We have all been there. The frustrated parent on the other end of the line is searching for someone to make her child better now. Tomorrow is too late. As you attempt to calm this anxious mother, and gather the necessary information to give an accurate assessment and advice, she becomes angry, and questions why you are asking her "unnecessary questions" when she just wants some straight answers. Does this sound familiar?
Let's pause for a moment, and consider what this parent may be going through.Parents like to be in control of every aspect of their child's life, especially when they are small. Most parents take the charge that is given to them seriously,and therefore,they desire to meet that child's basic needs for food, clothing, shelter, and love, and they continue to want to meet that child's needs when they are sick. Consider for a moment though, illness is the one thing that parents have no control over. They can't just pick that child up, love them, read them a book,rock them to sleep, and make it all go away. If the child has a chronic illness, the parent may have to endure watching their child suffer through hours of pain, tests, and treatments, and that is all they can do is watch. They feel very helpless, and often become angry at themselves, at God, at the physicians, nurses or anyone else who just happens to be there at that moment. They are angry this is happening to them, and to their child, and there is nothing they can do to stop it.
How do you deal with it you ask? It is certainly not an easy task to be the nurse on the other end of that line. It is very easy to become frustrated with the difficult parent, and feel like they are just being belligerent and inconsiderate of the Golden Rule.The best technique is to stop, take a deep breath, and consider some effective communication skills for a more effective outcome.
Even though the non-verbal aspects of communication are minimized when performing a telephone assessment, one study suggests that 85 percent of the telephone interaction is based on "tone of voice" with the remaining 15 percent being the word content.
When we think of communication skills, we often think of speaking, but active listening comes first and is often overlooked.
Let's look at blockers that prevent active listening. Are there environmental distractions? If you are in a call center, is it busy? Is there alot of background noise? Is someone standing in front of you? Is you cell phone going off simultaneously?
Do you have Third Ear Syndrome? Two ears are listening to the patient, but the 3rd ear is listening to the siren outside or to the teenager having a tantrum just outside your room.
Be careful of jumping ahead. We can think at 500 words per minute, we can hear at 300 words per minute, and we speak at 125 to 150 words per minute. It is easy to jump ahead in attempts to be more time efficient.
Be careful of emotional filters. Is the caller the same demanding one that calls about the same issue all the time? Good listeners will avoid the emotional filter unfairly influencing the interaction.
Avoid mental side trips. You are on your fourth call of the day giving out diarrhea advice, and what you are really thinking about is what you want for lunch.
Sometimes, it is easy to deal inappropriately with emotional cues, and instead display blocking behaviors, such as: offering advice and reassurance before the main problem has been identified, explaining away distress as normal, attending to the physical aspects only, switching topics or "jollying" the patient along.
Some more common sense approaches are paying attention, assess the patient's level of knowledge, read between the lines, consider the patient's prospective with empathy, and consider hidden agendas/unspoken requests.
The following are seven speaking principles when triaging a call:
*Smile
*Use the caller's name.
*Reflect back important points
*Incorporate courteous remarks
*Display empathy
*Mirror the patient (using similar vocabulary, if appropriate)
Finally, don't use jargon or abbreviations when speaking, don't mumble, and don't use negative language(eg. "I am sorry the doctor will not go back to the office to see you" versus "The quickest way to be seen would be if you are able to make it to an Urgent Care".
Remember the angry caller? One rule of thumb to always keep in mind is "They don't care what you know, until they know you care".
Friday, June 4, 2010
Monday, May 17, 2010
How To Safely and Effectively Remove A Tick
Through its bite, a tick can transmit the spirochete, virus, rickettsiae, bacteria, and protozoa that cause a wide array of infectious diseases in children, including Lyme disease, Q-fever, ehrlichiosis, babesiosis, Rocky Mountain spotted fever, and tularemia.Some ticks secrete a neurotoxin that produces tick paralysis, with neurologic manifestations and ascending paralysis.
Not all species of tick attach to humans and, of those that do, the likelihood that one will transmit a pathogen depends on its developmental stage and prevalence of infectious pathogens in a particular geographic area. Estimates are that the prevalence of the spirochete responsible for Lyme disease, Borrelia burgdorferi, in the nymphal stage of Ixodes scapularis, the deer tick, in endemic areas of the Northeast and Midwest, is 15% to 30%. (The responsible vector in the western states is I pacificus, a deer and cattle tick.) The likelihood of disease transmission from the bite of an infected tick is only 1% to 3%.A patient who develops a tick-borne disease is unlikely to recall a tick bite—generally because a tick drops off its host after feeding.
