Gene therapy represents a fundamentally new way to treat disease. Originally conceived as an approach to hereditary disease, it is now being applied to a broad range of acquired conditions such as infections, cancers, and degenerative disorders. A current overview of gene therapy is presented in this article, including descriptions of two clinical protocols and perspectives for new directions.
Nurse home visiting with pregnant women and new mothers in the early decades of the twentieth century was designed to improve birth and newborn outcomes, hasten Americanization of immigrant mothers, and improve their parenting skills. Today the Nurse Family Partnership home visitation program improves newborn and child outcomes by positively influencing maternal role attainment and significantly decreasing maternal smoking and other substance abuse, child abuse and neglect, and children's emergency room visits. It also improves life possibilities for vulnerable young women by decreasing the interval and frequency of subsequent pregnancies and reduces dependence on welfare by increasing workforce participation. This article reviews the history of home visits by nurses to pregnant women and demonstrates the benefits achieved by these programs today.
Multidisciplinary teams, therapeutic research, and large successful clinical trials have led to the exciting improved survival outlook in pediatric oncology. The development of sophisticated supportive care measures and the identification of significant prognostic variables within disease categories have dramatically altered the management and outcome for many children with cancer. Prolonged survival has focused attention on the quality of life and strategies to enable these children and their families to cope effectively with chronic, life-threatening illness. Research is ongoing on several fronts: to find innovative treatment approaches for children who currently have a poorer prognosis, to minimize or prevent acute and late toxicities by modifying treatment plans so less intensive treatment can be given to patients with a low risk of disease recurrence, and to increase our understanding of the epidemiology and etiology of childhood cancer. With the continued efforts of researchers in the laboratory and at the bedside, prevention of these catastrophic diseases may some day become a reality.
Quality management is the vehicle for integrating the critical aspects of patient care into nursing service delivery approaches. Predetermined standards for quality, productivity, risk, and cost are correlated in this quality management approach. Information systems facilitate this integration. Nurses must now structure their quality management data elements to accurately reflect nursing practice and relationships of nursing care to the whole.
The Omnibus Reconciliation Act of 1987 set forth new provisions for Medicare and Medicaid sections related to new standards for care in the nursing home setting. One major provision was for nurse aide training. Within that provision there are four specified requirements: (1) nurse aide training for 75 hours, (2) competency evaluation of newly trained nurse aides, (3) competency evaluation of nurse aides already providing care, and (4) a registry for nurse aides. The primary implications of the these requirements center on the responsibility of the individual nurse or nurse community in ensuring appropriate implementation of the new requirement. Without appropriate implementation, some of the provisions increase the liability of the nurse and the risk to the public. The reality of OBRA 1987 and its intent of bringing a measure of quality assurance to the nursing home industry should only serve as an impetus for the nursing community to better translate the nurse role and its contribution in the nursing home setting to policy makers at local, state, and federal levels.
In the preface to the Core Curriculum, editor Terri Goodman, RN, MA, CPSN, CNOR, eloquently describes plastic surgical nursing as "a dynamic specialty that is expanding rapidly in response to technology, creativity, and the increasing autonomy of both nurse and patient." She goes on to say that today's "plastic surgical nurse [is] a sensitive, skilled communicator [possessing] a broad knowledge base and the ability to apply principle." These are exciting times in which to be a nurse. Yes, the winds of change are blowing. Some see them as threatening the core of medical practice, that is, caring for patients. Others see them bringing opportunity, empowerment for nurse specialists, and freedom to reach new levels of professionalism. The specialty of plastic surgical nursing is proud to be a part of this exciting future.
Beginning in 1984, the long-term decline in tuberculosis (TB) cases stopped, and since 1985 the number of cases has actually increased by 18%, from 22,201 new cases in 1985 to 26,283 in 1991. The change in the morbidity trend appears to be primarily due to three factors: HIV coinfection, TB occurring in persons from countries where this disease is prevalent, and deterioration of the health care infrastructure with resultant outbreaks of TB. This article presents six interventions that address major areas where action is needed. These efforts will require coordinated action by health care providers, public health departments, and other public and private organizations. Protection of all workers and patients in health care settings is one important goal of these efforts.
