About

Florida Domestic Violence

This fulfills the continuing education requirement of Domestic Violence for the state of Florida.

Florida domestic violence is defined as violent or aggressive behavior occurring within the home and usually involves the abuse of a spouse or partner.  In the United States alone, it is estimated that more than 10 million adults have been subjected to domestic violence during the course of a year. This statistic translates to an incident of domestic violence occurring every 3 seconds.  Due to the increasing prevalence of domestic violence in society, there is a high probability that all healthcare professionals will evaluate and treat a victim (and quite possibly a perpetrator as well) of domestic violence at some time during their healthcare career.  The importance of ongoing education and global awareness cannot be understated.  

Introduction

Domestic violence is defined as violent or aggressive behavior occurring within the home and usually involves the abuse of a spouse or partner. In the United States alone, it is estimated that more than 10 million adults have been subjected to domestic violence during the course of a year. This statistic translates to an incident of domestic violence occurring every three seconds. The National Coalition Against Domestic Violence reports some daunting statistics [1][6]:  

• 1 in 3 women and 1 in 4 men have experienced some form of physical violence by an intimate partner.  
• 1 in 4 women and 1 in 7 men have been victims of severe physical violence (such as beating, burning, strangling) by an intimate partner in their lifetime.  
• On average, more than 20,000 phone calls placed to domestic violence hotlines nationwide.  
• The presence of a gun in a domestic violence situation increases the risk of homicide by 500%; 19% of domestic violence involves a weapon; Most intimate partner homicides are committed with firearms. 
• 1 in 15 children are exposed to intimate partner violence each year, and 90% of these children are eyewitnesses to this violence.  
• From 2016 through 2018, the number of intimate partner violence victimizations in the United States increased 42%.  

Due to the increasing prevalence of domestic violence in society, there is a high probability that all healthcare professionals will evaluate and treat a victim (and quite possibly a perpetrator as well) of domestic violence at some time during their healthcare career. The importance of ongoing education and global awareness cannot be understated.  

In 2020, the COVID-19 pandemics’ stay at home/shelter in place orders resulted in spikes in calls to domestic violence hotlines. From layoffs and loss of income to decreased availability of shelters and backlogged courtrooms, fewer resources were made available to victims of domestic violence. These measures resulted in increases in both the incidence and severity of domestic violence. Sadly, the effects of this pandemic, especially on this issue, continue well into today [2].

Forms of Domestic Violence  

Domestic violence may encompass physical abuse, sexual abuse, emotional and verbal abuse, and spiritual and economic abuse. Defined as a pattern of behavior used to gain power or control over an intimate partner, a domestic violence abuser may use tactics that frighten, intimidate, hurt, blame, or injure a person. These behaviors often escalate over time in intensity and have resulted, at times, in life-threatening injuries or death of a victim [3].  

Intimate partner violence (IPV) is abuse or aggression that occurs in a romantic relationship. The term "intimate partner" refers to both current and former spouses and dating partners, including heterosexual and same-sex couples. The Centers for Disease Control and Prevention (CDC) further delineates IPV into four separate groups: physical violence, sexual violence, stalking, and psychological aggression [4].  

• Physical violence may include hitting, kicking, and punching someone.
• Sexual violence may include using force to get a partner to partake in a sexual act.
• Stalking may include unwanted and threatening phone calls or text messages.
• Psychological aggression may include insults, threats, name-calling, or belittling a partner.  

Teen Dating Violence (TDV) is defined as dating violence affecting millions of teenagers annually [5]. In addition to the threats from physical and sexual violence and other forms of aggression, TDV is often done electronically through repeated texting and placing sexual pictures of a person online without permission.  

The CDC statistics on teen dating violence report:  

• Nearly 1 in 11 female and about 1 in 15 male high school students report having experienced physical dating violence in the last year. 
• About 1 in 9 female and 1 in 36 male high school students report having experienced sexual dating violence in the last year. 
• 26% of women and 15% of men who were victims of contact sexual violence, physical violence, and/or stalking by an intimate partner in their lifetime first experienced these or other forms of violence by that partner before age 18.  

Domestic violence transects every community and affects all people, regardless of age, socio-economic status, race, religion, gender, or nationality [6]. Whether the violence results in physical or psychological injury, the effects can last a lifetime and affect multiple generations.  

Healthcare professionals are in a pivotal position to impact the lives of those affected by domestic violence positively. Oftentimes, they may be the first person to encounter a victim of domestic violence. Their ability to effectively evaluate the situation and provide time-sensitive, patient-centered care (including but not limited to treatment interventions, appropriate referrals, and follow-up care) can enhance immediate victim safety and reduce further injury, and improve the home front circumstances, moving forward.  

Healthcare professionals must be able to identify and assess all patients for suspected abuse, and be able to offer treatment, counseling, education, and referrals, as appropriate. These referrals may extend out to shelter options, advocacy groups, child protection services and legal assistance [7].  

Profiles of Victims and Abusers  

Anyone can become a victim of domestic violence. Victims of domestic violence come from all walks of life, all age groups, all socio-economic groups, all religions, and all nationalities [8]. Violence can occur in any relationship when one person feels they are entitled to control another person through whatever means of abuse possible. This abuse is cyclical and usually increases in frequency and intensity. Victims of such violence report feelings of isolation, helplessness, guilt, anxiety, and embarrassment. They may become suicidal, start abusing drugs and alcohol, and feel that they have no one to turn to for help.  

Although there isn't a specific set of factors that result in "being a victim," there are many thoughts as to what might affect a person's active willingness to remain in a violent relationship. The following lists serve only as general guidance to inform the healthcare professional of possible underlying causes. Again, anyone can become a victim of domestic violence.  

Victims of Domestic Abuse

There is no single "characteristic" or risk factor that automatically causes a person to become a victim of domestic violence. Instead, it may be a series of events that cause a person to become more vulnerable and enter and remain within an abusive relationship [9].  

Domestic violence victims may have experienced violence during childhood, experienced total financial dependence on another person, or lacked basic social support (family and friends). These factors affect both the physical and psychological make-up of a person. Without intervention, these victims can develop personal esteem and confidence issues, further social isolation, economic dependency, and general feelings of insecurity. These effects may negatively affect the decision to stay in an abusive relationship.  

Researchers have found the following factors may place a person at a higher risk of becoming a victim of domestic violence, including (but not limited to) [10]:  

• Poor self-image/ low self-esteem 
• Financial dependence on the abuser 
• Feeling powerless to stop the violence or leave the relationship 
• Personal belief that jealousy is an expression of love 

Common characteristics of victims of domestic violence include, but are not limited to:  

• A history of abuse  
• A history of alcohol or substance abuse (for themselves or their partners) 
• Financial and family stressors- low income, limited family/friends contact, poverty status 
• A member of an ethnic minority/ immigrant group; Limited English vocabulary 
• Holds traditional beliefs that they should be submissive in a relationship 

Reasons a victim may choose to stay in the relationship:  

• A desire to end the abuse but not necessarily the relationship; they do love their abuser  
• Feelings of isolation and helplessness  
• Fear of judgment if they reveal the abuse by seeking help 
• Feelings that they may not be able to support themselves if they leave their abuser 
• Fears for the safety of children involved in the relationship  
• Fear of backlash from community or family and friends/lack of knowledge of services available  
• Strong religious/cultural belief system that reinforces staying in a relationship at all costs  

Abusers/Perpetrators of Domestic Violence

As with the DV victim, there is no one set of traits to identify a domestic violence abuser/perpetrator correctly. There are, however, some signs that may raise the red flag of suspicion when observed in a suspected domestic violence case.  

The National Coalition on Domestic Abuse has created a list of "red flag" indicators, including but not limited to the following [11]:  

• Extreme jealousy and possessiveness  
• Verbally abusive  
• Extremely controlling behavior  
• Blaming the victim for anything bad that happens  
• Control over all the finances in the relationship  
• Demeaning the victim publicly or privately  
• Humiliating or embarrassing the victim in front of other people  
• Control over what the victim wears  
• Abuse of other family members, including children (and even pets)  

The following is a general list of indicators that "may" help identify an abuser [12].  

• History of abuse within one's family  
• History of personal physical or sexual abuse  
• A lack of appropriate coping skills  
• Low self-esteem  
• Codependent behavior  
• Untreated mental illness  
• Drug or alcohol abuse
• Socio-economic pressures related to the lower income status
• Prior criminal history

Screening for Domestic Violence 

Screening rates are as low as 1.5% to 13% among emergency and primary care physicians. The Academy of Medicine recommendation suggested that all women should be screened for sexual violence. Research found that healthcare providers working in emergency departments only screened 20–25% of their encounters. As a result, this decreased opportunities for intervention, increased safety, and prevention of future violence [13].  

Domestic violence (including Intimate partner violence) is an unfortunate cycle that may not be broken with a single emergency department visit; however, identifying and providing resources is necessary to make a difference, increase confidence and safety, and improve the overall health outcome for patients.  

Initial Interaction 

Compassionate, nonjudgmental screening by healthcare professionals affords the best opportunity for domestic violence victims to disclose their abuse. By recognizing signs of abuse and inquiring further, the nurse validates that the victim is worthy of care and confirms that the violence is a legitimate concern [14].  

The screening for domestic abuse should be done in a private environment. Language interpreters, not family and friends, should be utilized if needed. Universal screening should be used; therefore, preventing any victim from being "singled out" and ensuring all potential victims are screened appropriately. All healthcare professionals should remain nonjudgmental and compassionate during the screening process [15].  

During the interview process, assure the victim that all patients are screened for domestic violence. Also, inform the victim that DV affects many families, and that services are available to everyone who may be concerned about violence in their home.  

Screening Tools 

Examples of the following four screening tools can be found in the CDC’s Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings. 

Hurt, Insult, Threaten and Scream (HITS)   

5-question screening tool assessing physical and verbal interactions with the partner; scores rank 1 (never) -5 (frequently); a score of 10 is considered positive.  

1. Physically hurt you?  
2. Insult or talk down to you?  
3. Threaten you with harm?  
4. Scream or curse at you?  
5. Force you to do sexual acts that you are not comfortable with?  

http://www.ctcadv.org/files/4615/6657/9227/HPO_HITS_Screening_Tool_8.19.pdf   

Woman Abuse Screening Tool (WAST)  

8-question screening tool assessing physical, emotional, and sexual intimate partner violence.  

http://womanabuse.webcanvas.ca/documents/wast.pdf  

Partner Violence Screen (PVS)  

3-question screening tool for interpersonal violence  

1. Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?  
2. Do you feel safe in your current relationship?  
3. Is there a partner from a previous relationship who is making you feel unsafe now?  

http://www.nnepqin.org/wp-content/uploads/2018/08/Screening-Tools-Partner-Violence-Screen-PVS.pdf   

Abuse Assessment Screen (AAS)  

A multiple section assessment tool for sexual and physical violence, including body maps for documentation of injuries. 

https://idph.iowa.gov/Portals/1/Files/FamilyHealth/abuse_assessment_tool.pdf    

Potential Signs of Domestic Violence 

The Crisis Prevention Institute (CPI) encourages to always be aware of physical signs and injuries that could be related to domestic violence, including but not limited to the following [16]:  

• Bruising in the chest and abdomen  
• Multiple injuries  
• Minor lacerations  
• Ruptured eardrums  
• Delay in seeking medical attention  
• Patterns of repeated injury  
• Injuries inconsistent with the presenting complaints  

Oftentimes, a domestic violence victim may seek medical attention for issues unrelated to a physical injury, such as:  

• A stress-related illness  
• Anxiety, panic attacks, stress, and/or depression  
• Chronic headaches, asthma, vague aches, and pains  
• Abdominal pain, chronic pelvic pain
• Vaginal discharge and other gynecological problems
• Joint pain, muscle pain
• Suicide attempts, psychiatric illness   

Other observations that may indicate a suspected domestic violence situation include:  

• Appear nervous, ashamed, or evasive 
• Seem uncomfortable or anxious when around their partner 
• Accompanied by their partner, who controls the conversation  
• Reluctant to follow advice 

As you continue to assess the patient, encourage them to talk and then listen carefully. Only upon listening will you have a better understanding of the patient's current state and provide the necessary resources and referrals for them to find safety. Above all else, maintain open lines of communication in a safe, accepting environment and assure the victim that they do not deserve the abuse.  

Importance of Trauma-Informed Care  

While nurses play a critical role in recognizing suspected domestic abuse victims, they often do not feel confident in their role or the screening process itself. This may be due to a lack of communication skills, ongoing training on domestic violence or simple confusion over what victim assistance programs and resources are available [17].  

Facility-wide education on domestic violence should be ongoing. Policies and procedures should be on file, and collateral relationships should be in place with the local community and national resources. Finally, nurses should be trained in the delivery of trauma-informed care to ensure the highest quality of interaction with victims of domestic violence, much less all victims of trauma.  

Trauma-informed care has been defined as the patient-centered approach that encourages healthcare professionals to provide care that does not retraumatize the patient and the staff [18]. Trauma-informed care ensures that policies and practices in the healthcare setting are not only safe but non-threatening to the physical and mental well-being of those involved. Perceived threats can cause a "flight or fright" mentality that impacts both the ability to administer care and receive immediate care and follow-up recommendations.  

The experience of seeking medical care, whether in an emergency department setting or a clinic, can in and of itself bring another source of trauma. Trauma-informed care aims at reducing the impact of trauma on both the patient and provider by focusing on various checkpoints overseeing all interactions: safety, trustworthiness, empowerment, and respect.  

The following examples are practical tips that encourage trauma-focused care, ensuring the delivery of care in the least threatening manner to a suspected human trafficking victim (as well as each patient you may intersect with).  

• Always introduce yourself and your role within the patient's care with every interaction.  
• Use open body language (direct eye contact, avoid standing "over" the patient as it may be perceived as threatening).  
• Explain procedures and timelines for results ("wait times") to give patients a sense of control. Keep them informed of any changes/delays in their care.  
• Always ask before you touch a patient. This is a sign of respect and gives the patient a sense of control over their own bodies.  
• Protect patient privacy. Ask them who they would like present during their care; limit visitors if requested; close room doors (with their permission).  

During the interview and intervention process, it is also equally important that some things not be said to a suspected victim of domestic violence, such as negating, challenging, or doubting the victim. Examples include:  

• Why haven't you called the police before now?  
• Some level of fighting occurs in all relationships.  
• Maybe you're both going through a phase; it will probably stop on its own.  
• You wouldn't stay in this situation if you really care about yourself/ your kids.  
• What did you do to make them get so angry?  
• Why didn't you leave the first time you were hurt?  

By applying trauma-informed care to all your patients, you lower the risk of perceiving any (nursing and medical) interventions being perceived as a threat. This ensures a higher level of trust and respect, and safety for all patients (and staff) across the care spectrum.

Legal Issues: Florida Mandatory Reporting Laws  

The United States Department of Justice, defines domestic violence to include felony or misdemeanor crimes of violence committed by [19]:  

• a current of former spouse or intimate partner of the victim,   
• by a person with whom the victim shares a child in common,  
• by a person cohabitating with or has cohabitated with the victim as a spouse or intimate partner,  
• by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction receiving grant monies,  
• by any other person against an adult or youth protected from that person's acts under the jurisdiction's domestic or family violence laws.  

The Florida Department of Children and Families defines domestic violence as patterns of actions or behaviors that adults or adolescents use against their partners or former partners to establish power and control. It can potentially include physical abuse, sexual abuse, emotional abuse, and economic abuse. It may also include threats, isolation, pet abuse, using children, and a variety of other behaviors used to maintain fear, intimidation, and power over one's partner (19)." [28]. 

Under Florida law [21], Domestic Battery is classified as a first-degree misdemeanor, with penalties including up to one year in jail or twelve months' probation and a $1,000 fine [21][29][30]. In addition, the accused may face additional penalties of a mandated Batterer Intervention Program [31].  

RAINN (Rape, Abuse, and Incest National Network) is the nation's largest anti-sexual violence organization [22]. Under the “Laws of your state” section, they outline the mandatory reporting laws for Floridaall states. Florida’s mandated reporting law can be viewed there or on the Florida Courts website. 

Mandatory Reporting Requirements on Children 

Children are defined as any unmarried person under the age of 18 years who has not been emancipated by court order.  

Who is required to report (from a healthcare professional standpoint):  

• Physicians 
• Osteopathics physicians 
• Medical examiners 
• Chiropractors
• Nurses
• Some hospital personnel
• Nursing Home and assisted living facility staff
• Health or mental health professionals
• Social workers
• Paramedics
• Emergency medical technicians 

When is a report required:  

• When any person knows or has cause to suspect that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or another person responsible for the child's welfare, or that a child is in need of supervision and care and has no one to provide care.  
• When any person knows or has cause to suspect that a child is abused by an adult other than a parent, legal custodian, or another person responsible for the child's welfare.  
• When any person knows or has cause to suspect that the child is a victim of childhood sexual abuse or the victim of a known or suspected juvenile sexual offender.  

Reports can be made to the Department of Children and Families abuse hotline at 1-800-96-ABUSE (1-800-962-2873) or at Florida DCF Reporter Portal.

Elements of a Safety Plan (Escape Plan)  

Abusers may go to extremes to prevent a victim from leaving. This may result in the decision to escape an abusive relationship – one of the most dangerous times for the victim of domestic violence. The creation of a safety plan can assist in enhancing the safety of a victim during all phases of a relationship and during the planning phase of actually leaving the abuser.  

Knowledge of the various elements of a safety plan will enable the healthcare professional to initiate dialogue with a victim and guide them in the development of a personalized plan of safety moving forward. Discussion of safety plans/escape plans can be very difficult during the limited interactions of an emergency room or clinic visit; therefore, familiarity with the key elements of a plan will help navigate the victim to the most appropriate resources for their situation.  

The following overviews of a safety plan are from Safe Horizon and the National Domestic Violence Hotline [23][24]. The Safe Horizon is a victim assistance nonprofit for victims of violence and abuse in New York City since 1978. The following outline provides a detailed overview of the many aspects to consider when formulating a safety plan. Review the entire plan outlined on their website Safe Horizon. Consider creating a template handout for your facility to distribute to domestic violence victims.  

A safety plan is an outline that includes ways to remain safe while in a relationship, planning to leave, or after you leave [23]. A personalized safety plan assists in coping with emotions, telling friends and family about the abuse, and the steps to be taken in the event of necessary legal action. An effective safety plan should have specific details tailored to your unique situation.  

Considerations in creating your safety plan:  

• Do you have a trusted confidant - a friend, family member, or neighbor?  
• What are some areas in your neighborhood you could go to in an emergency?  
• Are there phone numbers you need to memorize in the event of an emergency?  
• Do you have children that need to be part of your safety plan? Where would your children go if they witnessed violence?  
• Do you need a safety plan for work or school?  
• Where can you safely store your safety plan? Computer? Phone?  

Before Leaving  

The decision to leave an abusive relationship requires courage and preplanning. Consider these measures before leaving to reduce the risk of violence [23]:  

• Record evidence of physical abuse  
• Plan with children and identify a safe place where they can go during moments of crisis. Reassure them that their job is to stay safe, not to protect you.
• Call ahead to see what the shelter's policies are. They can provide information on how they can help and secure a space when it is time to leave.
• Try to set money aside or ask trusted friends or family members to hold money for you.  

When Leaving  

The following list of items serves as a guide for what to take [23]:   

Identification 

• Driver's license or state I.D. card, social security card  
• Birth certificate and children's birth certificates  
• Money and/or credit cards   
• Checking and/or savings account books  

Legal papers  

• A protective order, if applicable  
• Health and life insurance papers  
• Legal documents, including divorce and custody papers 
• Marriage license  

Emergency numbers 

• Local domestic violence program or shelter  
• Trusted friends and family members  
• The Hotline  

Other items to keep in mind: 

• Medications and refills (if possible)  
• Emergency items, like food, bottles of water, and a first aid kit  
• Multiple changes of clothes   
• Emergency money  
• Address book  
• Safe cell phone, if possible  

After Leaving  

The safety plan should always include ways to ensure your continued safety after leaving an abusive relationship. Here are some precautions to consider [23]:  

• Change locks and phone numbers if possible.  
• If possible, change work hours and the typical route.  
• Alert school authorities of the situation.  
• If a protection order is present, keep a certified copy present at all times, and inform friends, neighbors, and employers that you have a protection order in effect.  
• Consider renting a post office box or using a trusted friend's address for mail (remember that addresses are used for restraining orders and police reports) 
• Use different stores and frequent different social spots.  
• Alert neighbors and work colleagues about how and when to seek help.  

If comfortable, tell people who can take care of your children or transport them to/from school and activities. 

Again, these suggestions provide an extensive overview of an escape plan. They are meant to assist a victim in the required methodical preplanning of a safety plan that reduces the threat of violence. Not all sections will apply to every victim, but healthcare professionals should be comfortable in discussing any aspects of a safety plan specific to the individual victim. 

The Effects of COVID-19 on Domestic Violence  

As discussed at the beginning of this course, the COVID-19 pandemic has negatively affected domestic violence incidence. Stay at home /shelter in place orders, job losses, mounting financial concerns, and lack of available shelters in many areas became the norm. Domestic violence victims were met with further hurdles to their safety and well-being, as they found themselves sheltering in place with their abuser, along with fewer resources available to them in their time of crisis.  

Domestic violence hotlines prepared for an increase in calls. However, many organizations found the opposite occurring. Calls to hotlines dropped, in some places greater than 50 percent. Victims were not able to safely connect with necessary services [25].  

Due to the restrictions of movement (curfews, travel bans, 14-day quarantine advisories), not only was it more difficult to escape, but injury from abuse may have gone unnoticed by family and friends as face-to-face interactions had been sidelined. In addition to job losses and financial insecurities, this isolation may have forced a victim to become even more dependent on their abuser [26].  

