISSN 2162-8629 [online]) is published monthly by HealthCom Media, Lantern Hill Business Park, 259 Veterans Lane, Suite 201, Doylestown, PA 18901. Printed in the U.S.A. Copyright © 2020 by HealthCom Media. All rights re- served. No part of this publication may be reproduced, stored, or transmitted in any form or by any means, elec- tronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without per- mission in writing from the copyright holder. Periodicals Postage paid at Doylestown, PA and additional offices. Postmaster: Send address changes to American Nurse Journal, Lantern Hill Business Park, 259 Veterans Lane, Suite 201, Doylestown, PA 18901. Subscription information: Annual subscriptions: $49.00 U.S.; $59.00 Canada; $71.00 outside U.S./Canada. Single copies: $7 U.S.; $15 outside U.S. Institutional subscriptions available by request. Digital-only subscription: $14.97. Reprints and back issues: Contact Chris Evans Gartley (Pro- duction Director) at 215-489-7000 or production@healthcom media.com. Availability may be limited. July 2020 • Volume 15 • Number 7 MyAmericanNurse.com STRICTLY CLINICAL FEATURES EDITORIAL PRACTICE MATTERS 4036 COVID-19 resilience and recovery By Kendra McMillan Now is the time to advocate for a healthcare system that’s safe, equitable, and better prepared for emergent issues. F ROM W HERE I S TAND 40 Claiming our rights By Leah Curtin The concept of human rights comes alive when it’s applied to specific people and situations. W EB EXCLUSIVE ! What works: Assessing and addressing care management education and competency By Diane DiFiore Find out how this onboarding program helps reduce turnover, increase staff morale, and improve care. myamericannurse.com/?p=67066 W EB EXCLUSIVE ! Take note Access a round-up of clinical and practice news and alerts at myamericannurse.com/article-type/take-note- practice-updates/. 27 Learn about the top issues facing ANA member nurses, how ANA is working for you, and what ANA is doing to advance nursing. F EATURE ARTICLE : Conflict management 37 Nurse preceptors and new graduate success By Kelly Powers, Julie Pagel, and Elizabeth K. Herron Preceptors can help facilitate new nurses’ transition into the workplace and improve their clinical 15 Leadership challenge: Learning to let go By Rose O. Sherman and Tanya M. Cohn Don’t let what happened in the past hinder your future success. 23 Lean on me Tari Dilks, DNP, APRN, PMHNP-BC, FAANP, president of the American Psychiatric Nurses Association, talks about the mental health challenges faced by nurses during the pandemic. 24 Mindfulness for medication safety By Marianne L. Durham Slow down, take a deep breath, and focus on the task at hand. MyAmericanNurse.com July 2020 American Nurse Journal 3 Subscription Questions? Christian Evans Gartley, Production Director 215.489.7004 cevansgartley@healthcommedia.com Change in Mailing Information? To change your subscription information online, send re- quest to Christian Evans Gartley, Production Director, at cevansgartley@healthcommedia.com Indexing American Nurse Journal is indexed in the Cumulative Index to Nursing and Allied Health Literature. Submit an Article Please email Cynthia Saver, MS, RN, at csaver@health commedia.com . 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July 2020 American Nurse Journal 27 ANA ON THE FRONTLINE NEWS FROM THE AMERICAN NURSES ASSOCIATION nn Conflict management for stronger teams C OMING NEXT MONTH •Asthma education for pediatric patients •Improving self-management of hypertension in older adults •Palliative care for heart failure patients ANA ON THE FRONTLINE LEADING THE WAY HEALTHY NURSE LIFE AT WORKAnother thought on The Year of the Nurse: Everyday appreciation Value yourself and your colleagues every day of the year. Y EAR OF THE N URSE is well under way, but the COVID-19 crisis has swiftly created an even greater recognition of nurses and oth- er healthcare providers as “heroes”—make that “everyday heroes.” The news reports of the outpouring of gratitude for what care- givers are doing and sacrificing on the frontlines to fight this pandemic made me stop and realize that International Nurses Day, National Nurses Month, and the World Health Organiza- tion’s “2020—The Year of the Nurse and the Midwife” aren’t the only ways to rec- ognize nurses. Per- haps COVID-19 has given us a wake-up call for another kind of appreciation. In previous edi- torials, I’ve written about issues our pro - fession constantly tack- les, such as speaking out against bullying, recognizing each other as professionals, treat- ing each other with respect, and functioning as a team. Add avoiding negative circum- stances and colleagues and creating healthier work environments to the list. Across all of these issues, a “bell curve” spans the range of what I call “mutual appreciation.” On the right side of the curve, you find high levels of mutual respect and collegiality; on the left are colleagues who behave as if they’re iso- lated and not part of a larger nursing commu- nity. I propose we