Author: Claire

Claire Galea is the Owner and Director of Mariposa Holistic Care, through which she provides holistic care services tailored to her clients' personal needs. She is also in her final year following a Degree in Nursing at the Faculty of Health Sciences, University of Malta. Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading positivity and awareness on various subjects through her blog Student Nurse Life.

Suicide Facts and Interventions

According to the World Health Organisation, suicide is responsible for approximately 2200 deaths per day, which amount to 800,000 deaths per year, or 1 death per 40 seconds (WHO, 2016). In addition, with every successful attempt there are many more attempted suicides. The highest suicide rate can be attributed to the elderly.

4/5^ths of individuals who die from suicide have attempted to do it at least once before.

Whilst attempts are three times more often performed by women, men are three times more likely than men to complete it.

Some researchers claim that people with low levels of serotonin are up to ten times more likely to commit suicide than those with normal serotonin levels.

Other researchers claim that 25% of drivers who die in car accidents actually cause them subconsciously, hence the term ‘autocides’, meaning suicides in which individuals crash their cars with the aim of ending their lives.

Psychiatric In-Patient Suicide

Up to 0.4% of suicides take place in a mental health hospital.

Psychiatric inpatients are at particular risk for suicide. Studies show that the inpatients who are most at risk for suicide are those with affective disorders and schizophrenia. Precautions should be taken to reduce the risk of inpatient suicide, and following a suicide, the impact on the individual’s family as well as the other inpatients and staff should be considered.

Level 1 supervision is highly intrusive, but can also be therapeutic. Level 3 supervision is more related to care eg. to prevent falls, not just related to mental health. Based on past observations however, even constant supervision can fail at stopping or avoiding suicide.

Suicide Nursing Assessment

Suicide nursing assessment depth depends on the setting, ability and willingness of the person to provide information about previous and current mental health state, and availability of further information from other healthcare professionals in relation to the same person.

The SAFE-T card pictured below lists key risks and protective factors to be considered while evaluating the person’s suicide risk level. It provides guidance in conducting a comprehensive assessment and triage, risk estimation, and development of treatment plans and interventions based on the person’s mental health state.

SAFE-T assessment — Retrieved from https://store.samhsa.gov/product/SAFE-T-Pocket-Card-Suicide-Assessment-Five-Step-Evaluation-and-Triage-for-Clinicians/sma09-4432 on 22nd January 2022

Suicide enquiry should ideally include questioning about thoughts, plans, behaviours and intent in relation to suicide:

Ideation: frequency, intensity and duration
Planning: timing, location, lethality, availability, preparation
Behaviour: past attempts, rehearsing, self injury
Intent: how the person plans to carry out the act, whether the person believes the attempt will be lethal or injuring, and for what reason/s does the person think he should die

NOTE: In Malta, teenagers from 14 years up can ask for treatment even if parents refuse to accept that their child needs treatment, and this is possible thanks to the Mental Health Act.

Protective Factors

Protective factors that may help the person during contemplation phase include:

ability to cope with stress
religious/spiritual beliefs
tolerance to frustration
responsibilities eg. children and pets
positive therapeutic relationships with healthcare professionals who can provide guidance and help
social support eg. support groups or family help

Documentation

Documentation should include assessed risk level and the rationale behind the level assigned. It should contain interventions to reduce risk as well as plans for follow-up treatment. Psychotherapy, medication, treatment setting contact with others, and consultation with other past or present healthcare providers should be considered to reduce the possibility of suicide.

Retrieved from https://alea-research.com/suicide-prevention-the-columbia-protocol/ on 22nd January 2022

Are You Contemplating Suicide?

If you landed on this blogpost and you are contemplating suicide, please know that there are people who do care about you and your well-being. Please seek professional support. You can contact Richmond Foundation on 1770, Kellimni.com and Victim Support Malta.

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Psychiatric Emergency VS Mental Health Crisis

A psychiatric emergency is when an individual experiences an acute disturbance of behaviour, thought or mood. If untreated, a psychiatric emergency may lead the individual to harm self or others. It may happen anywhere in any person, whether diagnosed with a mental health problem or not, and requires intervention by another person (not necessarily by mental health professionals).

A mental health crisis is a situation in which an individual’s actions, feelings, and behaviors can lead them to hurt themselves or others. During a mental health crisis, the individual is at risk of becoming unable to self-care and function in a healthy way within the community.

Psychiatric Emergency Features

A person experiencing a psychiatric emergency exhibits the following 4 behavioural elements:

change and the person’s response towards it
intolerance towards change and towards other persons involved in the situation
reaction of significant others
behavioural change being an instant one

During a psychiatric emergency:

the person appears to be extremely agitated, possibly tearful, and highly distressed
the person may make extreme demands to others
the person may take irrational decisions which seem to be lacking rational judgement
the person may put self in danger, the consequences of which are not obvious to the person at the time
the person may lack the capacity to relate to the surrounding reality
those present during the psychiatric emergency may experience distress and fear, and may act spontaneously in a way that may cause emotional pain or anger following the event

(Ward, 1995)

Psychiatric Emergency Risk Factors

A psychiatric emergency may be triggered by the following psychological responses:

fear
rejection
frustration
intrusion
inferiority
embarassment
grief
reality conflict
psychiatric disturbance

Additionally, a person is more susceptible to experience a psychiatric emergency when:

experiencing an acute psychological disturbance
experiencing a stressful situation
undergoing a detox program
being admitted to a psychiatric facility
recovering from anaesthesia
in an intoxicated state
medication is being changed
unexpected worsening of physical condition occurs eg. infection
witnessing another person’s psychiatric emergency
being discharged
receiving follow-up community care
being cared for in an unfamiliar culture incl. different religious background

Psychiatric Emergency Nursing

Psychiatric emergency nursing may require different types of interventions:

verbal intervention
physical intervention
background management

As a nurse witnessing a PE, aim to:

provide immediate support to help the person regain control over feelings and actions
be flexible by treating the person as an individual with different needs
reduce any possible environmental triggering factors, moving away from the immediate area if required
provide psychiatric first aid to try to reduce the emotional tension being experienced by the person, steering away from the immediate feelings
protect the person experiencing a PE and yourself from physical harm
evaluate the event in both a concurrent and retrospective way to determine the best possible support required by the person
Ask for help or assistance if needed

PE Nursing Care Cycle

Assessment > Intervention > Resolution > Support

Assessment

The person experiencing a PE should be continuously monitored, assessed and re-evaluated. Focus on what the person wants, whether the person (or anyone else) is in danger, what was the behavioural cause, whether any similar situation occurred to the person before and how it was handled, and what it meant for the person if it happened before.

Intervention

Intervention should be provided as mediation between the person experiencing the PE and what is immediately available. Mediate between danger and safety, acting reasonably and quickly in a concise and unambiguous way. Focus on the person’s immediate thoughts and beliefs about self and what is currently causing the issue. Most importantly, act in a calm and confident way.

Safety

Inform your colleagues about the situation
Do not leave the person alone
Stay at arm’s length from a potentially aggressive or an aggressive person
Do not let the person stand between you and an exit point
Approach slowly
Speak slowly and calmly in a ‘matter of fact’ tone, but show that you care
Expect that the person may not even reply to your questions
Be ‘unshockable’
Do not retaliate, do not manhandle, do not belittle, do not respond to personal abuse, and never strike a person even if provoked
If grabbed by your clothing, move towards the person rather than away
If restraining the person is required, do so in a safe manner for all
Always treat the person experiencing a PE with dignity and respect

Resolution

Resolution occurs when the intervention produces a positive effect and the situation becomes no longer critical. In this stage, provide positive reassurance and affirm that it is safe for the person to feel better and relieved. Avoid patronising – keep acting in a kind and calm way without giving away your authority as a nurse. Make sure you reassess the person’s mental state.

Support

During this stage the nurse should re-evaluate the incident’s effects, and encourage the person to reflect on the incident and any possible triggers that could have led to the PE. The nurse should provide emotional support to the person, as well as seek professional support or support from other colleagues.

