Care in Action
Students from Nanjing Medical University in China were impressed with the level of teaching that occurred during rounds, and how technology was being incorporated in caring for the patient.
Within the Detroit Medical Center, we care for patients from a team perspective. The interdisciplinary team consists of practitioners from different disciplines who share a common patient population and patient care goals, and who have responsibility for corresponding tasks. The team is interdependent, with an established means of ongoing communication among team members and with patients and families, to ensure that various aspects of patients’ health care needs are integrated and addressed.
For the second year, medical students from Nanjing Medical University in China have come to the DMC to examine this interdisciplinary team concept in action. On February 3, six medical students and one physician began their day on rounds with Dr. A. Soubani, MD, FCCP, HUH medical director of critical care medicine/professor of medicine. This interdisciplinary team rounded on their intensive care patients. The residents, fellows, nurses, APN, pharmacist and respiratory therapist contributed to the patient’s plan of care. The students were impressed with the level of teaching that occurred during rounds and how technology was being incorporated in caring for the patient.
Later in the morning, the Nanjing students traveled to Detroit Receiving Hospital where they were greeted by Mengdan (Cindy) Shi, RN, BSN, DRH ED Staff Nurse, who speaks Mandarin (the official language of China). Mengdan toured the group through the Emergency Department explaining what occurs in every area and the role each person has to play to be effective. The students had many questions ranging from how a person accesses the ED to how patients are triaged and what happens beyond the ED. Emergency psychiatry, the OR area and PACU were also highlighted on the tour. There was even time to show how anyone can log on from their smart phones to see ED wait times at any of the six DMC EDs.
This group of students recognized that an interdisciplinary team approach empowers patients as active partners in care, allows the health care system to provide a more efficient delivery of care and lets healthcare professionals focus on individual areas of expertise, increasing professional satisfaction.
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Food for Thought –
Food for Healing
All patients at risk for pressure ulcers or with existing pressure ulcers should have a nutritional assessment and a plan created by a qualified professional.
Hydration and nutrition are needed for life and for healing. Assessment of the hospitalized patient's nutritional status is important for pressure ulcer prevention and healing.
Factors present in the chronically ill hospitalized person including unintentional weight loss, malnutrition, protein-energy malnutrition (PEM) and fluid deficits interfere with wound healing, and they place the individual at risk for pressure ulcer development. Clinical conditions that occur in the hospitalized elderly and in patients with debilitating diseases may affect their appetites or their ability to eat. Infection, trauma, and other chronic and acute medical problems increase the caloric need for organ functions. A combination of increased need and decreased nutrition consumption exacerbates the patient's risk for tissue breakdown. Frail or bed bound persons are at a high risk for pressure ulcers, which are associated with decreased quality of life and increased mortality. (1)
A well known factor for pressure ulcer development is malnutrition. It is found to be one of the significant factors associated with pressure ulcers in hospitals and long term care facilities. (2) However, the patient who comes from home to the hospital with a pressure ulcer may also be in need of enhanced nutrition. There may be a need for education of the caregiver as well. One Japanese study (3) found that only 20% of caregivers had information about nutritional management for prevention of pressure ulcers.
Poor outcomes, including morbidity and mortality risk, are associated with nutrition deficits. Identification of the at-risk patient early is mandatory to minimize problems with healing and further pressure ulcer development. Malnutrition is a reversible risk factor and should be assessed by a qualified dietitian using validated nutrition screening and assessment tools. (4) It is suggested that patients with wounds should have serial nutritional assessments to track trends (5). Patients may be receiving antibiotics for wound or other infections. Antibiotics damage the microbes in the GI tract, which also may slow wound healing. (4)
Nutritional Needs for Healing
Protein is needed for the maintenance of skin integrity, cellular function, fluid and electrolyte balance and all stages of healing. It is essential for fibroblasts, collagen, and blood vessel growth. Proteins are lost in draining wound fluids. Patients with heavily draining wounds and suction dressings continue to lose protein. (5) The NPUAP recommends 1.25 to 1.5 g/kg/day of protein intake for patients with pressure ulcers. (6)
Energy requirements for healing are based on body weight, current nutritional state, activity, age, other co morbidities, and wound characteristics. Carbohydrates and fat provide energy and are worked into the dietary plan based on individual factors.
