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current resident or
Non-Profit Org.U.S. Postage Paid
Princeton, MNPermit No. 14
Inside Alabama Nurse
Huntsville Has It All
Page 7
You’ve Been Kidnapped!
Page 6
Quarterly publication direct mailed to more than 84,000 Registered Nurses and Licensed Practical Nurses in Alabama Alabama State Nurses Association • 360 North Hull Street • Montgomery, AL 36104
Provided to Alabama’s Nursing Community and Funded by the Alabama State Nurses Association.
urseN
Phone 334-262-8321 alabamanurses.org
June, July, August 2016 • Volume 43 • Issue 2
ASNA President Brian Buchmann,
MSN, MBA, RN Nominated to ANA’s
Non-RN Membership Task Force
DO YOU HAVE YOURS YET?Order the nurse tag from your local tag office.
Proceeds from tags go to the Alabama Nurses Foundation to provide scholarships and promote the profession.
Join Us in Huntsville!See pages 7-10 for more information
IndexASNA Board of Directors . . . . . . . . . . . . . . . . . . . . 2
CE Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-15
CONVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10
ED’s Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Elizabeth A . Morris Clinical Sessions
(FACES ‘16) News . . . . . . . . . . . . . . . . . . . . . . . 3
Legal Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
LPN Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Membership News . . . . . . . . . . . . . . . . . . . . . . . . 6
Page 2 • The Alabama Nurse June, July, August 2016
ASNA Board of Directors
President: Brian Buchmann, MSN, MBA, RNPresident-Elect: Rebecca Huie, DNP, ACNPVice President: Carthenia Jefferson, BSN, RN, JD, ESQSecretary: Lindsey Harris, MSN, FNP-BCTreasurer: Debbie Litton, DNP, MSN, RN, MBADistrict 1: Sarah Wilkinson, MSN, BSN, BA, RNDistrict 2: Julie Savage Jones, MSN, RN, CNEDistrict 3: Wanda Spillers, DNP, RN, CCMDistrict 4: Erica Elkins Little, MSN, RNDistrict 5: VACANTCommission on Professional Issues: Marilyn Sullivan, DSN, RN, CPE, FCN, ChairParliamentarian: Sue Morgan, PhD, RN
ASNA Staff
Executive Director, John C. Ziegler, MA, D. MINDirector Leadership Services,
Charlene Roberson, MEd, RN-BCASNA Attorney, Don Eddins, JD
Administrative Coordinator, Betty ChamblissPrograms Coordinator, April Bishop, BS, ASIT
Our Vision
ASNA is the professional voice of all registered nurses in Alabama.
Our Values
• Modelingprofessionalnursingpracticestoothernurses
• AdheringtotheCode of Ethics for Nurses• Becomingmorerecognizablyinfluentialasan
association• Unifyingnurses• Advocatingfornurses• Promotingculturaldiversity• Promotinghealthparity• Advancingprofessionalcompetence• Promotingtheethicalcareandthehumandignityof
every person• Maintainingintegrityinallnursingcareers
Our Mission
ASNA is committed to promoting excellence in nursing.
Advertising
For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, [email protected]. ASNA and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.
Acceptance of advertising does not imply endorsement or approval by the Alabama State Nurses Association of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. ASNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of ASNA or those of the national or local associations.
The Alabama Nurse is published quarterly every March, June, September and December for the Alabama State Nurses Association, 360 North Hull Street, Montgomery, AL 36104
© Copyright by the Alabama State Nurses Association.Alabama State Nurses Association is a constituent member of the American Nurses Association.
Alabama nurse
ALABAMA BOARD OF NURSING
VACANCIESThere will be 1 RN position open and 1
LPN position open as of January 1, 2017. The term of Amy Price, Nursing Practice will expire December 31, 2016. Applications must be in the ASNA office by July 15, 2016. RN applications ONLY are available from the ASNA office. Call Betty!
Published by:Arthur L. Davis
Publishing Agency, Inc.www.alabamanurses.org
Condolences:ASNA member Margaret Howard
on the loss of her mother
ASNA member Donna Blount Everetton the loss of her mother.
Notify ASNA of Member Condolences
PUBLICATIONThe Alabama Nurse Publication Schedule for 2016
Issue Material Due to ASNA OfficeSept/Oct/Nov August 1, 2016Dec/Jan/Feb 2017 October 24, 2016
Guidelines for Article DevelopmentThe ASNA welcomes articles for publication. There is no payment for articles published in The Alabama Nurse.
1. Articles should be Microsoft Word using a 12 point font.2. Article length should not exceed five (5) pages 8 x 11.3. All references should be cited at the end of the
article.4. Articles (if possible) should be submitted
electronically.5. Images should credit source.
Submissions should be sent to:[email protected]
orEditor, The Alabama Nurse
Alabama State Nurses Association360 North Hull Street
Montgomery, AL 36104
ASNA reserves the right to not publish submissions.
Welcome to Huntsville
Located in downtown Huntsville among the tranquil beauty of Big Spring International Park, the Huntsville Museum of Art is a complete experience.
June, July, August 2016 The Alabama Nurse • Page 3
Dr. Susan G. Williams wins “Best Scientific Poster” at FACES ‘16
FACES ‘16
Not only is America’s space program on exhibit in Huntsville, it was forged in
Huntsville. We’re known as the “Rocket City” because Huntsville, Alabama is where rockets
were developed that put men on the moon.
Looking for qualified LPNs, RNs & CNAs
to work in a loving environment.
Offers CNA paid training.
Contact Tameka Payne at 205-849-2352http://www.northhillnursing.applicantpro.com
Register NOW! jurexnurse.comor call (901) 496-5447
Earn $150/hr!Any Nurse Can Get Certif ied as a Legal Nurse Consultant in only 2 Days.
New Orleans: Sep 24 & 25. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Atlanta: Oct 8 & 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Birmingham: Oct 22 & 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Memphis: Oct 29 & 30
GRMC is the only hospital in Northeast Alabama that holds certifications/accreditations from JCAHO, Society of Cardiovascular Patient Care, American College of Surgeons, Commission on Cancer and more!
We offer a competitive salary and benefits package. For immediate consideration, please apply online at:www.gadsdenregional.com
Gadsden Regional is an Equal Opportunity Employer .
RNs NEEDEDGadsden Regional Medical Center,located in beautiful Northeast Alabama, has full-time positions available immediately in many nursing areas .
Job Board: Search job listings in all 50 states.
Publications: New publicationsand articles added weekly!
Events: Find events for nursing professionals in your area.
www.nursingALD.com
Stay up-to-date and find your dream job!
Page 4 • The Alabama Nurse June, July, August 2016
Greg Howard, LPN
The Author of this phrase is unknown. The phrase was used during slavery when education was denied to slaves.
Then in the first half of the 20th Century, the phrase was used when Christian Missionaries were trying to address poverty and illiteracy in the Philippines. Since that time, the phrase has been used by nonprofit organizations andother disciplines to describe
Don Eddins, BS, MS, JD
Representing the registered nurses of Alabama is an honor to me as part of my law practice in Auburn. The Alabama State Nurses’ Association (ASNA) certainly is among my very favorite clients.
Recently, I noticed on the Alabama Board of Nursing website that the state on that particular day had 73,981 registered nurses. That is a lot of expertise and compassion served uptothecitizensofAlabama!
Sadly, though, fewer than 5 percent of the active RNs belong to their professional organization, ASNA. Let mestate that just because a nurse receives this publication, The Alabama Nurse, it does not mean that you are a member of ASNA.
ASNAisaserviceorganization–anassociationwhichadvocates for and provides various services for members. Registered Nurses pay a monthly or annual fee to be part of the association.