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Substance Misuse and Addictions

Substance misuse and addictions can be attributed to many reasons other than just an aim of getting high. Studies show that only 20% of individuals who make use of drugs do so with the primary aim of seeking pleasure. Other reasons for substance misuse and addictions include anxiety, depression, anger, boredom, peer pressure, lack of self confidence and lack of self control.

Substance misuse is more probable where there is availability and peer pressure. It is usually obtained either in an illicit way, or else through the chemist (certain drugs such as codeine), shops (such as solvents) and doctors (such as benzodiazepines).

Terminology related To Substance Misuse and Addictions

Acute Intoxication – a transient condition which follows alcohol or psychoactive substance misuse, resulting in disturbances in the individual’s level of consciousness, cognition, perception, judgment, affect or behavior, or other psycho-physiological functions and responses.

Harmful Use – damage incurred by psychoactive substance misuse in the individual as well as the implicated negative effects on the individual’s family and surrounding society eg. at work, in health, etc.

Physiological Dependence – withdrawal symptoms (eg. urgent need for more) and drug tolerance (needing more than before to experience the same ‘high’ effect).

Psychological Dependence – a sense of urgency to take a substance experienced by a drug-dependent individual, even when knowing of its related consequences; social, occupational and recreational activities are usually neglected by an individual with substance psychological dependence. A person with psychological dependence usually becomes addicted to the whole drug-taking process itself – including making sure they’re not being followed.

Diagnosis

Dependence diagnosis requires 3 of the following to be present for at least a year:

increased tolerance to a psychoactive drug
physiological withdrawal symptoms exhibited when drug is reduced or stopped
a sense of urgency to make use of the drug
inability to control substance misuse behaviour
neglecting other social, occupational and recreational activities
increased amount of time required to obtain and make use of the drug, and to recover from its effects
persistent use of drug despite knowing its attributed negative consequences

Experimentation/Recreation Drug Use vs Addiction

A recreational drug user is an individual who has tried the drug, enjoyed its use, may want to re-use it, but does not treat it as a priority.

On the other hand, for a drug addict, the drug becomes the main focus of attention, to a point in which other necessities such as nutrition become unimportant compared to the drug. Addiction is a chronic disorder.

substance misuse and addictions — Retrieved from https://greatoaksrecovery.com/cycle-of-addiction/ on 19th January 2022

The Pharmacology of Drugs

Drug pharmacology can be divided into 2 components: desired effects and unwanted effects. Most drug users do not become addicted, dependent or tolerant to the drug. All drugs cause dopamine to be released within the brain‘s nucleus accumbens, which leads to a pleasurable effect. However, it is motivation that may cause cravings for a drug, and drug-seeking behaviour.

Opiates

Opiates such as heroin (illegal), codeine, morphine, and methadone, are analgesic agents which bind to opioid receptors in the central nervous system, causing pain to be reduced or eliminated.

Opiates create a rush sensation of peace followed by CNS depression. Withdrawal symptoms, such as craving, sweating, yawning, diarrhoea, agitation, goose-flesh, abdominal cramping, and flu-like symptoms, can start developing from as early as 24 hours following dose administration.

Retrieved from https://www.colleaga.org/tools/clinical-opiate-withdrawal-scale on 20th January 2022

Opiate Replacement Therapy

Methadone is an opiate receptor agonist which is given as a replacement to heroin and other opioids in the case of addiction. Methadone has a longer half-life when compared with heroin, which means that withdrawal symptoms and cravings are reduced without providing the same euphoric effect that heroin provides, giving opioid users a better chance of weaning off or reducing their dose of opioids.

Buprenorphine is an opiate partial agonist. Together with naloxone, which is an antagonist that blocks the euphoric effect related to opioids, buprenorphine is given in tablet form as Suboxone, with the aim of preventing relapse.

An opioid overdose may cause miosis (pinpoint pupils) and respiratory depression (hypoventilation). Naloxone may be required to rapidly reverse opioid overdose by binding to opioid receptors, thus blocking the effects of the other opioids.

Hallucinogens

Hallucinogens – drugs (such as LSD) which cause dilated pupils, increased temperature, vasoconstriction, and hallucinations (distortions in an individual’s perception of reality), can be found in some plants and mushrooms (or their extracts) or can be man-made.

Hallucinogens do not cause physiological dependence, but rare adverse effects may include flashbacks, psychosis, and seizures.

Ecstasy (MDMA in powder form) can induce hyperactivity, and dehydration which can be fatal.

Flakka is a synthetic drug which has been changing in the past. It is very common, yet very dangerous. Psychosis is a common effect of Flakka.

Magic Mushrooms are similar to LSD with regards to effects.

Stimulants

Amphetamines (stimulant drugs eg. speed) cause euphoria, increased concentration, increased energy, mydriasis (pupil dilation), tachycardia, and hyperreflexia, followed by depression, fatigue and headache.

Cocaine can be sniffed, chewed, or taken through the IV route. Its effects are similar to hypomania, and may include visual and tactile hallucinations. Crack cocaine is a highly addictive form of cocaine with a relatively short ‘high’ effect, which may cause persecutory delusions as a withdrawal symptom.

Cannabis

One of cannabis’s active components is THC, which produces psychological effects such as euphoria, relaxation, an overall well-being sensation, omnipotence and hallucinations. Physiologically, THC causes increased appetite and lowered body temperature.

Cannabis is also associated with depression and schizophrenia. However, to develop schizophrenia, the person using cannabis needs to be at a higher risk of developing it due to factors such as genetic predisposition.

Cannabis may also cause adverse effects such as conjunctival (eye) irritation, decreased sperm production, lung disease, transient psychosis, and apathy. It also causes psychological dependence.

Sedatives and Hypnotics

Benzodiazepines such as Ativan and Valium are commonly used addictive drugs which can cause dependence, withdrawal symptoms, and tolerance. They also carry a risk of seizures and respiratory depression. In the hospital setting, Ativan and Valium are two medications that fall under the Dangerous Drug Act (DDAs).

Solvents

Solvents are typically sniffed with the intention of getting high due to the initial euphoria it causes. This however is followed by drowsiness. Chronic solvent sniffing can lead to weight loss, nausea and vomiting, polyneuropathy (widespread malfunction of peripheral nerves), cognitive impairment, and aplastic anaemia (body ceases to produce new blood cells).

Sniffing solvents may cause a red rush around the mouth and nose – this is a good way of detecting sniffing solvent abuse.

Khat

Khat is commonly used by Somali and Yemeni men. It contains cathionone, which is an amphetamine-like stimulant which causes excitement and euphoria. It is typically consumed through chewing.

Alcohol

Alcohol safe drinking limits are 31 units per week in men, 14 units per week in women, with at least 2 drink-free days per week. Whilst rates of alcohol consumption by women and adolescents are increasing rapidly, younger people are more prone to exceed the stipulated safe limits.

Detecting alcohol abuse is important so as to avoid long-term complications and acute withdrawal effects. A good way to detect alcohol abuse is through screening questionnaires such as FAST and CAGE. CAGE is an ideal questionnaire when alcoholism is suspected. Once detected, an alcoholic individual should be referred for counseling.

Retrieved from https://www.researchgate.net/figure/The-Fast-Alcohol-Screening-Test-FAST_tbl2_260423389 on 20th January 2022

Retrieved from http://www.familyvan.org/module-week-9-substance-use on 20th January 2022

Alcoholism-related terminology

Acute Intoxication – a state in which an individual shows signs of slurred speech, impaired coordination, impaired judgement, and labile affect (inappropriate emotion expression). More severe repercussions include hypoglycaemia, stupor and coma.

Acute Withdrawal – following 1-2 days of abstinence, the individual experiences malaise, nausea, autonomic hyperactivity, tremor, labile mood (uncontrollable crying or laughing at an improper time or situation), insomnia, transient (mostly visual) hallucinations, and seizures. In the worst case scenario, delirium tremens, which is a severe withdrawal symptom related only to alcohol withdrawal, may be experienced. This is characterised by altered mental status and sympathetic overdrive that may progress to cardiovascular collapse. Delirium Tremens carries a 15% mortality rate.