eliminate the bell curve. I’d like us to develop an “everyday appre- ciation” campaign that includes each and every one of us. It starts right here with the American Nurse Journal. We are nurses. We are at the center of healthcare delivery. We are the professionals who “nurse” our communi- ties back to health. We perform a vital role, and we shouldn’t need a pandemic to recog- nize that fact. Yes, we’re teammates with other professionals, such as physicians and other care delivery staff, but nurses are the fulcrum around which most other care is delivered and coordinated. Nursing is a profession still in flux, but this is a time when we need to become clearer about our path, our role, and our value. Nurs- es are the hub of the care wheel in most set- tings, and we’re the foundation of caregiving. So let’s celebrate and recognize each other every day—not just on a day, a week, a month, or a year—to strengthen the cohesiveness of our professional identity and the overall fab- ric of the nursing community. What can you do to develop an “everyday appreciation” for our importance and value? How can we appreciate each other no matter who we are, what role we play, and what disease we’re helping to fight? Let’s find ways to take the Year of the Nurse and extend that global recognition into an “everyday appreci- ation” in your unit, your department, your clinic, or wherever you work. Let’s start to- day! Lillee Gelinas, MSN, RN, CPPS, FAAN Editor-in-Chief EDITORIAL 4 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com6 American Nurse Journal Volume 15, Number 7 MyAmericanNurse.com P ALLIATIVE CARE MEASURES for patients with serious or end-stage illnesses can be confus- ing and lack clarity. Typically, patient care goals focus on curative measures, and pa- tients and families may not be familiar with palliative care. To complicate matters, pa- tients, families, and even providers frequently associate palliative care with imminent death and “giving up.” However, when we under- stand the effects of a disease, its interven- tions, and know patients’ care goals, we can be better patient advocates across the spec- trum of care. We can serve as nurse leaders on an interprofessional team to manage pa- tient and family care and help patients and their loved ones cope with the disease process. Here we address some commonly asked palliative care questions. What is the biggest issue for patients with serious or end-stage illness? Managing symptoms and side effects of the disease process and its treatment typically is the primary goal of patients who are serious- ly ill or dying. Palliative care focuses on im- proving patient quality of life and is available to all patients with a serious or end-stage ill- ness, whether or not they’re receiving cura- tive treatment. According to the American Nurses Associa- tion’s Call for Action: Nurses Lead and Trans- form Palliative Care, all nurses should be pre- pared to provide primary palliative care ac- cording to the eight domains outlined by the National Consensus Project for Quality Pallia- tive Care. (See 8 domains of palliative care.) What are the most common signs and symptoms, and how are they treated pharmacologically? Patients may experience signs and symptoms related to disease progression, treatment, or both. Common physical symptoms are pain, dyspnea, nausea, anorexia/cachexia, and con- stipation. Nurses also should assess patients for psychological and spiritual symptoms, such as delirium, anxiety, and spiritual unrest. Even if patients are unconscious or sleep- ing, symptoms such as pain, anxiety, and dys- pnea don’t abate. In unconscious patients, signs and symptoms may manifest as brow furrowing, clenched teeth, vocalizations, and tachycardia. Medications must be continued for patient comfort. Pain Patients can have somatic, visceral, and neu- rologic pain, or a combination. Mild pain can be treated with acetaminophen or non - steroidal anti-inflammatory drugs (NSAIDs), and moderate pain with hydrocodone, oxy- codone, acetaminophen, and NSAIDs. Severe somatic or visceral pain typically is treated with opioids, starting with an oral low-dose medication, such as morphine (2.5 to 5 mg every 6 hours), and slowly titrating based on the patient’s pain level. With severe or end- stage illness, pain likely will progress. Re- assess the patient’s pain level frequently. If the patient is using p.r.n. pain medication fre- quently, a long-acting medication (such as MS Contin) may be ordered. Continuous I.V. or subcutaneous opioid infusions may be or- dered for severe pain. Hydromorphone and hydrocodone can be used p.r.n. for breakthrough pain, but multiple types of opioids should not be used concur- rently. Using a consistent p.r.n. or break- through medication is important when titrating long-acting medication because the amount of Frequently asked questions about palliative care L EARNING O BJECTIVES 1.Discuss pharmacologic strategies for relieving distress in patients with seri- ous to end-stage illness. 