ASNA services are many in number and varied is character – everything from continuing education togenerous discounts on goods and services, from uniforms
Why every registered nurse should be a member of the Alabama State Nurses’ Association
Legal Corner
to liability insurance. ASNA even has a credit card. Just log on to the ASNA website for details. The Association got an affinity car tag created for the state’s nurses too. The tag, which can be purchased the month you renew your license plate, proudly proclaims, “Nurses Save Lives.”
ASNA advocates for the cause of nursing non-stop, whether it’s before the Alabama Legislature on legislation, before the Alabama Board of Nursing on a proposed rule or regulation, or at any agency or institution that deals with health care in Alabama.
I am biased, but in my opinion one of the most important advantages of ASNA membership is the legal services program. If you receive a letter from the Board of Nursing indicating that a complaint has been made against you in your performance as a nurse, I will, as ASNA attorney, represent you before the Board. You will not have to pay me a dime; my fee is taken care of through your membership.
That membership advantage not only could save you thousands of dollars, but offers good old peace of mind. The only caveat is that you must be a member of ASNA when the event complained of occurred. After all, you cannot wait until the house catches fire to buy insurance.
Under the legal services program, you also have a freeone-hour’s consultation on the topic of your choice.
ASNA membership just has so many advantages. Not only that, but you don’t want to be left out of your professional organization. So Google “Alabama StateNurses Association” today and sign up online.
The Huntsville Botanical Garden is a beautiful 120-acre site with stunning floral collections,
inviting woodland paths, broad grassy meadows, aquatic areas, demonstration
vegetable and herb gardens and the Nature Center. The two-acre Children’s Garden is
adjacent to the Nature Center.
Welcome to Huntsville
LPN Corner
We are dedicated to developing and supporting your career with more opportunities for advancement. Our Clinical Ladder program provides staff clinicians with the opportunity to advance their careers.
Registered Nurses• Benefit from our unique Clinical Ladder• Enjoy specialized training and career advancement
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Visit us at www.gentiva.com/careersCall us today at 1.866.GENTIVAEmail [email protected]
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An Affiliate of Kindred at Home
Respect comes with the job when you’re a U.S. Air Force Nurse. The reason? You’ll be a commissioned officer with greater responsibilities. Of course, with greater responsibility comes greater opportunity to expand your areas of expertise or dig deeper into what you do now. Find out how the Air Force can make your career in nursing even more rewarding.
airforce.com/healthcareFor more information, call
Sgt Darrell Suazo, 225-767-0738©2013 Paid for by the U .S . Air Force . All rights reserved .
THE APPRECIATION OF YOUR PATIENTS.THE RESPECT OF YOUR COLLEAGUES.
problems they were addressing in their quest to help others.
As seasoned nurses, are we sharing our wisdom and lessons learned? It is important to the profession to reach back, to the side, or reach up to share what we have learned and to enhance what is already known. For one day we, or a loved one, may need nursing care.
It is my wish that if I need care, the person will possess the qualities that can’t be taught, such as: compassion and commitment.
Let’s hope that the system continues to be the “Watch Dog” for nursing. And that we strongly encourage and practice, “Each One, Teach One” and allow it to be the “GoldStandard” forpassingon to thenextgenerationofnurses what we have learned.
“Each One, Teach One”
June, July, August 2016 The Alabama Nurse • Page 5
The E.D.’s Notes
John C. Ziegler, MA, D, MIN
In a recent Medscape poll of over 8,000 nurses more than 50% of the respondents said they would NOT choose nursing as a career if they had it to do over again. WOW! When I read that statistic I was astonished! The nurses I have known during my tenure as Executive Director of the Alabama State Nurses Association have sustained a high level of passion about their profession. I can’t believe that half of them would choose a different field of work if they had it to do over again. I felt that surely the Medscape poll had gotten it wrong. Nevertheless, the poll motivated me to look into this issue more. Soon I found that there is plenty of information out there on the issue of burnout and/or disillusionment with a chosen career path. A number of things can contribute to the loss of passion and the ensuing career path doubts that follow.
There are numerous studies that correlate a stressful work environment to burnout. Nurses are taught in school and on the job to “take care of themselves.” We are told that if one’s emotional tanks are empty… one does not have the capacity to authentically care for others. I want to stress the word “authentically.” Interestingly, even when we are in “burnout” mode, we can continue to do a job mechanically and even perform in a caring manner.Butinanhonestmomentwhenwelookourselves“inthemirror”werealize…the passion has faded. We admit that it has eroded over time and we don’t know how to get it back! Here are some of the key factors that contribute to a diminished career passion and at least one suggestion for regaining the pleasure of working in a critically important field.
Sometimes lack of inspiration comes from difficult relationships, not the work itself. This could include your boss, irritating coworkers or office politics. Another contributor to a negative work environment is the proliferation of rules that divert energy away from the main reason you became a nurse…delivering quality personal care to patients. An environment with too few staff and too much work that is not directly enhancing patient
Need to Revive Your Passion for Being a Nurse? ASNA Can Help.
care can wear you down. Exhaustion and fatigue are two of the most common passion killers. In short, there is a lot of information on the web and through HR that can give you warnings about nurse burnout along with numerous suggestions for re-kindling one’s passion for being a nurse. I would like to give you a simple way to regain the spark that made you feel like a part of a family, a community of nurses who all wanted to make a difference in the system and in patients’ lives.
Remember when you were in nursing school the unity, collegiality and sense of purpose you shared with your fellow students? After graduation, people went their own way seeking their place in the career world of nursing. In spite of inviting recruitment, orientation and assimilation efforts a new work environment always has its challenges. The turnover rate for nurses in the early years of their career is quite high. This is not all bad. Young nurses are eager to grow in employment status and income. In many cases that means moving around. Each move…is stressful. Acclimating oneself to a new culture, new people, new rules and things as simple as finding a parking place can pile up on the already heavy stress of caring for people’s lives! There is one place you can experience CONTINUITY, COMMUNITY and COMPASSION regardless of careerchanges…ASNA membership. For over 103 years, nurses have rallied around a single causeunderthebannerofasingleorganization–TheAlabamaStateNursesAssociation.I don’t believe that it is an exaggeration to say that one of the reasons our members have sustained their passion for the nursing profession and their nursing practice is the support and encouragement they receive in being part of the ASNA family. I hope that you will take care of yourself and follow all the sound advice related to nurse burnout. But, there is nothing like the support of family…and ASNA can be your nursing family no matter where you work, who you work for or what kind of work you do.
Forrest General is looking for individuals who embrace our “We C.A.R.E.”
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Forrest General Experience. Are you that person?
Forrest General Hospital is an Equal Opportunity Employer.
• Generous Paid Time Off Plan• Sick leave• Full health, dental, vision and Rx• Employee Health Services• Employee Pharmacy• 403B retirement plan with 5-year vesting period. For prior employees, we may
be able to bridge your years of service if you have not been gone for longer than 5 years.
Outstanding benefits offered:
www.forresthealth.org/ careers-volunteers/apply-now
Page 6 • The Alabama Nurse June, July, August 2016
April Bishop, BS, ASIT
Actually, you’ve been infected with a malicious creature known as ransomware. As a nurse you are already aware of the importance of infection control. However, many of you don’t take that same defensive technique with you when it comes to computers. We all know about the importance of antivirus protection. It’s been drummed into us not to open suspiciousfiles–orfilesfromsomeoneyoudon’tknow.Theproblem is that cybercriminals are using familiar platforms and people you know to infect your computer.
So what is ransomware? Simply put, it’s a malware that attacks your computer and encrypts your files and makes them unusable. Criminals are targeting healthcare facilities and you may be caught in the crossfire simply because you happen to be a healthcare provider. Once your files are corrupted, you have only a few options; pay the hackers (not always a guaranteed safe return to normal), pay big bucks for an expert to restore your files (also not a guarantee), or take your computer back to factory settings and restore your files from a backup.