Alcohol Dependence – individual experiences cognitive, behavioural and psychological features with compulsion to drink, preoccupation with alcohol, stereotyped drinking pattern, loss in drinking regulation, and tolerance of alcohol intoxicant effect.

Psychotic Disorders – hallucinations with 2nd person threatening voices and at times pathological or morbid jealousy.

Amnesic Syndrome – Korsakoff’s psychosis: a severe, diencephalic amnesia caused by thiamine deficiency, which is typically noted in alcoholic patients with very poor diets.

Alcohol Abuse Residual Problems – residual depression and dementia.

Alcohol Abuse Detection and Screening

collect collateral history
look for signs of alcohol disease eg. jaundice, palmar erythema (a skin condition that makes the palms of your hands turn red), gynaecomastia (a common condition that causes boys’ and men’s breasts to swell and become larger than normal), and spider naevi (swollen spider-like blood vessels on the skin often containing a central red spot and deep reddish extensions)
blood tests should be performed to check for macrocytosis (red blood cells that are larger than normal), high gamma-glutamyltransferase (GGT – indicative of liver disease), and high blood alcohol levels

Complications related to alcoholism are usually encountered in the acute setting. These include:

gastrointestinal complications
haematological complications
cardiovascular complications
wernicke’s encephalopathy (a life-threatening illness caused by thiamine deficiency, which primarily affects the peripheral and central nervous system)
korsakoff’s psychosis
peripheral neuropathy
cerebellar degeneration (a condition in which cerebellar cells a.k.a. neurons, become damaged and progressively weaken in the cerebellum)
erectile dysfunction
social complications
fetal alcohol syndrome (in pregnancy)

Management

motivational interviewing
detoxification (possibly including hospitalisation with administration of benzodiazepines and thiamine)
learning relapse-prevention strategies
referral to self-help groups such as Alcoholics Anonymous
administration of Disulfiram, which causes an unpleasant reaction if the individual consumes alcohol, and Acamprosate, which reduces cravings
public health measures eg. taxation

Synthetic Drugs

Synthetic drugs are manufactured to chemically resemble illicit drugs such as cocaine, LSD, MDMA, or methamphetamines, yet can be purchased legally as the manufacturers continuously change the chemical structure to circumvent drug laws. They are usually not detected in urine tests.

Synthetic Cannabinoids, which are commonly used in Malta, are products that mimic the effect of Cannabis in a more potent way. These can be found as solids or oils. Smoking mixtures with added cannabinoids are mostly sold in metal-foil sachets.

Synthetic Cannabinoids cause psychotic symptoms such as extreme anxiety, confusion, paranoia, and hallucinations.

Other synthetic drug names include:

Spice – synthetic marijuana / cannabinoids
Ecstasy – Molly
Bath Salts – contain one or more synthetic chemicals related to cathinone
Mephedrone – Meow Meow: commonly found in bath salts
Krokodil – cheaper heroin substitute which is a synthetic morphine derivative, commonly used in Russia

NOTE: Psychosis following intoxication can usually be reversed.

The Stages of Change Model

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Palliative Nursing Care ~ Pain & Symptom Management and Quality of Life

What is palliative nursing care?

An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
WHO, n.d.

Palliative care is not only available for patients with cancer, but also for patients with no possible recovery, such as patients with end-stage organ failure.

palliative nursing care — Retrieved from https://online.stanford.edu/courses/som-xche0017-palliative-care-always-capstone on 18th January 2022

What is suffering in palliative care?

A multidimensional and dynamic experience of severe stress that occurs when there is a significant threat to the whole person and regulatory processes (which would normally enable adaptation) are insufficient.
Krikorian & Limonero, 2012

Promoting Quality of Life in Palliative Nursing Care

Palliative Nursing Care should aim to provide quality of life, which in other words refers to care in all aspects that palliative patients deem necessary for what they perceive quality of life to be. Such aspects include:

emotional needs
autonomy
healthcare
cognitive aspects
physical aspects
social aspects
spiritual aspects
preparatory aspects

A primary assessment aims to point out all current issues as well as potential ones. Palliative Nursing Care should include the following domains when it comes to patient assessment:

symptoms
function
interpersonal
well-being
transcendent

These should be measured through assessment, satisfaction and importance…

Palliative Nursing Care Systematic Symptom Assessment

A systematic symptom assessment provides a deeper insight when compared to a primary assessment…

Symptomatic Pain Management

Symptomatic Pain Management needs to be applied through the nursing process:

ASSESSMENT of the pain
PLANNING pain management
IMPLEMENTATION of medical and non-medical regimen
EVALUATION of applied pain management and its effectiveness

Detailed information about the pain being experienced by the patient, such as location, intensity, quality, effect, and impact (even including the patient’s own descriptive words about experienced pain), leads to an accurate diagnosis and thus, better pain management strategies.

Pain can be classified as either Neuropathic Pain or Nociceptive Pain. Nociceptive Pain is a combination of Somatic Pain and Visceral Pain…

Retrieved from https://edu.glogster.com/glog/acutechronic-pain/2afxqocdhjg?=glogpedia-source on 18th January 2022

Medical Pain Management Strategies

Retrieved from https://www.researchgate.net/figure/New-adaptation-of-the-analgesic-ladder_fig2_258112804 on 18th January 2022

(‘weak opioids’ include Codeine)

Retrieved from https://www.uspharmacist.com/article/special-considerations-for-opioid-use-in-elderly-patients-with-chronic-pain on 18th January 2022

Non-Medical Pain Management Strategies

Non-medical pain management strategies may help in conjunction with medical pain management methods. Helpful methods may include:

complementary therapy
transcutaneous electrical nerve stimulation (TENS)
acupuncture
music therapy
hypnosis
reflexology
mind-body therapy
art therapy

The Nurse’s Role in Pain Management

pain assessment
pain management
evaluation
palliative approach
patient education
support
research
patient inclusion in pain management choices through provision of information, enabling informed consent for intervention choices

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Cancer Treatments – Chemotherapy, Radiotherapy, Immunotherapy & More

Cancer treatments can be offered with various aims, depending on which type of cancer, its location, health status, and at what stage and grading it is discovered.

Cancer spreads through lymph nodes. Thus, when cancer is detected, the nearest lymph nodes are checked for signs of cancer, which, if found, would mean that cancer would have started spreading.

Cancer treatments aims include prevention, cure, control (prolonging survival where cure is unattainable), and palliative care (symptom relief), as well as prophylactic care. Active treatment lasts around 8-12 months, however, in some cases, this may take up to 8-10 years.

Cancer treatments include the following options: surgery, chemotherapy, radiotherapy, hormone therapy, targeted therapy, complimentary therapy, bone marrow transplantation, and supportive therapy. Supportive Therapy aims to treat symptoms of cancer through the use of antiemetics, immunotherapy, etc.

The Nurse’s Role in Cancer Treatments

Patient education is a must with regards to patients with cancer. Providing adequate patient education helps minimise risks during cancer treatment. For example, the nurse should teach the patient to avoid areas which are prone to illness if possible, since a patient undergoing certain cancer treatment is considered to be immunocompromised.

A nurse navigator is assigned to patients with cancer, whose role is to look after a patient throughout the whole treatment journey, as well as provide support for both the patient and other family members.

Cancer and its treatment options impact all domains of a patient’s life.

Patient Perspective of Quality Care in Cancer Treatments

Cancer Grading and Staging

Cancer Treatments Responses

Surgery

As one of the options for cancer treatments, surgery can be chosen for the following reasons:

prevention
diagnosis and staging
to prevent further growth and spread
to reduce the tumour’s size if size becomes a burden to the individual
to interfere with the tumour’s growth process
to correct defects caused by the tumour
to provide pain relief

Factors for consideration prior to surgery include:

diagnosis
prognosis
risks
health status
impact of recommended surgical procedure

In patients who are predisposed to breast cancer, blood testing is performed to check for BRCA1 and BRCA2 cancer genes. Genetic predisposition carries a risk factor of 10-12% for breast cancer development. If the patient is found positive for BRCA, a prophylactic mastectomy may be recommended.