Whether any pathogen is transmitted by the bite of a tick is determined by the location of that organism in the tick's gut and the duration of the tick's attachment to its host. A pathogen residing in the salivary glands of the tick will pass to its host more quickly and efficiently than one in the tick's lower gastrointestinal tract. The principal determinant of disease transmission, however, is the duration of the tick's attachment: The longer a tick is attached, the greater the likelihood that the pathogen will transmit to host.
Each pathogen requires a different duration of attachment.3 Transmission of B burgdorferi from an infected deer tick is unlikely with less than 24 hours of attachment, more likely after 48 hours than after 24, and highly likely after 72. Shorter periods of attachment may suffice for an infected tick to transmit Ehrlichia chaffeensis and E ewingii, the pathogens responsible for ehrlichiosis.This research confirming the relationship between duration of attachment and the spread of infectious agents underscores the importance of timely tick removal.
The tick employs several appendages to achieve its tenacious grip on your patient host. On each side of the hypostome—a rod-shaped structure through which the tick sucks blood from the host—are cheliceral digits that painlessly penetrate the host epithelium (see figure). Hundreds of barbs on the outer surface of the hypostome grip the skin like fishhooks as it enters the break in the epithelium. To strengthen its hold, the tick secretes a ring of cement around the cavity, fixing itself in place for a feast. It is while the tick feeds—a meal that can last several days or a week—that pathogens may be transferred to the host. Meal complete, the tick detaches from the patient's epidermis, leaving the cement behind. (Depth of attachment varies by tick; dog ticks, for example, attach superficially, whereas lone star ticks and Ixodes species attach more deeply within the epidermis.
Petroleum jelly? Gasoline? How about angled forceps?
The definitive treatise of tick removal has yet to be published, despite the abundance of anecdotal suggestions in the medical literature.The few randomized trials that have compared removal techniques have significant limitations; most studies used animal models, and others were underpowered.
The primary goal of tick removal is to remove the tick's body, head, mouth and mouth parts, and the cement—anything left in the skin can cause infection and local irritation or lead to a granuloma. The best technique is one that allows you to:
* remove the tick as soon as possible to minimize or interrupt the transfer of infectious material
* prevent the tick from regurgitating infectious material into the patient
* minimize damage or pain to the patient undergoing the procedure.
Techniques to remove an embedded tick employ either mechanical force to pull it out or application of agents such as viscous lidocaine, petroleum jelly, nail polish, isopropyl alcohol, or gasoline that irritate or suffocate the tick and cause it to spontaneously detach. Because a tick breathes at a rate of three to 15 breaths an hour, suffocation methods are rarely effective. Animal studies have demonstrated that irritating the tick with a lighted match, heated nail, or pocketknife—which may burn the child or cause the tick to regurgitate its contents into the host—do not stimulate the tick to detach.Researchers who injected lidocaine and lidocaine with epinephrine below the site of attachment also failed to induce the tick to detach.
Nine steps and a steady hand—surest way to remove a tick
Although no technique will remove completely every tick, one that employs slow, steady traction applied at the point of attachment is more likely to remove the tick intact with the cement.One such method is described in "Nine steps and a steady hand—surest way to remove a tick." Success depends on the type of tick, its developmental stage, and depth of attachment. Note that nymphs that penetrate deeply are less likely to be removed intact by any method.
Experts recommend a blunt, medium-tipped, angled mosquito or splinter forceps. (Using your fingers to grasp the tick will force its contents into the host and is less likely to remove the mouth parts and cement.) Any retained mouthparts or cement should be removed promptly with forceps; alternatively, the area can be excised with an 18-gauge needle, as would be done for a splinter.
Commercial devices for tick removal demonstrate varying degrees of utility.One such tool has jaws that allow the operator to grasp the tick at its mouth and then pull it away from the skin. A second tool incorporates a V-shaped notch so that, as the operator slides the tool along the patient's skin, the tick is trapped at the apex and then pulled from the skin. Although these instruments may be as useful as tweezers or forceps for tick removal, they are not commonly found in most offices or hospital emergency departments.
Post-procedure considerations
It is unnecessary to preserve the tick's remains in alcohol because the predictive value of tick analysis has not been defined.Post-exposure prophylaxis with antibiotics also is not recommended, because of, first, the low risk of disease transmission after a tick bite and, second, the risk of adverse effects from doxycycline and the unproven efficacy of amoxicillin for prophylaxis.Consider prophylaxis, however, in a patient who has multiple tick bites or if a tick's attachment is known to have lasted at least 72 hours. Counsel parents to monitor the child for signs and symptoms of infection.