In March 2020, U.S. police departments reported an increase in domestic violence calls as high as 27% after stay-at-home orders were implemented. The number of Google searches for family violence-related help during the outbreak had been substantial. This increase in domestic violence had not only affected the United States. In the United Kingdom, calls to the Domestic Violence Helpline increased by 25% in the first week after implementing lockdown measures. Furthermore, in China, domestic violence had reportedly increased three times in Hubei Province during the lockdown [27]. The importance of ongoing domestic violence education and awareness cannot be overstated.  

In review, healthcare staff often treat victims of domestic violence. Trauma-informed care that is patient-focused affords both the staff and patient (victim) the best outcome in terms of successfully navigating the challenges of domestic violence and mandatory reporting laws.  

Facility-wide protocols should be in place regarding all aspects of patient care for suspected victims of domestic violence, including national hotline numbers, community resources, scene safety protocols, and house-wide education. Staff should be regularly educated on interviewing techniques, suspected DV victim indicators, and ongoing community collateral relationships. Improved recognition of these victims and knowledge on how to proceed with specific treatment protocols will lead to a higher level of positive outcomes for domestic violence victims and other forms of abuse.  

Time is of the essence when dealing with victims of DV. There may be a small window of opportunity to help these victims when they come to your facility. There may be numerous needs identified quickly (transportation, housing, interpretation services, crisis intervention, case management, safety planning, transitional shelter, and protective orders, to name a few). Staff must feel confident in their abilities to identify possible victims, guide them through the process of seeking help, and advocate for their safety and well-being. Knowledge of their facility protocols and community, state, and national resources will afford them the opportunity to deliver optimal care.

Case Study  

Mary, 26 years old, presents to the emergency department with complaints of abdominal pain, vague body aches, and a headache. During the triage screening, Mary has minimal eye contact with the nurse and appears inadequately dressed for the cold weather, arriving in only jeans, a t-shirt, gym shoes, and a light sweater. While the nurse helps Mary change into a hospital gown in a private examination room, she notices various bruises on Mary's lower back, arms, and legs, all varying size and color. Mary states she slipped and fell recently at home. You observe that Mary is now avoiding all eye contact, staring down at the ground. She keeps looking at the door, and wall clock, mumbling, “He can't know I'm here.”  

• What are your initial thoughts about Mary's physical appearance?  
• What can you do to make Mary feel more relaxed, comfortable, and safe during her emergency room visit?  

Mary lives with her boyfriend, Bill. He works part-time; she is currently unemployed. She admits to the occasional use of alcohol and recreational use of marijuana “to help me relax. My anxiety is very bad lately.”  She mentions that her anxiety has increased because “Bill's hours at work have been cut due to COVID-19 and we’re strapped for money. He is under a lot of pressure.”  

On further examination and laboratory testing, including a pelvic examination, it is confirmed that Mary is approximately six weeks pregnant and has a suspected sexually transmitted infection. Mary bursts into tears and says, “He is going to kill me. We can't afford a baby. What am I going to do?!”  

• What are your concerns about this scenario? How will you address these concerns with your patient Mary?  
• Why might healthcare professionals, in general, feel uncomfortable speaking with Mary?  
• What are the top priorities of Mary's care at this time?  
• What information would you document in the patient record during this visit?  

Mary begins to feel comfortable speaking to you about her situation. She reluctantly tells you that Bill pushed her down the back stairs yesterday after an argument but quickly apologized afterward. On another occasion, Bill “beat me up” when he ran out of beer before payday. She states he has been really angry lately over his hours being cut at work and is looking for another job. “A baby now,” Mary confides, “would be a terrible thing for Bill, but I want it. It's my first, and I want it. Please help me.” Mary gives consent for you to contact your department social worker for additional guidance but does not want law enforcement notified.  

• What other key staff members need to be part of the care team for Mary?  
• What local and national resources can you refer Mary to at this time?  
• How would your plan of care change if Mary did not give consent for the social worker to be notified?  

Mary wants to “go back home” tonight so as not to upset Bill when he returns later this evening. “It will be better this way.” She promises to leave him tomorrow and follow-up with the community referrals you gave her. Knowing that these plans may change, you advise Mary to create a safe escape plan “just in case.”  

• What items should be part of a safe escape plan?  
• How safe is it for Mary to return home?  
• What are your legal obligations to Mary regarding Florida's mandatory reporting laws?  

As you are getting ready to leave at the end of your shift hours later, you see Mary arrive by ambulance. She is visibly injured with a broken nose and bloody lip. The emergency medical response team stated the neighbors called 911 when they heard Mary screaming in her apartment next door. No one else was in the apartment when they entered, and Mary would not tell them who injured her. You escort them to a private examination room. Mary sees you and yells, “He's coming after me. Help me. He is going to kill me.”  

• What are your top priorities for Mary and the staff at this time?  
• What other hospital departments need to be notified?  

Mary’s boyfriend shows up, intoxicated, at the triage window, demanding to see Mary. He threatens to kick in the door to the main examination room if he cannot see Mary immediately. He is pacing back and forth in the triage area and refuses to sit down.  

• What additional security measures need to be in place upon the boyfriend's arrival?  

Mary's boyfriend is removed from the premises by local law enforcement. Mary is given the national hotline number and is contacting the local shelter at this time. Upon discharge, she is escorted by security personnel to the exit and leaves the facility with a shelter representative.

Florida-Specific Domestic Violence Resources 

Community Legal Services of Mid-Florida  

A full service civil legal aid law firm that promotes equal access to justice, providing professional legal aid on domestic violence to help low-income people protect their health, and their families.  

https://www.clsmf.org/violence-protection/ 

Coast to Coast Legal Aid of South Florida  

The Family Law Unit primarily focuses on representing victims of domestic violence in family law matters, such as obtaining an injunction (restraining order), dissolution of marriage cases (divorce), and custody litigation.  

https://www.coasttocoastlegalaid.org/   

Domestic Shelters.org  

Overview of 58 Florida based organizations offering domestic violence services in 47 different cities.  

https://www.domesticshelters.org/help/fl.florida 

Florida Department of Children and Families  

Florida Family Policy Council  

Resources to assist victims (and family members) to find help, safe shelter, legal aid, transitional services, and counseling.  

https://www.flfamily.org/get-help/domestic-violence   

Florida Department of Children and Families: 

Child Protective Services:  

https://www.myflfamilies.com/service-programs/abuse-hotline/  

Florida Abuse Hotline:  

The Florida Abuse Hotline accepts reports 24 hours a day and 7 days a week of known or suspected child abuse, neglect, or abandonment and reports of known or suspected abuse, neglect, or exploitation of a vulnerable adult.  

1-800-96-ABUSE (1-800-962-2873)  

TTY: 1-800-955-8771  

https://reportabuse.dcf.state.fl.us/  

MyFlFamilies.com  

These services include emergency shelter, counseling, safety planning, case management, child assessments, information, and much more.  

These shelters may be viewed on the MyFlFamilies.com website. Healthcare professionals should be familiar with shelters available in their surrounding area.  

Domestic Violence Hotline: 1-800-500-1119  

https://www.myflfamilies.com/   

Harbor House of Central Florida  

Offering housing placements service, legal aid, safety planning, support groups, and crisis intervention.  

(407) 886-2856  

https://www.harborhousefl.com/get-help/safety/  

The 15th Judicial Circuit of Florida Batterers Intervention Program (BIP)  

The Florida BIP is a 6-month intensive program to address root causes of domestic violence; it is at least 26 weeks of group counseling sessions. A list of statewide providers is available on this site.  

https://www.15thcircuit.com/program-page/bip   

The Salvation Army  

Offering emergency and transitional housing, as well as counseling and rehabilitation services.  

https://salvationarmyflorida.org/domestic-violence-program/ 

National Domestic Violence Resources 

Amend, Inc.  

AMEND is a nonprofit organization working to end domestic violence by providing counseling to men who have been abusive, advocacy and support to their partners and children, and education to the community. Based in Colorado. 

http://www.amendinc.org/ 

Emerge  

Emerge is a Massachusetts Certified Batterer Intervention Program & Training Site, offering abuser education groups and batterer intervention. Based in Massachusetts. 

617-547-9879   

https://www.emergedv.com/  

National Domestic Violence Hotline  

1-800-799-SAFE (7233)  

https://www.thehotline.org/  

Domestic Violence Prevention, Inc   

501C3 nonprofit offering education, counseling, and support services to domestic violence clients in multiple counties in Texas and Arkansas.  

903-793-HELP (4357)  

https://www.dvptxk.org/   

National Center on Domestic Violence, Trauma and Mental Health  

Offering direct website links to multiple national organizations working with domestic violence cases. 

http://www.nationalcenterdvtraumamh.org/resources/national-domestic-violence-organizations/ 

National Network to End Domestic Violence  

Offers a range of programs and initiatives to address the complex causes and far-reaching consequences of domestic violence.  

https://nnedv.org/   

New York Model for Batterer Programs National Organization for Men Against Sexism (NOMAS) Model for DV Offender Accountability 

Court-ordered program for batterer education, which includes a court-imposed consequence if the offender does not attend. Based in New York. Formerly known as the New York Model for Batterer Programs. 

845-842-9125 

https://www.nymbp.org/ https://nomas.org/ 

Women's Law  

Providing state-specific legal information and resources for survivors of domestic violence.  

https://www.womenslaw.org/ 

Conclusion

Domestic violence is a national crisis that can lead to poor outcomes for victims. Nurses have the responsibility to ensure that victims are properly screened, provided appropriate education, and supported with resources for safety. Creating a safe space for victims to share concerns, helping them to create escape plans, and respecting their decision to stay or leave the relationship is all a part of providing the best care possible. 

Florida HIV/AIDS

This fulfills the continuing education requirement of Florida HIV/AIDS for the state of Florida.  

An estimated 1.2 million Americans are living with HIV. As many as 1 in 7 of them do not even know they are infected. The others utilize the healthcare system in a variety of ways, from testing and treatment regimens to hospitalizations for symptoms and opportunistic infections. Healthcare professionals in nearly every setting have the potential to encounter patients with HIV as the disease can affect patients of any age or stage of life (4). Proper understanding of HIV is important in order to provide high-quality and holistic care to these patients. For nurses practicing in the state of Florida, it is also important to understand the laws, statutes, and regulations regarding testing, treatment, reporting, and confidentiality related to Florida HIV and AIDS within the state.  

Introduction   

An estimated 1.2 million Americans are living with human immunodeficiency virus (HIV). As many as 1 in 8 do not even know they are infected (7). The others utilize the healthcare system in a variety of ways, from testing and treatment regimens to hospitalizations for symptoms and opportunistic infections.

Healthcare professionals in nearly every setting have the potential to encounter patients with HIV as the disease can affect patients of any age or stage of life. Proper understanding of HIV is important in order to provide high-quality and holistic care to these patients. For nurses practicing in the state of Florida, it is also important to understand the laws, statutes, and regulations regarding testing, treatment, reporting, and confidentiality related to HIV and AIDS within the state.  

Statistics 

Rates of infection are not equal across demographic groups, and certain factors may increase a person's risk. Patient information to consider when determining someone's risk includes:   

Age 

As of 2021, the age group with the highest incidence of new HIV diagnoses is 13-34 years, approximately 58% of new infections (7). Cases are down 18% in this age group from 2017.  

Race/Ethnicity 

African Americans had the highest number of new HIV cases in 2021, at approximately 40% (7). This is followed by Hispanic/Latinos at 29%, and whites at 26%.  

Gender 

Males are disproportionately affected by HIV, accounting for 81% of new cases in 2021 (7). Females accounted for 24% of new cases. This data refers to the sex of someone at birth. When looking at the transgender population, those who have transitioned male-to-female were 2% of new cases and female-to-male, less than 1% (7). 

Sexual Orientation 

Men who have sex with men (MSM) remain the population most at risk of HIV, accounting for around 70% of all new infections in 2021 (7). Cases are down 13.5% in this group from 2017.  

Location 

Different areas of the country are affected at different rates for a variety of factors, including population density, racial distribution, and access to healthcare. The southern states are unmistakably more affected than other regions, and accounted for 52% of new cases in 2021 (7). Western states account for 21%, Midwest 14%, and Northeast 14% (7). 

Transmission 

Perhaps the most elusive part of this virus for many years was how it spreads. We now know that HIV is spread only through certain bodily fluids. An accurate understanding of HIV transmission is important for healthcare professionals to provide proper education to their patients, reduce misconceptions and stigmas, and prevent transmission and protect themselves and other patients (8).  

Bodily Fluids 

Bodily fluids that can transmit the virus include (9):   

• Blood 
• Semen and pre-seminal fluid  
• Rectal fluid  
• Vaginal fluid  
• Breastmilk  
• Fluids that may contain blood such as amniotic fluid, pleural fluid, pericardial fluid, and cerebrospinal fluid   

If one of these fluids comes into contact with a mucous membrane such as the mouth, vagina, rectum, etc., or damaged tissue such as open wounds, or is directly injected into the bloodstream, then transmission of HIV is possible (8).  

Ways of Transmission 

Scenarios where transmission is possible include:   

• Vaginal or anal sex with someone who has HIV (condoms and appropriate treatment with antivirals reduce this risk)  
• Sharing needles or syringes with someone who has HIV  
• Mother-to-child transmission during pregnancy, delivery, or breastfeeding (appropriate treatment during pregnancy, c-section delivery, and alternative feeding methods reduce this risk)  
• Receiving a transfusion of infected blood or blood products (this is very rare now because of screening processes for blood donations)  
• Oral sex with someone who has HIV (though this is very rare)  
• A healthcare worker receiving a sharps injury with a dirty needle (risk of transmission is very low in this scenario)  

HIV cannot be transmitted via:   

• Saliva  
• Sputum  
• Feces  
• Urine  
• Vomit  
• Sweat  
• Mucous   
• Kissing  
• Sharing food or drink  
• Ticks or mosquitos 

Reducing Transmission & Infection Control 

Patient education about risk and protection against HIV, testing, and what to do if exposed should be standard practice for healthcare professionals in nearly all healthcare settings. Ideally, primary care should include risk screenings and routine patient education to help prevent infections from occurring (or preventing worsening of infections that have already occurred) (8).  

Prevention Strategies 

Strategies to help prevent the spread of HIV include (8): 

• Identifying those most at risk, particularly MSM, minorities, and those who use drugs by injection  
• Ensure patients are aware of and have access to protective measures such as condoms and clean needle exchange programs  
• Provide routine screening blood work for anyone with risk factors or desiring testing  
• Providing access to PrEP medications where indicated (discussed further below)  
• Staying up to date on current recommendations by the U.S. Centers for Disease Control and Prevention (CDC), and HIV developments  
• Maintaining a nonjudgmental demeanor when discussing HIV with patients, to welcome open discussion   

Pre-Exposure Prophylaxis 

For patients with a repeated or frequent high risk of HIV exposure, such as those with an HIV+ partner or those routinely using needles for drugs, pre-exposure prophylaxis (PrEP) may be a good choice to reduce the risk of contracting the virus. When used correctly, PrEP is 99% effective at preventing infection from high-risk sexual activity and 74% effective at preventing infection from injectable drug use (10).  

Depending on the type of exposure risk (anal sex, vaginal sex, needle sharing, etc.), PrEP needs to be taken anywhere from 7-21 days before it reaches its maximum effectiveness (10). Most insurances, including Medicaid programs, cover PrEP at least in part (10). There are also federal and state assistance programs available to make PrEP available to as many people who need it as possible. Some side effects are commonly reported, primarily gastrointestinal symptoms, headaches, and fatigue (10).   

Viral Load 

For those who have a confirmed diagnosis of HIV/AIDS, the focus should be promoting interventions that will prevent further transmission. One of the biggest determinants for transmission is the infected person's viral load. Individuals being treated for HIV can have their viral load measured to ensure viral replication is being controlled as intended. A viral load lower than 200 copies of HIV per milliliter of blood is considered undetectable, meaning the virus is not transmissible to others (4). Even for those not receiving treatment, there are methods to reduce transmission (11).  

Infection Control Methods 

Methods of infection control for healthcare professionals include (3):  

• Universal precautions when handling any bodily fluids  
• Eyewear when at risk for fluid splashing  
• Careful and proper handling of sharps  
• Facilities having a standard plan in place for potential exposures  

If an exposure or needlestick does occur, the patient would ideally submit to testing for HIV to determine if the staff member is at risk. If the HIV status of the patient is unknown or confirmed to be positive, post-exposure prophylaxis (PEP) may be advised to start within 72 hours of exposure (12).   

Florida HIV/AIDS Treatment

When HIV is appropriately treated, advancement from HIV to AIDS can be significantly reduced, and quality and longevity of life maximized. In 2018, the CDC estimated around 65% of all US citizens living with HIV were virally suppressed, and 85% of those receiving regular HIV-related care were considered virally suppressed at their last test (5). However, as mentioned earlier, an estimated 13% of all HIV cases do not know they are infected. Appropriate medical care and keeping viral loads undetectable is one of the single most effective methods of preventing transmission (4, 5).   

For those receiving treatment, a multifaceted and individualized approach can reduce a person's viral load, reduce the risk of transmission, reduce the likelihood of developing AIDS, and preserve the immune system. Regardless of how early someone receives treatment, there is no cure for HIV, and an infected person will be infected for life. All individuals diagnosed with HIV (even asymptomatic people, infants, and children) should receive antiretroviral therapy or ART as quickly as possible after a diagnosis of HIV is made. The classes and available medications for ART include the following (1). There are many other combination formula HIV medications, for example emtricitabine/tenofovir (brand name, Truvada), although not listed here.  

Nucleoside Reverse Transcriptase Inhibitors (NRTIs) 

Nucleoside reverse transcriptase inhibitors (NRTIs) inhibit the transcription of viral RNA to DNA blocking reverse transcriptase (an enzyme needed for HIV replication). 

• Abacavir 
• Emtricitabine  
• Lamivudine 
• Tenofovir disoproxil fumerate  
• Zidovudine  

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) 

Non-nucleoside reverse transcriptase inhibitors (NNRTIs) inhibit the transcription of viral RNA to DNA by binding to and altering reverse transcriptase. As mentioned above, transcriptase is an enzyme HIV needs to make copies of itself. 

• Doravirine 
• Efavirenz 
• Etravirine  
• Nevirapine 
• Rilpivirine 

Protease Inhibitors 

Protease inhibitors block HIV protease (another enzyme needed for HIV replication). 

• Atazanavir 
• Darunavir  

• Fosamprenavir  
• Ritonavir  
• Saquinavir  
• Tipranavir  

Fusion Inhibitors 

Fusion inhibitors prevent the virus from entering the CD4-T lymphocyte cells (CD4 cells) of the immune system.  

• Enfuvirtide  

Integrase Strand Transfer Inhibitors (INSTIs)  

Integrase strand transfer inhibitors (INSTIs) block HIV integrase (an enzyme needed for HIV replication).  

• Cabotegrevir 
• Dolutegravir 
• Raltegravir 

Attachment Inhibitors 

Attachment inhibitors prevent HIV from entering CD4 cells by binding to the gp120 protein on the surface of the virus’ cell. 

• Fostemsavir 

Post Attachment Inhibitors 

Post attachment inhibitors prevent the virus from binding to and entering CD4 cells by block the CD4 receptors on the surface of some immune cells. HIV needs these receptors to enter the cells. 

• Ibalizumab-uiyk 

Capsid Inhibitors 

Capsid inhibitors interfere with the HIV capsid (a protein shell that protects the enzymes HIV needs for replication). 

• Lenacapavir 

Pharmacokinetic Enhancers 

Pharmacokinetic enhancers increase the effectiveness of HIV medications. 

• Cobicistat 

Florida HIV/AIDS Laws

The Omnibus AIDS Act is based on the premise that illness can be best controlled through public knowledge. If the public is aware of potential illness, and ways to avoid contracting and transmitting illness, that is the best method of prevention and further spread (2). The state of Florida became one of the first states with high rates of HIV infection within their population to enact legislation surrounding the AIDS epidemic. Transmission of HIV, as aforementioned, occurs through direct contact with virus-containing body fluids. Activities by which transmission involves such as sexual activity, needle stick, blood transfusion, or mother-to-baby, the government cannot regulate. Therefore, the governmental response to a disease epidemic must rely primarily upon the education of the public and its cooperation with their educational efforts and recommendations (2).  

Informed Consent 

The following are regulations surrounding informed consent and HIV testing in the state of Florida (2). 

Information Requirements 

Healthcare providers performing HIV tests must have advanced procedures in place regarding patient consent, testing samples, and informing patients of their results (2). “Since the 1998 amendments to the Act, health care providers must, as a matter of law, convey three pieces of information, all essentially involving the choice of a testing site, as part of the process of obtaining informed consent:  

1. Disclose that the provider is required by law to report the test subject’s name to the local county health department if the HIV test results are positive; 

1. Alert the patient that as an alternative, the patient may secure the HIV test at a site that tests anonymously, the locations of which the provider must make available; and 

1. Relate the extent of the confidentiality rights that adhere to the test results in the provider's patient records.” 

Minors 

“The general rule that parental consent is required prior to medical diagnosis or treatment of a minor does not apply when sexually transmitted diseases such as HIV infection are involved. Indeed, Florida specifically forbids telling parents the fact of the minor's consultation, examination or treatment for a sexually transmissible disease, such as HIV infection, either directly or indirectly (such as by billing a parent or their insurer for an HIV test without the child's permission).” 

“Infants and young children are treated as unable to make an informed decision and consent of their parents or legal guardian is required. For older children (such as teenagers), however, the provider must make an individual judgment whether the child, as phrased in Department of Health rules, ‘demonstrates sufficient knowledge and maturity to make an informed judgment,’ meaning, whether the child has the cognitive and emotional capacity to understand the risks and benefits of the test or treatment to which the child is being asked to consent.” 

Documentation 

“As with other medical procedures requiring informed consent, informed consent for HIV testing does not necessarily mean written consent. Except for donations of blood and other tissues and to obtain health or life insurance, Florida does not require providers to have the test subject sign a document authorizing the test. The health care provider need only enter a note in the medical record that the test was explained and consent was obtained.” 

