12/9/05   Issue XLV  850-477-1234   Toll Free 866-CDI-NURSE
Making A Difference
Build a levy to withstand a
tempest-$30 billion.  To loose
countless lives and property -
Prevention is always the better
course.  Sometimes it will take time,
energy and even some money, but in
the end it pays off.  It seems the
government isn’t the only ones who
need to be reminded.  Last year
approximately 45,000 feet were
amputated in the US due to Diabetes.  
Eighty-five percent of these human
catastrophes were preventable
according to an American Diabetes
Association study.  Another study by
Dr. Bakker showed that only 14.1% of
health care professionals examined
their diabetic patient’s feet!
Our patients watch us like hawks.  If it
is something we can skip, they will as
well, with horrific affect.   Even worse,  
our colleagues watch us as well and
modify their practices.  If they are the
only ones doing something, very soon
they stop.  This one shortcut balloons
into something that causes incredible
misery year after year.  We are taught
to do the whole job, we hold
ourselves to this standard for more
than one reason.  
Skipping foot exams on diabetics -
38,250 amputations.
Practicing what we are taught-
Kids Care Program
A training program run out
of Children’s Hosp. of
Philadelphia shows some
information and promising
results.  Based on surveys
done with family and staff,
the researchers found
many differences. One was
the family’s desire to feel
that the care giver cared
about their child, whereas
the caregivers were of the
mind that the family was
most interested in the child’
s medical care. They came
up with some behaviors
that could apply to patient
care everywhere.  Knock,
introduce yourself.  
Determine who the people
at the beside are and how
they would like to be
addressed.  Check to see if
the room and patient are
The percent of students graduating
high school addicted to cigarettes.

A Full Boeing 747
The number of people who die each
day from lung cancer, equal to a full
jumbo jet crashing and killing all
Retinas At Risk
New evidence by Dr. Hamman shows
that the human retina is incredibly
sensitive to even small elevations in
blood sugar.  In his study he found
nearly 8% of patients with
(fasting blood glucose of 100 to
125mg/dL)already had clinically
detectable retinopathy.
Zap V.A.P.   
Ventilator-associated Pneumonia is
now the second most common cause
of nosocomial infection in the U.S.  
CDC recommends a ventilated patient’
s head of  bed be elevated 30-45
degrees.  In a study by the NIH, the
average backrest elevation among all
patients was 22 degrees.  When
patients without signs of pneumonia
were tracked, 26% would develop V.A.
P. by day four, 31% by day seven. The
study suggests that if the patient is
hemodynamically stable, raise the HOB
to at least 30 degrees.

Big 3 Causes Of Cardiac Arrest
Dysrhythmias (49%)
Acute respiratory insufficiency (37%)
Hypotension (32%)
safe.  Wash your hands.  
Remember you’re an
advocate for the patient.  
Make sure the family
knows how they can
reach you on the floor.  
Explain what is going on,
procedures etc.  These
are behaviors that show
you care, common sense
items, but with
uncommon results.
Look Beyond The
When your patient with
Dementia repeats a
question, he may not
really be asking when
dinner is, but may be
trying to tell you he is
9/9/05   Issue XLVI  850-477-1234   Toll Free 866-CDI-NURSE
Making a Difference
A moment of silence for those in our lives who have
steered us on to the right path.  Whether teachers,
coworkers, family, or neighbors people who cared
enough to take a moment of their lives to enrich
ours.  None of us takes this journey through life
alone. We live in a interdependent world,
depending on each other, to do what we are
supposed to do. There are special souls who go
beyond this, who are able to see where we are
going astray and set us right.   Doing so is rarely
easy for them, nor done at no cost, many times
angering or embarrassing us and incurring a hot
glare or worse.  To all those saints, a moment of
A new national survey done by the American
Association of Critical Care Nurses and Vital Smarts
with 1,700 respondents shows less than 10% of
clinicians would challenge a colleague making a
patient care error.
How easy it is to mind your own business, and in
the crush of life, with all we have on our plates, to
look the other way, and let a poorly prepared
colleague fail.  You hardly have time for the extra
work load you already have.  After all,
administration has been made aware of the
problem.  They know what your nurse patient ratios
are.  They were made aware of this clinician’s short
comings.  What did they think it would come to?
As nurses, we are empowered to preserve a
patients life, their liberty, and any hope of future
happiness they might have.  Rarely in this world is
so much power entrusted to a single person.  It has
evolved that way because of formal education,
testing, special training and an unbelievable track
record of caring.  We are on a path to destroy what
generations of nurses before us have given so
much to achieve.  We must decide to change this
path.  All change is self change and it begins with
each of us now.  We must look over each others
shoulders, we must correct errors, we must take up
the pen to follow through

with the appropriate measures needed
to retrain, or remove, a coworker who
is a danger.  It is in your hands that
your practice will live or die, as all our
reputations are painted with the same
brush.  JFK was to give a speech the
day he was shot.  In it he was to say,
“We ask that we may be worthy of our
power and responsibility, that we may
exercise our strength with wisdom.”
A moment of silence for those good
souls who steer us on to the right
7 Neonatal Deaths Per
10-11 thousand neonatal
deaths a day. According
to a four part series in
the Lancet, ¾’s of them
are unnecessary and
preventable.  Two thirds
of the est. 4 million
annual deaths occur in
India, Africa, the Far East,
and Afghanistan.  The
study concluded that
most of the
deaths could have been
avoided using 16 simple
measures including
tetanus shots, access to
antibiotics, breastfeeding
education, and sanitary
delivery rooms. Take a
moment and give Doctors
Without Borders a call 1-
888-392-0392. Pledge a
couple of bucks and get
on their mailing list.  The
impact of who you are
and what you do grows
by the day.  You do make
a difference.