2.Discuss nonpharmacologic strategies for relieving distress in patients with serious to end-stage illness. 3.Identify the stages of death. The author and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. See the last page of the article to learn how to earn CNE credit. Expiration: 7/1/23 CNE 1.5 contact hours Nurses can serve as leaders as they help patients and families through a difficult time. By Kaveri M. Roy, DNP, RNMyAmericanNurse.com July 2020 American Nurse Journal 7 p.r.n. medication taken within 24 hours can be used to start or adjust long-acting medications. Using a consistent p.r.n. medication also can prevent adverse effects. Fentanyl patches can be used for long-acting pain management, but be cautious; patches can’t easily be titrated, and the patient must have a sufficient amount of subcutaneous fat for the medication to be effective. Patients who are thin or emaciated run the risk of absorbing the medication too quickly. For patients with neurologic pain, adju- vants such as gabapentin, tricyclic antidepres- sants, or low-dose methadone may be ordered. Methadone is considered effective for neuro- logic pain and builds up to a stable concentra- tion in the blood, functioning as a long-acting medication. Note that as methadone builds to a therapeutic concentration, faster-acting med- ications for pain control must be used and titrated down as the methadone takes effect. Dyspnea Dyspnea is a common end-of-life symptom. Typically, it’s associated with lung and heart diseases, such as chronic obstructive pul- monary disease (COPD), lung cancer, and chronic heart failure (CHF). Patients with end- stage lung disease will require oxygen. Adding bronchodilators and steroids can help relieve chest constriction and lessen dyspnea. Low-dose opioids (such as morphine) also re- lieve dyspnea, but the exact mechanism of ac- tion is unknown. Continuous opioid infusions also can be given for severe dyspnea. To address the anxiety that may accompa- ny dyspnea, the provider may order an anxi- olytic such as a short-acting benzodiazepine (for example, lorazepam and alprazolam) to control dyspnea or prevent it from worsening. If a patient is dyspneic but not hypoxic, which occurs with cancer and some other disease pro - cesses, oxygen may not help manage symptoms. For CHF exacerbation, the provider may order oral, subcutaneous, or I.V. diuretics (for example, furosemide) to drain excess fluid and help ease breathing. Oxygen and opioids also may help reduce dyspnea for patients with CHF, and nitroglycerin will decrease car- diac preload and afterload. Many patients have both CHF and COPD. A complete assessment will help determine which condition is exacerbated and which symptoms to treat. Nausea Different disease processes (such as a bowel obstruction) and treatments (such as chemo - therapy) can cause nausea and vomiting. As- sessing the cause of the nausea will determine the best antiemetic treatment. If the nausea is chemotherapy-related, sero- tonin 5HT3 antagonists, such as ondansetron, work well. However, after treatment ends, ondansetron won’t work as well. The best antiemetic agent for patients with end-stage disease is haloperidol, which blocks the dop - a mine receptors and decreases nausea. If nausea and vomiting are related to con- stipation or a partial bowel obstruction, a pro- kinetic agent (such as metoclopramide) may be ordered. Metoclopramide will cause GI muscle contraction and decrease gastric emp- tying time, propelling gastric contents forward and relieving a partial obstruction. However, it shouldn’t be used if the patient has a com- plete bowel obstruction; the obstruction must be removed. If that isn’t possible, I.V. oc- treotide, which increases gastric emptying time and inhibits gastric hormones, may be used to relieve intractable vomiting. Anorexia/cachexia Loss of appetite and weight loss are distress- ing symptoms for patients and their families. Patients may not feel like eating because of nausea, medications, or disease complica- tions, and it can be hard for both patients and The National Consensus Project for Quality Palliative Care outlines eight domains of care, which are supported by the American Nurses Association. 1 Structure and processes of care. Providing care via an interpro- fessional team based on the patient’s and family’s care goals 2 Physical aspects of care. Treating physical symptoms, such as pain and nausea 3 Psychological aspects of care. Treating psychological symptoms, such as anxiety and depression 4 Social aspects of care. Assessing caregivers, family, friends, social network; communicating prognosis 5 Spiritual aspects of care. Assessing spiritual or religious beliefs, hopes, and fears 6 Cultural aspects of care. Assessing customs, language, and belief systems 7 Care of patients at the end of life. Recognizing imminent death, be- ing present, and educating patient and family about what to expect 8 Ethical and legal aspects of care. Identifying healthcare proxies and using advance directives 8 domains of palliative careNext >