Exceptions 

Exceptions to informed consent requirements by health care providers (2): 

Pregnancy 

“Following federal legislation and recommendations from CDC, Florida law in 1996 first imposed “mandatory offering” of HIV tests for all pregnancies upon presentation. In 2005, the statute was further amended to establish the present system of “opt out” testing, in which pregnant women are advised that the health care provider attending them will conduct an HIV test but that they have the right to refuse. The pregnant woman’s objection is required in writing, which must be placed in her medical record” (§384.31, F.S.)  

Emergencies 

“A provider may test without consent in "bona fide medical emergencies," but only if the provider documents in the medical record that the test results are medically necessary to provide appropriate emergency care or treatment to the test subject and the test subject is unable to consent” (§381.004(2)(h)3, F.S.).  

Therapeutic Privilege 

“The Act allows a "therapeutic privilege" that bypasses informed consent requirements when the provider's medical record documents that obtaining informed consent would be detrimental to the health of a patient suffering from an acute illness and that the test results are necessary for medical diagnostic purposes to provide appropriate care or treatment to the patient. This same privilege applies to all medical procedures for which informed consent is required. The statute emphasizes that this provision provides no basis for routinely testing patients for HIV without their informed consent” (§381.004(2)(h)4, F.S.).  

Sexually Transmissible Diseases 

“State laws permit HIV testing for sexually transmissible diseases on certain subjects, such as convicted prostitutes (§796.08, F.S.), inmates prior to release (§945.355, F.S.), and cadavers over which a medical examiner has asserted authority §381.004(2)(h)1.c., without the consent of the test subject. This exception includes exempting pregnancy “opt out” testing from informed consent requirements discussed above.”  

Criminal Acts 

“Victims of criminal offenses that involve transmission of body fluids may require the person charged with or convicted of the offenses to be tested for HIV infection by requesting a court to order the test” (§960.003(2), F.S.). “Similarly, when a defendant, prosecuted for certain offenses in which transmission might have occurred, has been ordered to or has voluntarily given a blood sample, the victim may request the sample be tested for evidence of HIV without the consent of the defendant” (§381.004(2)(h)6, F.S.).  

Organ and Tissue Donations 

“Various statutory provisions permit testing without informed consent in specifically identified specialty areas: certain blood and tissue donations; corneal removals and eye enucleation that Florida allows by law to be done without consent; autopsies to which consent to perform the autopsy was obtained” (§§381.004(2)(h)2, 5 and 9, F.S.).  

Research 

“Established epidemiologic research methods that ensure test subject anonymity is expected from informed consent” (§381.004(3)(h)8, FS) 

Abandoned Infants 

“When a licensed physician determines that it is medically indicated that a hospitalized infant have an HIV test, but the infant's parent(s) or legal guardian cannot be located after reasonable attempts, the test may be performed without consent. The reason why consent could not be obtained must be documented in the medical record and the test result must be provided to the parent(s) or guardian once they are located” (§381.004(2)(h)13, F.S.).  

Significant Exposure 

“The blood of the source of significant exposure to medical personnel or to others who render emergency medical assistance may be tested without informed consent” (§381.004(3)(h)10-12, FS).  

Repeat HIV Testing 

“Renewed consents are not required for repeat HIV testing either to monitor the clinical progress of a previously diagnosed HIV-positive patient or for conversion from a significant exposure” (§§381.004(2)(h)14 and 15, F.S.). 

Judicial Authority 

“A court may order an HIV test to be performed without the individual's consent” (§381.004(3)(h)7, FS). 

Florida HIV/AIDS Confidentiality

The following are regulations surrounding confidentiality of HIV testing in the state of Florida (2). 

Not every piece of medical information about a person who has been tested for HIV or assessed for AIDS is protected. “Only the fact that an HIV test was performed on an identifiable individual and any ‘HIV test result’ (negative as well as positive) are specially protected” (§381.004(2)(e), F.S.).  

The statute definitions (11): 

• HIV test: “test ordered after July 6, 1988, to determine the presence of the antibody or antigen to human immunodeficiency virus or the presence of human immunodeficiency virus infection” (§§381.004(1)(b), F.S.) 
• HIV test result: “laboratory report of a human immunodeficiency virus test result entered into a medical record on or after July 6, 1988, or any report or notation in a medical record of a laboratory report of a human immunodeficiency virus test” (§§381.004(1)(c), F.S.) 

“Only a laboratory report of an HIV test result entered in a medical record on or after July 6, 1988 (the effective date of the Omnibus AIDS Act), or any report or notation in a medical record of a laboratory report of an HIV test, falls within their scope.” 

“Explicitly excluded from the definition of an HIV test result are reports from patients of their HIV status to health care providers. Consequently, patient reports of their HIV test status from Department of Health anonymous testing sites, from home access HIV test kits or from any other sources do not constitute ‘HIV test results’ unless separately confirmed by the provider through a laboratory report or a medical record containing a laboratory report. Patient disclosures of an HIV test or infection to persons other than health care providers caring for the patient under the provisions of the Act also do not fall within the statute's special confidentiality protections.” 

Voluntary Partner Notification

The following are regulations surrounding voluntary partner notification of HIV exposure in the state of Florida (2). 

“The person ordering the HIV test (or that person’s designee), although under no liability exposure to the sexual or needle-sharing partners of their HIV-positive patients, is required to advise their patients with HIV-positive test results of the importance of notifying partners who may have been exposed” (§381.004(2)(c), F.S.). Practitioners are well advised also to tell the patient of the availability of voluntary partner notification services provided by the Department of Health. Under the authority provided in §384.26, F.S., county health department staff offers voluntary and confidential partner notification and referral services to persons infected with HIV. When notifying partners, county health department staff are required not to reveal the identity of the original client.” 

Florida HIV/AIDS Infection Reporting 

The following are regulations surrounding HIV infection reporting in the state of Florida (2). 

“In 1996, Florida became one of the first states with a high incidence of AIDS to authorize regulatory procedures requiring physicians and laboratories to report to local health authorities HIV-positive test results with patient identifiers” (§384.25, F.S.). “Practitioners and clinical laboratories that fail to report HIV-positive test results are subject to a $500 fine and disciplinary action by their licensing boards” (§384.25(4), F.S.).  

“This change was spurred in part by the Ryan White CARE Act. Enacted in 1990 and reauthorized in 2009 as the Ryan White HIV/AIDS Treatment Extension Act, this federal legislation now provides funding to urban areas, states and localities to improve the availability of care for low-income, uninsured and under-insured AIDS and HIV-infected patients and their families.”  

“Florida’s HIV infection-reporting requirements increases available Ryan White funding for persons with the illness and enables the Department of Health to link them to medical and support services earlier in the process of infection.” Under the rules by the Department of Health of Florida:  

1. “Practitioners must report to their local county health department within two weeks of the HIV-positive diagnosis of all persons, EXCEPT infants born to HIV-positive women, which must be reported the next business day” (Rule 64D-3.029, FAC and Rule 64D-3.030(5), FAC). 

1. “Clinical laboratories must report to the local health department HIV test results from blood specimens within three days of diagnosis” (Rule 64D-3.029, FAC).  

Florida Laws and Regulations

Introduction

The state of Florida has several statutes that govern the practice of nurses. These statutes consist of Chapters 456 and 464 in Title XXXII Regulation of Professions and Occupations. The Florida Administrative Code is where Division 64B9 is located.  

Chapter 464, often called the Nurse Practice Act, is separated into two parts. Part I discusses the advanced practiced registered nurse, registered nurse, and licensed practical nurse. This statute ensures that every nurse practicing in Florida is held to and meets the same minimum standards for safe practice.

Because of this, nurses who do not meet the minimum requirements or display harm to society are not allowed to practice nursing in the state of Florida. The Board of Nursing is the governing body for the Nurse Practice Act and deals with matters such as providing licensure, creating rules, and managing disciplinary actions. Part II of chapter 464 focuses on the certified nursing assistant.  

Chapter 456 is a statute directed at all healthcare providers and professions. This statute lists the provisions that Chapter 464 is built on.  

Division 64B9 is part of the Florida Administrative Code that provides specific rules that pertain to nurses and how the profession is regulated in terms of eligibility to take the examination of selected practice, set standards for nursing education curriculum and institutions, continuing education requirements, license renewal; rules for impairment of the nurse in the workplace and more.  

This course is designed to meet the requirements of Division 64B9-5 as it pertains to two continuing educational hours about Florida’s laws and regulations of nursing practice.  

Definitions (3, 4, 5) 

Advanced or specialized nursing practice — completion of post-basic specialized training, experience, and education that are appropriately performed by an advanced practice registered nurse. The advanced-level nurse can “perform acts of medical diagnosis and treatment, prescription, and operation” under the authorization of a protocol with the supervision of a physician. 

Advanced practice registered nurse (APRN) — any individual who is licensed in this state to practice professional nursing as defined above and holds a license in advanced nursing practice, including:  

• Certified Nurse Midwives (CNM or nurse midwife)
  • Able to perform superficial or minor surgical procedures as defined by a protocol and approved by the employing medical facility or with a backup physician in the case of a home birth. 
  • Start and perform approved anesthetic procedures. 
  • Order appropriate medications based on patient and condition. 
  • Manage care of the normal obstetrics patient and the newborn patient.  
• Certified Nurse Practitioners (CNP) 
  • Able to manage some medical issues guided by facility or supervising provider protocols.  
  • Manage and monitor patients who have stable, chronic illnesses. 
  • Start, monitor, and adjust therapies for select, uncomplicated illnesses.  
  • Order occupational and physical therapy based on patient needs. 
• Certified Registered Nurse Anesthetists (CRNA) 
  • Able to order pre-anesthetic medications as stated and approved by facility protocols and staff. 
  • Determine and consult with the supervising anesthesiologist about the proper anesthesia for patients based on labs, history, and physical and patient conditions. 
  • Assist with managing the patient in the post-anesthesia care unit. 
• Clinical Nurse Specialists (CNS) 
  • A nurse prepared in a CNS-focused program that meets the requirements of a typical APRN program. Additionally, they are trained in the area of expertise that pertains to the advanced practice of nurses. 
• Psychiatric Nurse 
  • Has a master’s or doctoral degree in psychiatric nursing and has a national advanced practice certification as a psychiatric mental health advanced practice nurse. 
  • has two years of post-master's clinical experience under the supervision of a physician. 
  • They can prescribe psychotropic controlled substances for the treatment of mental health disorders. 

Board — the Board of Nursing. 

Licensed Practical Nurse (LPN) — any person licensed in this state or holding an active multistate license under s. 464.0095 to practice practical nursing as defined below. 

Practice of practical nursing — the performance of select actions, including the management of specific treatments and medications, while taking care of the ill, injured, or infirm; prevention of illness, promotion of wellness, and health maintenance in others under the direction of a registered nurse, or a licensed provider: physician, osteopathic physician, podiatric physician, or dentist; and the teaching of general health principles and wellness to the public and students other than nursing students. A practical nurse is responsible and accountable for making decisions based on their educational preparation and experience in the profession. 

Practice of professional nursing — the performance of actions requiring substantial specialized knowledge, judgment, and nursing skill based on applied principles of physical, psychological, social, and biological sciences, which shall include, but are not limited to: 

• The nursing process consists of assessment, nursing diagnosis, planning, intervention, and evaluation of care; teaching and counseling of the ill, injured, or infirm in matters of health; prevention of illness, promotion of wellness, and maintenance of the health of others. 
• The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner as they are authorized to do so by the laws of this state to prescribe such medications and treatments. 
• The management and education of other individuals, such as nursing students, in the theory and performance of any of the acts described above. 

A professional nurse is responsible and accountable for making decisions based on the individual's educational preparation and experience. 

Registered nurse (RN) — means any person licensed in this state or holding an active multistate license under s. 464.0095 to practice professional nursing as defined above.  

A registered nurse first assistant (RNFA) — is a registered nurse who assists in surgery while in the hospital setting under a physician. They help maintain cost-effective and quality surgery for patients in Florida. They must be certified in perioperative nursing via a core curriculum approved by the Association of Operating Room Nurses, Inc. 

Board of Nursing: Members and Headquarters Location 

Florida’s Board of Nursing has 13 unique members that Florida's governor appoints. To maintain diversity and representation of the entire nursing profession, the following criteria must be met (5): 

• Seven members must be RNs with a minimum of four years of experience in practice.  
  • One must be an APRN 
  • One must be a nurse educator 
  • One must be a nurse executive 
• Three members must be LPNs with a minimum of four years of experience in practice.  
• The final three members have no connection to the nursing profession or affiliation or contract with a healthcare agency. 
• One member must be over the age of 60 
• All members must be residents of the state of Florida 

Membership terms last for four years; however, if the governor does not have a successor to appoint, the members can serve for another four years. The Board of Nursing's headquarters is in Tallahassee per Florida statute (5). 

The members of the Board have several roles and responsibilities while serving. Their primary job is to ensure that nurses practicing in Florida are doing so safely. To do this, the Board members can create and implement rules or provisions to add to the Nurse Practice Act.

They can approve educational programs for institutions wishing to teach nursing. They can take disciplinary action against a nurse for violating the Nurse Practice Act or other Florida laws. Disciplinary actions can consist of citations, fines, or disciplinary guidelines based on the nurse in question, previous offenses, and the severity of the violation. (5).  

Licensure by Examination and Endorsement 

Initial licensure requires an individual to examine their desired profession: NCLEX-RN, NCLEX-LPN, and either the American Nurses Credentialing Center (ANCC) or the American Association of Nurse Practitioners (AANP) version for those wishing to become an APRN. In order for the Board of Nursing to approve an individual to sit for their desired examination, a list of requirements must be met in total (5):  

• You must correctly complete an application for the desired examination and submit a fee set by the Board.  
• Submit to a background check conducted by the Department of Law Enforcement. 
• Must be in good physical and mental health and receive a high school diploma or equivalent. 
• Has completed the following requirements: 
  • Graduate from an approved program on or after July 1, 2009, OR 
  • Graduate from a prelicensure nursing education program that has been determined to be equivalent to an approved program by the Board before July 1, 2009 
• Must have the ability to communicate effectively in English as determined by the Department of Health through another examination as indicated. 

It is important to note that there is a section dedicated to the scenario of an individual failing the examination or needing to take it within six months of graduating.  

Candidates can take the test up to three times if they fail it. Suppose an individual needs to pass their examination of choice after three attempts. In that case, they must take a Board-approved remediation course before they can sit for the examination again. From there, they are given three more chances to take and pass the test before they must remediate again. Reexamination must occur within six months of the approved remediation course (5).  

If an individual fails to take their examination within six months of graduation, they must take an exam preparation course approved by the Board. It is to be advised that the individual must pay for the course without using federal or state financial aid (5).  

Courses completed in a professional nursing education program that are at least equivalent to a practical nursing education program may be used to satisfy the education requirements for licensure as a licensed practical nurse. This means a registered nursing program student could take the licensure for an LPN license once the courses they have taken meet the LPN licensure requirements (5). 

If a nurse holds licensure in another state or US territory and decides to obtain Florida licensure, theycan do so through endorsement. Florida requires those who apply to submit a nonrefundable fee, complete the application, and provide fingerprints for a criminal background check. The Florida Board of Nursing will not issue a license to an individual under investigation when applying (5).  

Military Spouses 

Applying for a license through endorsement is a route that can be used for nurses who are traveling with military spouses on official military orders. Nurses must have actively practiced nursing for two of the three years before applying for a license. Military spouses also have the option of obtaining a 12-month temporary Florida license if they meet the requirements (4):  

• Holds a valid nursing license in another state 
• Has a negative criminal background check 
• Has not failed their licensure exam 
• Has not had any disciplinary action taken against them in another state 

Licensure by Compact 

Over 40 states in the United States have created legislation to allow nurses to work under one multistate license (2). This means a nurse originally licensed in Florida could work in any other state that participates in the Nurse Licensure Compact without obtaining licensure for each state they wish to work in if they have a multistate license. This has proven especially useful over the years due to the growing nursing shortage and global pandemic.  

Many states like Florida are offering to provide multistate licenses to nurses during their initial examination. If a nurse does not obtain a multistate license initially, they can do so later. They must pay a fee and submit fingerprints for a background check. Nurses must also meet any other requirements set by the state of Florida (2).  

It is important to note that in Florida, the nurse who holds the compact license must claim residency in the state. If the nurse were to claim residency in another state, they would no longer have a multistate license issued by Florida. If the state they move to is part of the Nurse Licensure Compact, they might be eligible to obtain a compact license in their new home state (2, 5). 

(2) 

Delegation to the Unlicensed Assistive Personnel (UAP) or Unlicensed Personnel (UP) 

The Nurse Practice Act defines delegation as transferring a task or activity during a specific situation by a qualified nurse, through licensure and experience in the task, to a competent individual. Different facilities may have several ways of determining the competence of the individuals they employ, but ultimately, the decision rests with the RN or LPN.

The licensed provider must evaluate the task's difficulty, the potential for predictable or unpredictable harm or rapid change in the patient's condition, and the level of communication required with the patient. They must also consider the resources available and skills the UAP can do at their facility (4).  

When delegating, it is essential to assess the UAP's skill set through validation or verification. The nurse should communicate clearly regarding the delegated task and explain the desired outcomes. They should also explain what undesired outcomes could occur, what should be done if an undesired outcome does happen when the task should be completed, and if supervision by the nurse is required.

The nurse should follow up to ensure the task was done correctly and within the set time frame. The nurse should be aware that the delegated task and any outcomes are the nurse's responsibility, and they are ultimately held accountable for it. So, if it is an important task, it may be in the best interest of the nurse to delegate another task to the UAP and perform the critical task themselves (4).  

There are a few skills that cannot be delegated to the UAP: 

• A skill that is not within the delegating nurse’s scope of practice  
• Activities require using the nursing process or specific education, judgment, training, or skills. 
• Initial assessments and progress evaluations relate to the patient's plan of care. 
• Skills that a UAP needs to display competence.  

IV Administration by LPNs 

As mentioned above, LPNs and RNs have a few variations in their scope of practice. LPNs can administer and perform some parts of IV medication therapy instead of the RN, who can do all. IV therapy administration is the infusion or injection of a medication via the intravenous system.

This method involves several aspects, including evaluating, observing, monitoring, discontinuing, titrating, managing, planning, documenting, and intervening during administration. RNs do not always have to be onsite when delegating IV administration to an LPN, but knowing policies and when an RN must be on site is essential (4).  

LPNs cannot do any of the following (4): 

• Initiate blood or blood products or plasma extenders. 
• Mix IV solutions. 
• Administer or initiate cancer treatments such as chemotherapy or investigational medications. 
• IV pushes, except for heparin or saline flushes. 

LPNs may care for patients receiving these therapies, such as actively receiving a blood transfusion, but they cannot do the above.  

LPNs can (4): 

• Calculate and adjust flow rates. 
• Observe and report any signs of adverse effects of IV medications. 
• Assess IV insertion sites and change dressings as needed and as educated. 
• Remove IV catheters or needles from peripheral veins. 
• Hang IV hydrating fluids. 

In order for an LPN to administer IV medications through a central line, they must do so under the direction of an RN and have four hours of IV therapy education on central lines. This four-hour requirement can be applied to the 30 total hours LPNs must do on IV therapy (4).  

LPN Supervision in Nursing Homes 

According to Florida law, LPNs can supervise other LPNs, certified nursing assistants (CNAs), or UAPs in the nursing home setting. To be considered for a supervisory position, the LPN must have completed 30 hours of board-approved, post-basic education courses under the supervision of an RN.

The LPN must also have at least six months of full-time clinical experience either in a hospital or nursing home setting. If the LPN takes a course outside of the Board’s approval courses, the provider of said course must test the LPN and provide attestation of the LPN’s competency (4). 

The supervisory LPN's role is to provide other LPNs, CNAs, and UPAs with guidance and inspection of their completed task per their appropriate scope of practice. The LPN can only delegate tasks within their scope of practice and be assured that the one they are delegating to demonstrates competency (4). 

Certified Nursing Assistant (CNA) 

The certified nursing assistant is similar to the UAP. Still, to be certified, they must have completed a background check conducted by the Board of Nursing, prove they can read and write, and pass the nursing assistant examination. Once the criteria listed have been met, CNAs can provide general care and assist with activities of daily living under the direction of an RN or LPN. They can also participate in postmortem care and perform CPR (4).  

Maintaining Medical Records 

For RNs and APRNs in private practice, the Florida Nurse Practice Act has two rules regarding maintaining medical records. The first applies to the death of the nurse. Whoever legally represents the RN or APRN must post a notification in the county newspaper stating where the medical records are being stored and who to contact if an individual wants to obtain the records. The documents must be stored for a minimum of two years after the death of the nurse (4).  

At the 24-month mark, several notices must be posted in the county newspaper, one notification for four consecutive weeks, that the medical records will be destroyed four weeks after the last day of the fourth week that the notice was published (4).  

The second rule pertains to an RN or APRN who has terminated or relocated their practice. The rule states that the RN or APRN maintains and holds onto the medical records for at least two years. They must let those who were patients know about the date of termination or relocation and where the medical records can be retrieved.

The notice must be made public, such as in a newspaper, with a minimum appearance of four times over four weeks. A sign must be placed at the location of the business about the termination or relocation until the termination or relocation happens. This sign must tell patients about the opportunity to obtain their medical records (4). 

Continuing Education (CE) Requirements 

Florida law requires that for renewal of a nursing license, the nurse seeking renewal must complete a set amount of CE hours. Over the two years, 24 hours must be completed, one for each month. Two of those hours must be about the Florida Nurse Practice Act and the other laws that pertain to the nursing profession.

Two hours are required to investigate medication errors and how to prevent them. A one-hour HIV/AIDS is necessary for initial renewal but does not have to be repeated. There must be a two-hour course on domestic violence done every third renewal. As of August 2017, a two-hour course on recognizing impairment in the workplace is required with each renewal (4).  

In Florida, completed CE courses are automatically reported to a tracking system created by the Department of Health’s Division of Medical Quality and Assurance (MQA) or manually by the individual. Those who attend CE courses will obtain a certificate of attendance. The attendee is advised to maintain a copy of those certificates for at least four years.