Parents and child may need to be reminded that avoiding tick bites is key to avoiding Lyme and other tick-borne diseases, and that avoidance can be achieved by simple measures:
* Wear long pants in areas where tick exposure is likely, and tuck pant legs into socks to ward off the immature ticks on the ground and on low growth.
* Inspect the skin, especially the armpit and groin areas, immediately after outdoor activities to detect and remove ticks before transmission can occur.
* If skin exposure is unavoidable, apply an appropriate insect repellent to skin or clothing to protect against tick bites.
Not all species of tick attach to humans and, of those that do, the likelihood that one will transmit a pathogen depends on its developmental stage and prevalence of infectious pathogens in a particular geographic area. Estimates are that the prevalence of the spirochete responsible for Lyme disease, Borrelia burgdorferi, in the nymphal stage of Ixodes scapularis, the deer tick, in endemic areas of the Northeast and Midwest, is 15% to 30%. (The responsible vector in the western states is I pacificus, a deer and cattle tick.) The likelihood of disease transmission from the bite of an infected tick is only 1% to 3%.A patient who develops a tick-borne disease is unlikely to recall a tick bite—generally because a tick drops off its host after feeding.
Whether any pathogen is transmitted by the bite of a tick is determined by the location of that organism in the tick's gut and the duration of the tick's attachment to its host. A pathogen residing in the salivary glands of the tick will pass to its host more quickly and efficiently than one in the tick's lower gastrointestinal tract. The principal determinant of disease transmission, however, is the duration of the tick's attachment: The longer a tick is attached, the greater the likelihood that the pathogen will transmit to host.
Each pathogen requires a different duration of attachment.3 Transmission of B burgdorferi from an infected deer tick is unlikely with less than 24 hours of attachment, more likely after 48 hours than after 24, and highly likely after 72. Shorter periods of attachment may suffice for an infected tick to transmit Ehrlichia chaffeensis and E ewingii, the pathogens responsible for ehrlichiosis.This research confirming the relationship between duration of attachment and the spread of infectious agents underscores the importance of timely tick removal.
The tick employs several appendages to achieve its tenacious grip on your patient host. On each side of the hypostome—a rod-shaped structure through which the tick sucks blood from the host—are cheliceral digits that painlessly penetrate the host epithelium (see figure). Hundreds of barbs on the outer surface of the hypostome grip the skin like fishhooks as it enters the break in the epithelium. To strengthen its hold, the tick secretes a ring of cement around the cavity, fixing itself in place for a feast. It is while the tick feeds—a meal that can last several days or a week—that pathogens may be transferred to the host. Meal complete, the tick detaches from the patient's epidermis, leaving the cement behind. (Depth of attachment varies by tick; dog ticks, for example, attach superficially, whereas lone star ticks and Ixodes species attach more deeply within the epidermis.
Petroleum jelly? Gasoline? How about angled forceps?
The definitive treatise of tick removal has yet to be published, despite the abundance of anecdotal suggestions in the medical literature.The few randomized trials that have compared removal techniques have significant limitations; most studies used animal models, and others were underpowered.
The primary goal of tick removal is to remove the tick's body, head, mouth and mouth parts, and the cement—anything left in the skin can cause infection and local irritation or lead to a granuloma. The best technique is one that allows you to:
* remove the tick as soon as possible to minimize or interrupt the transfer of infectious material
* prevent the tick from regurgitating infectious material into the patient
* minimize damage or pain to the patient undergoing the procedure.
Techniques to remove an embedded tick employ either mechanical force to pull it out or application of agents such as viscous lidocaine, petroleum jelly, nail polish, isopropyl alcohol, or gasoline that irritate or suffocate the tick and cause it to spontaneously detach. Because a tick breathes at a rate of three to 15 breaths an hour, suffocation methods are rarely effective. Animal studies have demonstrated that irritating the tick with a lighted match, heated nail, or pocketknife—which may burn the child or cause the tick to regurgitate its contents into the host—do not stimulate the tick to detach.Researchers who injected lidocaine and lidocaine with epinephrine below the site of attachment also failed to induce the tick to detach.
Nine steps and a steady hand—surest way to remove a tick
Although no technique will remove completely every tick, one that employs slow, steady traction applied at the point of attachment is more likely to remove the tick intact with the cement.One such method is described in "Nine steps and a steady hand—surest way to remove a tick." Success depends on the type of tick, its developmental stage, and depth of attachment. Note that nymphs that penetrate deeply are less likely to be removed intact by any method.