Right now the consensus is that the methods of transmission vary (email, social media, and internet). Experts
suspect that ransomware such as cerber are coming out of former soviet bloc states, the Middle East, and Asia, but they have yet to verify this. It appears that the original software is sold to other hackers who then agree to share their takings with the author. While some have been lucky to see their files restored with only one payment (as happened to one of our ASNA members), others are quoted higher and higher fees never to see their files restored.
How can you protect yourself? Of course the usual –don’t open anything suspicious, especially from unknowns. Don’t click on emails from friends that only contain a link. If in doubt – reach out. Contact the individual and ask ifthey did in fact send you this link. Keep your software up to date. Yes, updates are annoying, but they are far less time-consuming that trying to restore all of your files. Make sure youusestrongpasswords–anddonotusethemformultipleproducts.Giveyourselfafightingchancebyhavingadifferentpassword for Facebook, Email, and your bank. Backup, backup, backup. If you have a copy of your files they are easily restored. Finally, invest in a good antivirus program. Check out customer satisfaction, consumer reports, and get expert opinions before you opt for “free” antivirus software. One California hospital paid $17,000 to get their files back. Is $25 - $50 per year too much to spend for your peace of mind?
References:Bloomberg, J. (2016, Jan. 26), Ransomware: Coming To a
Business Near You. Forbes.com. http://www.forbes.com/sites/jasonbloomberg/2016/01/26/ransomware-coming-to-a-business-near-you/#73d09d8c7b65
Miliard, M. (2016, Apr. 4) Two more hospitals struck by ransomware, in California and Indiana. Healthcare IT News. http://www.healthcareitnews.com/news/two-more-hospitals-struck-ransomware-california-and-indiana
Thompson, C. (2016, Feb. 23). 5 ways to protect yourself against the ‘ransomware’ that’s taking over the internet. http://www.techinsider.io/how-to-protect-against-ransomware-2016-2
Vaas,L.(2016,Apr.4).RansomwarealertissuedbyUSandCanadafollowing recent attacks. Naked Security. https://nakedsecurity.sophos.com/2016/04/04/ransomware-alert-issued-by-us-and-canada-following-recent-attacks/
ASNA Would Like to Honor Our Veteran Members
Please send in your Name, Rank, Branch, and Dates of Service to April Bishop at
[email protected]. We’ll include it in a special Veteran’s Day
tribute in our September/October/November issue of The Alabama Nurse.
Congratulations!Congratulations to ASNA District 2 member Dr.
Constance Hendricks on her induction into the Tuskegee UniversityNursingHallofFame.
VisitJoin ASNA Today!
www.alabamanurses.org
You’ve Been Kidnapped!
Continuing Education Classes American Heart Association• Basic Life Support (CPR)• Advanced Cardiac Life Support (ACLS)• Pediatric Advanced Life Support (PALS)
Short Term Programs• Emergency Medical Technician• Emergency Medical Technician Advanced
June, July, August 2016 The Alabama Nurse • Page 7
2016 Annual Convention
Huntsville Has it All
Mixed among upscale brands like Michael Kors, Pandora and Anthropologie, you’ll find specialty stores for everyone in your life – the cook, the active outdoorsy type, or the techie. There’s also a
stand-alone flagship Belk department store and more than 70 shops and restaurants.
The 2016 ASNA Convention Committee hopes you will take advantage of all of the awesome activities that North Alabama offers. We encourage you to come up to Huntsville with your families. There are tons of activities of interest to all ages. Of course many of us will be shopping at Bridge Street Town Center just steps from the Westin, but in addition to enjoying the Westin (our only 4 star hotel in Huntsville) and the Monaco Theater next door, we have the ScarecrowTrailat theBotanicalGarden,the Space and Rocket Center with iMAX theater, Big Spring Park downtown as well as the historical Harrison Brothers hardware store. Also downtown you will find lots to do at the Railroad Museum, EarlyWorks Museum for Children, the Alabama Constitution Village, the Huntsville Museum of Art, a Veterans Museum, year round ice skating and the Twickenham historical district. Just 2 miles out of downtown up on Monte Sano Mountain you’ll find the Monte Sano State Park and Burritt Museum and Barnyard. (The animals are all native to the area and original species for the 19th century timeperiod.) Other North Alabama
attractions include 3 caves, the Helen Keller house in Florence, DeSoto Falls in Ft Payne, CathedralCaverns,andtheRobertTrentGolf
course in Hampton Cove. If you stay over to Sunday, there is a once a year opportunity for
the Maple Hill Cemetery stroll...complete with period costumes, tales of the times and a talking
cow. Fun for all! There is a lot to do in historical, fun North Alabama. Come early and stay late. Bring your families.
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Dublin, GA 478-272-4404
Waynesville, NC 828-456-3309
Page 8 • The Alabama Nurse June, July, August 2016
2016 Annual Convention
Agenda Oct 13-15, 2016Alabama State Nurses Association Annual Convention
Thursday, 13 October
Mable Lamb Nursing Continuing Education Day(Pre Convention Nursing Continuing Education)
8:30 AM Registration
9:00 AM - 3:00 PM
Tract I – Human Trafficking, Lynn Chaffee, Human Trafficking Survivor
9:00 AM - 12:00 PM
Tract II – Clinical FocusPatient Falls – A Success Story! Brian Buchmann, MSN, MBA, RNRecognizing Our Differences: Two Tools for Improving Team Communication, Marsha Ferrell, BSN, RN-BC, CTHPN
12:00 PM - 1:00 PM
Lunch (on your own)
1:00 PM - 3:00 PM
Tract II – Clinical Focus cont.Clinical application of revised Code of Ethics, Arlene Morris, EdD, RN, CENSeptis: Embedding the Sepsis Six,Michael D. Johnson, BSN, RN
1:00 PM - 3:00 PM
Board of Directors Meeting
5:00 PM Opening of ASNA House of Delegates–CalltoOrder,BrianBuchmann,President–OpeningCeremony(TroopingofColors,
PledgeofAllegiance,OfficialGreetings)– Report of the Credentials Committee– President’s Report– Executive Director Report
6:30 PM Supper (Including Posters and meet the authors)Scavenger Hunt around Bridge Street, movies or shopping following supper
Friday, 14 October
7:15 AM - 8:00 AM
Breakfast
8:00 AM - 11:00 AM
HODChair Aerobics led by Dr. Bobbie Holt-Ragler– Call to Order: President Buchmann– Report of the Credential Committee– Reports (only if in addition to written report in
Convention Book)- Officers- District Presidents- Commission on Professional Issues- Standing Committee (only if in addition to
report in Convention Book)- Bylaws, Continuing Education, Ethics
and Human Rights, Finance, Legislative, Membership and Nominations
- Task Force Reports
8:00 AM - 2:00 PM
Exhibits
11:00 AM - 12:00 Noon
Keynote, David Spillers, MBA, CEO Huntsville Hospital Systems
12:00 PM - 1:00 PM
Lunch
1:00 PM - 2:30 PM
Leadership Academy Projects/Posters
2:30 PM Human Trafficking, Lynn Chaffee
3:30 PM Voting
4:00 PM - 5:00 PM
HOD (reconvenes only if needed)
5:15 PM Supper
6:00 PM Live Auction
8:00 PM Dr. Rony Najjar’s Junctional Rhythm Band (Halloween Costumes optional), AANA will join ASNA at this time
Saturday, 15 October
8:15 AM Breakfast
8:15 AM Posters
9:00 AM Electronic Cigarettes: What Do NursesKnow About It? Dr. Azita Amiri
10:00 AM House of Delegates reconvenesChair aerobics led by Dr. Bobbie Holt-Ragler–CalltoOrder:PresidentBuchmann–ReportoftheDelegateCredentialsCommittee–MemorialService–ReportofTellers–Adoptionof2015Resolutions–NewBusiness
- Bylaws- Strategic Plan- 2014 Resolutions Evaluated
–ConventionInvitation2017–Announcements– InstallationofNewOfficers
12:00 PM - 1:30 PM
Awards Luncheon
Preliminary Ballot for ASNA ConventionCandidates for 2016-2018
President-Elect/Delegate Ellen Buckner, DSN, RN, CNE
Write-in candidate: ________________________________
Treasurer: Bridget Moore, DNP, MBA, RNC-NIC Write-in candidate: ________________________________
Commission on Professional Issues (Vote for 4)
Write-in candidate: ________________________________
Nominating Committee (Vote for 3)
Write-in candidate: ________________________________
Nominations and Election of Officers Alabama State Nurses Association’s (ASNA) nomination and election of Officers shall be conducted in accordance
with Robert’s Rules of Order, 10th Edition during the official meeting of the ASNA House of Delegates (HOD).