The events of September 11, 2001, set in motion the broadest emergency response ever conducted by the US Department of Health and Human Services. In this article, some of the nurses who deployed to New York City in the aftermath of that horrific attack on the United States offer their recollections of the events. Although Public Health Service Commissioned Corps (PHS CC) officers participated in deployments before 9/11, this particular deployment accelerated the transformation of the PHS CC, because people came to realize the tremendous potential of a uniformed service of 6,000 health care professionals. When not responding to emergencies, PHS CC nurses daily serve the mission of the PHS to protect, promote, and advance the health and safety of the nation. In times of crisis, the PHS CC nurses stand ready to deploy in support of those in need of medical assistance.
The level of emergency preparedness in US hospitals is a concern in light of the steady threat of natural disasters, transportation and industrial accidents, and the possibility of terror attack resulting in mass casualties. The science of hospital emergency preparedness is in an early stage of development. For research to logically expand knowledge, an accurate assessment--or examination of the state of the science--is conducted to determine the current state of knowledge, gaps in knowledge, and opportunities for future research. Milsten reviewed the literature on hospital response to acute-onset disasters from 1977 to 1999. His review of 107 articles contains research studies, case studies,and lessons learned pieces largely published in the medical literature.Milsten's analysis provides a substantial starting point. This article examines Milsten's review, identifies articles that have been published that add to this knowledge base, and identifies additional phenomena of interest.
This article is about nursing leadership, workforce diversity, and underrepresentation in nursing. It is about long-term care, specifically the nursing home, the nurses, and the certified nursing assistants. The nursing shortage, the shortage of nurse educators, and curricular changes in the colleges and universities are not the focus of this work. The questions asked here are, who will care for the residents in nursing homes, and how will they recruit the much-needed leadership at a time of unprecedented need?
A health care program based on Healthy People 2010 objectives provides screening and treatment to homeless children residing in a homeless shelter through a nursing center located on site. In addition to treatment for minor acute illnesses, children receive physical assessment and screening for health problems for which they are at increased risk. Interventions address these problems within the context of the complex psychosocial issues they face. Outcomes of interventions are monitored to support the value of case management and health education with these families.
Transition into the workforce for the new graduate nurse is affected by many factors. New graduate nurses can benefit from support provided through participation in the UHC/AACN Residency Program. The retention of even one graduate nurse saves the employing institution up to an estimated $80,000 annually. St Joseph's Hospital has improved the retention of new graduate nurses from approximately 40% to 100% with the addition of the UHC/AACN Residency Program alongside other system changes. Data are being monitored at St Joseph's and on a national level through this multisite collaborative aimed at improving patient care and increasing nurse retention.
In a developing country such as Pakistan, where illiteracy, poverty, gender differences, and health issues are prevalent, violence against women is a commonly observed phenomenon. The rising incidences of abuse among women indicate a need to introduce evidence-based community-derived interventions for meeting Millennium Developmental Goals by 2015. This article discusses the application of counseling, economic skills building, and microcredit programs as practical and effective interventions to improve the health outcomes of abused women and, therefore, improving maternal and child health in the Pakistani society.
Men's health is a holistic, comprehensive approach that addresses the physical, mental, emotional, social, and spiritual life experiences and health needs of men throughout their lifespan. The men's health movement consists of various movements that are melding into a central focus on men's health and well being. Current health policy is attempting to establish an Office of Men's Health. A men's health nurse practitioner role is proposed for development.
Changes in health care policy must be made to pave the way for the appropriate treatment and prevention of child and adolescent mental health problems. Nurses can provide the leadership needed to make the changes. Organizations such as the Association for Child and Adolescent Psychiatric Nurses and the Society for Education and Research in Psychiatric/Mental Health Nursing are already making important contributions. Challenges in the arenas of treatment, education, and research are before us in child psychiatric nursing. We are facing these demands, however, and are moving forward into the twenty-first century.