Experts recommend a blunt, medium-tipped, angled mosquito or splinter forceps. (Using your fingers to grasp the tick will force its contents into the host and is less likely to remove the mouth parts and cement.) Any retained mouthparts or cement should be removed promptly with forceps; alternatively, the area can be excised with an 18-gauge needle, as would be done for a splinter.
Commercial devices for tick removal demonstrate varying degrees of utility.One such tool has jaws that allow the operator to grasp the tick at its mouth and then pull it away from the skin. A second tool incorporates a V-shaped notch so that, as the operator slides the tool along the patient's skin, the tick is trapped at the apex and then pulled from the skin. Although these instruments may be as useful as tweezers or forceps for tick removal, they are not commonly found in most offices or hospital emergency departments.
Post-procedure considerations
It is unnecessary to preserve the tick's remains in alcohol because the predictive value of tick analysis has not been defined.Post-exposure prophylaxis with antibiotics also is not recommended, because of, first, the low risk of disease transmission after a tick bite and, second, the risk of adverse effects from doxycycline and the unproven efficacy of amoxicillin for prophylaxis.Consider prophylaxis, however, in a patient who has multiple tick bites or if a tick's attachment is known to have lasted at least 72 hours. Counsel parents to monitor the child for signs and symptoms of infection.
Parents and child may need to be reminded that avoiding tick bites is key to avoiding Lyme and other tick-borne diseases, and that avoidance can be achieved by simple measures:
* Wear long pants in areas where tick exposure is likely, and tuck pant legs into socks to ward off the immature ticks on the ground and on low growth.
* Inspect the skin, especially the armpit and groin areas, immediately after outdoor activities to detect and remove ticks before transmission can occur.
* If skin exposure is unavoidable, apply an appropriate insect repellent to skin or clothing to protect against tick bites.
Wednesday, April 21, 2010
We Appreciate Our Nurses 365 Days A Year
National Nurses Week is coming soon in May. Most facilities and corporations put something together during that week, or maybe just for one day to show their nurses their appreciation. It is obvious however, that nurses give far more to their employers than anything that they could be given in return, monetarily or in any other way.
There are two kinds of people in this world, givers and takers. We nurses surely fit into the giver category. We literally pour ourselves out for others, in caring. How do we do this? How do we give and give and care and care, over and over again? What do we contribute to our community? In my opinion, our greatest “giving” contribution to our community is our children. You might feel this is irrelevant, but consider that most of us are parents or future parents. We realize that loving, teaching, and preparing our next generation of productive citizens is the GREATEST gift we can give to our community. We prepare our children for the joys and struggles that lie ahead for them. The giving and caring starts in our homes where we make parenting a priority and tremendous sacrifices for the family. Let us never forget the mighty work that dedicated parenting is for the community.
Beyond our homes, our attention and energy expands out to our studies and our work. We chose to be givers in this world when we answered that calling into nursing which we hear initially. We endure our rigorous studies and finally achieve that hard-earned goal, our nursing license. When we enter the profession, we are enchanted and enamored by the excitement and challenges, but all too soon the disillusionment sets in. We realize that things aren’t quite like the textbooks explain, and that maybe not every patient always gets the right amount of attention and effort devoted to them that they each deserves.
We realize that time and resources are finite, so we figure out ways to do more with less, and get more mileage out of our day. We learn to multi-task better, to streamline our processes better. We start to skip lunches, forget to drink and hydrate ourselves, and hardly ever make it to the bathroom. We put ourselves aside for the sake of the patients.
Throughout our careers, we CONTINUE to show that we are givers by not only living out our higher calling, but by choosing to stay and remain in our work. Even though we have our fair share of legitimate reasons to abandon ship, ALL of us here haven’t done that. We have CHOSEN NOT to. It’s our decision. It’s our decision to stay. It’s our decision to still care. It’s our decision to continue to endure the sometimes harsh conditions and situations we find ourselves in. The list of ways we show this determination and dedication to our patients is endless.(Christina Feist-Heilmeier, RN, MSN)
Nurse Telephone Triage Service is proud of our nurses, and appreciate the care they give to the patients we serve on a daily basis. For that, we say THANK YOU for your dedication, your hard work, your positive attitude, and your commitment to make NTTS the successful corporation that it is!