1. NOMINATIONSA. Nominations Committee a. Nominations from the Nominations Committee shall be accomplished according to ASNA Bylaws.B. Nominations from the floor of the HOD shall be accomplished according to Robert’s Rules of Order, 10th Edition.
1. ELECTION OF OFFICERSA. Elections will be by secret ballot.B. Only credentialed delegates will be allowed to vote at the ASNA Convention. See ASNA website
(alabamanurses.org) under members only section for convention information.
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June, July, August 2016 The Alabama Nurse • Page 9
ASNA Convention 2016 RegistrationRegister online at http://alabamanurses.org/
Name & Credentials: ___________________________________________
Address: _____________________________________________________
_____________________________________________________________ City State Zip
Day phone: ( ___ ) _______________ Fax: ( ____ ) __________________
E-mail: ______________________________________________________
Credit Card #: _________________________________________________
Exp. Date: _______________________________ CVV #:______________
Registration: The Mable Lamb Continuing Education Day registration includes continuing nursing educational sessions only. All may attend the ASNA Convention Keynote Address; but only those registered to attend Convention will receive continuing nursing education credit. Single-day Convention registration includes meal functions and continuing nursing education. Individuals registering the day of the Convention will be issued food tickets ONLY if available. Additional guest tickets may be purchased for food functions only.
Payment: Amount of registration is determined by postmark if mailed or date received in case of phone, fax, or online. Payment or Purchase Orders must accompany registration in order to be processed. All registrations received after October 1, 2016 will be considered “at door” and processed on site.
Before October 1, 2016 will be considered early registration.
Confirmations: Confirmations are available to print immediately following your online registration. Registrations received via mail will receive an email confirmation within two weeks of receipt.
Cancellations: A written request must be received prior to October 1, 2016. A refund minus a $20 processing fee will be given. No refund will be given after October 1, 2016. We reserve the right to cancel the activity if necessary. In that case a full refund will be given.
Continuing Nursing Education:
The Alabama State Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
Alabama Board of Nursing (Valid through March 30, 2017).
1.0 contact hour is awarded for each session attended, including Posters. A maximum of 6.5 (ANCC)/7.6 (ABN) contact hours may be earned. An additional 4.5 (ANCC)/5.4 (ABN) contact hours may be earned by attending the Pre Convention sessions.
Returned Check Fee: $30 returned check fee for any returned checks or dishonored payments.
How to Register for Convention:
Register online at http://alabamanurses.org or send registration form and payment to (check made payable to ASNA) ASNA, 360 North Hull Street, Montgomery, AL 36104-3644 or if paying by credit card Fax to 334-262-8578 (do not mail if faxing or registering on line).
For hotel reservations, contact the Westin Inn at 1-866-627-8560 . Attendees must identify themselves as participants of ASNA 103rd Annual Convention in order to receive the special room rate of $139.00 plus tax. Cut off for discount rate is 5:00 p.m., September 11, 2016. Reservations made after that date will be based on space and availability.
MABEL LAMB CONTINUING EDUCATION DAY Workshops, Thursday, October 1, 2015 | Mabel Lamb Contact Hours: 4.5 ANCC/5.4 ABN
Workshops:
_______ ASNA member $45 ______ Non-member $65 NOTE: Add $10 to fees if received after October 1, 2016
9:00 AM - 3:00 PM Tract I – Human Trafficking9:00 AM - 3:00 PM Tract II – Clinical
Convention, Thursday night, October 13, 2016; and Friday & Saturday, October 14-15, 2016 (includes tickets to all meal functions listed in this application) – Select one of the following choices:
ASNA Delegates Only (must register for entire convention)*
Received on or before October 1, 2016 ____ $249
Non – Delegates – Full convention *
Received on or before October 1, 2016 ____ ASNA Member $280 ____ Non Member $340
Daily Registration *
Received on or before October 1, 2016 ____ ASNA Member $125/day ____ Non Member $150/day
Note: AfterOctober1,2016,add$20toaboveprices– meals may not be available if received after October 1, 2016
Additional Meal/Function Tickets (for guests or those meals not included in your registration)
Thursday,October13,2016–OpeningCelebration ____________ $60
Friday,October14,2016–Breakfast ____________ $22
Friday,October14,2016–Lunch ____________ $25
Friday,October14,2016–Dinner ____________ $60
Saturday,October15,2016–Breakfast ____________ $22
Saturday,October15,2016–AwardsLuncheon ____________ $35
Total Enclosed: ____________
*ASNA Special Dues members (65+/Retired or Completely Disabled) receive an additional 10% discount on registration.
Registration postmarked or received after October 1, 2016 will be considered “at-door”.
LUNCHISONYOUROWN.
INDICATE AWARD LUNCHEON CHOICESaturday, October 15, 2016
_______ Chicken Piccata ______ Smoked Prime Rib
2016 Annual Convention
Free walking tours. Tours are guided by local experts and focus on the historic districts of both cities.
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Page 10 • The Alabama Nurse June, July, August 2016
2016 Annual Convention
ASNA’s Official Call for Resolutions
All You Need to KnowWhat Is a Resolution?
It is a formal written call to action on a subject of great importance to members of ASNA. In other words this is an action members would like ASNA to pursue. Resolutions are often the source of action in developing positions on issues affecting nurses, nursing, and the needs of the public. Once the resolution is voted on and passed by the House of Delegates ASNA will try to implement in order to meet the needs of the association. Resolutions may be sent to other organizations, governmental agencies, or otherindividuals. The resolution process is one of the most important functions of the House of Delegates.
Call for ResolutionsAny ASNA member may research, write, and/or submit a resolution for consideration
by theASNAHouse ofDelegates. Resolutions should be submitted to theGovernanceCommittee through the ASNA office at 360 N. Hull St., Montgomery, AL 36104 by JULY 23, 2016. Only an emergency resolution will be accepted after the designated date.
Types of ResolutionsResolution are classified according to the following:
• Substantive Resolution, which deal with basic principles and policies of ASNA, or issuesofstatewideornationalconcernsofnursesaspractitionersandcitizens.
• Courtesy Resolutions, which give recognition to outstanding persons who have made especially valuable contributions to ASNA or the nursing profession.
• Commemorative resolutions, which deal with commemoration of important events or developments in nursing, allied professions, or government.
• Emergency Resolutions, which have significance for the association and require immediate action.
How is a Resolution written?A resolution has two parts – the “whereas” section and the “resolved” section.
The “whereas” section is a series of single item, factual statements which present documentation of the need for the resolution. The “resolved” section is a series (or single) item action statement(s) of position by ASNA and is the actions by which the intended result will be obtained.