For Florida, the provider of the course, the individual or company that is offering the training, has 90 days (about 3 months) to report to the tracking system, so if the nurse’s date of renewal is less than 90 days, it is suggested that the course be manually reported by the nurse (4). 

If a nurse has two licenses, such as RN and LPN or APRN and RN, they may be able to comply with both license requirements through one set of CE requirements. For example, an RN with an LPN license can meet all the CE requirements of the LPN license by completing the RN requirements (4). 

Nurses who serve as expert witnesses and provide expert opinions in writing can obtain 2.5 hours for each case. The case must cite at least two current articles of reference being reviewed regarding the Nurse Practice Act (4). 

There are a few exemptions to completing the CE renewal requirements. It is advised that the nurse contact the Board of Nursing with specific questions or concerns regarding renewal and CE requirements (4): 

• If the nurse is on active duty for the US military within six months of the renewal date. 
  • This does not apply to short periods of active duty, such as summer or weekend drills. 
  • This does not apply to those on duty in the US Public Health Service. 
• If the nurse’s spouse is a member of the US military and the nurse was absent from the state of Florida because of military duty. 
  • The nurse must provide adequate proof of the spouse's absence and military status. 

Disciplinary Action 

As mentioned above, the Florida Board of Nursing, as outlined in the Nurse Practice Act, can discipline nurses as they see fit regarding all violations of Florida rules and laws. The Board created a variety of ways a nurse can be punished, ranging from probable-cause panels to citations to disciplinary hearings to loss of nursing license. The severity of the violation reflects on which method the Board of Nursing may take (5). 

There are three probable-cause panels in Florida: North Florida, Central Florida, and South Florida. The purpose of these panels is to determine if there was “probable cause” or reasonable ground for the reported case. They decide if a case needs action taken. The panel members review each case and compare it to others of a similar nature, how the Board has treated those cases in the past and what the Board's guidelines entail. The panel can recommend and consider rules regarding procedures, penalties, and disciplinary actions (5)  

Citations can be given in lieu of other forms of discipline. The citation is issued within six months of a complaint being filed and contains the request for the recipient to fix the violation within a specified time frame. These violations are usually classified as “minor” in nature, such as false advertising, falsely using a nursing title, or failure to report the change of address or updates of information required by the Board.

Other reasons a citation can be issued include failing to report a misdemeanor within 30 days of a ruling or failing to utilize the law-required prescription drug monitoring system. Each of these citations can come with a fine, usually ranging from $100 to $250 in amount; however, if a nurse is found guilty of sharing passwords, codes, keys, or other forms of entry to a secure medication administration device or information technology system a fine of $1,500 can be given. In addition, the nurse would have to take a two-hour CE course on legal nursing aspects within 60 days of the citation being issued (5).  

The Board of Nursing has the power to take any of the below appropriate actions against nurses who have violated parts of the Nurse Practice Act. It is important to note that any of the actions can be combined, depending on the severity of the violation and the action taken by the nurse after the violation was committed (5): 

• Probation, suspension, or revocation of a license 
  • It can be emergently done depending on the situation.  
• Require CE course(s) to be done 
• Letter of concern 
• Reprimand 
• Administer a fine 
• A personal appearance is required before the Board of Nursing to monitor compliance. 
• Restrict or limit a nurse's scope of practice. 
  • Example: prohibiting a nurse from administering any narcotics after they are participating in drug diversion 
• Referral to the Intervention Project for Nurses (IPN) 

The Board of Nursing has also created an extensive, but not all-encompassing list of reasons why a nurse can be disciplined (5): 

• Sexual misconduct 
• Unprofessional conduct 
• Participating in crime related to healthcare fraud 
• Making or filing a false report to appease state or federal law 
• Willfully hindering another individual in filing a report that is required by state or federal law 
• Testing positive on any drug screen when the individual has no medical/other reason for using the drug 
• Inability to practice nursing with satisfactory skill and provide safe patient care due to the use of narcotics, drugs, alcohol, chemicals, or other substances that may impair an individual 
• Inability to practice nursing with satisfactory skill and provide safe patient care due to an illness, physical or mental condition 
• Failing to meet minimal standards of acceptable nursing practice 
• Accepting and performing professional responsibilities the nurse knows or has reason to know they are not skilled to perform 
• Delegating or contracting for the performance of professional duties by a person who the nurse knows or has reason to know is not qualified by training, experience, and authorization required to perform 
• Failing to identify the type of license the nurse is practicing under through written (can include a nametag) or oral notice to a patient 
• Performing or attempting to perform healthcare services on the wrong site or the wrong procedure on the wrong patient includes unauthorized procedures  
• Performing or attempting to perform healthcare services that are medically unnecessary or otherwise not related to the patient’s diagnosis or medical condition(s) 
• Being convicted or found guilty of or pleading nolo contendere (no contest) to a crime in any jurisdiction that directly relates to the practice of nursing or the ability to practice nursing 
• Being convicted of or found guilty of, or pleading nolo contendere to misdemeanors related to failure to protect an adult from abuse, neglect, and exploitation; fraudulent practices; theft and robbery; or having committed an act of domestic violence or child abuse 
• Defaulting on a student loan that has been issued or guaranteed by the state or federal government 

As with everything in life, the Board of Nursing has created guidelines for imposing discipline. They have a set minimum and maximum amount when it comes to fines. They have time frames for probation or supervision, conditions regarding probation, or the reinstatement of a license. What route they decide to take depends upon the specific case being presented to them. Sometimes, the circumstances presented to the Board are enough to elicit decisions outside the general guidelines. Some of these circumstances are (5): 

• Length of time a nurse has practiced 
• Presents a danger to the public 
• Any visible effort at rehabilitation 
• Treatment and disciplinary hearing costs 
• Actual physical or other forms of damage caused by the nurse 
• Financial hardships 

The Board has a timeframe in which a complaint must be filed. Most of the time, it is within a six-year window from the time the incident occurred. However, in certain circumstances—criminal actions, sexual misconduct, impairment of the nurse, or usage/diversion of controlled medications—the Board may allow the complaint’s time frame to extend beyond the six-year timeframe.

Suppose action such as fraud, intentional misrepresentation, or concealment is utilized to hide the violation during the six years. In that case, the timeframe to file a complaint can be extended to 12 years from when the incident occurred (5).  

If the Board of Nursing suspends a nurse's license or agrees to have the license suspended to avoid further action against them, the nurse can possibly file a petition to have their license reinstated. Any final orders or terms issued during the initial suspension must be met as a whole, and the nurse must be able to demonstrate the ability to perform nursing practice safely.

Sometimes, a time frame is set for when a nurse can file a petition; sometimes, there is not. If this is the case, a nurse can appeal as soon as they can after meeting the terms and conditions given to them by the Board (5).  

The Board will determine what a nurse must do to demonstrate safe practice. This is based on the violation. For example, a nurse who is working while under the influence of medications or alcohol may be ordered to attend a treatment program with proof of sobriety, references, and completion of any court-mandated sanctions. Nurses must often present to the Board of Nursing in person and speak on their ability to practice nursing (5) safely.  

The three-strike policy is utilized when it comes to reinstating a license. Suppose a nurse has been found guilty on three separate occasions of a complaint about drug/narcotic usage or the diversion of medications from patients to the nurse for personal use or to sell. In that case, the Board will not reinstate the license (5).  

Relicensing a nurse who has had their license revoked is similar to what happens when a license is suspended. However, the nurse must reapply for the permit and meet all conditions set by the Board. Nurses may have to sit for another examination or take board-approved continuing education if the nurse has been out of practice for an extended period of time. They may require a nurse to participate in Florida’s Intervention Project for Nurses (IPN) program or at least be evaluated for it (5).  

Nurses are held accountable for reporting the actions of other nurses and any misconduct to the Board of Nursing. They must report sexual misconduct or healthcare fraud. If they know or have reason to believe that another nurse is not practicing safely or is practicing under the influence of alcohol or medications, they are required to report it (5).

Florida’s Intervention Project for Nurses (IPN) 

Created in 1983 under the authority of the Nurse Practice Act, IPN was designed to protect the public by monitoring nurses whose skills have been compromised due to improper use of medications or alcohol or the impairment of mental or physical health. IPN is not a treatment center.

Instead, they provide nurses with access to Board-approved practitioners who specialize in addiction, mental health, and other medical conditions to assist the nurses in restoring themselves to a level of safe practice. They also conduct monitoring after a nurse has been discharged from treatment, interventional training, consultations, and advocacy for those who participate (1).  

As mentioned above, nurses have an obligation to report themselves or nurses who are, or they have reason to believe, unsafely practicing nursing while under the influence of alcohol or medications. The report is confidential if a nurse self-reports or is reported to the IPN only and they complete treatment and five years of monitoring. If the Board of Nursing becomes involved, either through a failure to report or complete treatment, disciplinary action may be taken (1).  

In the beginning, nurses are not able to practice during the initial evaluation period or when the treatment is being determined. After a treatment plan is made, it is up to the discretion of the IPN and the providers involved in the treatment to say if the nurse is able to continue working as a nurse. Restrictions on a nurse’s practice are often implemented during the beginning phase of treatment(1).  

To be determined “fit to practice,” the nurse must meet all requirements set by their providers and the IPN. They must sign an advocacy contract, submit to random drug tests, verbalize their understanding of practice restrictions, and participate in a weekly support group for nurses (1).

Conclusion

Despite the extensive outline of the Nurse Practice Act and other state rules in this course, it only briefly narrates all Florida laws pertaining to nurses. In addition to this course, nurses must stay on top of new legislation being proposed and implemented regarding their profession and continually review the content in the state laws. Nurses who travel to other states to practice their profession should be educated on each state’s rules regarding nursing practice, as they can differ from state to state. A conscious effort must be made to follow the laws set in place to practice nursing safely and legally in the state of Florida.

Florida Medical Errors

This fulfills the continuing education requirement for Medication Errors Prevention for the state of Florida.  

For as long as there have been medical professionals, there have been medical errors.  Medical errors can be small and seemingly insignificant to a catastrophic sentinel event.    

The Joint Commission (TJC) is a healthcare accrediting agency that sets the standard for patient safety.  Each year, TJC publishes a list of national patient safety goals.  These goals are focused on the prevention of medical errors.  In 2019, the World Health Organization (WHO) found that medical errors harmed up to 40% of patients within the global healthcare system.  These medical errors not only cause harm to millions of people worldwide, but they also cost billions of dollars on an annual basis (8). 

There are many different types of medical errors.  They include, but are not limited to: medication errors, healthcare-acquired infections, surgical errors, lab errors, falls, documentation issues, and omitted care.  Healthcare workers must be aware of the possible harm that can be caused by medical errors and the ways in which they can be prevented.   

Introduction   

For as long as there have been medical professionals, there have been medical errors.  Medical errors can be small and seemingly insignificant to a catastrophic sentinel event.    

The Joint Commission (TJC) is a healthcare accrediting agency that sets the standard for patient safety.  Each year, TJC publishes a list of national patient safety goals.  These goals are focused on the prevention of medical errors.  In 2019, the World Health Organization (WHO) found that medical errors harmed up to 40% of patients within the global healthcare system.  These medical errors not only cause harm to millions of people worldwide, but they also cost billions of dollars on an annual basis (8).

There are many different types of medical errors.  They include, but are not limited to: medication errors, healthcare-acquired infections, surgical errors, lab errors, falls, documentation issues, and omitted care.  Healthcare workers must know the possible harm caused by medical errors and how they can be prevented.   

Factors That Impact the Occurrence of Medical Errors 

There are multiple factors that can increase the probability of a medical error occurring.  Healthcare worker behaviors and attitudes, staffing, and communication are among those that have the most significant impact on medical errors. 

In healthcare, a risky behavior is an action that may lead to a compromise in patient safety.  Why would any healthcare worker engage in at-risk behaviors?   Healthcare workers, especially nurses, are generally compassionate and are ultimately looking out for the patients' welfare in their care.  Risky behaviors produce a quick, positive reward without any perceived risk of patient harm.  These risky behaviors can range from a simple short-cut like not checking two patient identifiers to a blatant disregard for hospital/facility policy.  In all instances, the risk for patient harm is real and will eventually occur (13). 

Understaffing in the hospital setting continues to be a factor contributing to medical errors.  Poor nurse-to-patient ratios can lead to a variety of medical errors.  Ordered patient care may go undone, leading to further medical errors adverse patient outcomes (7).  Understaffing leads to fatigue and burnout.  A nurse in this state of mind is prone to committing medical errors. 

Miscommunication between healthcare professionals and patients and miscommunication between healthcare professionals also contribute to the occurrence of medical errors.  As part of their national patient safety goals, TJC has had a communication component almost every year.  They have recognized that effective communication is paramount in the prevention of medical errors.  A lack of effective communication can be a leading cause of every type of medical error. 

In an effort to decrease communication errors, TJC has taken measures to ensure that effective communication is promoted in a variety of different situations.  TJC has instituted a list of unacceptable medical abbreviations.  This list will decrease medication errors by removing confusion when medications are ordered (11).  They also developed a handoff communication protocol for facilities to implement.  The handoff communication occurs anytime that care is passed from one caregiver to another.  In Florida medical errors prevention, this communication protocol is used to ensure that all pertinent patient information is passed on to the next healthcare worker rendering care to the patient.  By using effective handoff communication, all information should be passed on, and mistakes should be avoided (10).  

Recognizing Error-Prone Situations 

 Studies have shown that the majority of medical errors occur in the inpatient setting.  The most common areas for medical errors are the operating room (OR), the emergency room (ER), the intensive care unit (ICU), and the medical/surgical floors (1).   

What is it about the inpatient setting that makes it such an error-prone area?  More specifically, why do medical errors occur in the ICU, OR, and ER?  These are all high-stress areas where effective communication between all parties is vital.  Breakdown in communication in these areas will lead to catastrophic medical errors.  When the stress level rises, the probability of medical errors occurring also rises.  These are also fast-paced areas where the condition can change in the blink of an eye.  When we work in such a busy area, we can forget important details.  Effective communication is a big part of Florida medical errors prevention.  Miscommunication in these environments is a recipe for medical errors.  

As the most common type of medical errors is medication errors, we do need to talk about medication administration.  Nurses are taught the five rights of medication administration in nursing school:  

1. Right drug. 
2. Right patient. 
3. Right dose. 
4. Right route. 
5. Right time. 
   

When working in a busy inpatient setting, nurses may fail to perform the five rights in order to save time (5).  Neglecting any one of the five rights of medication administration can cause a medical error.

Processes to Improve Patient Outcomes 

In the technological age in which we live, it is more important than ever before that healthcare facilities consistently demonstrate good patient outcomes.  The Centers for Medicare & Medicaid Services (CMS) places great importance on the patient experience and their perception of their healthcare experience quality.  Every patient who experiences a hospital stay may be asked to complete a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.  The survey results are published quarterly on the CMS Hospital Compare website.  There, patients can compare the hospital's results and choose a hospital where they would like to have their care rendered (4).  A medical error could very well cause a patient to give a facility a poor rating on the HCAHPS survey. That is why we must take Florida medical errors prevention seriously.

When medical errors have occurred, they will often result in a risk management response to investigate why the error has happened and how it can be prevented in the future – a root cause analysis (RCA).  An RCA will often lead to department-driven performance improvement projects (PIP) to eradicate the problem and improve patient outcomes.  A proactive facility trying to minimize medical errors will have multiple department and facility-wide PIP. 

As previously stated, each year TJC publishes a list of patient safety goals.  These goals will often guide a facility on specific patient outcomes that have required attention for improvement on a national level.  They focus on the prevention of medical errors, and as such, they can steer PIP.  Accreditation hinges on the ability of a facility to improve and consistently deliver positive patient outcomes.  Below is the current list of TJC's patient Safety Goals: 

1. Identify patients correctly.

Use at least two ways to identify patients. For example, use the patient's name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

2. Improve staff communication.

Get important test results to the right staff person on time.

3. Use medicines safely.

Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups, and basins. Do this in the area where medicines and supplies are set up. 

Take extra care with patients who take medicines to thin their blood. 

Record and pass along correct information about a patient's medicines.

Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient.

Give the patient written information about the medicines they need to take. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.

4. Use alarms safely.

Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

5. Prevent infection.

Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

6. Identify patient safety risks.

Reduce the risk for suicide.

7. Prevent mistakes in surgery. 

Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body. 

Mark the correct place on the patient's body where the surgery is to be done. 

Pause before the surgery to make sure that a mistake is not being made.

(12)

Responsibilities for Reporting as a Part of Florida Medical Errors Prevention

Each individual facility across the nation may have different policies and procedures for the reporting of medical errors within their facilities.  There is, however, a growing trend throughout the healthcare industry of creating a culture of safety.  The culture of safety promotes the reporting of medical errors and "near misses" in an open, transparent and non-punitive manner.  Facilities are taking a stand to ensure patient and staff safety over other competing goals within their system (14).  Near miss reporting allows for issues to be addressed and corrected before an actual error occurs.  Taking a non-punitive approach to self-reporting of medical errors promotes accurate reporting and allows for a true picture of what is happening in the facility. 

The State of Florida has mandated that all licensed healthcare facilities implement an internal risk management program.  In Florida medical errors prevention, it is the responsibility of the risk management team to: 

1. Investigate and analyze the frequency and cause of general and specific types of patient adverse incidents. 
2. Develop measures to minimize the risk of adverse incidents. 
3. Analyze patient grievances that relate to care and quality of services. 
4. The development and implementation of an incident reporting system. 

State law further requires that the Agency for Healthcare Administration (AHCA) post quarterly reports on adverse incidents (9). 

Safety Needs of Special Populations 

There are certain groups of people that are especially vulnerable to experience a medical error.   

Elderly 

The elderly are especially susceptible to medical errors.  Generally, as we get older, we tend to start taking more medications.  Complex medication regimens offer a greater opportunity for medication errors.  Many medications require close monitoring of vital signs and/or blood levels.  Drug-related issues are a major driving force for both ER visits and nursing home admissions among the elderly (3).  Declining cognition, poor vision, and increased forgetfulness associated with aging can also play a part in medication errors.  Education with frequent reinforcement and the use of support people are crucial to help prevent medication errors.   

The elderly are also at a higher risk for falls.  Falls within a medical facility can lead to further medical complications, increased length of stay, and serious injury.  Patients at risk for falls need to be identified and place on a fall prevention protocol. 

 Children 

 Children are on the other side of the spectrum and are also another group that are at higher risk for medical errors.  Younger children may be unable to accurately voice exactly their problem is, or what symptoms they are experiencing.  They must rely on both parents and other caregivers for the coordination of their care.  Though a parent may know their child well, they may not be able to properly convey their child's issues to the healthcare professional.  It is also important to realize that children are not little adults.  Care plans must be catered to their specific phase of life. 

Limited Health Literacy/Education

Another population that is vulnerable to medical errors are patients with limited health care literacy or education.  These patients may have difficulty obtaining, retaining, and implementing health information to make proper decisions for their healthcare needs.  Populations within this group may include the elderly, low-income populations, immigrants, and minorities.  There is also a strong correlation between limited health literacy and the uninsured, undereducated, and unemployed populations.  It is important that information be presented to this group at a level that they can understand.  The use of interpreters can also be helpful if the patient does not have a good grasp of the English language (6). 

Public Education 

Now, more than ever before, the general public has greater access to information of all sorts.  This includes access to health information, specifically, patient outcomes.  The public is able to make informed decisions on where they would like to be cared for by comparing healthcare facilities.   

The public is seeking information not only on which facility is the safest with the best outcomes but also on ways that they can actively prevent medical errors from happening to them.  There are many resources that patients can find online to help them recognize scenarios that may place them at risk for the occurrence of medical errors.  The Agency for Healthcare Research and Quality (AHRQ) has published a list of 20 tips patients can use to help prevent medical errors: 

Medicines 

1.    Make sure that all of your doctors know about every medicine you are taking.
This includes prescription and over-the-counter medicines and dietary supplements, such as vitamins and herbs. 

2.    Bring all of your medicines and supplements to your doctor visits.
"Brown bagging" your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date and help you get better quality care. 

3.    Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.
This can help you to avoid getting a medicine that could harm you. 

4.    When your doctor writes a prescription for you, make sure you can read it.
If you cannot read your doctor's handwriting, your pharmacist might not be able to either. 

5.    Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you get them: 

• What is the medicine for? 
• How am I supposed to take it, and for how long? 
• What side effects are likely? What do I do if they occur? 
• Is this medicine safe to take with other medicines or dietary supplements I am taking? 
• What food, drink, or activities should I avoid while taking this medicine? 

6.    When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed? 

7.    If you have any questions about the directions on your medicine labels, ask.
Medicine labels can be hard to understand. For example, ask if "four times daily" means taking a dose every 6 hours around the clock or just during regular waking hours. 

8.    Ask your pharmacist for the best device to measure your liquid medicine.
For example, many people use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people measure the right dose. 

9.    Ask for written information about the side effects your medicine could cause.
If you know what might happen, you will be better prepared if it does or if something unexpected happens. 

Hospital Stays 

10. If you are in a hospital, consider asking all health care workers who will touch you whether they have washed their hands.
Handwashing can prevent the spread of infections in hospitals. 

11. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will follow at home.
This includes learning about your new medicines, making sure you know when to schedule follow-up appointments, and finding out when you can get back to your regular activities.
It is important to know whether or not you should keep taking the medicines you were taking before your hospital stay. Getting clear instructions may help prevent an unexpected return trip to the hospital. 

Surgery 

12. If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done.
Having surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery. 

13. If you have a choice, choose a hospital where many patients have had the procedure or surgery you need.
Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition. 

Other Steps in Florida Medical Errors Prevention

14. Speak up if you have questions or concerns.
You have a right to question anyone who is involved with your care. 

15. Make sure that someone, such as your primary care doctor, coordinates your care.
This is especially important if you have any health problems or are in the hospital. 

16. Make sure that all your doctors have your important health information.
Do not assume that everyone has all the information they need. 

17. Ask a family member or friend to go to appointments with you.
Even if you do not need help now, you might need it later. 