There are two kinds of people in this world, givers and takers. We nurses surely fit into the giver category. We literally pour ourselves out for others, in caring. How do we do this? How do we give and give and care and care, over and over again? What do we contribute to our community? In my opinion, our greatest “giving” contribution to our community is our children. You might feel this is irrelevant, but consider that most of us are parents or future parents. We realize that loving, teaching, and preparing our next generation of productive citizens is the GREATEST gift we can give to our community. We prepare our children for the joys and struggles that lie ahead for them. The giving and caring starts in our homes where we make parenting a priority and tremendous sacrifices for the family. Let us never forget the mighty work that dedicated parenting is for the community.
Beyond our homes, our attention and energy expands out to our studies and our work. We chose to be givers in this world when we answered that calling into nursing which we hear initially. We endure our rigorous studies and finally achieve that hard-earned goal, our nursing license. When we enter the profession, we are enchanted and enamored by the excitement and challenges, but all too soon the disillusionment sets in. We realize that things aren’t quite like the textbooks explain, and that maybe not every patient always gets the right amount of attention and effort devoted to them that they each deserves.
We realize that time and resources are finite, so we figure out ways to do more with less, and get more mileage out of our day. We learn to multi-task better, to streamline our processes better. We start to skip lunches, forget to drink and hydrate ourselves, and hardly ever make it to the bathroom. We put ourselves aside for the sake of the patients.
Throughout our careers, we CONTINUE to show that we are givers by not only living out our higher calling, but by choosing to stay and remain in our work. Even though we have our fair share of legitimate reasons to abandon ship, ALL of us here haven’t done that. We have CHOSEN NOT to. It’s our decision. It’s our decision to stay. It’s our decision to still care. It’s our decision to continue to endure the sometimes harsh conditions and situations we find ourselves in. The list of ways we show this determination and dedication to our patients is endless.(Christina Feist-Heilmeier, RN, MSN)
Nurse Telephone Triage Service is proud of our nurses, and appreciate the care they give to the patients we serve on a daily basis. For that, we say THANK YOU for your dedication, your hard work, your positive attitude, and your commitment to make NTTS the successful corporation that it is!
Wednesday, April 14, 2010
Foreign Body Ingestion in Children
It is inevitable that children will put objects into their mouths from time to time, and sometimes they end up swallowing them. The age group most prone to swallowing foreign bodies is preschoolers. Most of the time, it is either coins or non metallic sharp objects. X-rays can detect 100 percent of metallic objects swallowed, and about 85 percent of glass objects, while detection of fish bones is only about 25 percent. Children who swallow foreign bodies are not always symptomatic. About 50 percent have no symptoms at all. Often, non metallic sharp objects that are swallowed are lodged in an area that can be successfully removed with direct laryngoscopy alone. About 40 percent of swallowed coins can be removed in this manner. Absence of symptoms should not preclude presence of a foreign body in children. Particular attention should be paid to mentally handicapped children with vague GI symptoms.
Most swallowed foreign bodies pass harmlessly through the GI tract. However, if it has a sharp edge, is greater than 1 inch in diameter, or batteries, the patient must be evaluated as soon as possible. Children with preexisting GI abnormalities (eg. tracheoesophageal fistula, stenosing lesions, previous GI surgery)are at increased risk of complications and are more likely to retain foreign bodies in the stomach.
Most complications of pediatric foreign body ingestion are due to esophageal impaction either at the thoracic inlet, cricopharyngeus sling or the mid esophagus. Once the foreign body reaches the stomach of a child with a normal GI tract, it is much less likely to lead to complications. Foreign bodies occasionally become lodged at the ileocecal valve. Foreign-body induced appendicitis has been reported. Besides sharp, pointed, toxic, or objects that are too long or wide, another important exception is the child who has swallowed more than one magnet. Reports exist of swallowed toy magnets attracting and adhering tightly to each other through the GI tract, leading to small bowel obstruction or necrosis of intervening tissues. Systemic reactions, such as a nickel allergy, are unusual but have been reported.
Retained foreign bodies may cause GI mucosal erosion, abrasion, local scarring or perforation. Foreign body migration may lead to peritonitis, mediastinitis, pneumothorax, pneumomediastinum, pneumonia or other respiratory disease. Migration into the aorta may produce an aortoenteric fistula, a horrific complication with a high mortality rate.
Esophageal foreign body symptoms may include dysphagia, food refusal or weight loss, drooling, emesis or hematemesis, foreign body sensation, chest pain, sore throat, stridor, cough, unexplained fever or altered mental status.