ASNA Delegate ResponsibilitiesAwards Nominations Made Incredibly Easy
The Awards nomination process just got easier. You can now nominate some deserving person/organization for ASNA awards by going to the ASNA website at www.alabamanurses.org. On the home page click on “ASNA Awards Criteria/Nomination Forms.” All the awards and the criteria are listed. You can go under the awards and enter the information right online or you can download the form, fill it in and send it back to ASNA by email, mail or fax. For a person, you can download and fill out the Biographical Form or you can send in a Curriculum Vitae (CV) if you like. You can download a letter of support form, fill it out and send it back to April at ASNA or you can send in a letter by mail, email or fax. Awards for this year must be sent in by July 23, 2016. There are a lot of very special people out there we need tohonorandrecognizefortheirefforts.Pleasetakethetimetodothis.We challenge each of the Districts to send in a nomination for each of the awards.Comeon–Makethe Awards Committee’s job harder; it would thrill us.
Being a Delegate to a state convention can be an exciting experience but one that also has some inherent responsibility. As you may know, the House of Delegates (HOD) is the governing and official voting body of the Alabama State Nurses Association (ASNA). The House meets annually. Members of the HOD have a crucial role in providing direction and support of the work of the Alabama State Nurses Association. Delegates are elected to the HOD to work for the betterment of ASNA and the nursing profession. Each delegate is expected to study the issues thoroughly, attend each session of the HOD (including the Open Forums), and engage in active listening and debate. Also, delegates are encouraged to use the extensive resources and collective knowledge available at each meeting to provide direction and support for theworkof theorganization.Such a commitment benefits theindividual delegate, the association, and the nursing profession.
If a delegate in unable to attend the 2016 ASNA House of Delegates, his/her district nurses association (DNA) should be notified at once. When alternate delegates are substituted for delegates, it is the responsibility of the District President to notify ASNA of the change immediately.
Important information for ASNA Delegate RegistrationDelegates are encouraged to register for convention in advance to expedite the on-
site credentialing process. See the registration form in the pull out section of this issue for registration fees. Full registration includes all convention functions. Additional tickets can bepurchasedfortheseevents.UtilizethespecialpulloutsectionofThe Alabama Nurse to register for convention. Please note the cut off date for the hotel discount is October 11, 2016. ASNA has blocked a certain amount of rooms for this convention. Please consider thatoff-sitehotelregistrationofdelegatescausesafinancialhardshiptotheorganizationifthe room block is not met.
To ensure eligibility for the credentialing process, delegates are required to present their current ANA membership card and one picture ID at the Delegate Registration desk. If you do not have a current membership card please contact April Bishop, Programs Coordinator for assistance. Each delegate will be issued a name badge, a delegate ribbon, and informational materials upon proof of identification. The name badge and delegate ribbon must be worn in order to be admitted to the floor of the House of Delegates.
Please call the ASNA office at 1-800-270-2762 or 334-262-8321 if you have questions or concerns.
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June, July, August 2016 The Alabama Nurse • Page 11
when they convened a consensus panel to provide guidance for use of medications in clinical practice. Panel members included experts in alcohol research, clinical care, medical education, and public policy. In essence they developed best practicesforthetreatmentofAUD.Theyemphasizedthatitis even more incumbent for health care providers to address theAUDissuebecausemany individualsengaging in riskydrinking behaviors also have other physical and social issues. These issues can and do influence the course, incidence and treatment of concurrent medical and psychiatric issues.
Although medications are the cornerstone of the treatment plan, they should be viewed as only part of the total treatment approach. This approach will include psychosocial therapies (with a referral to a psychiatrist, psychologist or professional counselor), or participation in social supports such as AA or other mutual self-help programs.
Treatment Plan
Screening/assessing for AUD can easily beaccomplished concurrently while assessing for other conditions. Ideally this practice should occur with every patient using a validated screen tool. One easy, commonly used tool is AUDIT (Alcohol Use Disorders Identification) which may be downloaded at http://www.talkingalcohol.com/files/pdfs/WHO_audit.pdf. It takes less than five minutes to complete. An even easier tool to use is the single question, “How many times in the past year have you had _____ drinks in one day?” SAMHSA states that five drinks for men and four drinks for women is 82% sensitive to detecting individuals with alcohol problems. Another frequently used tool is the SBRIT (Screening, Brief Interventions, and Referral to Treatment).Using this enables the healthcare provider toask brief questions and if appropriate provides guidance for a brief intervention and referral to treatment if needed. Information about the tool may be located at http://www.samhsa.gov/sbrit. In addition, and even more convenient, is the Baylor College of Medicine free app located in the ITunes store called SBRIT App for administering the tool.
Ideally all patients need some degree of screening but certain groups are more venerable. They include the following:
C.E. Corner
Alcohol Use Disorder - Medication Assisted TreatmentCharlene Roberson, MEd, RN, BC,
Disclosures: The author and Planning Committee have declared no conflict of interest.
Contact Hours: 3.0 (ANCC) and 3.0 (ABN) 3.6 (PHARM) contact hours are valid May 10, 2016 through May 9, 2018.
Target Audience: Registered Nurses, Advance Practice Nurses, health care providers involved in substance abuse treatment.
Purpose: Contrast the benefits of the three treatment modalities of the treatment plan. Examine the benefits and complications of each
medication approved by FDA for treatment of AlcoholUseDisorder.
Fees: ASNA Member - $ FREE Non-Member - $30
Instructions for Credit: Participants should read the purpose and then study the activity on-line or printed out. After reading, complete the post-test at the end of the activity and compare your responses to the answers provided, and review any incorrect responses. Participants must complete the evaluation on line and submit the appropriate fee to receive continuing nursing education credit. The certificate of attendance will be generated after the evaluation has been completed. ASNA will report continuing nursing education hours to the ABN within 2 weeks of completion.
Evaluation: Complete at https://form.jotform.com/61233651829962
Accreditation: The Alabama State Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Alabama Board of Nursing Provider Number ABNP0002 (valid through March 30, 2017).
Alabama State Nurses Association360 N. Hull St.Montgomery, AL 36104
Fax: 334-262-8578
IntroductionAccording to SAMHSA (Substance Abuse and Mental
Health Services Administration) between 10-20 percent of all patients seen in either a primary care or an acute health care setting have a diagnosis of Alcohol Use Disorder(AUD)asdefinedbytheAmericanPsychiatricAssociation’sDiagnostic and Statistical Manual of Mental Disorders (DSM-5). In 2014 they cited that 17.6 million individuals met this criteria but only 1.6 million (8.9%) received any type of treatment; however, this number does exclude mutual help programs such as Alcoholics Anonymous (AA). Many addiction experts believe that all individuals with either moderate or severe alcohol-related problems should be offered medication-assisted treatment on a routine basis. But inordertoreceivetreatment,thediagnosisofAUDismadeand this is problematic. The main issue seems to be social exclusion for both the patients and their health care providers. SAMHSA attributes this fact to a lack of understanding that AUD is a treatable disorder. Fifty years ago the AmericanMedical Association affirmed that dependence on alcohol or other drugs was a medical disorder, yet the ongoing non-treatment issue remains. Since that time all health care providers, health care organizations, and policy makershave been encouraged to frame activities and decisions to reflect that AUD is treatable. In 2012, an effort to finallybring clarity to this dilemma was initiated by SAMHSA and the National Institute on Alcohol Abuse and Alcoholism
1. Any woman who is pregnant or trying to conceive.2. Anyone at risk for binge drinking or heavy
drinking.3. Those with health problems which might be
induced or exacerbated by drinking such as cardiac or liver disease, anxiety, depression, PTSD, dyspepsia, or history of traumatic injury.
4. A person with one or more chronic diseases not respondingtotreatment–diabetes,gastrointestinaldisorders, hypertension, or heart disease.
5. Individuals with social or legal problems that may be caused or worsened by alcohol intake - family/marital issues or driving under the influence conventions.