18. Know that "more" is not always better.
It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it. 

19. If you have a test, do not assume that no news is good news.
Ask how and when you will get the results. 

20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.
For example, treatment options based on the latest scientific evidence are available from the Effective Health Care Web site. Ask your doctor if your treatment is based on the latest evidence (2). 

Case Studies 

Mr. Smith is a 68-year-old male with diabetes type 2, hypertension, and chronic renal failure stage 4.  He takes both long-acting and short-acting insulin for his diabetes and a beta-blocker for his high blood pressure.  He is also taking a diuretic to help regulate his fluids.  Mr. Smith was recently admitted to the hospital for a hypoglycemic event.  Once in the hospital, Mr. Smith expressed to his nurse that he has been having difficulty reading his medication labels.  He also confided that he feels dizzy when he stands up and has fallen back onto his bed on more than 1 occasion.   

After two days, Mr. Smith was ready to be discharged.  The diabetic educator brought him some pamphlets and educated him on proper blood glucose monitoring and insulin administration.  His blood pressure medicines were also changed, and Mr. Smith was given a new prescription to be filled once he left the hospital.  He was alone when discharge instructions were given, and his current medications were not removed from his medicine bag.   

Two days later, Mr. Smith was readmitted to the hospital with hypoglycemia and hypotension (BP 87/52).

Exercise

1. What are some factors that lead to the occurrence of medical errors with Mr. Smith? 

2. What are the medical errors that occurred? 

3. What could the nurse/educator have done differently to prevent further medical errors, using steps addressed in this Florida medical errors prevention course? 

Bernice is a staff nurse working in a busy ICU.  Due to the COVID-19 pandemic, the unit has been short-staffed, with each nurse taking care of 3-4 patients.  This is Bernice's fifth day in a row, working fourteen plus hours.  There have been multiple "code blue" situations in the ICU over the course of Bernice's workweek, some involving her patients.  She was only able to have a full lunch hour on her second day, and she has not been able to sleep much during the night.   

One of her patients was having severe abdominal pain, 9/10 on the pain scale.  Bernice went in to administer the ordered narcotic and injected the wrong patient. 

Exercise 

1. What factors lead to Bernice's medical error? 

2. What could have been done to prevent the error? 

3. Is this a situation that could happen in a unit where you work?

Conclusion  

Medical errors are an ongoing problem in the healthcare setting.  They affect patients in all phases of life and come with a large price tag of both money and medical resources.  It is everyone's responsibility to help prevent the occurrence of medical errors.  Though we may not be able to totally eradicate them, we can all play a big part in Florida medical errors prevention by learning from previous mistakes and taking measures to ensure that they do not happen again. 

Florida Recognizing Impairment in the Workplace

This fulfills the continuing education requirement of 2 contact hours on Recognizing Impairment in the Workplace for the state of Florida.    

Up to 20% of nurses in the United States are chemically dependent. Substance use disorders, addictions, drug diversions, and other related impairment processes present a threat to the health and safety of those around them. Increasing in concern are overdoses and deaths that are on the rise due to substance abuse and addiction. Early identification of the signs and symptoms of a substance abuse disorder in the workplace contributes to reducing the risk and harm to patients and other healthcare team members. Co-workers play a crucial role in recognizing and reporting suspicious behaviors to their supervisors or appropriate personnel. 

Introduction – Florida Recognizing Impairment in the Workplace

Impairment within the workplace of a healthcare environment is, unfortunately, more common than one may realize. Impairment results when a healthcare professional cannot provide competent and safe patient care because they may be impaired by alcohol, prescription, or non-prescription drugs, or other mind-altering substances (2).  Impairments can also result from a psychological or neurological condition that may affect a person’s judgment. Because of impairment, the healthcare professional is unable to perform duties essential to their profession safely. 

Acknowledging the Problem 

Ideally, from a professional standpoint, healthcare personnel should acknowledge their condition and seek help voluntarily without requiring intervention; however, this is often not the case. Co-workers play an important role in helping the impaired person get treatment. Often, the abuser has denial with the condition, the social stigma, or fear of potential job loss. Colleagues are often reluctant to report their co-workers because they feel it is not their responsibility. They feel like the individual they are reporting may be punished excessively. They may believe that someone else has already addressed the issue or fear the loss of their colleague’s job or license. Despite these potential reasons, colleagues may have certain legal responsibilities in identifying and reporting. States may have specific reporting laws that could hold colleagues responsible for harm to patients if they fail to report.

Definitions 

Substance Use Disorder :  a disease of the brain characterized by the recurrent use of substances such as alcohol and drugs that cause clinical and functional impairment such as health problems, disability, and failure to meet responsibilities at work or school.  

The disease involves reward, withdrawal, memory, and motivation and can be classified as mild, moderate or severe depending on the level of impairment (1).  

Addiction:  the most severe, chronic stage of substance use disorder. There is a substantial loss of self-control, indicated by compulsive substance use despite the desire to stop using (1). 

Drug Diversion:  is the transfer of any substance from the purpose for which it was intended for any illicit use, such as personal use or sale (1). 

Impairment: is the inability or impending inability to engage safely in professional and daily life activities as a result of physical, mental, or behavior disorders such as substance use, abuse, or addiction (1). 

Impairment Behaviors in the Workplace  

Some behaviors are associated with emotional problems but are specific to alcohol or other drug abuse. Some signs common to alcohol and other drugs may also be signs of psychological or psychiatric conditions (2). Each situation is individualistic to the person. Health care professionals must be educated appropriately regarding the signs and symptoms of chemical dependence. The workplace is often the last place that addiction may manifest; disruptions in family, personal health, and social life can happen while the workplace remains unaffected.

Behaviors Associated with Substance Abuse

• Severe mood swings/personality changes 
• Frequent or unexplained tardiness, work absence, illness, or physical complaint 
• Elaborate excuses 
• Under-performance 
• Difficulty with authority 
• Poorly explained errors, accident, or injury 
• Confusion, memory loss, difficulty concentrating 
• Visibly intoxicated 
• Refuses drug testing 

Signs Associated with Substance Abuse

• Unreliability in keeping appointments and meetings 
• Trouble with relationships (professional familial, marital) 
• Physical indications such as track marks or bloodshot eyes 
• Signs indicative of drug diversion 
• Deterioration in personal appearance 
• Significant weight loss or gain 
• Discovered comatose or dead  

Signs and Behaviors Associated to Drug Diversion Specific to Anesthesia Personnel (1)   

• Consistently uses more drugs for cases than colleagues. 
• Frequent volunteering to administer narcotics, relieve colleagues for casework
  
• Heavy wastage of drugs 
• Frequent trips to the restroom or breaks 
• Drugs and syringes in pockets 
• Anesthesia record does not match up with drug dispensed and administered to patient 
• Patient has unusually significant or uncontrolled pain after anesthesia.
  
• The patient has a higher pain score as compared to other anesthesia providers. 
• Times of cases do not correlate when provider dispenses drug from automated dispenser 
• Inappropriate drug choices and doses for patients are made by the provider 
• Missing medications or prescription pads  

Substances such as opioids (e.g., morphine and fentanyl), inhalational anesthetics and volatile agents (e.g., sevoflurane, nitrous oxide), and intravenous anesthetic agents (e.g., propofol) are readily available to many healthcare providers (1). Despite medication dispensing and audit controls in place, drugs can be diverted for misuse. This may happen through the procurement of medicines directly from the pharmacy, automated dispensing units, retrieval from sharps containers of medication remaining in syringes, directly from patient medications, or indirectly through dilution of a medication that appears that nothing is missing from the container (1).

Regardless of the substance being abused, impairment in the workplace can negatively impact patient and provider safety. Facilities should have policies and education addressing symptom awareness, prevention, and reporting to help minimize the risk of diversion and adverse outcomes. Studies have shown that substance use disorder is a disease of the brain (1). As a responsible healthcare provider, by arming yourself with knowledge and the signs and behaviors of impairment in the workplace, it will prevent further harm. 

Healthcare providers are usually successful at disguising their issues or potential signs are ignored because they are respected or an intelligent member of the healthcare team. Significant changes in behavior in the workplace may various many causes. If signs of substance abuse and drug diversion are left unrecognized or reported, the user may be placed in danger and patient safety compromised. Impaired health professionals sometimes develop coping mechanisms that allow them to cover up their diminished capacity to provide safe and efficient patient care. Eventually, mistakes are made, including medication and procedural errors that become apparent to their co-workers (3).

Consequences of Drug Diversion and Substance Use in the Workplace  

Healthcare providers are responsible for their patients’ safety, including their duty to deliver safe and competent care without impairment. Impairment in the workplace can create a disorganized environment (1). The consequences to associate with substance use and drug diversion in the workplace may cause the following consequences for the patient themselves, their colleagues, and the facility in which they are employed. 

Patient

• Pain, anxiety, and side effects from improper dosing 
• Allergic reaction to wrongly substituted drug 
• Victim of medical errors
  Loss of trust in the healthcare system
  Communicable infection from a contaminated needle (1) 

Impaired Professional

• Adverse health effects related to abuse 
• Chronic health problems (heart disease, liver impairment) 
• Familial and financial difficulties 
• Loss of social status 
• Felony prosecution, incarceration, and civil malpractice 
• Actions against a professional license 
• Accidents resulting from physical harm (1) 

 Colleagues

• Injury or infection from blood-borne pathogens from improperly stored equipment 
• At risk for shared-patient care responsibilities with an impaired professional resulting in adverse patient outcomes 
• The stress of increased workload from an impaired healthcare team member 
• Disciplinary action for false witness of leftover medication, improper disposal, or failure to report (1) 

 Facility   

• Costly investigation 
• Civil liability for patient harm 
• Damaged reputation due to public knowledge of mandatory reporting or drug diversion instances, especially those that led to patient harm 
• Poor work quality 
• Loss of revenue from diverted drugs or reimbursement from adverse events due to impaired provider (1) 

The use of addictive substances over time may result in the deterioration of the healthcare professional’s overall health. For example, the use of stimulants may result in cardiovascular problems such as angina, hypertension, and Myocardial Infarction. Alcohol can lead to liver disease, such as cirrhosis. Depression, suicide, and anxiety are mental health disorders that are often coexisting problems with substance abuse. The healthcare workers’ impairment can also lead to traumatic injuries such as falls, fractures, and head injuries (1).

Florida Rules and Regulations  

Many states have rules and regulations regarding the use of alcohol and controlled substances that include disciplinary action. Drug diversion is a significant offense that is taken very seriously. Almost every state requires the reporting of a health practitioner who is suspected of impairment in the workplace. The penalties associated with this vary state by state. Florida requires that all nurses take a Florida Recognizing Impairment in the Workplace CE course every other renewal to improve the recognition and outcomes of workplace impairment.

The state of Florida has an efficient reporting system. Nurses report to the Florida Department of Health or Intervention Project for Nurses (IPN). The IPN’s mission is to enhance public safety by assisting nurses and other nursing related personnel whose practice may have been impaired by substance abuse (4). Their call of the acknowledgment of impairment remains confidential. The Intervention Project for Nurses in Florida allows for an opportunity for intervention and the monitoring of nurses that are using alcohol or controlled substances (4). 

The IPN after receiving a referral of impairment will:  

• Initiate a consultation 
• Provide an intervention 
• The nurse will be required to stop practicing within 1-3 days-the entire process may take up to 12 months
• Assist the person in obtaining the appropriate treatment needed
• Evaluate the progress of the person and the adherence to their treatment plan
• Continuously monitor the person for 2-5 years

Reporting and Intervention  

Once a nurse or other employee has determined that there is an issue with a coworker regarding impairment in the workplace, an intervention must occur to prevent further harm from happening to patients, themselves, or other co-workers. According to the Intervention Project For Nurses, the co-worker determines that there is sufficient evidence and documentation to support their concerns of the impairment of a health professional, an intervention should be planned (4). The planning and participation related to such intervention is usually the responsibility of the employee’s nursing manager. 

• Intervention process steps: (4)
• Prepare a plan 
• Review documentation 
• Request help from others 
• Ask the person to listen to what is said before allowing them to respond 
• Stick to their job performance 
• Have evaluator options ready 
• Expect denial 
• Report as necessary to the Board
  

Return to Practice  

A recovering nurse’s return to practice requires planning and oversight by a nursing manager. Once a nurse has been determined that they are safe to return to practice, several things must fall into place. These things include developing a return to practice guidelines for that specific employee, such as returning to work agreement. Experts must also advocate for the employees to return to work, provide support, review expectations, monitor requirements, and answer questions (4).

Considerations Of Relapse 

Substance use is a chronic illness that comes unfortunately with periods of remission and exacerbation. The rate of relapse among nurses is lower than the general population (4). This is due to several factors, such as support programs and stringent state monitoring programs. Despite the fact, some nurses relapse. Knowledge of the management of relapse in the workplace is a crucial part of impairment in the workplace and plays a significant role in the safety of patients and other employees (4).

Conclusion – Florida Recognizing Impairment in the Workplace

Substance abuse is a chronic and progressive disease. Being able to recognize impairment in the workplace is imperative for the safety of patients, the impaired person, and other co-workers. Impairment can come in many forms. Being knowledgeable of the signs and symptoms as well as reporting responsibilities and policies will not only improve safety but also improve the overall practice environment. Nurses can be very good at picking up subtle clues as to another individual’s impairment. Be aware, be knowledgeable, and be supportive. 

Florida Human Trafficking

This course meets the Florida Human Trafficking requirement for nurses in the state of Florida.

Human trafficking is a significant humanitarian issue in the United States and the world that has continued to grow in the past several years despite government and public efforts to combat it. With increasing news coverage of high-profile human and sex trafficking cases, the problem was recently brought into the American public’s eye. However, the results published by the Polaris Project make it evident that human trafficking is not just a problem of the elite or occurring in poorer areas. It is within our own neighborhoods, workplaces, and throughout the State of Florida. 

For healthcare workers in Florida, human trafficking can be prevented through gaining the knowledge to recognize the warning signs and specific characteristics of a potential trafficking victim; the most effective ways to intervene, which will enable the victims to gain access to help; and where to garner additional support in addressing the issue. 

Prevalence and Definitions

The Polaris Project estimates that collectively there are over 25 million victims of human trafficking worldwide. These are individuals that have been forced into sexual or labor servitude. Of those, several hundred thousand are estimated to be in the United States (1). It is very difficult to estimate accurately as so often this is a crime that is unseen and hidden from the public eye. Since 2007, there were  20,415 contacts made concerning human trafficking reported within Florida to the National Human Trafficking Hotline via telephone calls, texts, or online submissions. Of those, there were 6,168 cases of human trafficking with 15,063 victims being identified.These numbers exemplify the number of potential victims that are not reaching out for help. 

Often, when human trafficking is discussed, a common misconception is that it is simply the transporting of humans. Human trafficking covers a much broader scope than this. It is this a modern age form of slavery and involves the exploitation of individuals for monetary or sexual gain. As stated by the Department of Homeland Security, “Human trafficking involves the use of force, fraud, or coercion to obtain some type of labor or commercial sex act” (3). 

As defined by U.S. law, there are three categories of human trafficking (all from 1): 

• Children under the age of 18 induced into commercial sex 
• Adults (age 18 or over) induced into commercial sex through force, fraud, or coercion 
• Children and adults induced to perform labor or services through force, fraud, or coercion 

The majority of trafficking in the United States involves sex crimes, followed by labor.  An increase of rates with 16% for sexual exploitation and 25% for labor was noted in North America during Covid-19 restrictions (4). These crimes may be occurring simultaneously to the same victim. Types of trafficking can include forced prostitution, pornography, strip dancing, criminal enterprise and bonded labor in domestic servitude or migrant work. Outside of street prostitution, sex trafficking is most likely to be occurring in venues such as strip clubs, massage parlors, or other fictitious business fronts for prostitution. A major difference with sex trafficking of minors is that, unlike adults, force, coercion, or fraud does not need to be present for prosecution (6). As there are a number of different avenues for and types of human trafficking, recognition can be challenging. 

Risk Factors

The profile of the human trafficking victim is not easy to define. Victims of human trafficking come from varied backgrounds that may or may not be what is expected or stereotypical. Victims may come from any race, socioeconomic status, color, religion, age, gender, sexual orientation or gender identity, and on. The main commonality is that there is a layer of deception whereby the human trafficker is targeting a vulnerability in the victim. As stated by the Department of Justice, trafficking victims are deceived with “... false promises of love, a good job, or a stable life and are lured into situations where they are made to work in deplorable conditions with little or no pay” (5). There are some trends noted that do make certain populations more at risk, but keep in mind that this does not encompass all potential victims and vigilance should be taken to avoid assumptions. 

The risk factors for human trafficking are just as varied and dependent upon the type of trafficking and method by which the abuser is able to hold the victim indentured or captive. This figurative prison may be physically, emotionally, or monetarily induced. The Center for Disease Control and Prevention (CDC) lists the following characteristics and factors: 

• Many victims are women and girls, though men and boys are also impacted. 
• Victims include all races, ethnicities, sexual orientations, gender identifies, citizens, non-citizens, and income levels. 
• Victims are trapped and controlled through assault, threat, false promises, perceived sense of protection, isolation, shaming, and debt.           

Several higher risk populations have been identified through the data gathered from the Polaris Project. It was found that children who were or had been within the foster care system or runaway homeless youth were more likely to encounter sexual victimization. Other factors include substance abuse, recent relocation or migration, unstable housing situations, and underlying mental health disorders (7). 

As a population that is often overlooked, shamed, or lacks resources, members of the lesbian, gay, bisexual, transgender, queer, or questions (LGBTQ) community are more vulnerable to being subject to human trafficking. Up to 40% of homeless youth are part of the LGBTQ community and may not seek assistance for fear of being shunned (8). 

Illegal and sponsored immigration remains at a higher risk of trafficking and exploitation. The NHRTC reports a significant number of calls that reference foreign nationals (2). Individuals wishing to become American citizens are lured with the promise of freedom in exchange for large fees that are made impossible to be worked off. While there are laws in place to prevent, this type of servant bondage is forced upon the victims who are in a new country and often lack resources or are unable to seek assistance due to cultural, language, and accessibility barriers. Further, cases have been reported where the employer or trafficker withhold visas or identification barriers in order promote compliance and essentially are holding the victim hostage (9). 

Recruitment Techniques

A major tactic of the perpetrators of these crimes is to prey on vulnerable individuals with a lack of resources. Thus, a primary ploy used is a layer of deception whereby the human trafficker is targeting the needs or wants of the victim. 

Traffickers are often individuals that the victim has come to trust. This may be a girlfriend or boyfriend, spouse, or other family member. Victims are also commonly sold to outside parties. 

In cases of sexual trafficking, typically young women and men are groomed and given preferential treatment, gifts, and drugs until they become reliant upon the “John”. In other cases, individuals are tempted with the promise of a better life, or in the case of immigration, the sponsorship for a visa (9). 

Florida Human Trafficking & Mandatory Reporting

Mandatory reporting of human trafficking by health care professionals is incorporated into the law in a growing number of locations in the United States. Health care professionals are already mandated reporters through previous existing laws that require reporting of child abuse, domestic violence, as well as knife and gunshot wounds (10). 

The following states the criminal and civil liability of failing to follow the law as a mandatory reporter in some states: 

In a civil action, the mandated reporter may be held liable for all damages that any person suffers due to the mandated reporters’ failure to file a report. In a criminal action, the mandated reporter may be found guilty of a misdemeanor punishable by imprisonment for up to 93 days and a fine of $500. 

Reporting of suspected adult human trafficking is not as clear in regard to mandatory reporting. However, vulnerable adults suspected of being abused, exploited, or victimized fall under the same guidelines and are reported to CI in the same manner as above.  

Federal Laws

Today, there are 39 states that have committed to the crusade of establishing a statute banning human trafficking.  

A specific U.S. Federal law addressing trafficking crimes was first enacted with the Trafficking Victims Protection Act of 2000. The bill has since been revised several times; however, the fundamental of it is to provide guidance and authorization for their “three-pronged approach that includes prevention, protection, and prosecution” and covers both sex and labor trafficking (11). 

Preventing Sex Trafficking and Strengthening Families Act of 2014 and The Justice for Victims of Trafficking Act of 2015 are both aimed at providing victims increased protection for exploitation and increased resources specifically aimed at prevention and support for child and youth sex trafficking crimes (11). 

The Customs and Facilitations and Trade Enforcement Reauthorization Act of 2009 is aimed towards prohibiting the importation of goods made by the benefit of human trafficking (11). 

Recognizing Signs of Human Trafficking

According to the Department of Health and Human Services, close to 90% of human trafficking victims visit a health care facility at least once while in servitude and are not identified as such by health care providers (14). This is due to a lack of education, lack of consistent use of identification and screening tools, and time constraints within the current health care system. As a mandatory reporter and healthcare team member, it is imperative to use best practice in recognizing the signs and symptoms as well as the tools that are available. 

Signs and Symptoms

Human trafficking victims may present to a healthcare setting with primary or underlying signs that may be related to physical or mental abuse. These signs and symptoms may be related to the reason that they are seeking treatment or may be identified by the healthcare provider during a thorough assessment. The following physical and psychological sequelae may be noted during an assessment as potential evidence of victimization (all derived from 9, 15): 

Physical

• Unexplained or implausible injuries
• Bruising
• Wounds and Cuts
• Missing or broken teeth
• Closed head injuries
• Blunt force trauma

Neurological

• Headaches
• Migraines
• Memory loss or difficulty concentrating
• Vertigo
• Insomnia
• Brain trauma

Gastrointestinal

• Diarrhea
• Constipation

Dietary

• Malnutrition
• Anorexia
• Severe weight loss

Cardiovascular and Respiratory

• Tachyarrhythmias
• Hypertension
• Respiratory Distress

Reproductive System

• Sexually transmitted disease
• Vaginal and/or anal fissures
• Previous Abortions

Psychological

• Depression
• Suicidal Ideation
• Anxiety
• Self-harm including cutting or branding
• Drug and alcohol abuse
• PTSD symptoms
• Regression
• Anger
• Dissociative and depersonalization tendencies

Red Flags and Indicators

There are several characteristics that should be kept in mind as red flags during the interview and assessment that may indicate potential trafficking. These include, but are not limited to (all derived from 9, 15, 14): 

• Tattoos that indicate ownership, a number, or tracking system or are out of character/obscene
• Inappropriate clothing for climate
• Workplace violence or abuse
• Unsanitary living conditions
• Multiple families or people sharing a living space that is too small
• Shares living space with employer
• Is not in control of financial assets
• Refusal to speak alone with health professionals
• Accompanied by individual that refuses to allow patient to speak for themselves or be alone
• Sex work under age 18
• Answers are scripted
• Answers are implausible or contraindicate
• Appears younger or older than stated age

Interview Tools and Techniques

Check with your facilities protocol for specific guidance on assessment and examination protocols for suspected abuse victims. There are also many scripted interviewing tools available online that assist with asking targeted questions. First and foremost, it is important to establish the patient’s safety and to gain trust. 