Advanced practice nurses have the capability of providing a variety of services in women's health care. The role and functions of certified nurse midwives, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists are discussed. Current issues and barriers to advanced practice nursing are presented and include role definitions and regulations, second licensure, educational level, prescriptive authority, third party reimbursement, admitting privileges, and malpractice reform. Future directions and recommendations are provided.
The need for the early detection of ovarian cancer continues to be one of the most important issues in women's health care. The overall 5-year survival rate for epithelial ovarian cancer remains approximately 30% and has not improved over the last three decades. The failure to improve the prognosis for women with ovarian cancer is directly attributable to the lack of an effective screening test for early-stage disease. It is hoped that with the study of those women at high risk, an appropriate screening method will be discovered. Nurses should become knowledgeable about the nature of ovarian cancer, should be able to identify the woman at familial risk, and should look at a symptomatic woman with a high degree of suspicion. As health educators, nurses can provide up-to-date information about Ca 125 serum tests and vaginal ultrasonography used to screen high-risk populations. Nurses must educate women about the importance of the pelvic examination. Historically, nurses are trained to view the patient holistically. Such a viewpoint will help to put together all of the pieces of a difficult puzzle.
There are many unique physical assessment findings that are associated with specific gastrointestinal disorders. The detection of these findings enables the nurse to manage gastrointestinal emergencies on the patient unit in a timely fashion, preventing deterioration and maintaining the safety of the patient. These skills build well on the traditional, detailed, and comprehensive assessments the nurse makes when using the nursing process. Specific abdominal assessments include detection of signs associated with appendicitis such as rebound tenderness and McBurney's, Rosvig's, and Aaron's signs. The nurse must always be alert to the possibility of peritonitis and the urgency of early detection and treatment. The patient with cirrhosis of the liver presents a distinct clinical picture. There is a need for subtle evaluation of mental status to detect early signs of hepatic coma. Another extra-abdominal assessment of this complication is asterixis. Finally, the assessment of the patient is enhanced when the nurse is able to help identify the location of bleeding. Improving abdominal and gastrointestinal system assessment leads to early detection of nursing problems and appropriate interventions.
Pathology of blunt and penetrating abdominal trauma is presented in specific sections. Samples of a focused cue search, nursing diagnostic statements, and defining characteristics are included. Utilization of the aforementioned items are discussed within the context of a case involving victims of an accident resulting from a high-speed chase.
Blunt abdominal trauma is a possible sequel of many accidents and can result in death from hemorrhage or sepsis if it is not detected early and managed aggressively. A thorough history of the causative accident, a systematic abdominal examination, selected laboratory studies, and x-ray films are helpful in establishing the diagnosis. Peritoneal lavage is, however, the most reliable assessment tool (besides an exploratory laparotomy) for confirming significant viscus injury and intra-abdominal hemorrhage. Nurses who are assisting in the evaluation of trauma victims should be thoroughly familiar with the mechanics responsible for blunt abdominal injury, the initial steps for stabilizing the victim, and the usual tests and procedures that aid in diagnosis.
The trucking industry employs approximately 9 million workers, with approximately 3 million being long-haul truck drivers. Truck drivers are exposed to a variety of stressful situations, such as working long hours, no sleep, inadequate rest and relaxation, being away from home and support systems, and driving in hazardous conditions. These risk factors place the long-haul truck driver at an increased risk for possible use or abuse of alcohol and drugs. Identification of those at risk and those who are abusing alcohol and drugs is vitally important for the health of these truckers.
The multidisciplinary approach has been utilized extensively by health care professions working with child abuse and neglect families. The multidisciplinary approach has allowed nurses, physicians, social workers, and mental health workers to collaborate in resolving complex problems. Multidisciplinary teams have taken many forms, depending on the demonstrated needs of the clinical setting. The many functions of the team may be summarized as: information-sharing, decision-making, support, and planning. Additional advantages include role clarification and many benefits for patients and families. Despite a number of well-recognized disadvantages, the multidisciplinary approach appears to have become well established in the child abuse field. Its application to other health care problems may lead to further collaboration among members of the health care professions.