Individuals especially needing follow-up are those with anAUDIT score greater than 8 and/or thosewho reportone or more heavy drinking episodes in the past year.
The patient history should include a medical and psychiatric overview, substance abuse history of both self and family, as well as available psychosocial support. The family/significant other history is especially important as it can provide useful insights into the patient’s perspective as well their current status. Another useful screening tool, if possible to obtain, are records from the patient’s other health care providers. The process should also include the patient’s prescription drug use history. If available, the state’s prescription drug monitoring program (PDMP) records of prescription dispensed to detect any unreported use of other medications. Not all states have this information available. This survey would include evaluating any opioid analgesic or sedative-hypnotic medications that may react negatively with alcohol treatment or alcohol treatment medications. During the assessment process special attention should be placed on the factors such as motivation toward treatment, potential for relapse, severity of concurrent medical or psychiatric conditions, past history of tolerance to medications, and pregnancy. And if pregnant or planning to become pregnant certain medications, which will be discussed later in the document should be avoided.
A physical examination should be completed and include evidence of hepatic dysfunction, neurocognitive function, and sequelea of alcohol use. Many patients
Which populations/groups are especially vulnerable to alcohol abuse and absolutely need screening for AUD?
CE continued on page 12
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Page 12 • The Alabama Nurse June, July, August 2016
have no impairment of any of these functions but when present this is an indicator of the severity of the disease. Some long term physical sequelea include cirrhosis; encephalopathy; and vitamin deficiencies (especially thiamine, folic acid, and pyridoxine); tachycardia (especially superventricular); tremors of hand and tongue; hypertension; hepatosplenomegaly, tender liver edge, peripheral neuropathy, spider angiomata; and unexplained trauma.
Laboratory testing is essential to confirm or eliminate alcohol-related damage. Sometimes the actual testing process, whether initial or follow up provides some motivation for clients to continue treatment. There is not a specific test that can exactly pinpointAUD;however, the following tests are veryhelpful in identifying alcohol useand alcohol-related abnormalities.
1. Blood alcohol levels will measure the current consumption and are useful to determine capacity to perform certain tasks such as driving.
2. AST, GGT, CDT, and other hepatic and renal function tests are elevated withindividuals who have chronically consumed alcohol as the medications used to treatAUDshouldbeusedwithcautionwithpatientwithrenalorliverdysfunction.
3. Complete Blood Count is useful to determine anemia as alcohol can have a toxic effect on bone marrow and some individuals may have macrocytosis.
4. Vitamin deficiencies are usually related to inadequate healthy diet which can lead to abnormal cellular function. The most common deficiencies are thiamine, folic
acid, and pyridoxine. The long term, excessive vitamin deficiency – especiallythiamine may result in Wernicke-Koraskoff/amnesic syndrome.
5. Urinetoxicologytodeterminepresenceofotherdrugs.6. Pregnancy test on all women of childbearing age.
Developing a Treatment Plan
Thefirst step inworkingwithapatientwithAUDwilling toenter treatmentshouldbedeveloping a mutually acceptable treatment plan. This plan must be acceptable to the patient and revised based on their desires and wiliness to comply. When plans are static and not revised the chances of success are greatly reduced. The plan needs to address all options such as medications and other therapies as well as the rationale for use. A schedule needs to be developed for follow-up visits and laboratory testing to monitor their progress. A frank discussion of participation in mutual self-help groups which would include reasons and expectations and would include locations, cost and frequency. The degree of family/significant others involvement should be explored with both patients and family/significant others. Plans need to address any co-occurring conditions such as medical, psychiatric, other substance abuse disorders, and/or smoking. A discussion of medications to be used including steps to promote adherence and discontinuing of medication. Included in the plan is to address discontinuation of therapies, medications, and/or possibility of referral to a higher level of care.
Certain conditions require complete abstinence from alcohol. They are pregnancy, concurrently taking a medication that may cause a harmful drug reaction, or if the person has a medical condition that is either associated with or exacerbated with alcohol use.
SomepatientsengageinriskydrinkingbutdonotmeetthecriteriaofAUDasdeterminedby theAUDIT score.The clinicianmust rely on their professional judgment to determineif reducing alcohol or abstinence is the more appropriate goal. Factors to consider include family history of alcohol consumption either in the current or preceding generations, patient’s age and any history of traumatic injuries or events related to drinking.
A treatment plan is just more effective when developed with face to face discussions and providing written educational materials to both the patient and family/significant others. Elements of patient education for an effective treatment plan include the following:
1. Knowledge of what to expect overall.2. Information ingeneral aboutAUDandespecially thechronicnatureof thedisease
process.3. Why a particular medication has been selected, how it works, including the associated
risks and benefits; and anticipated time for full medication benefits.4. Importance of an effective birth control methods for women of childbearing age.5. Explicit information about what to do if alcohol is consumed after a period of
abstinence.6. Need to convey to other health care providers and dentists that they are taking
medicationforAUDinordertoavoidinadvertentdrugreactions-especiallyifsurgery(or dental surgery) is being considered.
7. Symptoms that should not be ignored and reported to their health care provider.8. Discussions about the importance of concurrent psychosocial treatment and
participation of a mutual help group.9. Need to carry a medical alert card identifying the medication-assisted treatment,
include name(s) of drugs being prescribed, and potential adverse effects if given other medications. In addition the medical alert card should provide contact information of the treating health care provider and/or institution.
It is essential to obtain a written informed consent and include in the patient record. In addition it should be recorded that the patient and family/significant other (if appropriate) has received the written plan and understands the information. As with any plan it is not enough to just present or even just read and expect the patient and others just to sign. It is essential to include a frank, open discussion of elements, provide opportunities for questions and input into the plan. The plan may need discussion more than once. Ideally the plan’s components should be reviewed and revised as necessary with follow up visits to the health care providers.
Medically Managed DetoxificationAn alcohol withdrawal syndrome may be very serious –even life threatening.
Patients in this syndrome should be referred to an addiction treatment program than can provide a medically monitored withdrawal treatment. The symptoms of withdrawal usually begin 24-48 hours after the blood alcohol drops to zero. Thesyndrome may last 5-7 days during which time the person needs to be monitored and provided withdrawal treatment. Very briefly symptoms include (generally in order of severity)–restlessness,irritability,anxiety,agitation,anorexia,nausea,vomiting,tremor,elevated heart rate and blood pressure, insomnia, intense dreaming and nightmares, poor concentration, impaired memory and judgment, increased sensitivity to sound and light, auditory, visual, and/or tactile hallucinations, delusions, grandmal seizures,
C.E. Corner
What essential elements of effective patient education should be considered in developing a treatment plan?
CE continued from page 11
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hyperthermia, delirium with disorientation concerning time, place, person, and situation, and fluctuations in level of conscious. NOTE: not all patients will have all these symptoms. When assessing the likelihood of alcohol withdrawal syndrome consider the past history of previous withdrawal experiences - whether treated or not. A history of 3-4 previous episodes is a strong indicator of a severe withdrawal will occur and the person needs adequate medical care before a treatment plan may be considered.