With regards to pain relief, surgery may be an option too. For example, if a patient has a tumor which is pressing on a neuropathic nerve, removing it surgically would reduce the pain.

Cancer Surgical Treatment Perioperative Nursing Care

patient assessment
provision of health literacy
enabling decision-making and informed consent – patients have a right to refuse treatment
providing and/or enabling physical, functional, psychological, social, and spiritual supportive care

Chemotherapy

In chemotherapy, cytotoxic chemicals are used with the aim of eradicating or controlling cancer.

Types of chemotherapy include:

cytotoxic therapy
systemic treatment
neoadjunvant
adjuvant
chemoradiation
first-order kinetics – kills almost all cancer cells through cycle treatments
primary and secondary tumour resistance

Chemotherapy can be administered via the following routes:

oral
intravenous (continuous and bolus)
intra-arterial
intrapleural
intravesical (through the bladder)
intrathecal/intraventricular (in the subarachnoid space)
intraperitoneal
topical

Retrieved from https://bio.libretexts.org/Courses/Lumen_Learning/Book%3A_Biology_for_Non-Majors_I_(Lumen)/07%3A_Cell_Division/7.05%3A_Cell_Cycle_Checkpoints on 16th January 2022

Retrieved from https://doctorlib.info/pharmacology/medical-pharmacology-therapeutics/52.html on 16th January 2022

When selecting the ideal chemotherapy for a patient, the following considerations are taken into account:

therapy which offers the maximum therapeutic effect and with what is considered as acceptable toxicity levels
assessment of the patient’s physiological and psychosocial status
benefits vs toxicity
in multi-drug regimen, the aim is to kill as many tumour cells as possible, reduce toxicity, and reduce drug resistance possibility

Prior to chemotherapy administration, the patient should be evaluated so as to determine whether he/she is healthy enough to receive chemotherapy treatment.

Histology results provide accurate tumor grading information.

Chemotherapy Side Effects

Chemotherapy side effects include:

myelosuppression – a condition which causes a decrease in bone marrow activity that results in less red blood cells, white blood cells and platelets
neutropaenia – an abnormal low concentration of neutrophils (white blood cells) in the blood; may lead to febrile neutropaenia which is characterised by a fever and other signs indicating infection
thrombocytopaenia – low blood platelet count
anaemia – a deficiency in the number and/or quality of red blood cells
alopecia – hair loss
oral mucositis – tissue swelling in the mouth
fatigue
nausea and vomiting

Retrieved from https://www.healthline.com/health/cancer/effects-on-body on 16th January 2022

Nurse’s Role During Chemotherapy Administration

patient education – enabling informed consent and establishing reachable goals
chemotherapy targets cells that multiply fast, hence why it destroys cancer cells as well as other cells in the body which do the same eg. hair cells (causing alopecia with certain chemotherapies), the lining of the digestive system (causing nausea, vomiting, and diarrhoea)
if patient loses hair following chemotherapy, advise patient that hair will regrow once all chemotherapy sessions are completed, even if the texture and colour may be different
if patient experiences nausea and vomiting, parameters should be taken so as to check for sepsis; antiemetics may be prescribed so as to reduce side effect; tepid-sponging face and neck may also help the patient feel better; prop up patient so as to avoid aspiration in case of vomiting, as this may cause pneumonia; if patient vomits, encourage oral hygiene since gastric contents would contain chemotherapy, which would lead to the oral mucosa to become damaged – encourage to brush teeth, tongue and gums well with toothpaste, mouthwash, and even rinse throughout the day with a solution made out of 1 tsp baking soda in a cup of water – this balances the acidity in the mouth from gastric content, with the alkaline solution used for rinsing
if patient experiences fatigue, encourage to rest, but also encourage bed exercises so as to promote mobility and avoid complications (DVT and pneumonia); reassure patient that once chemotherapy is completed, fatigue lessens; teach patient to identify times during the day in which fatigue is lessened, so as to be able to shower and do other tasks at that time; monitor the patient’s haemoglobin level, as if this is very low, a blood transfusion may be needed
chemotherapy administration & safety – safe handling and disposing of chemotherapy for the benefit of all; spillage protocol; extravasation protocol
prevention of complications
management of side effects
ongoing support

NOTE: Chemotherapy is excreted through bodily fluids including urine. Thus patient should aim to use a different bathroom than other family members, or else clean well after use, since if another person comes in contact with the patient’s bodily fluid, there would be a risk of developing cancer and killing cells (chemotherapy is cytotoxic).

Radiotherapy

Radiotherapy a.k.a. radiation therapy is a cancer treatment that uses high doses of radiation to kill cancer cells and shrink tumors through the use of Ionising Radiation. This is done either through External Beam Radiotherapy (EBRT) which works through linear accelerators that produce high energy x-rays that can treat deep tumours, or as Internal Radiotherapy / targeted therapy eg. radioisotope therapy, brachytherapy etc).

Radiotherapy Side Effects

Radiotherapy side effects are usually related to the area being treated for cancer.

Acute side effects usually show up around 10 days following treatment initiation, with its peak effects showing up around 10 days after the full treatment course.

Late side effects usually develop gradually around 6 months following treatment. These side effects are often permanent.

Side Effects of Radiotherapy for Breast Cancer including Axilla

Acute side effects include skin reactions, pain, and fatigue.

Long-term side effects include Brachial Plexopathy (type of peripheral neuropathy in which damage to the brachial plexus is incurred), Lymphoedema (a condition in which build-up of lymph fluid in the body’s soft tissues causes swelling), Lung Fibrosis (damaged and scarred lung tissue), and Bone Necrosis (death of bone tissue).

Skin Reactions to Radiation Therapy

Retrieved from https://www.researchgate.net/figure/RTOG-Scoring-Criteria-for-Acute-Radiation-Skin-Reactions_tbl3_49780739 on 17th January 2022

If skin reactions to radiation therapy are noted:

use a gentle washing technique with mild soap
use an electric shaver when shaving
avoid exposure of affected area to the sun
promote skin hydration using aqueous cream twice daily
avoid using deodorants, perfumes and other irritants
promote adequate hydration
encourage clothing made of natural fibre

Nurse’s Role During Radiotherapy Administration

holistic assessment – take into consideration side effect risks
patient education
aiming to minimise side effects through continuous patient assessment

Hormone Receptors and Hormone Manipulation Therapy

Hormone Manipulation Therapy is a treatment which adds, blocks or removes hormones with the aim of stopping or slowing down cancer cell growth which require hormones to grow.

Side effects of hormone manipulation therapy may include:

hot flushes
sweating
physical changes
low libido
fatigue
nausea

Targeted Therapy

Targeted Therapy refers to the use of drugs or substances which target particular molecules to stop cancer cells from growing and/or spreading. Targeted Therapy doesn’t cause harm to cells other than the ones targeted – cancer cells.

Retrieved from https://www.cell.com/fulltext/S0092-8674(11)00127-9 on 17th January 2022

Immunotherapy

Immunotherapy , which is another type of targeted therapy, stimulates specific components of the immune system and counteracts signals produced by cancer cells that suppress immune responses through checkpoint inhibitors.

Bone Marrow Transplantation

Bone Marrow Transplant (BMT) is a type of cancer (or other diseases) therapy in which cells that are usually found in the bone marrow (eg. stem cells) are filtered and given back to the patient or to another person in need of a bone marrow transplant.

Bone Marrow Transplantation is usually carried out once a patient is in remission. Patient may be sent abroad for this procedure. It is ideal for patients with Leukaemia (the bone marrow is where all blood cells are produced).

Complementary Therapies and Psychological Support for Cancer Patients

Homeopathy
Detoxification/Antioxidant
Nutritional Supplements
Diet
Acupuncture
Aromatherapy
Reflexology
Therapeutic Massage
Reiki / Universal Energy
Counseling
Psychotherapy
Music Therapy
Meditation/Relaxation Techniques

NOTE: Homeopathy isn’t recommended when pharmacological therapy for cancer is involved. Similarly, it is important that a cancer patient mentions all medicines and supplements (even vitamins) that are being ingested.