Optimal fluid intake is necessary for prevention and treatment of pressure ulcers. Providing adequate fluid intake is needed for oxygenation and perfusion.
Vitamins A, C, and Zinc are necessary for wound healing. Individual needs for these nutrients should be assessed by a dietitian.
Supplements created to enhance wound healing have essential amino acids and can be given to patients with reduced appetites. Many foods are fortified with nutrients to provide the essential vitamins and minerals.
Mary Ellen Posthauer, a Registered Dietitian, provides suggestions to caregivers to increase calorie and protein intake for those persons able to consume oral foods (7).
- Add whole milk or half and half to cereals and cream soups to increase calories and protein
- Add skim milk powder to cereals, scrambled eggs, soups, puddings, potatoes, casseroles, muffins or meat mixtures (1 Tbsp/serving)
- Add grated cheese to mashed potatoes
- Mix whole milk with instant breakfast. Add in cream to boost calories
- Make homemade milkshakes with ice cream, top with whipped cream
- Use peanut butter (or other nut butters) in sandwiches, spread on crackers or bananas or added to pudding or muffins
- Use eggs in sandwiches, deviled eggs, hard boiled and in casseroles, omelets or quiche
- Add cheese to salads, eggs, vegetables, casseroles
- Lentils, split peas, kidney, navy and pinto beans in soups and casseroles
- Add yogurt to a baked potato
Offer several small meals during the day rather than large meals. Include a good quality protein with each meal.
Dietary Supplements that are available for inpatients include:
All but Juven come on a patient's meal tray when ordered in EMR – QD at lunch; BID at L&D; and TID at all three meals.
||Magic Cup 4.61oz per serving
||Juven (1 pkg)
||Resource® Beneprotein® Instant Protein Powder
||14gm amino acid
|Indications for Use/Flavors
thickened liquid Flavors: Vanilla, Chocolate
|Fluid-restricted or volume-limited patients; interim sole-source feeding. Flavors: Vanilla, Chocolate, Strawberry, Butter Pecan
||Diabetes or impaired glucose tolerance Flavors: Vanilla, Chocolate, Strawberry
||2 servings per day. Mix with 8–10oz water for PO. For TF, mix with 4oz water and flush with 30ml water pre- and post-administration. Flavors: Orange, Fruit Punch
||For increased protein needs. Mix with 30ml fluid or smooth food for PO. For TF, mix with 60ml water and flush with 30ml pre- and post-administration
Juven must be ordered by a physician or registered dietitian, and is supplied to room by the registered dietitian. The benefits of Juven are found when taken BID x 14 days. Juven is indicated for patients with stage III/IV pressure ulcers, major surgical wounds, or many areas of skin breakdown. It includes the amino acids arginine and glutamine, which have been clinically shown to aid in wound healing and tissue building. RN encouragement and assistance in preparing this supplement is imperative. Juven should be mixed with 8–10oz. water for PO. For TF, mix with 4oz. of water and flush with 30ml of water pre/post administration.
Each patient is an individual with individual nutritional needs. The registered dietitian will have the most up-to-date information on nutritional assessment and interventions. All patients at risk for pressure ulcers or with existing pressure ulcers should have a nutritional assessment and a plan created by a qualified professional. Other caregivers and staff can help by following the dietitian's recommendations for use of supplements and encouraging patient's oral intake.
- Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure Ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. ADV Wound Care (1999); 12:22–30.
- Baumgarten M, Margolis DJ, Localio AR, Kagan SH, Lowe RA, Kinosian B, et al. Pressure Ulcers among elderly patients early in the hospital stay. J Gerontol A Bio Sci Med Aci (2006); 61: 749–54.
- Iizaka S, Okuwa M, Sugama J, Sanada H. The impact of malnutrition and nutrition-related factors on the development and severity of pressure ulcers in older patients receiving home care. Clinical Nutrition 29 (2010) 47–53.