Gaining trust can be difficult and conducting assessments and interviews should be completed in a non-threatening environment with an unbiased and non-judgmental tone. Creating a space that is quiet and will not be interrupted is important. This will ensure that the potential victim feels safe communicating and is not concerned that she or he will be overheard. Present your demeanor in a non-threatening manner, at eye level, and focus on being attentive with observant listening. Maintain respectful eye contact to convey interest and reflective listening. If taking notes during the interview is required, explain to the patient what will be documented and what it will be utilized for (15). 

The National Human Trafficking Resource Center (NHTRC) offers a plethora of resources and scripted questions. The following are general questions on assessing if the individual is being forced into a situation and can be applied to any of the specific types of human trafficking (all from 15): 

“Did someone control, supervise or monitor your work/your actions?”
“Was your communication ever restricted or monitored?”
“Were you able to access medical care?”
“Were you ever allowed to leave the place that you were living/working? Under what conditions?”
“Was your movement outside of your residence/workplace ever monitored or controlled?”
“What did you think would have happened if you left the situation?"
"Was there ever a time when you wanted to leave, but felt that you couldn’t?"
"What do you think would have happened if you left without telling anyone?”
“Did you feel that it was your only option to stay in the situation?”
“Did anyone ever force you to do something physically or sexually that you didn’t feel comfortable doing?”
“Were you ever physically abused (shoved, slapped, hit, kicked, scratched, punched, burned, etc.) by anyone?”
“Were you ever sexually abused (sexual assault/unwanted touching, rape, sexual exploitation, etc.) by anyone?”
“Did anyone ever introduce you to drugs or medications as a method of control?”

While screening tools provide a base for asking difficult questions, the NHTRC advises “Before screening, users should also be prepared to draw upon the expertise of local legal and medical staff and to refer identified trafficking victims to appropriate housing, health, and social services in their area . . . the tool is a complement to, not a substitute for, specialized training in human trafficking, good professional practice and victim-centered service” (15). 

The NHTRC also provides a 24-hour national hotline that is able to guide health professionals through completing assessments and determining the next best steps to intervene or offer the victim assistance. 

Interventions and Collaboration

When presented with a suspected human trafficking victim, it is likely that the individual will not be alone. Maintaining safety and support for the patient may require separation from the suspected trafficker. While this may not be possible, an attempt should be made to bring the patient to a room or examination area unaccompanied. 

Be conscious of any cultural preferences that may affect the patient. If there are language barriers preventing meaningful communication, enlist the assistance of a professional interpreter. This is especially vital in cases where the accompanying visitor or family is attempting to interpret for the patient and may be filtering the victim’s responses. 

For patients that seek healthcare related to sexual abuse, a SANE assessment and rape kit should be obtained per facility protocol. With permission, patients should be tested for sexually transmitted infections including HIV, gonorrhea, UTIs, syphilis, and pubic lice, as well as a pregnancy test for females. Forced and coerced abortions are frequent among minor females in the sex industry (16). 

Thorough documentation of the patient’s reported reason for visit, physical and neurological assessment including any trauma, bruising, wounds, affect, and pertinent statements should be noted in the patient’s electronic medical record. 

Educate yourself on local resources and be able to provide assistance with finding access to healthcare, mental health, and rehabilitative resources that are available in the community. Victims may not want to take pamphlets with them that may be found, so providing locations or addresses of shelters or clinics with operating times may be a safer option. 

Collaborate with the healthcare team, law enforcement, and social work for suspected child or vulnerable adult trafficking. 

Mandatory reporting of suspected cases of child abuse or trafficking is not encumbered by HIPAA disclosure when reporting to authorities; however, when reporting suspected adult trafficking, disclosure and permission must be granted unless there is an imminent threat to the safety of the patient, or the patient has been identified as a vulnerable population. Thoroughly assess if the individual meets criteria as a vulnerable adult and proceed accordingly. If the adult does not meet criteria, permission must be gained to report. 

If a competent adult does disclose that they are a trafficking victim, determine if the patient is in immediate, life-threatening danger. If so, follow facility protocol and encourage and support the patient in reporting to a law enforcement agency. If there is no immediate danger, supportive care and assistance should be provided. The patient should be informed of the options available for social services, reporting, and resources. The creation of a safety plan is highly recommended (13). 

Prevention

Prevention of human trafficking requires public education, awareness, and knowing how to properly respond when faced with suspicions. The Blue Campaign is a strategy from the Department of Homeland Security to bring national awareness to the issue and provide specialized training to law enforcement and federal employees. Blue Campaign pamphlets and other materials are available at their website, www.dhs.gov/blue-campaign, for distribution. 

The Center for Disease Control takes the stance that sex trafficking is preventable via community awareness and acknowledging exploitation when it does occur. They state “Strategies based on the best available evidence exist to prevent related forms of violence, and they may also reduce sex trafficking. States and communities can implement and evaluate efforts that: 

• Encourage health behaviors in relationships
• Foster safe homes and neighborhoods
• Identify and address vulnerabilities during health care visits
• Reduce demand for commercial sex
• End business profits from trafficking-related transactions” (6).

One of the largest barriers to prevention in the healthcare system is the inability to recognize signs and symptoms. As cited above, a significant number of human trafficking victims have filtered in and out of healthcare systems without being recognized. This misses the opportunity to connect, provide resources, and offer further assistance. The NHTRC provides many resources for training within healthcare facilities and standardized forms and interviewing questions that may be tailored to individual situations and facility needs. 

Patient Education

UNICEF provides excellent resources for human trafficking prevention. Below is an excerpt from UNICEF, with “key messages” for children, which can help prevent trafficking. 

1. Educate yourself on the issue, and learn the signs of a trafficked victim.
2. Don’t accept friend requests from people you don’t know on social media. Traffickers commonly use sites like Twitter, Facebook, and Instagram to lure their victims.
3. Be aware of how traffickers recruit people, and pay attention to your surroundings.
4. Don’t reveal too much about yourself (i.e. your full name, address, school, or living situation) to people you don’t know, whether on your social media sites or in person, no matter how friendly the person may be.
5. Never agree to meet someone you don’t know without first consulting a trusted adult (i.e. parent, teacher, guidance counselor).
6. If you feel uncomfortable or are hesitant about a situation, confide in an adult who you can help you make the best choices.
7. Making a decision to leave a situation or relationship where you feel unsafe or are being harmed or threatened can be hard and scary. If possible, talk to someone you trust, like a friend, family member, counselor, or youth worker.
8. If you are in immediate danger or are being physically harmed, call 911 for help.
9. If running away from home, try to find a safe place to go or call the runaway switchboard at 1-800-Runaway.
10. If you suspect you or a friend are at risk trafficking, call the National Human Trafficking Hotline at 888-3737-888 or text “BeFree” (233733)

GI Bleed: An Introduction

Introduction   

Gastrointestinal bleeding (GI Bleed) is an acute and potentially life-threatening condition. It is meaningful to recognize that GI bleed manifests an underlying disorder. Bleeding is a symptom of a problem comparable to pain and fever in that it raises a red flag. The healthcare team must wear their detective hat and determine the culprit to impede the bleeding.  

Nurses, in particular, have a critical duty to recognize signs and symptoms, question the severity, consider possible underlying disease processes, anticipate labs and diagnostic studies, apply nursing interventions, and provide support and education to the patient. 

Epidemiology  

The incidence of Gastrointestinal Bleeding (GIB) is broad and comprises cases of Upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB). GI Bleed is a common diagnosis in the US responsible for approximately 1 million hospitalizations yearly (2). The positive news is that the prevalence of GIB is declining within the US (1). This could reflect effective management of the underlying conditions.  

Upper gastrointestinal bleeding (UGIB) is more common than lower gastrointestinal bleeding (LGIB) (2). Hypovolemic shock related to GIB significantly impacts mortality rates. UGIB has a mortality rate of 11% (2), and LGIB can be up to 5%; these cases are typically a consequence of hypovolemic shock (2).  

Certain risk factors and predispositions impact the prevalence. Lower GI bleed is more common in men due to vascular diseases and diverticulosis being more common in men (1). Extensive data supports the following risk factors for GIB: older age, male, smoking, alcohol use, and medication use (7).  

We will discuss these risk factors as we dive into the common underlying conditions responsible for GI Bleed.  

Etiology/ Pathophysiology

Gastrointestinal (GI) bleeding includes any bleeding within the gastrointestinal tract, from the mouth to the rectum. The term also encompasses a wide range of quantity of bleeding, from minor, limited bleeding to severe, life-threatening hemorrhage.

We will review the basic anatomy of the gastrointestinal system and closely examine the underlying conditions responsible for upper and lower gastrointestinal bleeding.

Let's briefly review the basic anatomy of the gastrointestinal (GI) system, which comprises the GI tract and accessory organs. You may have watched The Magic School Bus as a child and recall the journey in the bus from the mouth to the rectum! Take this journey once more to understand the gastrointestinal (GI) tract better.

The GI tract consists of the following: oral cavity, pharynx, esophagus, stomach, small intestine, large intestine, and anal canal (5). The accessory organs include our teeth, tongue, and organs such as salivary glands, liver, gallbladder, and pancreas (5). The primary duties of the gastrointestinal system are digestion, nutrient absorption, secretion of water and enzymes, and excretion (5, 3). Consider these essential functions and their impact on each other.

This design was created on Canva.com on August 31, 2023. It is copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

As mentioned, gastrointestinal bleeding has two broad subcategories: upper and lower sources of bleeding. You may be wondering where the upper GI tract ends and the lower GI tract begins. The answer is the ligament of Treitz. The ligament of Treitz is a thin band of tissue that connects the end of the duodenum  and the beginning of the jejunum (small intestine); it is also referred to as the suspensory muscle of the duodenum (4). This membrane separates the upper and lower GI tract. Upper GIB is defined as bleeding proximal to the ligament of Treitz, while Lower GIB is defined as bleeding beyond the ligament of Treitz (4). 

Upper GI Bleeding (UGIB) Etiology 

Underlying conditions that may be responsible for the UGIB include: 

• Peptic ulcer disease 

• Esophagitis 
• Foreign body ingestion 
• Post-surgical bleeding 
• Upper GI tumors 
• Gastritis and Duodenitis 

• Varices 
• Portal hypertensive gastropathy (PHG) 
• Angiodysplasia 
• Dieulafoy lesion 
• Gastric antral valvular ectasia 

• Mallory-Weiss tears 
• Cameron lesions (bleeding ulcers occurring at the site of a hiatal hernia 
• Aortoenteric fistulas 
• Hemobilia (bleeding from the biliary tract) 
• Hemosuccus pancreaticus (bleeding from the pancreatic duct) 

(1, 4, 5, 8. 9) 

Pathophysiology of Variceal Bleeding. Variceal bleeding should be suspected in any patient with known liver disease or cirrhosis (2). Typically, blood from the intestines and spleen is transported to the liver via the portal vein (9). The blood flow may be impaired in severe liver scarring (cirrhosis). Blood from the intestines may be re-routed around the liver via small vessels, primarily in the stomach and esophagus (9). Sometimes, these blood vessels become large and swollen, called varices. Varices occur most commonly in the esophagus and stomach, so high pressure (portal hypertension) and thinning of the walls of varices can cause bleeding within the Upper GI tract (9). 

Liver Disease + Varices + Portal Hypertension = Recipe for UGIB Disaster 

Lower GI Bleeding (LGIB) Etiology

• Diverticulosis
• Post-surgical bleeding
• Angiodysplasia
• Infectious colitis
• Ischemic colitis
• Inflammatory bowel disease
• Colon cancer
• Hemorrhoids
• Anal fissures
• Rectal varices
• Dieulafoy lesion
• Radiation-induced damage

(1, 4, 5, 9)

Unfortunately, a source is identified in only approximately 60% of cases of GIB (8). Among this percentage of patients, upper gastrointestinal sources are responsible for 30–55%, while 20–30% have a colorectal source (8).

Laboratory and Diagnostic Testing

Esophagogastroduodenoscopy (EGD) and colonoscopy identify the source of bleeding in 80–90% of patients (4). The initial clinical presentation of GI bleeding is typically iron deficiency/microscopic anemia and microscopic detection of blood in stool tests (6).

The following laboratory tests are advised to assist in finding the cause of GI bleeding (2):

• Complete blood count
• Hemoglobin/hematocrit
• International normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (PTT)
• Liver function tests

Low hemoglobin and hematocrit levels result from blood loss, and blood urea nitrogen (BUN) may be elevated due to the GI system's breakdown of proteins within the blood (9).

The following laboratory tests are advised to assist in finding the cause of GI bleeding:

• EGD (esophagogastroduodenoscopy)- Upper GI endoscopy
  • Clinicians can visualize the upper GI tract using a camera probe that enters the oral cavity and travels to the duodenum (9)
• Colonoscopy- Lower GI endoscopy/ (9)
  • Clinicians can visualize the lower GI tract.
• CT angiography
  • Used to identify an actively bleeding vessel

Signs and Symptoms 

Clinical signs and symptoms depend on the volume/ rate of blood loss and the location/ source of the bleeding. A few key terms to be familiar with when evaluating GI blood loss are overt GI bleeding, occult GI bleeding, hematemesis, hematochezia, and melena. Overt GI bleeding means blood is visible, while occult GI bleeding is not visible to the naked eye but is diagnosed with a fecal occult blood test (FOBT) yielding positive results of the presence of blood (5). Hematemesis is emesis/ vomit with blood present; melena is a stool with a black/maroon-colored tar-like appearance that signifies blood from the upper GI tract (5). Melena has this appearance because when blood mixes with hydrochloric acid and stomach enzymes, it produces this dark, granular substance that looks like coffee grounds (9). 

Mild vs. Severe Bleeding  

A patient with mild blood loss may present with weakness and diaphoresis (9). Chronic iron deficiency anemia symptoms include hair loss, hand and feet paresthesia, restless leg syndrome, and impotence in men (8). The following symptoms may appear over time once anemia becomes more severe and hemoglobin is consistently less than 7 mg/dl: pallor, headache, dizziness from hypoxia, tinnitus from the increased circulatory response, and the increased cardiac output and dysfunction may lead to dyspnea (8). Findings of a positive occult GI bleed may be the initial red flag. 

A patient with severe blood loss, which is defined as a loss greater than 1 L within 24 hours, hypotensive, diaphoretic, pale, and have a weak, thready pulse (9). Signs and symptoms will reflect the critical loss of circulating blood volume with systemic hypoperfusion and oxygen deprivation, so that cyanosis will also be evident (9). This is considered a medical emergency, and rapid intervention is needed. 

Stool Appearance: Black, coffee ground = Upper GI; Bright red blood = Lower GI. 

History and Physical Assessment

History

A thorough and accurate history and physical assessment is a key part of identifying and managing GI bleed. Remember to avoid medical terminology/jargon while asking specific questions, as this can be extremely helpful in narrowing down potential cases. It is a good idea to start with broad categories (general bleeding) then narrow to specific conditions.

Assess for the following:

• Previous episodes of GI Bleed
• Medical history with contributing factors for potential bleeding sources (e.g., ulcers, inflammatory bowel disease, liver disease, varices, PUD, alcohol abuse, tobacco abuse, H.pylori, diverticulitis) (3)
• Contributory medications (non-steroidal anti-inflammatory drugs (NSAIDs, anticoagulants, antiplatelet agents, bismuth, iron) (3)
• Comorbid diseases that could affect management of GI Bleed (8)

Physical Assessment

1. Head to toe and focused Gastrointestinal, Hepatobiliary, Cardiac and Pancreatic
2. Assessments
   Assess stool for presence of blood (visible) and anticipate orders/ collect specimen for occult blood testing.
3. Vital Signs

Signs of hemodynamic instability associated with loss of blood volume (3):

• Resting tachycardia
• Orthostatic hypotension
• Supine hypotension
• Abdominal pain (may indicate perforation or ischemia)
• A rectal exam is important for the evaluation of hemorrhoids, anal fissures, or anorectal mass (3)

Certain conditions place patients at higher risk for GI bleed. For example, patients with end-stage renal disease (ESRD) have a five times higher risk of GIB and mortality than those without kidney disease (2).

Treatment and Interventions

Treatment and interventions for GIB bleed will depend on the severity of the bleeding. Apply the ABCs (airway, breathing, circulation) prioritization tool appropriately with each unique case. Treatment is guided by the underlying condition causing the GIB, so this data is too broad to cover. It would be best to familiarize yourself with tools and algorithms available within your organization that guide treatment for certain underlying conditions. Image 2 is an example of an algorithm used to treat UGIB (8). The Glasgow-Blatchford bleeding score (GBS) tool is another example of a valuable tool to guide interventions. Once UGIB is identified, the Glasgow-Blatchford bleeding score (GBS) can be applied to assess if the patient will need medical intervention such as blood transfusion, endoscopic intervention, or hospitalization (4).

Unfortunately, there is currently a lack of tools available for risk stratification of emergency department patients with lower gastrointestinal bleeding (LGIB) (6). This gap represents an opportunity for nurses to develop and implement tools based on their experience with LGIB.

(8) 

The first step of nursing care is the assessment. The assessment should be ongoing and recurrent, as the patient's condition may change rapidly with GI bleed. During the evaluation, the nurse will gather subjective and objective data related to physical, psychosocial, and diagnostic data. Effective communication is essential to prevent and mitigate potential risk factors.

Subjective Data (Client verbalizes)

• Abdominal pain
• Nausea
• Loss of appetite
• Dizziness
• Weakness

Objective Data (Clinician notes during assessment)

• Hematemesis (vomiting blood)
• Melena (black, tarry stools)
• Hypotension
• Tachycardia
• Pallor
• Cool, clammy skin

Nursing Interventions

Ineffective Tissue Perfusion:

1. Monitor vital signs frequently to assess blood pressure, heart rate, and oxygen saturation changes.
2. Obtain IV access.
3. Administer oxygen as ordered.
4. Elevate the head of the bed (support venous return and enhance tissue perfusion).
5. Administer blood products (packed red blood cells, fresh frozen plasma) as ordered to replace lost blood volume.

Acute Pain:

1. Assess the patient's pain (quantifiable pain scale)
2. Administer pain medications as ordered.
3. Obtain and implement NPO Orders: Allow the GI tract to rest and prevent further irritation while preparing for possible endoscopic procedures.
4. Apply heat/cold therapy for comfort.

Risk for Decreased Cardiac Output

1. Assess the patient's heart rate and rhythm. (Bleeding and low cardiac output may trigger compensatory tachycardia.) (9)
2. Assess and monitor the patient's complete blood count.
3. Assess the patient's BUN level.
4. Monitor the patient's urine output.
5. Perform hemodynamic monitoring.
6. Administer supplemental oxygenation as needed.
7. Administer intravenous fluids as ordered.
8. Prepare and initiate blood transfusions as ordered.
9. Educate and prepare the patient for endoscopic procedures and surgical intervention as needed.

Risk for Deficient Fluid Volume:

1. Monitor intake and output.
2. Maintain hydration.
3. Administer intravenous fluids as ordered.
4. Monitor labs, including hemoglobin and hematocrit, to assess the effectiveness of fluid replacement therapy.
5. Educate the patient on increasing oral fluid intake once the bleeding is controlled.
6. Vital signs
7. Assess the patient's level of consciousness and capillary refill time to evaluate tissue perfusion and response to fluid replacement.
8. Collaborate with the healthcare team to adjust fluid replacement therapy based on the patient's response and laboratory findings.

Nursing Goals / Outcomes for GI Bleed:

• The patient's vital signs and lab values will stabilize within normal limits.
• The patient will be able to demonstrate efficient fluid volume as evidenced by stable hemoglobin and hematocrit, regular vital signs, balanced intake and output, and capillary refill < 3 seconds.
• The patient will exhibit increased oral intake and adequate nutrition.
• The patient will verbalize relief or control of pain.
• The patient will appear relaxed and able to sleep or rest appropriately.
• The patient verbalizes understanding of patient education on gastrointestinal bleeding, actively engages in self-care strategies, and seeks appropriate support when needed.

Case Study

Mr. Blackstool presents to the emergency department with the following:

CHIEF COMPLAINT: "My stool looked like a ball of black tar this morning."

He also reports feeling "extra tired" and "lightheaded" for 3-5 days.

HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old tractor salesman who presents to the emergency room complaining of the passage of black stools, fatigue, and lightheadedness. He reports worsening chronic epigastric pain and reflux, intermittent for 10+ years.

He takes NSAIDS as needed for back, and joint pain and was recently started on a daily baby aspirin by his PCP for cardiac prophylaxis. He reports "occasional" alcohol intake and smokes two packs of cigarettes daily.

PHYSICAL EXAMINATION: Examination reveals an alert and oriented 65-YO male. He appears anxious and irritated. Vital sips are as follows. Blood Pressure 130/80 mmHg, Heart Rate 120/min - HR Thready - Respiratory Rate - 20 /minute; Temperature 98.0 ENT/SKIN: Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity is noted. The parotid glands appear full.

CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals a regular rhythm with an S4. No murmur is appreciated. Peripheral pulses are present but are rapid and weak.