Stomach/lower GI tract foreign body symptoms may include abdominal distention/pain, vomiting, hematochezia, or unexplained fever.
Most children who have swallowed a foreign body do not need specialized care. Although a theoretical risk of spontaneously vomiting and then aspiration of a foreign body exists, this is unusual. Do not attempt to dislodge a foreign body from a spontaneously breathing patient by giving abdominal thrusts or syrup of ipecac.
If the child is not at increased risk, asymptomatic, and the object swallowed is not determined to be harmful, homecare advice can be given. Reassure the parent that most anything that can get to the stomach will pass through the intestines over the next 3-4 days without difficulty. Test the child's ability to swallow foods. If no symptoms are present and the object was small and smooth, ask the parent to give the child some water to drink. If the water is swallowed easily, the child should be able to eat some bread or other soft foods. Inform the parent that most foreign bodies are passed in a normal BM in 3-4 days, and there is nothing you can do to hurry the process. Have the parent call back if the foreign body was not passed in 3 days, abdominal pain, vomiting or bloody stools develop, or the child becomes worse.
Most swallowed foreign bodies pass harmlessly through the GI tract. However, if it has a sharp edge, is greater than 1 inch in diameter, or batteries, the patient must be evaluated as soon as possible. Children with preexisting GI abnormalities (eg. tracheoesophageal fistula, stenosing lesions, previous GI surgery)are at increased risk of complications and are more likely to retain foreign bodies in the stomach.
Most complications of pediatric foreign body ingestion are due to esophageal impaction either at the thoracic inlet, cricopharyngeus sling or the mid esophagus. Once the foreign body reaches the stomach of a child with a normal GI tract, it is much less likely to lead to complications. Foreign bodies occasionally become lodged at the ileocecal valve. Foreign-body induced appendicitis has been reported. Besides sharp, pointed, toxic, or objects that are too long or wide, another important exception is the child who has swallowed more than one magnet. Reports exist of swallowed toy magnets attracting and adhering tightly to each other through the GI tract, leading to small bowel obstruction or necrosis of intervening tissues. Systemic reactions, such as a nickel allergy, are unusual but have been reported.
Retained foreign bodies may cause GI mucosal erosion, abrasion, local scarring or perforation. Foreign body migration may lead to peritonitis, mediastinitis, pneumothorax, pneumomediastinum, pneumonia or other respiratory disease. Migration into the aorta may produce an aortoenteric fistula, a horrific complication with a high mortality rate.
Esophageal foreign body symptoms may include dysphagia, food refusal or weight loss, drooling, emesis or hematemesis, foreign body sensation, chest pain, sore throat, stridor, cough, unexplained fever or altered mental status.
Stomach/lower GI tract foreign body symptoms may include abdominal distention/pain, vomiting, hematochezia, or unexplained fever.
Most children who have swallowed a foreign body do not need specialized care. Although a theoretical risk of spontaneously vomiting and then aspiration of a foreign body exists, this is unusual. Do not attempt to dislodge a foreign body from a spontaneously breathing patient by giving abdominal thrusts or syrup of ipecac.
If the child is not at increased risk, asymptomatic, and the object swallowed is not determined to be harmful, homecare advice can be given. Reassure the parent that most anything that can get to the stomach will pass through the intestines over the next 3-4 days without difficulty. Test the child's ability to swallow foods. If no symptoms are present and the object was small and smooth, ask the parent to give the child some water to drink. If the water is swallowed easily, the child should be able to eat some bread or other soft foods. Inform the parent that most foreign bodies are passed in a normal BM in 3-4 days, and there is nothing you can do to hurry the process. Have the parent call back if the foreign body was not passed in 3 days, abdominal pain, vomiting or bloody stools develop, or the child becomes worse.
28 states seek to expand the role of nurse practitioners
With a looming shortage of primary care doctors, 28 states are considering expanding the authority of nurse practitioners. These nurses with advanced degrees want the right to practice without a doctor's watchful eye and to prescribe narcotics. And if they hold a doctorate, they want to be called "Doctor."
For years, nurse practitioners have been playing a bigger role. With 32 million Americans gaining health insurance within a few years, the health care overhaul is putting more money into nurse-managed clinics.
Newly insured patients will be looking for doctors and may find nurses instead.
The medical establishment is fighting to protect turf. In some statehouses, doctors have shown up in white coats to testify against nurse practitioner bills. The American Medical Association says a doctor shortage is no reason to put nurses in charge and endanger patients.
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