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Preventing Surgical Site Infections SSIs

Surgical site infections are the second most common types of healthcare associated infections (HAIs). A surgical site is the incision made by the surgeon during a surgical procedure as well as any manipulated surrounding tissue. Surgical site infections may be caused by intrinsic factors (related to the patient) or extrinsic factors (related to the environment or the equipment used). They develop from 2 to 3 days following surgery or during the wound healing period (up to 3 weeks post-surgery).

Pathogenesis of Surgical Site Infections

SSIs develop through an interaction between microorganisms and host, which is also affected by the surgeon and environment. All surgical wounds have microorganisms, including bacteria, but not all develop a clinical infection, since innate host defenses can be very efficient in eliminating contaminants within the surgical site. If however the concentration of microorganisms in the wound is very high, developing a surgical site infection becomes quite possible.

Risk Factors for Surgical Site Infections

Patient-Related Risk Factors:

increasing age
diabetes
obesity
smoking
immunosuppressants
staphylococcus aureus carriage
distant infection focus
malnutrition

Pre-operative Risk Factors:

length of pre-operative stay
antibiotic prophylaxis
hair removal technique

Operative Risk Factors:

wound classification
operative technique
degree of tissue trauma
prolonged duration of surgery
traffic intensity in the operating room
foreign body presence

Retrieved from https://www.researchgate.net/figure/American-Society-of-Anesthesiologists-classification_tbl1_330901325 on 14th January 2022

Increasing Risk for SSI

intact skin > intact mucous membrane > broken skin or mucous membrane > foreign body implant > foreign body from outside to inside of the body

(foreign body implant eg. prosthetic)

Retrieved from https://www.researchgate.net/figure/Classification-of-surgical-site-infections-according-to-CDC-National-Nosocomial_fig1_44670847 on 14th January 2022

Superficial Incisional SSI:

purulent drainage from superficial incision with or without lab confirmation
pain OR swelling OR erythema OR heat at incision site (at least one)
surgeon deliberately opens incision (unless culture-negative)

Retrieved from https://www.who.int/infection-prevention/tools/surgical/SSI_student-handbook.pdf on 14th January 2022

Deep Incisional SSI:

abscess involving deep incision found during radiological exam, direct exam or re-operation
deep incision deliberately opened by surgeon when patient has at least one of the following: fever, localised pain, tenderness (unless culture-negative)
purulent drainage found during deep incision but not from organ/space component
teach patient to monitor for SSIs for 90 days post-operation, and give contact details in case a SSI is suspected

preventing surgical site infections — Retrieved from https://www.who.int/infection-prevention/tools/surgical/SSI_student-handbook.pdf on 14th January 2022

Organ/Space SSI:

Involves organs or spaces other than the surgical incision site such as:

Mediastinitis
Endocarditis
Osteopmyelitis
Meningitis
Ventriculitis
Intra-abdominal

Organ/Space SSI should also include at least one of the following: purulent drainage, organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space, abscess or other evidence of infection.

Wound Healing

Phases of Wound Healing

Surgical Wound Classification

Post-Discharge Surveillance for Surgical Site Infections

Post-discharge surveillance for surgical site infections are important for early detection of SSIs. Following surgery, the nurse should advise the patient to watch out for signs of SSIs for 30 days post-operation, and give contact details the patient should use in case a SSI is suspected.

Post-discharge SSI surveillance methods include:

medical records review
admission
readmission
patient charts for SSI signs and symptoms
lab, imaging and other diagnostic tests
clinician notes
questionaires
patient surveys (may be performed through phone or mail)

If an SSI is suspected, or if there is no sign of healing, or if there is unexpected wound healing process deterioration, a specimen should be collected as soon as possible, ideally prior to starting antibiotic treatment.

Organisms Causing SSIs

Staphylococcus aureus
Coagulase-negative staphylococci
Gram negative bacilli
Anaerobes
group B streptococci

WHO Guidelines on Surgical Site Infections

Surgical Handrubbing Technique

Retrieved from https://www.journalofhospitalinfection.com/article/S0195-6701(09)00257-6/references on 14th January 2022

Hyperglycaemia and Surgical Site Infections

Hyperglycaemia is associated with an increased risk of developing surgical site infections, especially in the post-operative period. Early post-operative glycaemic control should reduce the incidence of surgical site infections eg. diabetic protocol.

Pre-operative Hair Removal

Unless the presence of hair at the surgery site may interfere with the surgery itself, hair should not be removed. However, if required, hair should be removed with the use of surgical hair clippers with disposable heads. This should be done on the ward at the latest time possible – NEVER at the theatre due to potential contamination of the sterile field. Shavers should NOT be used since these create micro-abrasions in the skin, increasing the of infection.

Following hair removal, patients need to shower with 4% chlorhexidine solution.

Normothermia

Hypothermia increases the risk of developing a SSI since it causes physiological changes, impairs the immune system, causes subcutaneous vasoconstriction, and tissue hypoxia at the incision site. Additionally, hypothermia increases the risk of bleeding, risk of haematoma, and risk of needing a blood transfusion. Thus, pre-operative and intraoperative normothermia should be targeted – ideal temperature is that of 36°C or more.

MRSA and Surgical Site Infections

MRSA carriage increases the risk of developing a SSI. For this reason, patients are screened prior to surgical procedures such as Coronary Artery Bypass Graft, Aortic Valve Replacement, Total Knee Replacement, Total Hip Replacement, cardiac implants, renal catheter insertions, and central venous catheters.

If MRSA is cultivated, decolonisation treatment in the form of washes and mupirocin nasal ointment is required. The patient is screened three times for MSSA (methicillin-susceptible Staphylococcus aureus) prior to the procedure.

Preoperative Washing

Preoperative bathing or showering should aim to reduce skin bacterial load, leading to a reduction in the development of endogenous surgical site infections.

4% Chlorhexidine Solution for MRSA Colonisation: 4% Chlorhexidine solution is a topical antibiotic commonly used as a skin cleanser prior to surgery due to its protective effects against gram-positive and gram-negative organisms, facultative anaerobes, aerobes, and yeast. This is ideal if MRSA colonisation is present.

2% Chlorhexidine Solution for Prolonged/Deep Surgeries: Skin disinfection with 2% Chlorhexidine is enough in the case of prolonged surgery or deep surgery.

Plain Soap for Minor Surgeries: For other minor surgeries, washing with plain soap is enough.

NOTE: Make sure the patient stays warm prior to being operated upon, since this reduces the chance of developing SSIs.

Prophylactic Use of Antibiotic

CHOICE OF ANTIBIOTIC TREATMENT

Antibiotic treatment choice for prophylactic use should be based on the wound contamination level and efficacy against expected pathogens related to the specific surgery being performed.

TIMING

First dose of prophylactic antibiotic should be given 60-120 minutes prior to surgery being performed, as this ensures bactericidal concentration in serum and tissues from incision until closure. Additional doses may be required for longer surgeries.

DURATION

Unnecessary continuation of antibiotic treatment may contribute to the ever-growing problem of antibiotic resistance.

Retrieved from https://www.who.int/docs/default-source/antibiotic-awareness-week/infographic-ssi-sap011118-bis.pdf on 15th January 2022

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Infection Prevention and Control

Infection prevention and control (IPC) is a practical, evidence-based approach which prevents patients and health workers from being harmed by avoidable infection and as a result of antimicrobial resistance.
No one should catch an infection while receiving health care, yet, these infections can spread through outbreaks and many regular care practices, affecting hundreds of millions of people across the world every year.
World Health Organisation

The Chain of Infection

infection prevention and control — Retrieved from https://activesocialcare.com/handbook/infection-prevention-and-control/the-chain-of-infection on 12th January 2022

A HAI (hospital acquired infection) occurs:

up to 48 hours after hospital admission
up to 3 days after discharge
up to 30 days after an operation

RESERVOIR:

A microorganism lives and multiplies in what we call ‘reservoirs’: humans (eg. chickenpox, hepatitis B, and HIV), animals (eg. rabies, and salmonella), or inanimate objects (eg. tetanus).

INFECTION SOURCE:

This is the source of infection – a specific infection outbreak or an individual infection. An endogenous infection refers to an infection caused by the patient’s own microflora, while an exogenous infection refers to an infection caused through an environmental source. Zoonosis refers to an infection originating from an animal source.