ABDOMEN/RECTUM: The waist shows a rounded belly. Bowel sounds are hyperactive. Percussion of the liver is 13 cm (mal); the edge feels firm. Rectal examination revealed a black, tarry stool. No Dupuytren's contractions were noted.

LABORATORY TESTS: Hemoglobin 9gm/dL, Hematocrit 27%, WBC 13,000/mm. PT/PTT - normal. BUN 46mg/dL.

Discuss abnormal findings noted during History and Physical Examination; Evaluate additional data to obtain possible diagnostic testing, treatment, nursing interventions, and care plans.

Conclusion

After this course, I hope you feel more knowledgeable and empowered in caring for patients with Gastrointestinal bleeding (GIB). As discussed, GIB is a potentially life-threatening condition that manifests as an underlying disorder. Think of gastrointestinal bleeding as a loud alarm signaling a possible medical emergency. Nurses can significantly impact the recognition of signs and symptoms that determine the severity of bleeding and underlying disease process while also implementing life-saving interventions as a part of the healthcare team. As evidence-based practice rapidly evolves, continue to learn, and grow your knowledge of GIB. 

Constipation Management and Treatment

Introduction   

In the realm of healthcare, where every aspect of patient well-being is meticulously tended to, constipation is a condition that often remains in the shadows. Often dismissed as a minor inconvenience, constipation is a prevalent concern that can have significant repercussions on the health and comfort of hospitalized and long-term care patients (8).  

Imagine a scenario where a middle-aged patient, recently admitted to a hospital for a non-related condition, is experiencing discomfort due to constipation. Despite the patient's hesitation to bring up this seemingly "embarrassing" topic, a skilled nurse takes the initiative to initiate an open conversation.  

By actively listening and empathetically addressing the patient's concerns, the nurse alleviates the discomfort and also plays a crucial role in preventing potential complications. This scenario exemplifies the pivotal role that nurses play in the comprehensive management of constipation. 

Envision a long-term care facility where an elderly resident's mobility is limited, leading to a sedentary lifestyle. As a result, this individual becomes more susceptible to constipation, which could potentially lead to more severe issues if left unattended. Here, the nurse's expertise in identifying risk factors and tailoring interventions comes into play.  

By suggesting gentle exercises, dietary adjustments, and adequate hydration, the nurse transforms the resident's daily routine, ensuring a healthier digestive tract and enhanced overall well-being. 

Through the above scenarios, it becomes evident that constipation is not merely a minor inconvenience but a legitimate concern that warrants attention. As the first line of defense in patient care, nurses are uniquely positioned to identify, address, and holistically prevent constipation.  

Nurses possess the knowledge and skills to create a profound impact on patient lives by acknowledging and addressing this issue. This course aims to equip nurses with an in-depth understanding of constipation, enabling them to be proactive vigilant advocates for patient comfort, bowel health, and overall well-being. 

Epidemiology  

To truly comprehend the significance of constipation in healthcare settings, it's essential to grasp its prevalence and impact. Statistics reveal that constipation holds a prominent spot in healthcare challenges, with up to 30% of patients in hospitals and long-term care facilities experiencing this discomfort (4). This means that in a unit with 100 patients, nearly a third of them might be grappling with constipation-related issues.  

Even though constipation transcends demographics, elderly patients, who are a substantial part of long-term care settings, are more susceptible to constipation due to factors like decreased mobility, altered dietary habits, and medication use. Understanding this demographic predisposition is crucial for nurses as it guides their vigilance in recognizing and managing constipation among this vulnerable group. By unraveling its prevalence and its penchant for affecting diverse patient groups, nurses can step into their roles armed with knowledge, ready to make a tangible difference in patient lives. 

Etiology/Pathophysiology  

Embarking on the journey to comprehend constipation's root causes and underlying mechanisms offers a fascinating glimpse into the intricate workings of the digestive system. The digestive system is a well-orchestrated symphony where even a slight disruption can lead to a discordant note, constipation being one such note.  

Constipation arises from an intricate interplay of factors. Lifestyle choices, such as physical inactivity, dietary habits, and even medication use, can disturb the symphony of digestion. These disruptions impact the stool's consistency, its journey through the intestines, and the efficiency of water absorption.  

Some examples of how lifestyle choices can cause constipation include the following: 

• The digestive tract, like a finely tuned instrument, requires regular movement to maintain its rhythm and balance. Without physical activity to nudge food along, its journey through the digestive process slows down, potentially leading to constipation. 
• Mismanagement of water absorption in the colon can also contribute to constipation. Excess absorption of water in the colon can turn the stool hard and dry, making it a formidable challenge to pass.  
• When fiber is lacking in the diet, stool encounters resistance and sluggishness, akin to a symphony losing its guiding rhythm. This lack of fiber can lead to constipation, underscoring the importance of dietary choices in maintaining a harmonious digestive process (10). 

Understanding the above dynamics empowers nurses to decode the origins of constipation and tailor interventions that restore the harmonious rhythm of the digestive orchestra. Just as a conductor guides a symphony to its crescendo, nurses can orchestrate the path to relief and comfort for patients grappling with constipation. 

Signs and Symptoms  

Constipation's signs and symptoms are the stars that guide nurses toward effective management. Infrequent bowel movements, excessive straining, abdominal discomfort, and bloating are like constellations, revealing the narrative of digestive imbalance. 

Recognizing the constellation of signs and symptoms becomes the compass guiding nurses toward effective care. Just as a seasoned sailor navigates by the stars, nurses navigate constipation's landscape by deciphering the cues that patients present. 

Research by Anderson and Brown (1) reveals that patients grappling with constipation often experience infrequent bowel movements as a telltale sign. Nurses, armed with this insight, recognize that infrequent bowel movements warrant vigilant assessment and timely interventions. 

Excessive straining, much like tugging at sails in adverse winds, emerges as another hallmark of constipation (6). Patients' tales of discomfort during bowel movements point to an underlying imbalance. Nurses adeptly interpret this discomfort as a call for action, initiating strategies that ease the passage of stool and restore harmony to the digestive symphony. 

Discomfort serves as an indicator of the digestive system's struggle to find its equilibrium. Nurses, like skilled navigators, probe further, discerning the nuances of the discomfort to tailor interventions that address its root cause (11). 

Bloating is another symptom. Research by Smith and Williams (9) illuminates the link between constipation and bloating. This connection heightens nurses' vigilance, prompting them to delve into patients' experiences and offer relief from the discomfort. 

Pharmacological/Non-Pharmacological Treatment 

Constipation management encompasses a harmonious blend of pharmacological and non-pharmacological strategies. Just as a symphony thrives on a balanced ensemble, nurses can orchestrate a symphony of relief and comfort by selecting the right interventions for each patient's unique needs. Through this holistic approach, nurses play a pivotal role in restoring the digestive symphony to its harmonious rhythm. 

Pharmacological 

As nurses step into the realm of constipation management, they encounter a diverse array of strategies that can harmonize the digestive symphony. Picture a pharmacist's shelf adorned with an assortment of medications, each with a specific role in alleviating constipation. 

Fiber supplements work by increasing stool bulk and promoting regular bowel movements. They're gentle and mimic the natural process, ensuring a harmonious flow. 

Osmotic laxatives introduce more water into the stool, creating a balanced blend of moisture, preventing dry and challenging stools, and facilitating movement.  

Stimulant laxatives stimulate bowel contractions, hastening the stool's journey through the digestive tract. They're like the energetic beats that invigorate a symphony, leading to a rhythmic and effective passage. 

Lastly, stool softeners ensure that the stool is neither too hard nor too soft, striking the perfect balance. They act by moistening the stool, making it easier to pass without straining. By introducing this harmony, stool softeners contribute to patient comfort. 

Non-pharmacological 

Beyond the realm of medications lies an equally vital avenue: non-pharmacological interventions. Nurses can craft a holistic care plan, carefully considering dietary adjustments and lifestyle modifications as the foundation. Examples of non-pharmacological interventions include the following: 

A diet rich in fiber guides the stool's journey with ease. Nurses can educate patients on incorporating fruits, vegetables, and whole grains, ensuring a harmonious flow through the intestines. 

Engaging in regular physical activity not only stimulates bowel movements but also enhances overall well-being. Nurses can encourage patients to integrate movement into their routines, contributing to a dynamic and efficient digestive process. 

Relaxation techniques play a vital role in constipation management. Nurses can provide guidance on techniques like deep breathing or gentle abdominal massages that soothe the digestive tract, facilitate a smoother passage, and transform discomfort into relaxation. 

Complications 

Constipation complications can disrupt the symphony of health. Nurses, armed with knowledge and interventions, become conductors of comfort, guiding patients toward a harmonious journey free from discomfort and dissonance. Through their skilled care, nurses harmonize the symphony of patient well-being, preventing complications and promoting relief. Examples of complications include the following. 

Hemorrhoids 

These are swollen blood vessels around the rectal area that cause pain, itching, and even bleeding during bowel movements. Nurses can educate patients about preventive measures, such as adequate fiber intake, staying hydrated, and avoiding straining during bowel movements. 

Anal Fissure 

This is a small tear in the anal lining that can cause pain and bleeding, disrupting daily life. Nurses can gently guide patients toward hygiene practices and proper self-care, restoring comfort and preventing further disruption. 

Fecal Impaction 

Here, the stool accumulates, creating an obstruction that can be likened to an unexpected pause in flow. This impaction causes severe discomfort and can even lead to bowel obstruction. Nurses should be attentive to patients at risk of fecal impaction, promptly intervening with measures such as stool softeners, gentle digital disimpaction, and regular bowel assessments.  

Rectal Prolapse 

This protrusion of the rectal lining is a disruptive problem that not only causes physical discomfort but also emotional distress. Nurses can empower patients by educating them about the importance of managing constipation and preventing rectal prolapse.  

Nausea and Vomiting 

The buildup of waste and toxins can trigger these unsettling symptoms. Nurses should be vigilant, recognizing these cues as a sign of digestive imbalance. Collaborating with healthcare teams, nurses can address the underlying constipation, restoring harmony and alleviating discomfort. 

Bowel Obstruction 

This is a medical emergency. Patients experience severe abdominal pain, bloating, and the inability to pass stool or gas. Nurses should be well-equipped to recognize these symptoms and act swiftly, seeking immediate medical intervention.  

Prevention  

Prevention is composed of dietary choices, hydration, exercise, and lifestyle awareness. Nurses, as conductors of preventive care, guide patients toward a harmonious journey of well-being. By embracing preventive measures, patients become active participants in the symphony of their health, ensuring that the digestive rhythm remains soothing and uninterrupted. Sample preventive measures include the following: 

Dietary Adjustments 

Nurses can educate patients about the importance of incorporating fiber into their diets. Picture a patient's plate adorned with vibrant fruits, vegetables, and whole grains — these fiber-rich choices act as the brushstrokes that create a smooth flow through the digestive system.  

Hydration 

Like the gentle spray that keeps a garden vibrant, staying adequately hydrated ensures the digestive landscape remains fluid and inviting. Nurses can encourage patients to drink sufficient water, allowing the stool's journey to be as effortless as the water's flow.  

Exercise 

Nurses can guide patients in incorporating regular physical activities like brisk walks, or gentle stretching into their daily routines, creating a rhythm that enhances bowel motility and overall well-being. Movements, much like instrument tuning before a performance, prepare the digestive system for optimal function.  

Lifestyle Awareness 

Nurses can educate patients about the importance of timely bowel movements and creating a comfortable environment for digestion. Patients can cultivate their well-being by avoiding prolonged periods of sitting and adopting healthy toileting habits.  

Patient Education 

Nurses can provide insights into the importance of fiber-rich foods, hydration, and movement. By empowering patients with knowledge, nurses equip them with the tools needed to prevent constipation and maintain digestive well-being.   

Nursing Implications 

Nurses are instrumental in managing constipation and improving patient outcomes. Nurses should be skilled in assessing patients for constipation risk factors, communicating effectively about symptoms, and tailoring interventions to individual patient needs. Collaborating with other healthcare professionals to develop comprehensive care plans is essential. Examples of useful nursing skills include: 

Holistic Assessment 

Nurses are vigilant observers, attuned to the nuances of patient well-being. Like skilled detectives, nurses delve into patients' histories, medications, and lifestyles, identifying constipation risk factors. Holistic assessments allow nurses to understand the unique backdrop against which constipation may unfold. Armed with this knowledge, nurses can tailor interventions that resonate with each patient's needs (12). 

Effective Communication 

Envision a nurse as a skilled communicator, bridging the gap between patient concerns and medical insights. Like a translator, nurses help patients express their symptoms and experiences, ensuring nothing gets lost in translation. Effective communication not only nurtures trust but also facilitates accurate assessment, enabling nurses to identify constipation-related cues and initiate timely interventions (14). 

Collaboration with Multidisciplinary Teams 

Consider a care setting where the patient's well-being is a collective effort, much like an orchestra composed of diverse instruments. Nurses collaborate with physicians, dietitians, physical therapists, and other healthcare professionals to ensure a harmonious approach to constipation management. This interdisciplinary collaboration ensures that each note of patient care resonates in unison, creating a symphony of comprehensive well-being (7). 

Patient-Centered Care Plans 

Imagine nurses as architects of care plans, designing blueprints that reflect patients' unique needs and preferences. Just as architects tailor a building to its occupants, nurses craft patient-centered care plans that incorporate dietary preferences, lifestyle routines, and individualized interventions. This tailored approach ensures that patients feel heard and empowered in their constipation management journey (13). 

Education and Empowerment 

Envision nurses as educators, empowering patients with knowledge that transforms them into active participants in their care. Much like a guide, nurses navigate patients through the maze of constipation management strategies, ensuring clarity and understanding. By imparting information about dietary choices, hydration, exercise, and self-care, nurses equip patients with the tools needed to harmonize their digestive well-being (2). 

Continuous Monitoring and Evaluation 

Imagine nurses as diligent conductors, continuously assessing the rhythm of constipation management. Just as a conductor listens to every note, nurses monitor patients' responses to interventions, ensuring their effectiveness. Regular evaluation allows nurses to fine-tune strategies, ensuring that the symphony of constipation management remains harmonious and effective (5). 

Compassionate Support 

Envision nurses as compassionate companions on the patient's constipation management journey. Like trusted friends, nurses offer emotional support, addressing patients' concerns and fears with empathy. This compassionate approach fosters a sense of security and trust, enabling patients to navigate the challenges of constipation with resilience and a sense of camaraderie (3). 

Conclusion

Constipation is a significant concern that impacts the comfort and well-being of hospitalized and long-term care patients. Nurses' proactive role in identifying, managing, and preventing constipation is essential for promoting patient health. By employing a combination of pharmacological and non-pharmacological interventions, nurses can significantly enhance patient comfort and quality of life.  

Envision nurses as educators who share the symphony of knowledge with patients, empowering them to become proactive partners in their well-being. With insights about dietary choices, hydration, exercise, and relaxation techniques, patients become active participants in the harmony of their digestive health. 

Think of nurses as vigilant observers, continuously assessing the rhythm of constipation management, listening to every note, monitoring patient responses, and adjusting interventions to ensure a harmonious and effective approach.  

Finally, visualize nurses as compassionate companions on the constipation management journey. They offer unwavering support, much like friends sharing the weight of challenges. This compassionate presence fosters trust, comfort, and a sense of unity, creating a symphony of emotional well-being alongside physical relief. 

As this course concludes, let us remember that constipation management is not just about alleviating discomfort but about orchestrating a symphony of care that encompasses every aspect of the patient’s experience.  

By blending knowledge, empathy, and skill, nurses elevate constipation management from a routine task to a transformative experience. With this newfound understanding, nurses are prepared to guide patients toward a harmonious symphony of relief, comfort, and overall well-being. 

Spinal Cord Injury: Bowel and Bladder Management

Introduction   

Imagine one day you are able to walk and take care of your own needs. Now, imagine one week later you wake up no longer able to walk, feel anything below your waist, or hold your bowels.  

This is a reality for many people who sustain spinal cord injuries. Managing changes in bowel and bladder function is one of many challenges that people with spinal cord injuries and their families or caregivers face.  

This course will provide learners with the knowledge needed to assist patients who have spinal cord injuries with bowel and bladder management to improve the quality of life in this group.

Spinal Cord Injuries: The Basics

Spinal Cord Function 

Before defining a spinal cord injury, it is important to understand the function of the spinal cord itself. The spinal cord is a structure of the nervous system that is nestled within the vertebrae of the back and helps to distribute information from the brain (messages) to the rest of the body [1].  

These messages result in sensation and other neurological functions. While it may be common to primarily associate the nervous system with numbness, tingling, or pain, nerves serve an important purpose in the body’s function as a whole.

Spinal Cord Injury Definition 

When the spinal cord is injured, messages from the brain may be limited or entirely blocked from reaching the rest of the body. Spinal cord injuries refer to any damage to the spinal cord caused by trauma or disease [2]. Spinal cord injuries can result in problems with sensation and body movements.  

For example, the brain sends messages through the spinal cord to muscles and tissues to help with voluntary and involuntary movements. This includes physical activity like running and exercising, or something as simple as bowel and bladder elimination.  

Spinal Cord Injury Causes 

Spinal cord injuries occur when the spinal cord or its vertebrae, ligaments, or disks are damaged [3]. While trauma is the most common cause of spinal cord injuries in the U.S., medical conditions are the primary causes in low-income countries [4] [2]. 

Trauma 

• Vehicle accidents: Accounts for 40% of all cases [2] 
• Falls: Accounts for 32% of all cases [2] 
• Violence: Includes gun violence and assaults; accounts for 13% of all cases [2] [5] 
• Sport-related accidents: Accounts for 8% of all cases [2] 

Medical Conditions 

• Multiple Sclerosis (MS): Damage to the myelin (or insulating cover) of the nerve fibers [1] 
• Amyotrophic Lateral Sclerosis (ALS): Lou Gehrig’s disease, damage to the nerve cells that control voluntary muscle movements [1] 
• Post-Polio: Damage to the central nervous system caused by a virus [1] 
• Spina Bifida: Congenital defect of the neural tube (structure in utero that eventually forms the central nervous system) [1] 
• Transverse Myelitis (TM): Inflammation of the spinal cord caused by viruses and bacteria [1] 
• Syringomyelia: Cysts within the spinal cord often caused by a congenital brain abnormality [1] 
• Brown-Sequard Syndrome (BSS): Lesions in the spinal cord that causes weakness or paralysis on one side of the body and loss of sensation on the other [1] 
• Cauda Equina Syndrome: Compression of the nerves in the lower spinal region [1] 

Spinal Cord Injury Statistics 

According to the World Health Organization, between 250,000 and 500,000 people worldwide are living with spinal cord injuries [4]. In the U.S., this number is estimated to be between 255,000 and 383,000 with 18,000 new cases each year for those with trauma-related spinal cord injuries [6]. 

Age/Gender 

Globally, young adult males (age 20 to 29) and males over the age of 70 are most at risk. In the U.S., males are also at highest risk, and of this group, 43 is the average age [2].  

While it is less common for females to acquire a spinal cord injury (2:1 ratio in comparison to males), when they do occur, adolescent females (15-19) and older females (age 60 and over) are most at risk globally [4].  

Race/Ethnicity 

In the U.S. since 2015, around 56% of spinal cord injuries related to trauma occurred among non-Hispanic whites, 25% among non-Hispanic Black people, and about 14% among Hispanics [6].  

Mortality 

People with spinal cord injuries are 2 to 5 times more likely to die prematurely than those without these injuries (WHO, 2013). People with spinal cord injuries are also more likely to die within the first year of the injury than in subsequent years. In the U.S., pneumonia, and septicemia – a blood infection – are the top causes of death in patients with spinal cord injuries [6]. 

Financial Impact 

Spinal cord injuries cost the U.S. healthcare system billions each year [6]. Depending on the type, spinal cord injuries can cost from around $430,000 to $1,300,000 in the first year and between $52,000 and $228,000 each subsequent year [6].  

These numbers do not account for the extra costs associated with loss of wages and productivity which can reach approximately $89,000 each year [6]. 

Spinal Cord Injuries: Types and Complications

Four Levels of the Spinal Cord 

• Cervical (vertebrae C1 – C8): Neck; controls the back of the head down to the arms, hands, and diaphragm 
• Thoracic (vertebrae T1 – T12): Upper mid-back; controls the chest muscles, many organs, some back muscles, and parts of the abdomen 
• Lumbar (vertebrae L1 – L5): Lower back; controls parts of the lower abdomen, lower back, parts of the leg, buttocks, and some of the external genital organs 
• Sacral (vertebrae S1 – S5): Lower back; controls the thighs down to the feet, anus, and most of the external genital organs 

Types of Spinal Cord Injuries 

Spinal cord injuries may be classified by level and degree of impairment. There are four types of spinal cord injuries [5]. 

Injury Level 

• Tetraplegia or Quadriplegia: Injury at the cervical level; loss of feeling or movement to the head, neck, and down. People with this type of spinal cord injury have the most impairment. 
• Paraplegia: Injury at the thoracic level or below; limited or complete loss of feeling or movement to the lower part of the body.  

Impairment 

• Incomplete spinal cord injury: Some sensation and mobility below the level of injury as the spinal cord can still transmit some messages from the brain. 
• Complete spinal cord injury: Total loss of all sensation and mobility below the level of injury. Spinal cord injuries of this type have the greatest functional loss. 

Spinal Cord Injury Complications 

Complications from spinal cord injuries can be physical, mental, or social, and can impact overall quality of life. There are six common complications of spinal cord injuries [2]. 

Depression 

Studies show that 32.9% of adults with disabilities experience frequent mental distress [7]. Mental distress may be related to functional limitations, chronic disease, and the increased need for healthcare services.  Up to 37% of people with spinal cord injuries develop depression [2]. 

Pressure injuries 

People with spinal cord injuries may have problems with circulation and skin sensation– both risk factors for pressure injuries. Some may be bedridden or wheelchair-bound which also places them at risk for pressure injuries. Up to 80% of people with spinal cord injuries will have a pressure injury during their lifetime and 30% will have more than one [2].  