Very strong links exist between abuse and depression in clinical practice. Abuse and depression often coexist in the victims and perpetrators of abuse. In nursing practice, responding to patients, particularly women, presenting with depression or depressive symptoms requires an understanding of the underlying and perhaps hidden issues of abuse and violence. Women who have experienced trauma often are diagnosed with depression, when in fact they have symptoms more consistent with posttraumatic stress disorder. Furthermore, depression often improves over time, when women manage to escape the abuse and violence in the relationship.
This article describes the experience of a medical internist caring for thousands of persons living with HIV/AIDS (PLWA) for more than 23 years, many of whom have abused illicit substances and ethanol. Divided in three major sections, the article looks at the effects of substance abuse on HIV treatment and how a community physician rallies the health team, patients, and the community to address the issues that pose barriers to quality HIV care. Many studies have documented that HIV-infected patients need to obtain 95% medication adherence to maintain optimal, sustained HIV viral suppression. Several publications state that. some of the determinants of poor adherence include active illicit substance or ethanol abuse, depression, and older age. As a physician practicing medicine within an urban environment in New Jersey (which has been among the states with the highest prevalence of HIV-positive patients, the majority of them being African American or Hispanic), it has been noted that lifestyle issues weigh in on improving a community's health. This paper also describes how the author developed a program that provides comprehensive health services within several public health settings, both in ambulatory and inpatient services facilities.
Substance use and abuse is a major public health problem that affects adolescents of both genders and of every socioeconomic level. Because of the nature of the nursing profession, nurses are often trusted with confidential queries from family members and friends and clients concerned about substance use by teenagers they know and love. The purpose of this article is to provide nurses information and strategies for helping adolescents and their families with this problem. Specifically, this article includes information about current trends in teenage substance use and abuse, risk factors that influence use and abuse, and strategies for prevention, identification, and treatment.
Child abuse is defined as physical, emotional, verbal, or sexual injury inflicted upon children. It is a complex problem requiring a systematic approach to intervention and treatment. All family members are victims of child abuse. Because child abuse tends to be a cyclic problem, rooted in several generations of parenting, long-term treatment in the community must be available for abusing families, both adults and children. At the core of all successful treatment are the significant relationships which must be established between parents and the case worker and the abused child and the case worker. These relationships must be based on mutual trust, respect, and support-characteristics that are lacking in the relationships of most victims of child abuse. The nurse who works with abusing families in the community brings empathy, a knowledge and understanding of child development, and a holistic approach to health, growth, and change to the relationship. Nurses have a significant role on the child abuse treatment team as primary workers with the family, case managers, and liaisons in a multi-agency interventional effort.
Nurses in a wide variety of settings can assist women with substance abuse concerns. This article briefly reviews prevalence, gender differences, mental health comorbidities and painful life events, screening tools, brief interventions, substance abuse treatment, and three specific populations of women--those that are pregnant, incarcerated, or older. Suggestions for general nursing interventions are included.
Clearly, substance abuse among traumatically disabled persons can potentially sabotage rehabilitation outcomes for this population. There is evidence that substance abusers will comprise a growing percentage of patients within rehabilitation programs. Rehabilitation professionals must examine their own attitudinal barriers toward making a substance-abuse program an integral part of comprehensive rehabilitation care. Rehabilitation nurses are in a unique position to assist the rehabilitation team to identify the need for development of a substance-abuse program.
The results of abuse may include repeated abuse, chronic pain, and physical and emotional illnesses. For some, the result is death, but others thrive. Males and females are abused at similar rates, but males are more likely to experience physical assault and females are more likely to experience sexual assault. Males and females experience psychological abuse at the same rates and there is evidence that the effects of psychological abuse are as detrimental to long-term functioning as the effects of physical abuse. This article discusses partner violence in adults and adolescents, child maltreatment, and peer abuse in children and adolescents.