ENTRY PORTALS:

respiratory tract eg. pneumonia
GI tract eg. Clostridioides difficile or C. difficile
genito-urinary tract eg. CAUTI (catheter acquired urinary tract infection)
skin breaks (including traumatic and surgical wounds)
blood (through needles and catheters)

All patients are at risk of acquiring a MDRO (multi-drug resistant organism)!

TRANSMISSION ROUTES

direct and indirect contact
air
food
drink
water
insects

Direct or indirect contact include transmission via hands, transmission by inanimate objects, transmission by contact with blood, and transmission through sex…

Transmission via Hands:

Staphylococcus aureus can be spread by staff, either through spreading their own nasal staph to their patients, or spreading staph from one patient to another.
Gram-negative bacteria can be found colonising a patient’s skin, and then transmitted onto staff hands.
Enteric Infections such as shigella and rotavirus (commonly found in children) are faecal-oral spreads transmitted via hands in the community and hospital setting.

Transmission via Inanimate Objects a.k.a. Fomites:

This type of transmission happens passively from one inanimate object to another. Objects include surgical instruments as well as more common objects such as pens, stethoscopes, books, suction catheters, bedpans etc.

Transmission via Sexual Contact:

Sexually transmitted diseases (STDs) are considered to be very fragile and so, they do not usually survive on inanimate objects. STDs include syphilis gonorrhoea, chlamydia, HIV, herpes, etc.

Transmission via Blood:

Transmission by contact with infected blood happens through wounds, menses, human bites, blood products, specimens, contaminated needles (including needle-stick injuries), and during traumatic sexual intercourse.

Endemic Hepatitis B is transmitted during birth from the mother to her baby. Other infections which can pass to the foetus during pregnancy includes rubella, cytomegalovirus and syphilis.

Transmission via Air a.k.a. Airborne Transmission

Transmission via air happens through sneezing, coughing and speaking. Small droplets (<0.1mm) evaporate; Solid droplet nuclei may remain airborne…these may be eventually inhaled. Measles, chickenpox and tuberculosis are spread in this way. Large droplets fall to the ground.

Transmission via Food, Drink, and Water:

Transmission of infection via food, drink and water usually happens in enteric infections via faecal-oral spread.

In food poisoning, bacteria multiply in food prior to ingestion, producing enteric toxin (eg. in staph aureus) or multiply and produce toxin in bowel lumen (eg. in cholera and E.coli). Salmonella happens through infection following ingestion of poorly-cooked food. Brucellosis is an infection resulting from drinking unpasteurised contaminated milk. In water-borne cholera, faecal excretion by-carriers contaminate river water which is then consumed downstream.

Transmission via Insects a.k.a Anthropod-borne Infections:

Anthropod-borne infections are transmitted by blood-sucking insects such as mosquitos (malaria). These parasites have the ability to multiply in their hosts.

The Infection Spectrum

Contamination => Colonisation => Critical Colonisation => Infection

Colonisation is the presence of multiplying bacteria with no reaction or symptoms.

Infection is the presence of multiplying bacteria which affects the host’s defenses, causing clinical symptoms.

Bacteria can be transmitted even if no infection is present. This explains why Staphylococcus aureus, which is endemic, can be found outside the hospital, within the community, undetected.

MRSA – Methicillin Resistant Staphylococcus Aureus

MRSA is resistant to common antibiotics such as penicillins and cephalosporins. MRSA can be carried around by healthy individuals without any symptoms for weeks to years.

MRSA in a patient with a low colonisation level may not be detected by culture. Anterior nares specimen testing result in the highest identification rate for MRSA. Gloves should be worn when caring for infected wounds of patients with MRSA.

Patients are screened for MRSA on admission and more importantly before important procedures.

Treatment for MRSA decolonisation:

2% Mupirocin (Bactroban) nasal ointment 3 times per day for 5 days (apply small amount to inner nostrils using tube, press nostrils together and massage for about 1 minute).
Daily full body and hair washes with 4% chlorhexidine gluconate.

Isolation and Contact Precautions for Infection Prevention and Control

Isolation and contact precautions should be put in place in the case of current or previous 6 months colonisation or infection with MDRO. Contact precautions notice should be put up on the patient’s door, and related information should be provided for both the patient and relatives.

Contact precautions can be stopped:

if the organism is not cultured again
in case of 3 consecutive negative MRSA screen cultures

Terminal cleaning of patient’s room must be performed!

Infection Prevention and Control

5 Moments for Hand Hygiene

BEFORE patient contact
BEFORE aseptic task
AFTER body fluid exposure
AFTER patient contact
AFTER leaving patient surrounding

Soap & Water mechanically remove microorganisms and soil but DO NOT kill microorganisms; remove transient skin flora, but only limited resident flora.
Alcohol Rub DOES NOT mechanically remove microorganisms or soil, but kills microorganisms; kills transient skin flora, but only limited resident flora.
Aqueous Antiseptic Solutions mechanically remove and kill microorganisms and soil; remove and kill transient and some resident skin flora.

Standard Precautions for Infection Prevention and Control

Standard precautions should be applied by all staff in all healthcare settings to all patients regardless of diagnosis and infection status all the time.

Good hand hygiene practice
Use waterproof dressings to cover wounds or skin lesions
Use cough etiquette
Do not touch your eyes, nose, mouth or face, or adjust PPEs with contaminated hands or gloves
Limit contact with patient’s items in immediate surrounding area to the minimum
Use recommended PPEs for required tasks anticipating possible risks

Donning PPEs Sequence:

Gown
Mask
Visor
Gloves

Doffing PPEs Sequence:

Gloves
Visor
Gown
Mask

Swabbing Methods

Staphylococcus aureus produces a higher cultivation of bacteria in the nose and throat, thus swabbing methods used for MRSA are the nasal swab or the throat swab. Note however, that MRSA can also be found in other locations within the body, such as in wounds.

Nasal Swab

Throat Swab

Wound Swab

Urine Sampling

Sputum Sampling

Stool Sampling

Blood Cultures

Retrieved from https://studylib.net/doc/8188811/bd-vacutainer%C2%AE-system—st-vincent-s-university-hospital on 13th January 2022

Peripheral Vascular Catheter Care

Retrieved from https://www.facebook.com/641909052635080/photos/visual-infusion-phlebitis-score-detail-has-been-attached-hereindetail-topic-will/1149380728554574/ on 13th January 2022

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Nutrition and Hydration for Older Adults

Nutrition and hydration for older adults are key elements for better health and good quality of life. Unfortunately, malnutrition is very common in older adults. The older the person, the less nutrients are absorbed by the body from food. Adequate food intake and proper hydration promote quicker recovery and shorter hospitalisation periods, as well as avoidance of hospital readmission, following illness and surgery in older adults.

Ideal Meal Plan

An ideal meal plan should include:

Breakfast
Snack
Lunch
Snack
Dinner

Nutrition for Older Adults

A healthy balanced diet helps maintain physical and mental well-being. Eating less than required may lead to weight-loss, vulnerability to infection, reduced muscle strength, and fatigue. Causes of weight loss may include:

reduced appetite
cooking difficulties
inability to recognise hunger cues
inability to ask for food
lack or poor coordination skills
cognitive impairment
physical disabilities
sensory disabilities
depression
medication
fatigue
dysphagia
inability to chew properly
lack of physical activity
pain (denture problems, sore gums, painful teeth, lack of oral hygiene)

In older adults with late-stage dementia, the nurse should ensure adequate nutrition is being provided, and in some cases, a high-calorie diet may also be appropriate.

An older adult experiencing weight-loss should be referred to a nutritionist or dietitian.

Meal Supplementation for Older Adults

Meal supplement options for older adults include:

Snacks
Yoghurts
Protein Powder (check liver/kidney function prior to administering protein powder)
Enteral Feeds (can be administered in between meals or as replacements if needed)

Vitamin supplements can be avoided if the person eats a varied and balanced nutritional diet.