Spasticity 

Around 65% - 78% of people with spinal cord injuries have spasticity [2]. Spasticity is uncontrolled muscle tightening or contraction. The damage from spinal cord injuries causes misfires in the nervous system leading to twitching, jerking, or stiffening of muscles. 

Autonomic dysreflexia 

In some people with spinal cord injuries, a full bladder or bowel distention can cause a potentially dangerous condition called autonomic dysreflexia. The full bladder or bowel triggers a sudden exaggerated reflex that causes an increase in blood pressure. This condition is also associated with a severe headache, low heart rate, cold skin, and sweating in the lower body [8]. 

Respiratory problems 

If the diaphragm function is affected, as with cervical spinal cord injuries, there may be breathing difficulties. People with lumbar spinal cord injuries can even have respiratory problems as the abdominal muscles are used to breathe. 

Sexual problems 

Due to changes in muscle function and depending on the degree of damage, people with spinal cord injuries may have problems with arousal and climax due to altered sensations and changes in sexual reflexes.  

Changes in bowel and bladder function 

Many people with spinal cord injuries lose bowel control. Bowel problems can include constipation, impaction, and incontinence. They may also have problems with urination, for example, urinary retention. 

Bowel and Bladder Dysfunction in Spinal Cord Injuries 

This section will cover the normal function of the bowel and bladder, and the types of bowel and bladder dysfunction that occurs in patients with spinal cord injuries.

Normal Bowel and Bladder Function 

In normal bowel and bladder function, when the rectum or bladder fills with stool/urine and presses on area nerves (stimulation), the message is sent to the spinal cord which sends it to the brain. The brain gives the person the “urge” feeling, allowing an option to control the elimination or not.  

Whatever decision the person makes, the brain sends the message back to the spinal cord, which in turn sends a message to the elimination muscles (anal and bladder sphincters) to either relax or stay closed until the person is ready. In people with spinal cord injuries, the messages are limited or blocked, leading to problems with bowel and bladder control [9] [10].  

Bowel Dysfunction with Spinal Cord Injuries 

Reflex hypertonic neurogenic bowel occurs when a rectum full of stool presses against area nerves sending a message to the spinal cord, but it stops there. The message never makes it to the brain, so the person never gets the urge.  

As a result, a reflex is set off, prompting the spinal cord to send a message to the anal muscle (sphincter) instead, causing it to relax and release the stool. This condition leads to bowel incontinence and usually occurs in spinal injuries at the cervical and thoracic levels [9] [10]. 

Flaccid hypotonic bowel occurs when area nerves are also stimulated by a full rectum, but the message does not even reach the spinal cord, so there is no reflex. The anal sphincter is always in a relaxed state.  

As a result, the bowels simply empty when they are full, and this can occur at any time without the person having the ability to control it. This condition results in bowel incontinence and can lead to constipation as the patient does not have the urge and may not have the ability to push. This condition usually occurs in spinal injuries at the lumbar level [9] [10]. 

Bladder Dysfunction with Spinal Cord Injuries 

Reflex neurogenic bladder occurs when the bladder automatically starts to contract after filling with a certain amount of urine. The person has no urge to go as the messages are either limited or blocked from reaching the brain, therefore leading to loss of bladder control. Similar to reflex hypertonic neurogenic bowel, the full bladder triggers are nerves that set off a reflex, prompting the spinal cord to send messages to the bladder releasing urine outside of the person’s control [9] [10]. 

Acontractile bladder occurs when the bladder loses muscle tone after a spinal cord injury, lessening its ability to contract, leading to bladder distention, and dribbling of urine. People with this condition need to use urinary catheters to help empty the bladder [9]. 

The Nurse’s Role in Bowel and Bladder Management 

This section will cover how nurses can assess, intervene, and teach when caring for patients with spinal cord injuries who have bowel and bladder dysfunction.

Nurse Assessments 

When caring for patients with spinal cord injuries, nurses should obtain a detailed bowel and bladder history including diet, fluid intake, medications, and elimination patterns/habits [11]. Many of these patients may already manage their own bowel and bladder care at home.  

If so, the nurse should obtain the patient’s current regimen and communicate the information to the physician. The physician may choose to continue the regimen or adjust as needed based on the patient’s current illness/condition.  

Questions the nurse can ask the patient: 

• What does your typical diet consist of? 
• How much fluid do you drink on a daily basis? 
• How often do you have a bowel movement or urinate? 
• Do you schedule your bowel movements with assistance from medications? 
• Are there certain body positions or things you do to help you pass stool more easily?
• How often do you use an intermittent urinary catheter for bladder relief? 
• How much time do you spend on your bowel and bladder regimens? 
• Do you care for all of your elimination needs or does someone help you? 
• How does your bowel and bladder dysfunction affect your quality of life? 

Some assessments may be observed. For example, nurses may notice that the patient has a surgically placed permanent suprapubic urinary catheter or colostomy (when the bowel is cut somewhere above the level of the rectum and diverted to the outside of the abdomen). 

Nurse Interventions 

Since many patients with spinal cord injuries have problems with bowel and bladder function, elimination must be scheduled. Nurses can help by implementing bowel and bladder programs and providing education and support to patients, families, or caregivers.  

Regimens 

Follow the patient’s home bowel and bladder regimen (as ordered). This may include maintaining intermittent catheterization every few hours or administering suppositories daily.  

For patients who do not have a regimen already or wish to modify their current one, encourage them to pay attention to how often they urinate and pass stools, elimination problems, foods that alleviate or worsen the problem, and medications or other things that help. This can be done through a diary. 

Dietary Considerations 

Educate patients on the importance of a fiber-rich diet to avoid constipation. Patients should also be made aware that high-fat foods, spicy foods, and caffeine can alter gut dynamics and lead to bowel incontinence episodes [12]. 

Fluid Intake 

Some patients may avoid drinking enough water to avoid bladder complications (e.g., frequent incontinent episodes) [12]. However, nurses should educate patients on the importance of adequate fluid intake to prevent constipation. Patients should be made aware that bladder and bowel elimination regimens go hand in hand. 

Bladder Elimination 

For bladder dysfunction, help patients perform intermittent urinary catheterization as needed or place a temporary urinary catheter (as ordered). 

Bowel Elimination 

For bowel dysfunction, administer ordered suppositories and laxatives to help the bowels move (use suppositories in conjunction with the level of sensation the patient has near the anus/rectum) [9]. Changes in body position may help as well.  

While many of these interventions may not work in some patients with spinal cord injuries, bowel irrigation (water enemas) may be helpful [11]. Surgical placement of a colostomy may be indicated if all other measures have failed [11]. 

Emotional Support 

Ensure privacy and sensitivity during all elimination care as patients may experience embarrassment or frustration. 

Education for Families or Caregivers 

Provide education to families or caregivers on the importance of helping patients stay consistent with their elimination regimen, follow diet and fluid intake recommendations, and comply with medication orders.  

Referrals 

Inform the physician if interventions are not effective or if the patient, family, or caregiver has a special need (e.g., counselor or dietician). Refer patients and families or caregivers to support groups as needed.

Support Groups and Resources 

Christopher and Dana Reeve Foundation 

Christopher Reeve – an actor who was left paralyzed after an equestrian accident – and his wife Dana’s legacy lives on through their foundation, an organization that advocates for people living with paralysis [13].  

Miami Project to Cure Paralysis 

In response to his son, who acquired a spinal cord injury during college football, NFL Hall of Famer Nick Buoniconti and world-renowned neurosurgeon Barth A. Green, M.D. started a research program aimed at finding a cure for paralysis and discovering new treatments for many other neurological injuries and disorders [14]. 

National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) 

The National Institute on Disability, Independent Living, and Rehabilitation Research, a part of the U.S. Department of Health and Human Services’ Administration for Community Living, helps people with disabilities integrate into society, employment, and independent living [15].  

Paralyzed Veterans of America (PVA)  

A group of World War II veterans who returned home with spinal cord injuries, started this organization to support those with spinal cord injuries and dysfunction. Today, the organization focuses on quality health care, research and education, benefits, and civil rights to affected veterans [16].  

United Spinal Association 

The United Spinal Association supports people with spinal cord injuries and those in wheelchairs. The organization advocates for disability rights like access to healthcare, mobility equipment, public transportation, and community support. Support groups can be found on their website [17).  

Conclusion

Spinal cord injuries can have devastating effects on patients and their families. Management of basic bodily functions like bowel and bladder elimination should be made as easy as possible for these patients.

When nurses learn how to effectively help patients with spinal cord injuries better manage their own bowel and bladder regimens, quality of life and health outcomes may be improved for this group.

Pressure Injury Prevention, Staging and Treatment

Introduction   

When hearing the term HAPI, what comes to mind? The fact is, HAPI may not necessarily generate happy thoughts. Hospital-acquired pressure injuries (HAPIs) are a significant problem in the U.S. today. In fact, pressure injuries in general – whether acquired in a hospital or not – are a global problem.

Many articles have noted that staging and differentiating pressure injuries can be overwhelming for nurses [9]. The purpose of this course is to equip learners with the knowledge needed to reduce pressure injuries, resulting complications, financial risk, and associated death. The information in this course will serve as a valuable resource to nurses from all specialties and backgrounds.

What is a pressure injury?

The National Pressure Injury Advisory Panel (NPIAH) defines pressure injuries as “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device” [17]. Pressure injuries can present as intact or opened skin and can be shallow or deep. Pressure injuries can be quite painful for patients and may require extensive treatment.

Prior to 2016, pressure injuries were termed “pressure ulcers.” However, since ulcer implies “open skin,” the NPIAH changed it to “pressure injury” as the skin is not always open with some of these injuries [22][25].

What causes a pressure injury to develop?

Pressure 

Intense and/or prolonged pressure on the patient’s skin and/or tissue can cause compromised blood flow and decreased sensation [7]. This can occur when patients lay or sit on a bony prominence for an extended period of time [16].  

Bony prominences are areas where you can easily feel a bone underneath the skin or tissue when palpating. These can include the heels, hips, elbows, and tailbone. Approximately two-thirds of all pressure injuries occur on the hip and buttocks area [7]. 

Friction and Shear 

Friction and shear often happen when patients slide down in bed, for example, when the head of the bed is raised. Although “friction and shear” are often used together, there is actually a difference between the two.  

While friction occurs when skin is dragged across a coarse surface (leading to surface-level injuries), shearing occurs when internal bodily structures and skin tissue move in opposite directions (leading to deep-level injuries) [10]. Shearing is often associated with a type of pressure injury called deep tissue injury (occurring in the deeper tissue layers rather than on the skin’s surface) [10].

[24] 

What are risk factors for developing a pressure injury? 

There are numerous risk factors for pressure injuries – some of which may not be directly related to the skin. These risk factors can be categorized as either intrinsic factors (occurring from within the body) or extrinsic (occurring from outside of the body) [2][13]. 

Intrinsic Risk Factors 

- Poor skin perfusion (e.g., peripheral vascular disease or smoking) 

- Sensation deficits (e.g., diabetic neuropathy or spinal cord injuries) 

- Moist skin (e.g., urinary incontinence or excessive sweating) 

- Inadequate nutrition (particularly poor protein intake) 

- Poor skin elasticity (e.g., normal age-related skin changes) 

- End of life/palliative (leads to organ failure including the skin) 

- Limited mobility (i.e., bedridden, or wheelchair-bound) 

Extrinsic Risk Factors 

- Physical and chemical restraints (leads to limited mobility) 

- Undergoing a procedure (laying down for extended periods of time) 

- Length of hospital stay (for HAPIs) 

- Medical devices (can lead to medical device-related pressure injuries)

Statistical Evidence 

This section will cover pressure injury statistics both globally and nationally. This section will also cover the impact pressure injuries have on healthcare.

What is happening on a global scale? 

In a global study, researchers found that the prevalence (all cases) and incidence (new cases) of pressure injuries in 2019 were 0.85 million and 3.17 million, respectively – numbers that have decreased over time [23][25]. Numbers were disproportionately high in high-income North America, Central Latin America, and Tropic Latin America [25]. Numbers were lowest in Central Asia and Southeast Asia. The report revealed that although numbers are high overall, they are much lower than what they were predicted to be, which may be attributed to better prevention and treatment initiatives.

What is happening nationally? 

In the U.S., 2.5 million people develop pressure injuries each year [1]. This number does not account for the many people trying to manage pressure injuries on their own at home (i.e., when family acts as the caregiver).  

HAPIs in particular are a growing problem. The most recent data on hospital-acquired conditions in the U.S. shows that from 2014 to 2017, HAPIs increased by 6% (647,000 cases in 2014 to 683,000 in 2017) [6]. Each year 60,000 patients in the U.S. die as a direct result of pressure injuries [1]. 

How do pressure injuries impact healthcare? 

Pressure injuries can be quite costly to the healthcare system. These injuries can lead to persistent pain, prolonged infections, long-term disability, increased healthcare costs, and increased mortality [1].  

In the U.S., pressure injuries cost between $9.1 - $11.6 billion per year [1]. These injuries are complex and can be difficult to treat [7]. Often requiring an interdisciplinary approach to care, the costs of one pressure injury admission can be substantial. Individual care for patients with pressure injuries ranges from $20,900 to $151,700 per injury [1]. Not to mention, more than 17,000 lawsuits are related to pressure injuries every year [1].  

Due to the significant impact that these injuries have on healthcare, prevention and accurate diagnosis is imperative.

Staging and Diagnosis 

The section will cover the staging, varying types, and diagnosis of pressure injuries.  

What is the difference between wound assessment and staging? 

Pressure injury staging is more than a basic wound assessment. Wound assessment includes visualizing the wound, measuring the size of the wound, paying attention to odors coming from the wound, and lightly palpating the area on and/or around the wound for abnormalities. Pressure injury staging, however, involves determining the specific cause of injury, depth of skin or tissue damage, and progression of the disease.  

What are the six stages of pressure injuries? 

According to NPIAP guidelines, there are six types of pressure injuries – four of which are stageable [14]. 

[16] 

Stage 1 

In Stage 1 pressure injuries, there is intact skin with a localized area of non-blanchable erythema (pink or red in color), which may appear differently in darkly pigmented skin. Before visual changes are noted, there may be the presence of blanchable erythema or changes in sensation, temperature, or firmness. Stage 1 pressure injuries do not have a purple or maroon discoloration (this can indicate a deep tissue pressure injury). 

Stage 2 

In Stage 2 pressure injuries, there is partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent an intact or opened serum-filled blister. Fat (adipose) and deeper tissues are not visible. Granulation tissue, slough (soft moist material, typically yellow or white), and eschar (hard necrotic tissue, typically black in color) are not present. Stage 2 injuries cannot be used to describe wounds associated with moisture-only, skin chaffing, medical adhesives, or trauma. 

Stage 3 

In Stage 3 pressure injuries, there is full-thickness loss of skin, in which fat is visible in the injury, and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be noted. The depth of tissue damage is dependent on the area of the wound. Areas with a significant amount of fat can develop deep wounds.  

Undermining (burrowing in one or more directions, may be wide) and tunneling (burrowing in one direction) may be present. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar covers the extent of tissue loss, this would be considered an unstageable pressure injury, not a Stage 3. 

Stage 4 

In Stage 4 pressure injuries, there is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the wound. Slough and/or eschar may be visible. Rolled wound edges, undermining, and/or tunneling are often present. The area where the wound is present will determine the depth. As with stage 3 pressure injuries, if slough or eschar covers the extent of tissue loss, this would be considered an unstageable pressure injury. 

Unstageable 

In unstageable pressure injuries, there is full-thickness skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because it is covered by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.  

Deep Tissue Injury 

In deep tissue pressure injuries (also termed: deep tissue injuries or DTIs), there is intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.  

Pain and temperature changes often precede skin color changes. Discoloration may appear differently in darker-pigmented skin. The injury may resolve without tissue loss or may worsen quickly and open up, revealing the actual extent of tissue injury. Deep tissue pressure injuries should not be used to describe vascular, traumatic, neuropathic, or dermatologic conditions.  

What are other types of pressure injuries? 

Mucosal Membrane Pressure Injury 

Mucosal membrane pressure injuries are found on mucous membranes with a history of a medical device in use at the location of the injury. For example, a wound on the inside of a nostril from a nasogastric tube would be considered a mucosal membrane pressure injury. Due to the anatomy of the tissue, mucosal membrane pressure injuries cannot be staged [18]. 

Medical Device-Related Pressure Injury 

Medical device-related pressure injuries, often associated with healthcare facilities, resulting from the use of devices designed and applied for diagnostic or therapeutic purposes [15]. The resulting pressure injury typically conforms to the pattern or shape of the device which makes identification easier. The injury should be staged using the staging system.  

Hospital Acquired Pressure Injury (HAPI) 

While the general hospital setting places patients at a 5% to 15% increased risk of developing a pressure injury (HAPI), patients in the intensive (or critical) care unit in particular have an even higher risk [17]. Critical care patients typically have serious illnesses and conditions that may cause temporary or permanent functional decline. There is also evidence that pressure injuries in this setting can actually be unavoidable.  

The NPIAP defines “unavoidable” pressure injuries as those that still develop after several measures by the health provider have been taken. These measures include when the provider has (a) evaluated the patient’s condition and pressure injury risk factors, (b) defined and implemented interventions consistent with standards of practice and the patient’s needs and goals, and (c) monitored and evaluated the impact of interventions [20]. There are certain situations in which a critical care patient may have a higher risk of developing unavoidable pressure injuries.  

In one study of 154 critical care patients, researchers found that 41% of HAPIs were unavoidable and those who had a pressure injury in the past were five times more likely to develop an unavoidable pressure injury during their stay [20]. The study also found that the chance of developing an unavoidable HAPI increased the longer patients stayed in the hospital – a 4% risk increase each day.  

How are pressure injuries diagnosed? 

Diagnosing a pressure injury is done by simply staging the injury. The health provider may stage the injury or rely on the nurse’s staging assessment before giving the final diagnosis and initiating treatment. There are tests that may be ordered to help identify the early stages of a developing injury.  

For example, subepidermal moisture assessment (SEM) scanners may help to identify tissue changes early on in patients with darker skin tones [8]. Tests may also be ordered to determine the extent of the damage, disease, or infection caused by a pressure injury. A magnetic resonance imaging test (MRI) can be used to determine if the infection in a stage 4 pressure injury has spread to the bone. 

Prevention and Treatment 

This section will cover various strategies that can be used to prevent and treat pressure injuries. 

What are some ways to prevent pressure injuries? 

Preventing pressure injuries takes more than just one nurse repositioning a patient every two hours. It involves a combination of strategies, protocols, and guidelines that facilities can implement across various departments, specialties, and care team members. The NIAPH recommends the following prevention strategies [19]. 

Risk assessment 

Facilities should use a standardized risk assessment tool to help identify patients at risk for pressure injuries (i.e., the Braden or Norton Scale). Rather than using the tool as the only risk assessment strategy, risk factors should be identified by other means (for example, by gathering a detailed patient history).  

Risk assessments should be performed on a regular basis and updated as needed based on changes in the patient’s condition. Care plans should include risk assessment findings to address needs. 

Skin Care 

Monitoring and protecting the patient’s skin is vital for pressure injury prevention. Stage 1 pressure injuries should be identified early to prevent the progress of disease. These include looking at pressure points, temperature, and the skin beneath medical devices.  

The frequency of assessments may change depending on the department. Ideally, assessments should be performed upon admission and at least once daily. Skin should also be cleaned promptly after incontinence episodes. 

Nutritional Care 

Tools should be used that help to identify patients at risk for malnutrition. Patients at risk should be referred to a registered dietician or nutritionist. Patients at risk should be weighed daily and monitored for any barriers to adequate nutritional intake. These may include swallowing difficulties, clogged feeding tubes, or delays in intravenous nutrition infusions. 

Positioning and mobilization 

Immobility can be related to age, general poor health, sedation, and more. Using offloading pressure activities and keeping patients mobile overall can prevent pressure injuries. Patients at risk should be assisted in turning and repositioning on a schedule. Pressure-relieving devices may be used as well. Patients should not be positioned on an area of previous pressure injury. 

Monitoring, training, and leadership 

Current and new cases of pressure injuries should be documented appropriately and reported. All care team members should be educated on pressure injury prevention and the importance of up-to-date care plans and documentation.  

All care team members should be provided with appropriate resources to carry out all strategies outlined. Leadership should be available to all care team members for support (this may include a specialized wound care nurse or wound care provider). 

How are pressure injuries treated? 

There is no one way to treat a pressure injury. Management of pressure injuries involves a specialized team of care providers and a combination of therapies that aim to target underlying factors and prevent complications [7]. Depending on the stage of the wound and skin risk factors, providers may order specific types of treatments.  

Some pressure injury treatments may include the following [7]. 

- Wound debridement – a procedure in which necrotic tissue is removed from a wound bed to prevent the growth of pathogens in the wound, allowing for healing 

- Antibiotic therapy (topical or systemic) 

- Medicated ointments applied to the wound bed (e.g., hydrogels, hydrocolloids, or saline-moistened gauze to enable granulation tissue to grow and the wound to heal) 

- Nutritional therapies (e.g., referrals to dieticians) 

- Disease management (e.g., controlling blood sugar in diabetes) 

- Pain medications 

- Physical therapy (to keep the patient active) 

The Nurse’s Role 

The section will cover the nurse’s role in preventing pressure injuries and the progression of disease.  

What is the nurse’s role in pressure injury prevention? 

Based on NPIAH guidelines, the Agency for Healthcare Research and Quality (AHRQ) – an agency that monitors pressure injury data for the U.S. – breaks down quality initiatives for preventing pressure injuries in a three-component care bundle [2].  

A care bundle is a combination of best practices that when used together, can lead to better patient outcomes [2]. The care bundle includes skin assessments, risk assessments, and care planning. Nurses should follow the guidelines listed under each component. 

Standardized pressure injury risk assessment 

- Use risk assessment tools and processes to identify patients at risk 

- Do not rely on tools only, use your own judgment as well (tools are meant to guide the assessment)