- Posthauer ME. The Role of Nutrition in Wound Care. Advances in Skin & Wound Care (2012) 25 (2) 62–63.
- Stechmiller JK. Pressure Ulcer Prevention and Management: Focus on Nutrition. Saxe Publication. (2011), 2, 7,8–9
- Dorner B, Posthauer ME. Thomas D. The role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. NPUAP (2009).
- Posthauer ME. Wound Healing and Nutrition: Increasing Protein and Calorie Intake in the Elderly. WoundSource (http://www.woundsource.com) (2013)
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Congratulations to the following for their outstanding accomplishments!
DMC Rehabilitation Institute of Michigan
Jessica Forrester, BSN, RN, CRRN (Spinal Cord Injury Unit), received her Rehabilitation Nursing Certification.
Iwona Malysa BSN, RN, CRRN (Neuroscience Unit), received her Rehabilitation Nursing Certification.
Whitney Scully RN, CRRN (Neuroscience Unit), received her Rehabilitation Nursing Certification.
Amy Yono BSN, RN, CRRN (Neuroscience Unit), received her Rehabilitation Nursing Certification.
Hannah Kim BSN, RN, CRRN (Float Pool), received her Rehabilitation Nursing Certification.
Mimoza Regazi RN, BSN (Neuroscience Unit) graduated Dec. 2013 from Oakland University with her Bachelor of Science in Nursing.
Shannon Robinson RN, BSN (Float Pool), graduated Dec. 2013 from Eastern University with her Bachelor of Science in Nursing.
Nilam Bhagalia, DPT (Harper Therapy Services), graduated Dec. 2013 from Utica College in NY from the Transitional Doctor of Physical Therapy program.
Xiaojie An RN, CRRN (Float Pool), promoted from Staff Nurse to day shift Administrative Supervisor/PAS Laision.
Sarah Marsh RN, BSN (PMR Unit), promoted to Nurse Preceptor.
LaJuana Bradshaw RN, BSN, promoted to Relief Administrative Supervisor.
Winner: Matthew Lyons BSN, RN (Physical Medicine & Rehab unit)
Runner-up: Kristopher Dombrowski RN (Physical Medicine & Rehab unit)
Winner: Monica Bates PCA (Physical Medicine & Rehab unit)
Runner-up: Tenesha Smiley PCA (Physical Medicine & Rehab unit)
Jamon Martin PA-S (Float Pool)
Jacqueline Muli PCA (Float Pool) – Induction into Phi Theta Kappa, International Honors Society for Academic Excellence
DMC Huron Valley-Sinai
HVSH hosted an Evidenced Based Nursing Practice and Nursing Research Poster Event, December 20-23, 2013. Nurses attended and could earn one contact hour. Additionally, HVSH awarded the first Annual Nursing Innovation Award to Kirsten Roberts, RN, MSN, CVN (Cardiopulmonary Services). The other nominees were Diana LaBumbard, RN, MSN, ACNP-BC, GNP-BC, and Shelley Killebrew, RN, MSN, CNOR.
From left: Kirsten Roberts, RN, MSN, CVN (winner); Diana LaBumbard, RN, MSN, ACNP-BC, GNP-BC; Shelley Killebrew, RN, MSN, CNOR; and Cathy Grant RN, BSN Associate Vice President Patient Care Services
HVSH wanted to recognize nurses who are motivated to engage in innovative practices while seeking to improve patient experiences and health outcomes. The nominees exemplified nursing innovation in patient care, leadership, empowerment, vision, and professionalism. The winner received a crystal engraved trophy and a $500 scholarship for future conference fees. See picture. Each of the nominees are innovators and leaders for advancing nursing practice and improving patient outcomes. All of the nominees are certified nurses. All nominees are actively involved in research.
DMC Children’s Hospital of Michigan
Mary Ruehle, RN, MS, CPN APHN-BC, SCID/Immunology coordinator received her ANCC Advanced Public Health Nursing certification
Karen Morris RN, BSN, promotion to NICU educator
Kim Roman PNP, promotion to NICU nurse practitioner
Denise Trotter, RN, BSN, promoted to lead preceptor for 6W
Cindi Vazquez, RN, BSN, Daisy Award winner
Cheryl King, NNP, nurse of the month
Kudos to the trauma/burn teams for both receiving specialty re-verification
DMC Harper University and Hutzel Women's Hospitals
Special Recognition/Caring in our environment
This goes beyond the phrase, I will give you the shirt off my back.