Definitions of sexual abuse vary, but can be summarized as inappropriate use of a child for sexual gratification. Sexual abuse includes not only the act of molestation, but also using children as models in pornographic pictures and movies. These sexual experiences are inappropriate because they are beyond the child's understanding and developmental level. Some long-term implications point to severe problems for the child. The frequency of sexual abuse is currently documented at 1.1 million reported cases per year. More females are reportedly abused as are preschoolers and school-age children. The nursing process provides a systematic framework for the nursing care of sexually abused children and their families. The first step is assessment, which utilizes such tools as a nursing history, drawings, and play to gather data in documenting the abuse. The child and the family may be interviewed separately to verify data. A variety of physical and psychosocial factors have been identified which lead the nurse to suspect the occurrence of sexual abuse. Based on a comprehensive nursing assessment, therapeutic interventions are planned and initiated. These include protecting the child and family and referral to community agencies. Nurses have a legal and moral obligation to report suspected or actual abuse of any nature. A multidisciplinary approach assures comprehensive treatment and continuity of professional services for the child and family. Sexually abused children may need long-term follow-up to overcome emotional trauma and to prevent recurrence of the abuse. Nurses who care for these children can play a major role in facilitating communication among professionals and making the referrals necessary for follow-up by community services.
There is an increasing awareness of the need for prevention of substance abuse related problems. The psychiatric nurse is especially equipped to strengthen the bonds among citizens and parents, health agencies and schools, law enforcement and hospitals to assist the community in the design and implementation of its own prevention program. The nurse is able to facilitate the community's own vested interests in a manner congruent with its needs. The nature and scope of nursing practice have traditionally included responses to health-conducive behavior. The nurse emphasizes self-determination and choice in health matters; therefore, substance abuse prevention efforts are likely to be incorporated by the community. The nurse provides the knowledge of addiction and abuse and assists the community in its health enhancement by using addiction and nursing theory, interpersonal process, research competencies, and teaching skills.
Elder abuse is a growing public health concern that affects elders regardless of residence, socioeconomic status, or geographic locale. Elder abuse includes acts of physical, psychological, verbal, and financial abuses as well as abandonment and neglect. Elder abuse has the potential to occur in multiple settings, whether in the home, rehabilitation centers, long-term care facilities, nursing homes, and/or senior day care centers. Children, family members, friends, and formal caregivers are prospective perpetrators of elder abuse. Public policy changes are necessary to standardize and delineate guidelines and procedures for the detection and prevention of elder abuse in the future.
As professional practitioners, nurses can promote prevention by becoming knowledgeable about all aspects of the phenomenon of child abuse, by carefully scrutinizing their own beliefs and values, and by monitoring their own behavior. By careful use of the problem-solving approach in their practices they can effectively intervene in potentially problematic situations. As citizens who have more complete and accurate information than their lay counterparts, they can be vital resources. They can support movements and legislation that seek to establish methods for preventing child neglect and abuse, and where neither movements nor legislation exists, they can promote both. Finally, nurses can promote and participate in relevant research that will continue to identify causes and seek solutions.
Elder mistreatment is a serious issue that effects the lives of thousands of older adults and results in emotional difficulties, such as depression,feelings of inadequacy, self-loathing, and lowered self-esteem. It has been shown to result in family distress, impaired life functioning, and difficulties with cognition and has been linked to health problems,such as immunologic dysfunction, and increased mortality. As the population ages, and with it the numbers of persons afflicted by diseases such as Alzheimer's, understanding and recognizing elder mistreatment becomes an important factor in maintaining quality of life for older adults.
The four most common types of abuse are physical, sexual, emotional, and economic. Abuse is often further categorized into child abuse, intimate partner violence, and elder abuse. This article describes the important role that nurses and health care providers play in detecting, assessing, and reporting abuse. Armed with increased knowledge about signs and symptoms of abuse, nurses can guide patients to the appropriate resources.
Current knowledge about the use of options for the management of patient pain opposes conventional practice, which is guided by misunderstandings and personal attitudes and beliefs. An understanding of substance abuse and the behavior and needs of the person with substance dependence are important elements in a nurse's knowledge base. This understanding allows him/her to safely and effectively manage pain in all patients. Effective pain management education needs to be comprehensive and should include not only updated information, but also explore origins of beliefs about pain and substance abuse and how these beliefs affect current practice. This article discusses the common myths that often guide nurses' management of patient pain and offers strategies for care that are based on current understandings.