Is Administration Blind?
The problem with administration is
that they still see you and your
profession through the lens of 150
years of pillow fluffing and sheet
straightening.  When approached
about needing a more qualified nurse,
it doesn’t seem possible to them. The
nursing role they envision could  be
taught to anyone.  How could
someone responsible for wise
spending of the budget, spend money
on finding a nurse when we already
have one in place?  They do not see
missing assessment skill sets, the
blank stare of the nurse who cannot
read an EKG let alone interpret that
the pacemaker is no longer capturing.  
The fetus put at risk because the
nurse was clue less as to what the
strip was telling her.  The nurse who
charts her patient was
hyperventilating but couldn’t interpret
the ABG’s showing a pH of 6.90.  
Giving the paper bag to the patient
was a fatal mistake.      
6/9/05   Issue XLIII    850-477-1234   Toll Free 866-CDI-NURSE
Making a Difference
“We are over budget.” Have you heard this one
before?  Who sets these budgets?   How come they  
always run out before the end of the fiscal year?  How
can there not be money for basic things such as
staffing and equipment?  You can already answer
some of these questions and add some insights of
your own.  Budgets divide up the pie of expected
income within a business.  Believe it…today’s hospitals
are big businesses.  To help in this process every
supervisor must submit a budget, their supervisors
submit a department budget, and so it goes on up
the line.  The numbers are staggering, and usually  
run far over  the expected income for the year.  
Priorities are assigned, overhead is trimmed to the
slimmest amount possible, and those priorities are
fought over at every level.  This year, expect
emergency generators, back up water supplies and
other storm related needs to be on the list.  Where is
the nurse in this budget? You and I are overhead.  
Our budget is considered a cost to be cut to the
barest minimum.  We are not a priority project / pet
program, nor the golden child who will reap the
budget windfall this year.  We are overhead.  Will
budget cuts be part of your future? …You know it.  If
one picks up the corporate cost cutting text written by
Bob Fifer, and turns to chapter 15 titled CUT COSTS
FIRST, ASK QUESTIONS LATER, you will read “…we
must put the burden of proof on the organization on
spending money… the comforting thing is if you do
make a mistake , somebody will tell you.”  In chapter
17, the text teaches administrators  “ Some
employees write me concise, convincing arguments  
for why they need the money, and I approve those
These requests are fairly rare.”  Note:
through training and education on the budgetary
administration’s bias is to cut budgets,  preserve
capital, and maximize savings first. Only when a
concise, convincing argument can be made to spend
the money, do they add it back.   Armed with this
knowledge, there is no excuse for anyone in nursing
to accept that there is no money for their patients’
needs.  It is up to you to sit down and write objective,
concise, patient centered convincing arguments as to
why your department’s money needs to be added to
the budget.  This should first be peer reviewed;  no
letter is perfect the first time.  Get input from others,
ask them to sleep on it and jot down ideas that you
may have over looked.  Sit down and rewrite the letter
and submit it to your supervisor.  Then follow up on
it.  “We are over budget” is no longer the last word.  
We now know better.    
CYP3A Does What?
In a recent article in the New England Journal of
Medicine a study links
patients concurrent use of erythromycin and other
drugs that inhibit the enzyme CYP3A, (such as
calcium channel blockers, Nizoral,Tagamet, and
grapefruit juice) as    5 times more likely to
experience sudden death then patients not on a
CYP3A inhibitor.  The reason appears to be that
erythromycin taken orally causes prolonged
cardiac repolarization.  It needs  CYP3A for its
metabolization.  Medications that block the
enzyme further increases the level of the
erythromycin in the system.
Added to the cheat sheet section:
Important research terms: an aid to
understanding research studies.  Added to the
News page, a link to  info on Calif. nurse-patient
Less Than 5%
According to a study by Dr.
Patterson et. al., missing as
little as 5% of HIV medication
doses, in a HIV positive
patient, can result in HIV drug
resistance and subsequent
treatment failure.  These drug
resistant strains of HIV can be
transmitted to others.  In an
article in AJN Vol.104, No.10  
Dr. Enriqez points out that in
1999 almost 80% of HIV
positive patients in the US had
a strain or strains of HIV that
were resistant to one or more
antiretroviral medications.  
As is the case with any patient
that has multiple medications,
setting up a dosage regimen is
complex.  It is not sufficient to
discharge a patient with
instructions to take
medications as ordered.  Many
of these medications must be
taken on a full stomach, others
on an empty stomach.  
Successful treatment regimens
are hinged on overcoming
barriers to adherence before
the antiretroviral therapy
begins.  Take a moment.  Go
over the medication schedule,
know when and why each
medication should be taken.  
Review all this with the patient.  
You can and do make a
Thanks for being a nurse

Douglas Terrell  RN
© Critical Difference Inc. 2005
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