Many tools are available to evaluate the potential need for medical managed detoxification. One of the most common validated instruments is the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised). The reliability is high and takes about 2-5 minutes to complete. A strength of this tool is the guidance it provides the clinician through multiple domains of alcohol withdrawal and allows for assessment of the various symptoms. The scale is in the public domain and may be downloaded at https://umem.org/files/uploads/1104212257_CIWA-Ar.pdf
Various TherapiesThereareonlythreedifferenttherapies–pharmacology,
psychosocial and mutual-self help programs. All are complimentary and address different aspects of the alcohol disorder. No single approach has proven to be more effective than the other. Psychosocial therapy enhances adherence to the treatment plan. Medications help reduce cravings to remain abstinent and thus usually making the person more receptive to the psychosocial aspects of the program. Mutual self-help groups provide mutual support to maintain sobriety. According to SAMHSA the latest evidence supports brief weekly or biweekly sessions (15-20 minutes) combined with medications is most effective in early treatment. Counseling sessions focus on adherence to medications, abstinence, and participation in mutual self help groups. Mutual self help groups are most effective in long term recovery. The oldest and best known of these groups remains AA (Alcoholic Anonymous). Many patients resist participation in AA, perhaps it is the stigma or of fear of disclosing concurrently taking medication to cease consuming alcohol. It is true that some AA members have negative attitudes toward medication therapy, but the organization itself supportsthis therapy. Patients should be encouraged to visit several different meetings to find the ‘right fit’. There are other mutual self help groups such as AA but they are not as universally available and often have a fee associated with attendance.
Special PopulationsAlcohol use in pregnancy presents special problems
as it is clearly associated with fetal abnormalities and long term cognitive issues in the offspring. No amount of alcohol is safe during pregnancy. Use of alcohol duringpregnancy may result in miscarriage, premature delivery, or stillbirth. Infant complications include both fetal alcohol syndrome or fetal alcohol spectrum disorder. None of the medications FDA approved for AUD have beenshown to be absolutely safe during pregnancy. However, they are sometimes prescribed off-label when in the judgment of the health care provider the probable benefits outweigh the risks.
Adolescents and young adults also present a special issues with medication management. None of the FDA approvedmedicationforAUDisapprovedforindividualsyounger than the age 18. Young adults and adolescents shouldbereferredtoaprogramspecializinginadolescentaddiction; one drawback is the limited number of these types of programs and often they are quite expensive. Sometimes medications are used off-label in older adolescents and young adults as there are no specific safety regulation for the use of the medications. The decision to use medications may be warranted when the older adolescent has severe AUD and psychosocialintervention have not achieved success alone.
The drugs approved by FDA are as safe for use in older individuals as with younger individuals. However, many older individuals have comorbid medical conditions necessitating taking multiple medication which may precipitate adverse reactions when used in combination with the AUD medications. Another issue is the olderadult has decreased ability to metabolize (liver) or
eliminate(kidney)medications–allofwhichmayleadtoan adverse drug event. Specific dosing precautions will be discussed later in this monograph.
Another challenging issue is diagnosing AUD in theolderadult.Healthcareprovidersshouldbecognizantthatolder adults tend to hide substance abuse problems often due to shame.They are less likely to recognize that it isan issue, less likely to seek help or talk about the issue. Inaddition theproblemmaybe ignoredorminimizedbyfamily members or significant others. Family members may be too ashamed, not aware, or just ignore the issue. Some family members think it is not a problem and the older person can ‘just drink if they want to.’ Sometimes health care providers may either overlook the diagnosis or misdiagnose attributing the behavior to depression or dementia.
The older adult is often seen with many health and social problems. These problems may increase the risk of hospitalizations,nursinghomeplacements,andevendeath.
Medications Approved by the FDA for Treatment of AUDThe FDA has approved only three oral medications and
one injectablemedication for treatment ofAUD. (NOTE:other medications are prescribed off-label, especially those dealing with psychiatric/mental issues, but this paper will focus on only those approved by the FDA.) The clinician is influenced by a couple of factors in prescribing the selected medications. They include patient’s past experience with medication-assisted treatment, personal opinion as to which medication may be the most effective, patient motivation for abstinence, history of medication compliance, medical status, and contraindications for the selected medication.
Disulfiram (Antabuse) was the first drug approved by FDA in 1951. The ideal patient is one who wants or needs to remain in a state of enforced sobriety so that supportive therapies may be used. It will decrease drinking days but does not increase abstinence. Disulfiram is taken daily. An ideal candidate is a person who has completed alcohol withdrawal, committed to abstinence, and has the concurrent supervision of a family member or treatment program. The patient knows that if alcohol is ingested an uncomfortable physical reaction will occur. The more alcohol the more adverse the physical reaction. In mild cases it usually lasts 30-60 minutes. In severe cases the alcohol may need to be completely metabolized before the symptoms disappear.And if larger quantities of alcohol are ingested the patient may have respiration depression, cardiovascular collapse, arrhythmias, myocardial infarction, congestive heart failure,
C.E. Corner
CE continued on page 14
What are the special challenges faced by health care providers when diagnosing older adults?
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of opioids when taking medications for AUD?
Page 14 • The Alabama Nurse June, July, August 2016
unconsciousness, convulsions, anddeath– thus, as statedbefore the drug needs to be taken with supervision. This drug is contraindicated in the presence of the following: severe myocardial disease, coronary occlusion, pregnancy, psychosis, and individuals who have high levels of impulsive behavior, suicidal ideations, or allergic/hypersensitive to the drug. A person is not a candidate for this drug if they have recently taken or are currently taking metronidazole (Flagyl), paraldehyde, or alcoholcontaining medications. Instead they must wait until these drugs clear the body. Use with caution in patients withacute hepatitis or other hepatic diseases, cerebral damage, chronic or acute nephritis, diabetes, hypothyroidism, epilepsy, heart disease, and in those 60 and older. Instruct patients to notify healthcare provider of any early symptoms of hepatitis – fatigue,weakness, nausea,anorexia, vomiting, jaundice, or dark urine especially if they have had no concurrent alcohol intake. A baseline liver function test should be completed and a follow up test 10-14 days later. Other tests ongoing during treatment include complete blood count, general chemistries, and liver function tests. A few patients develop psychotic reactions and it is believed to be a result of unmasking an underlying psychoses. These patients were probably self treating their psychiatric issues with alcohol. Safe use in pregnancy has not been established and it should not be given to nursing mothers. Patients need to be advised that mild side effects are expected only for the first two weeks of therapy. They include skin/acneiform eruptions, headache, allergic dermatitis, impotence, mild drowsiness, fatigue, and a metallic or garlic after taste.
The second drug Naltrexone (Trexan) was approved by FDA in 1994 for oral administration and the extended-release injectable formulation in 2006. The drug is most effective for patients who have a history of opioid use and seeking treatment for alcohol abuse. This drug curbs the cravings for both alcohol and opioids. Patients with very intense cravings for alcohol usually experience greater medication benefit than those with mild cravings. In addition patients with a family history of AUD maybenefit more than for patients who do not have this history. The purpose is for the treatment of alcohol dependence and the extended release is appropriate for individuals able to abstain from alcohol in the outpatient setting. The injectable form was developed because of the low rate of retention and adherence to the oral administration of the medication and the treatment plan overall. The oral formulation is taken daily and the injectable is taken monthly. Its action is to block the opiate receptors which are involved in the rewarding aspects of drinking. Put
very simply, it reduces craving for alcohol. The monthly injection provides a more consistent and predictable blood level of Naltrexone, because the depot injection bypasses first pass metabolism. It is only effective if the patient can abstain from alcohol in the outpatient setting. The best results occur when the patient is able to not consume alcohol several days before starting the medication. It is not effective if the person is drinking at the time of the first dose of medication. The injectable form is very effective to prevent relapse to opioid dependence following detoxification. The drug is contraindicated in patients receiving opioid analgesics or for those anticipating a need for opioids such as surgery; anyone currently on opioids such as methadone, buprenorphine; patients in opioid withdrawal; those who fail the naloxone challenge; or anyone who has a positive urine test for opioids. The person should take no opioids for at least 7 days prior to starting the drug. It could precipitate a severe opioid withdrawal or prevent opioid analgesia. The IM injection may only be given to patients whose body mass is adequate to receive an injection with the provided 2 inch needle. It must not be given in subcutaneous issue. The extended release form has been associated with liver dysfunction. All forms should be used with caution with patients with renal impairment. After treatment with the extended release format (and after the drug has been metabolized from the system) a patient needing opioidanalgesia may respond better to lower doses of the opioids. Failure to titrate the opioid dosage could result in a life-threatening intoxication and/or overdose. Patients must be cautioned about the dangers trying to go back on opioids after Naltrexone treatment. Common expected side effects include nausea, vomiting, headaches, dizziness, fatigue,anxiety, and somnolence. Drug interaction include cough and cold preparations as well as antidiarrheal medications. This oral version of the drug is a Category C pregnancy medication. It will transfer to infant through nursing and in animal studies (no human studies are available) may cause tumors and serious adverse reactions. Nursing mothers need to discontinue breastfeeding or discontinue Naltrexone.