Common Chronic Illnesses in Older Adults

Diabetes
Hypertension
Hyperlipidaemia
Renal Disease
Cancer
Gum Disease
Arthritis (certain proteins eg. nuts, legumes, and seeds, deposit fats in joints, which is very helpful for patients with arthritis)
Refeeding Syndrome (shifts in fluids and electrolytes resulting from hormonal and metabolic changes which may occur in malnourished individuals receiving enteral or parenteral artificial feeding that may lead to death)

Common Problems in Older Adults

anaemia
depression
overweight / underweight
constipation
food allergies
inability to chew food appropriately
dysphagia (problems encountered in swallowing)
cooking methods

Assessing Older Adults

Nutrition and hydration in older adults should be assessed:

to identify any existing problems
to provide help with existing problems
to promote safety
to improve quality of life
to improve current available services
to create new / better services

Encouraging Nutrition Intake in Older Adults

provide regular snacks or small meals
foods with low glycemic index (low GI) are more digestible
provide food that the older adult actually likes
provide appealing foods for appetite stimulation
experiment with different types of food such as smoothies and milkshakes
experiment with foods containing strong flavours and sweet flavours
find the right time to offer foods based on the individual’s day/night routines
provide dessert even if main meal is left unfinished or untouched, as it may be preferred
avoid giving cold food – reheat if necessary
if the older person finds it difficult to chew or swallow food, try opting for softer-textured foods such as scrambled egg or stewed apple before considering pureed food
provide encouragement
provide a relaxed friendly atmosphere

The Importance of Hydration for Older Adults

Water is helpful for bloating, oxygen saturation, headaches, circulation, depression, digestion, kidney function, metabolism, and promotes healthy skin. Moreover, the brain requires water to function well. More than 2/3 of the brain is made up of water. With age increase comes a reduction of thirst sensation, which may lead to dehydration.

Older adults with dementia may become easily dehydrated if they are unable to communicate or recognise thirst cues, or if they forget to drink. Dehydration may lead to headaches, confusion, UTIs and constipation, all of which can worsen the symptoms of dementia.

Older adults should be encouraged to drink between 1.5-2.5 liters of fluid on a daily basis.
Older adults may be taught to check their hydration level by observing their urine’s colour and smell.

Retrieved from https://www.pinterest.com/pin/174162710566911662/ on 9th January 2021

Retrieved from https://www.quotemaster.org/water+drinking on 9th January 2021

Retrieved from https://www.continencesupportnow.com/topic/Fluid%20intake on 9th January 2021

Retrieved from https://www.healthworks.my/hydrate/ on 9th January 2021

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Diet for Chronic Kidney Disease

Chronic Kidney Disease is characterised by progressive and irreversible loss of kidney function which occurs over a period of months or years. Ignoring chronic kidney disease leads to end-stage renal failure which requires dialysis or kidney transplantation. Adapting to a personalised diet for chronic kidney disease helps to prolong reaching end-stage renal failure through improvement in the patient’s nutritional status and compensation for the ongoing catabolic events.

Considerations ~ Diet for Chronic Kidney Disease

Personalised Modifications for patients undergoing dialysis are recommended in the following dietary aspects: calories, protein, sodium, potassium, phosphorus, calcium, fluids, carbohydrates, and cholesterol (fat).
Ideal Caloric Intake for adults undergoing dialysis = 35kcal/kg for individuals up to 60 years old; 30kcal/kg for individuals from 60 years old and for obese individuals.
Blood serum levels should be checked every few months so any diet-related adjustments are made earlier on.

A Diet for Chronic Kidney Disease requires ongoing monitoring of the patient’s Lab Results, Oral Intake, Nutritional Supplements, Dietary Reviews and Changes based on patient’s needs and results & most importantly Compliance to Medication and Diet.

Proteins

Proteins provide energy and help fight infection whilst maintaining fluid balance within the blood.

Proteins with high biological value = meat, fish, eggs, poultry, tofu, soya milk & dairy (beef/red meat is better than chicken for patients with kidney failure).

Proteins with low biological value = bread, grains, vegetables, dried beans, peas & fruit.

Phosphorus

Phosphorus helps build strong healthy bones whilst maintaining health within other parts of the body. It is found in almost all foods. In chronic kidney disease, the balancing of phosphorus during the kidneys’ filtering process is impaired, leading to an increase of phosphorus in the blood.

In a diet for chronic renal disease, high-phosphorus foods which include dairy products, dried beans and peas, nuts, bran cereals, whole wheat bread, meats, peanut butter and food additives should be limited or avoided as much as possible. Dietary intake of phosphorus in patients with chronic kidney disease should not exceed 1.5g per day.

Potassium

Potassium has an important role in heartbeat regulation. Potassium level should be monitored so hyperkalemia is avoided as this may lead to a myocardial infarction a.k.a. heart attack.

In a diet for chronic kidney disease, the dietary goal for potassium is between 2-3g per day. High-Potassium foods such as prunes, oranges, bananas, potatoes, tomatoes, brussel sprouts, spinach, beets, dried foods and milk should be avoided.

Sodium

Sodium has an important role in nerve and muscle function, as well as promotes water and electrolyte balance within the body. However, too much sodium in the blood may lead to hypertension and congestive heart failure.

In patients with chronic kidney disease, special attention should be given in controlling sodium intake. Patients on haemodialysis should consume between 2-4g of sodium per day. It is good to keep in mind that 1 teaspoon of salt contains 2000mg of sodium, thus, foods that are high in sodium such as processed and deli meats, canned soups and salty snacks should be avoided.

Fluids

Retrieved from https://www.luxuriousmagazine.com/drink-water-while-working-from-home/ on 26th December 2021

For a patient undergoing dialysis, fluid intake should be measured so the recommended intake amount is not exceeded. For patients undergoing haemodialysis, recommended fluid intake should take into consideration any fluid gains, blood pressure, and residual renal function. As for patients undergoing peritoneal dialysis, recommended fluid intake should be based on patient tolerance and minimum use of hypertonic solution for fluid balance maintenance.

Fluids include all drinks and foods that become liquid at room temperature, i.e. water, coffee and tea, soda, soups, juices, and jelly. Total intake of such fluids cannot exceed the individualised recommended amount which is usually between 1.5-2ltr per day.

Patients with kidney failure cannot get rid of extra fluid in their body, and so, the recommended daily intake shouldn’t be exceeded since extra fluid in patients with kidney failure results in oedema.

Calcium

Calcium in the body helps in building and maintaining strong bones, and has a role in the correct functioning of the nerves and muscles, including the heart.

Patients undergoing haemodialysis require balance, which is determined by the dietary calcium intake, vitamin D therapy, dialysate calcium levels, calcium supplements and calcium-based binders, as well as the monitoring of Parathormone or Parathyrin (hormone that regulates serum calcium concentration) by the physician.

Carbohydrates

Carbohydrates are nutrients which the body converts into glucose to produce energy for body function.

In patients with diabetes and chronic kidney disease, the ideal HgA1C is usually less than 7%.

Cholesterol

Cholesterol helps the body produce cell membranes, hormones and vitamin D. Too much cholesterol however may lead to cardiovascular disease, which incidentally is the most frequent cause of death in patients with kidney disease.

A diet for chronic kidney disease should take into consideration the individual’s metabolic profile, nutritional status, energy deficits, along with any other treatment goals.

Fast Foods, Italian & Asian foods

FAST FOODS

Fast foods are high in sodium content as they are usually pre-salted;
Fast food fries and baked potatoes are high in potassium – chronic kidney failure patients should ask for smaller and (if possible) unsalted servings;
Sauces, condiments and dressings should be avoided as these are high in sodium;
Balancing fast food with other food choices is recommended- ideally one should opt for healthier options in the day’s additional meals;
Broiled, steamed and grilled items are better options when compared to deep fried foods;
Larger-sized beverages should be avoided as these may lead to fluid overload
Removing the skin from fast foods reduces the fat and sodium content

ITALIAN CUISINE

The Italian cuisine has a lot of foods to offer for patients on a diet for chronic kidney disease;
Red sauces contain potassium;
White sauces contain a high amount of phosphorus;
Pesto is made of garlic, basil and oil, making it an ideal choice;
With salads or breads, one should ask for no olives and cheese, and request the dressing on the side;
Pasta dishes like lasagna, cannelloni and ravioli should be avoided since these are high in sodium, high in potassium and high in phosphorus.