Friday, November 29th, we had a patient in 6603-2, Mr. L, who was being discharged. He had a pair of pants but no shirt. Our PCA inquired if we had a clothing closet like DRH has, so she could get him a shirt. I was not sure. I had suggested that we can give him a gown or a paper gown that has long sleeves. That was the end of the conversation.
I went to see Mr. L to make sure his discharge needs were met and he was sitting waiting for transport to take him to the lobby. He looked up at me with tears in his eyes thanking me for having the kindest, most caring people. I said I would let them know and I thanked him. As I was talking with him I noticed he had on a tan/brown striped shirt, I asked the PCA Cathy where she got the shirt and she said "I was asked not to say." At that moment I knew that Farhan Baber, from the PT/OT Department had actually given the shirt off his back to our patient, a fellow human being.
I would like to recognize Farhan for going above the call to care for another.
Deborah A Lutz RN, BAS, MA
Harper University Hospital
Manager, 6 Brush
Daisy Award Winners
Patricia Cozens, RN, NICU-SWAT, September
Joe Ramos, BSN, RN, 4ICU, October
Professional Development Ladder (PDL) Nurses
NEW TO PDL
MaryEllen Zalev, RN, Level I, Patient Testing Center
Sharon Lawson, BSN, RN, Level II, Patient Testing Center
Kim Kleven, RN, Level I, Labor & Delivery
Kelle Tyitye, BSN, RN, Level II, 8WS
Sue Rehel, RN, BAS, Level I, Special Care Nursery
Amy Fisher, BSN, RN, Level I, Labor & Delivery
Jeanine Middleton, RN, Level III, Same Day Surgery
Charito Rabanes, BSN, RN, Level II, Same Day Surgery
Andrea Cholag, BSN, RNC, Level III, Labor & Delivery
Helen Smith, BSN, RN, Level III, Patient Testing Center
Chris Haggerty, RNC-BAS, Level II, Labor & Delivery
Diane Dengate, BSN, RNC, Level III, Labor & Delivery
Judith Malick, RN, Level I, Patient Testing Center
Judith Schaefer, BSN, RN, MHA, Administrative Director, Central Campus Imaging, received a Masters in Healthcare Administration from Walden University
Makeeba Hampton, MHA, RN, received a Masters in Healthcare Administration with a specialization in leadership and Management from Walden University.
Marjan Jojic passed the certification exam for Anesthesia Techs, making him the first DMC Anesthesia Tech to be certified through The American Society of Anesthesia Technologists and Technicians.
James Reppert, CEN, obtained Emergency Nurse certification through the Board of Emergency Nurses
Helen Strickler RNC-CLC, NICU, attained ANCC Lactation Counselor certification
LaShaaisha Moss, RNC-CLC, NICU, attained ANCC Lactation Counselor certification
Carolynn Nehring RNC-CLC, SCN, attained ANCC Lactation Counselor certification
Irene Cappelli, RNC-CLC, SCN, attained ANCC Lactation Counselor certification
Petra Valeri RNC-CLC, SCN, attained ANCC Lactation Counselor certification
Congratulations on passing the Patient Care Associate Certification Exam
Alana Hall, PACU
Joe Smith, ED
Christopher Jones, OR
Sonya Kindred, Endoscopy
Glenn Altman, 10 Webber South
Pamela Bunea, 10 Webber South
Steven Watson, 5 Webber South
Bruce Hopkins, 5 Webber South
Andrea Marshall, 5 Webber South
Tiffani Simpson, Endoscopy
Dawn Zuziak, ED
Melissa Saucedo, OR
Melissa Measel, 4ICU
DMC Detroit Receiving Hospital
Claudia Coombs, RN (5M-Telemetry), December 2013
Congratulations for passing the Patient Care Associate
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