The latest medication approved by the FDA for AUDisAcamprosate(Campral).Thedrugisadelayed-release compound and taken three times a day with or without food. They should be swallowed whole and not crushed. In the presence of impaired renal function the dose may be altered downward. It is indicated for patients who are alcohol dependent but are abstinent. The purpose is to maintain abstinence. It has no abuse potential and no significant interaction with other medications. The greatest strength from a patient perspective is the drug’s ability to reduce negative symptoms immediately following alcohol withdrawal. There are no safety factors and no risk of an overdose. The most common side effects are gastrointestinal issues. A mild, transient diarrhea which resolves in several days or less common abdominal cramps and flatulence and occasionally headache. It seems to be the safest of the three medications approved by FDA forAUD.Acamprosateismosteffectiveinpatientswhoare 1.) Abstinent from alcohol at onset of treatment and who are motivated to remain sober, 2.) Patients with hepatic disease, 3.) Those currently on opioids for pain or addiction, 4.) Patients coping with multiple medical issues and are taking many medications. The drug is contraindicated for those with severe renal impairment. Baseline renal function studies are essential before instituting treatment. In patients over 65 frequent renal function tests are important. It is a Category C for pregnancy. There are no human studies and it is not known if the drug is excreted in breast milk. Pregnant or nursing mothers should not take the drug.
Revising the Treatment Plan
AUDisachronicillnessanddespiteongoingtreatmentthe intensity of the disease process may change over time. In addition the patient goals may change which necessitates a change in focus. Sometimes alcohol issues reoccur during treatment when their concurrent chronic disease(s) treatment regimens conflictwithAUDtreatment. When problems of adherence to the treatment plan occurs, the health care provider needs to reassess the patient for underlying medical, psychiatric, or social factors. Examples would include the following:
1. Examining behavioral, medical and social factors that could contribute to alcohol consumption;
2. Increase monitoring; 3. Medication dose adjustment; 4. Increase frequency or level psychosocial services,
e.g., change from an AA mutual-support group to individual counseling; and/or
5. Refer the patient to specialty care.
Progress is achieved when the patient’s health has improvedasnotedby stabilizationofchronic issues suchas lowered BP or improved laboratory test results. In addition the patient becomes more aware of their personal health and adhering to medications needed for other health issues. The patient’s mental status should improve by observing less irritability and anxiety, improved mood and sleep, seeking appropriate treatment for psychiatric/mental health issues instead of treating self with alcohol. Improvement in family/social issues should resolve as the patient starts to spend more time with loved ones, not causing personal conflict, and engaging in leisure/recreational activities that do not involve alcohol. Work/School/Vocational status should improve as the patient returns to meaningful activities, gaining and/or continuing employment, being prepared for school or work, lives in a stable housing, and shows improved work or school performance. Legally, the patient has no parole or probation violation nor does the patient encounter new legal problems.
There are no validated studies that provide optimum duration of treatment. Mutual self help groups may and often do continue for life. Medication usually continues for 6 months to a year although some patients may need medication for long periods of time. Even after the medication regimen is over the patient may request, in periods of stress a brief return to medication e.g. disulfiram or naltrexone when visiting family members who drink heavily. In an ideal situation the decision to discontinue medication occurs when the patient has maintained stable abstinence over a long period of time and reports a reduced craving for alcohol, or the patient desires to discontinue the medication, or the patient is supported sufficiently by mutual self-help groups, or when the laboratory results reflect a diminished hepatic or renal function. In all cases the patient should withdraw from the medication with the help of the health care provider.
Nursing CareNursing care is somewhat limited to supporting
and monitoring. Very few nurses are substance abuse specialists and therefore will not create the treatment plan or prescribe medications. This does not negate the importance of nursing care. Patients and family/significant others need much support. They come to you broken due to past behaviors. Trust in one another is sometimes problematic. In addition the medications do not 100% cure the cravings as compared to an antibiotic curing an infection.The treatment ofAUD requires thepatient to change lifestyles; sometimes so difficult to do. Nurses, especially psychiatric/mental health are front line in leading groups. Constant assessment must be used to guide the discussions and personal growth of patients. Nurses are essential to help the patient’s support system understand this chronic disease process as treatment plans may be revised to accommodate the patient’s changing needs.
Selected BibliographyJohnson, Bankole and Ait-Daoud, Nassima. Medications
to Treat Alcoholism. Alcohol Research and Health 23(2). 1999.
National Institute on Alcohol Abuse and Alcoholism, Substance Abuse and Mental Health Services Administration. Medication for the Treatment of Alcohol Abuse Disorder, 2015.
National Institute of Alcohol Abuse and Alcoholism, Substance Abuse and Mental Health Services Administration. Medication for the Treatment of AlcoholUseDisorder:ABriefGuide.2015
Center for Disease Control. Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use, A Step-by-Step Guide for Primary CarePractitioners, 06/2014.
O’Conner, Anahad. Drugs to Aid Alcoholics See Little Use,StudyFinds.TheNewYorkTimes,5(13)14.
Thompson, Warren and Ahmed, Iqbal, Alcoholism Medicine. Medscape Reference, 5(22)15, accessioned 3-1-16.
C.E. Corner
CE continued from page 13
How do you know when to discontinue medications?
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June, July, August 2016 The Alabama Nurse • Page 15
Select the one best answer
1. What groups are most vulnerable in needing Alcohol UseDisorderscreening?a. pregnant and craving alcohol.b. weekend binge drinker and had received three (2)
DUIsinlastmonthc. PTSD and arthritisd. all of the above
2. Long term physical sequelea includea. enlarged heartb. pulmonary edemac. tender liver edged. dry skin
3. Complete Blood Counts are essential to notea. macrocytosisb. MCVHc. platelet countd. recti count
4. Elements of an effective patient education treatment plan includea. chronicnatureofAUDb. risks and benefits of a the medication selectedc. what to do if alcohol is consumed during treatmentd. all of the above
5. Symptoms of withdrawal syndrome begin _____ hoursafterbloodalcoholdropstozeroa. 12-24 b. 24-48c. 48-72d. 72-96
6. According to SAMHSA the most effective treatment plan are medications and a. AA dailyb. weekly or biweekly sessionsc. individual counselingd. any of the above
C.E. Corner
7. Older adults present special challenges when diagnosingAUDbecausea. alcoholism may be misdiagnosed as dementiab. limited social supportc. resistance to accept treatment from younger health
care providersd. may have dementia and cannot remember to take
medications on time
8. Disulfiram (Antabuse)a. increases abstinenceb. may be started while during detoxc. if alcohol is ingested may lead to acute hepatitisd. if alcohol is ingested the symptoms usually last 30-60 minutes
9. Naltrexone (Trexan) is the drug of choice for patients who have a history of a. opioid useb. diabetesc. hepatitisd. cardiac disease
10. Acamprosate (Campral) a. maybecrushedandgivenviaaNGtubeb. has an abuse potentialc. drug of choice for patient with renal impairmentd. has no significant interactions with other drugs
KEY1. B2. C3. A4. D5. B6. B7. A8. D9. A10. D
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