ASIAN CUISINE

Asian cuisine typically contains a high amount of sodium. Asian soups and broth-cooked noodles should be avoided;
Chinese foods typically contain a large amount of sauces and condiments which are high in sodium and MSG (Monosodium Glutamate – water, sodium and glutamate). Ideal Asian food choices in a diet for chronic kidney disease include egg rolls, steamed rice, and stir-fry vegetable dishes without sauces;
Japanese foods typically contain more spices but less sodium. Ideal Japanese food choices in a diet for chronic kidney disease include sashimi and sushi (avoid california rolls with avocado), and grilled fish or chicken without sauces;
Thai foods typically contain more spices but less sodium. Ideal Thai food choices in a diet for chronic kidney disease include spring rolls, steamed rice, and grilled fish and chicken dishes without sauces.

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Haemodialysis, Peritoneal Dialysis and Kidney Transplantation

In normal renal physiology, the kidneys remove waste and excess water from the body and release hormones such as renin (which regulates blood pressure), erythropoietin (which stimulates red blood cell production), and vitamin D (which promotes normal bone structure). However, in kidney failure or End Stage Renal Disease (ESRD), renal function becomes compromised and waste products and toxic materials start to accumulate rather than get excreted. This may cause permanent irreversible damage to the body’s cells, tissues, and organs. In End Stage Renal Disease, the kidneys function at less than 20% of their required capacity, and renal replacement therapy in the form of haemodialysis, peritoneal dialysis or kidney transplantation becomes a requirement.

Risk Factors for End Stage Renal Disease

inflammatory diseases
chronic infections
chronic diseases
blockage in the urinary collecting system
genetic disorders (rare)

Symptoms of End Stage Renal Disease

itching
nausea and vomiting
puffiness surrounding the eyes
swollen hands and ankles
lack of appetite
decreased urination
haematuria (blood in the urine)
anaemia
sleep disturbances
hypertension

If creatinine level in the blood increases to 900μmol/l and kidney failure is confirmed, treatment can be initiated in the form of dialysis (haemodialysis or peritoneal dialysis) or kidney transplant.

Haemodialysis vs Peritoneal Dialysis

Haemodialysis

Haemodialysis is a process that works based on the principle of diffusion, by which the blood of a patient with end stage renal disease is pumped out of the body and into a machine to be filtered and cleaned from excess waste products and water.

Haemodialysis is a fast process in which most often, the patient ends up feeling exhausted. The patient may also experience a hypovolaemic shock, which can be reversed quickly through the same pump by IVI (reversal usually takes just around 2 minutes to be completed).

The higher the bloodflow, the better the blood filtration; the larger the needle, the better the bloodflow.

Heparin is administered so as to help avoid blood clotting during the haemodialysis process.

The Haemodialysis process should be repeated 3 times a week on alternate days for 3 to 5 hours per visit.

HAEMODIALYSIS ADVANTAGES:

performed in the dialysis centre amongst healthcare professionals
regular contact with other service receivers and providers
permanent access required via an internal route
treatment is performed 3 times per week

HAEMODIALYSIS DISADVANTAGES:

traveling to and from dialysis centre is required per treatment
restricted diet and fluid intake required
fixed schedule for treatment
minimum two needle sticks are performed per treatment
rendered immobile during treatment

‘Washout Syndrome’ in Haemodialysis

weakness
fatigue
tremor
starts towards end of treatment or minutes following treatment
lasts 30 minutes or 12-14 hours in a dissipating form

Peritoneal Dialysis

In peritoneal dialysis, dialysis solution is passed into the peritoneal cavity through a catheter. With this method, it is the peritoneum itself that acts as a filter.

There are two different peritoneal dialysis methods:

Continuous Ambulatory Peritoneal Dialysis (CAPD) performs 4 exchanges throughout the day in 45 mins per session;
Automated Peritoneal Dialysis (APD) performs an exchange during the night while the patient is asleep.

PERITONEAL DIALYSIS ADVANTAGES:

the patient is directly involved in self-care
the patient has more control over self-treatment
may be performed during the night (using the Automated Peritoneal Dialysis method)
less restrictions required in relation to diet and fluids
this method is the closest to normal kidney function
ideal for patients with underlying heart disease due to it causing less severe cardiovascular instabilities

PERITONEAL DIALYSIS DISADVANTAGES:

body image change
4 exchanges are required per day
permanent external catheter
risk of infection
storage space is required for supplies
in Automated Peritoneal Dialysis, the patient is restricted/tied to the dialysis machine during the night

PERITONITIS:

If bacteria manages to travel into the peritoneum, the patient suffers from peritonitis, which is an inflammation of the peritoneum. This causes the peritoneum to weaken, and eventually, may require the patient to be switched to haemodialysis instead.

Kidney Transplantation

In kidney transplantation, a (compatible) kidney is removed from a living (donor) relative, friend, or a brain-dead individual, and is then surgically placed into the patient with end stage renal disease.

Unfortunately, this method is not always recommended. Medication is given to patients following kidney transplantation which suppresses their immune system so the body accepts the new kidney. This however may worsen the patients’ general health, and so, for this reason, a patient may not be deemed fit enough to undergo kidney transplantation.

KIDNEY TRANSPLANTATION ADVANTAGES:

better quality of life
better health
no diet and fluid intake restriction required
frequent dialysis treatment is not required
reduced medical cost
less severe cardiovascular instabilities are caused in patients with underlying cardiovascular disease

KIDNEY TRANSPLANT DISADVANTAGES:

surgery-related pain and discomfort
risk of kidney transplant rejection by the patient’s body
increased risk of infection
ongoing medication is required for life
frequent visits to the physician are required

Additional Notes…

Kidney function includes: removal of waste products, maintaining water balance, maintaining electrolyte balance, maintaining pH balance, Vitamin D metabolism, and excretion of drugs and poison.

A higher amount of creatinine is usually found in men, and especially in individuals with a higher muscle mass.

Urea results from breakdown of protein. In pregnancy, urea is very low as protein is required for fetal growth.

The kidneys have no function in temperature control.

Hypertension causes kidney damage over the years, unless controlled.

Obesity is a risk factor for kidney failure.

Kidney failure causes water imbalance in the body. If water is consumed excessively by a patient with kidney failure, oedema may result. Thus, water should be consumed in moderation.

The normal range of potassium level should be between 3.5-5.1; At potassium level 7, muscles cease to work – this includes the cardiac muscle a.k.a. the heart.

A patient with renal failure is prone to acidosis. Urine is acidic, and so, if a patient with kidney failure doesn’t excrete urine as necessary, the acid stays in the blood, leading to acidosis.

NSAIDs such as Catafast, Voltaren, Brufen and Arcoxia cause kidney problems if taken long term, thus, should be consumed under medical supervision.

EGFR stands for Estimated Glomerular Function Rate – which is an estimate of how the filtration in the kidneys is functioning. A normal EGFR is usually around 100. An adult around 60 years of age normally has an EGFR of about 70. An EGFR of 15 shows urgent dialysis requirement.

Chronic Renal Failure can only be indicated by blood tests and urine sampling. An EGFR of around 50 usually exhibits no symptoms. Patients with renal failure usually start exhibiting certain symptoms when the EGFR is somewhere between 10-30 – when dialysis should have been started at around EGFR 50.

In diabetes, hyperfiltration of the kidneys is commonly found due to the kidneys being uncontrollable. In this case, glucose should be eliminated if possible, so as to promote a decrease in the damage being incurred to the body through hyperfiltration. During hyperfiltration, EGFR is usually somewhere around 120-130, however, at some point it drops abruptly to around 30 or less, indicating kidney failure.

Following kidney transplantation, the new kidney is not placed in its usual location – it is placed under the belt, to the side. Due to this positioning, a patient with a kidney transplant can easily rupture if the abdomen is hit, and so, sports, fighting, etc., are not recommended for such patients.

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