Category: Nursing

The ‘Heart-Friendly Town’ and the Scourge of the Defibrillator

A community defibrillator? Surely that’s a no-brainer?

It’s an emotive issue and the received response is ‘Of course I’d want to see one in my high street or whatever’. Defibs save lives, and if money were no object (and we have to be realistic here) it would be great to have them everywhere.

At the risk of being completely shot down by the establishment, I’d say it needs a bit more thought. The question should not be ‘Do you want a defib on your High Street?’ but rather ‘Do you want more lives saved?’ And then following that, ‘How can we save the most lives with the resources we have available?’ Let’s not get distracted by the ‘Defib or no defib’ debate, it’s much more complex than that.

Buying a defib is emotive – surely it’s a good thing! But I’d encourage people to consider the opportunity cost – what other intervention could have been implemented, and would it have been more effective? As far as I know the BHF is still offering help to buy community defibs, and it is tempting to take the funding because it’s ‘free money’ – but if you donate to charity you hope it’s being used effectively, and there are other measures that would be good to implement and would benefit many more people. Yes, I’d like to see defibs but only as part of a wider health campaign.There’s a danger in installing a defib, ticking the box, and thinking that’s it, you’re done.

Heart attacks are frightening experiences for all involved. The likelihood of one happening in the first place should be of considerable concern, at least as much maximising survival rate when one actually does. Here’s a fact – most of them happen in the home. Not in the high street. Therefore there is more likelihood they could be successful if installed in a built up residential area rather than a shopping area. Why are they installed in high streets? Perhaps because the research on ideal placement is not done, or perhaps because decisions are made by those who have the budget but not the awareness (and pointing no fingers here), perhaps it is a political decision to make people feel cared for, or it’s an emotional decision – or perhaps for PR.

The defib only provides a return on investment when it is successfully used and a life is saved. It’s not enough to install one – it needs to be secure from thieves, but also accessible immediately to those who need it, with no wasted seconds. So I’d respectfully suggest that most of them are installed in the wrong place.

So what do we do if most heart attacks occur out of the range of where most defibs are installed? Of course look at relocating the defib (obviously!) But also look at other measures that could be implemented – is a defib the best solution? Naturally, if it’s a defib or nothing, I’d go for the defib every time. I want lives saved. However, I think the resources can be better deployed to greater effect in the same community by different interventions.

If defibs are going to be installed, I’d prefer to see them as part of a wider initiative. How about having a ‘heart-friendly town’ where organisations and individuals work together to tackle the root causes of heart disease? How about awareness evenings? More GP referrals to exercise outlets? Health buddies? A commitment to living healthier for longer rather than just longer? You might think that this is over-ambition – and maybe it is. But I’d argue although it’s more time-intensive than buying a defib, it stands to improve health in every generation in the community, for longer. It will prevent people needing the defib in the first place.

People need to take back control of their health. As a community we need a healthier outlook. There is a correlation between what life choices they make and what benefit or disbenefit this brings them.

I’m a nurse, and I can honestly say that the joy from seeing someone succeeding in reducing their cardiovascular or diabetes risk considerably is like no other. Seeing people take control, and get their lives back – seeing them excited by what they’ve achieved is indescribable. The change this brings to themselves and their families is amazing.

By making changes, you not only reduce the risk of needing a defib:

  • You decrease your future need of diabetic drugs
  • You increase your body image
  • You increase self-esteem
  • You increase confidence
  • You facilitate healthier relationships with those you love
  • You have a lighter mood.

I have seen all these outcomes and more. I would like to see health promotion – proper health promotion at the top of the community list. It’s all too easy to install a ‘just in case’ box on a wall and leave it at that – but do we not deserve better than that? In fact a project in Salford, Manchester was set up to address health inequalities and ended up achieving all sorts of unexpected outcomes as a result – and for every £1 invested it yielded £12 of social and health benefit for the participants and their communities – and this carried on as long as the project was running; even afterwards, much of the benefit remained as people maintained the changes they’d made and reaped the rewards.

Yes, a defib is great, but what if in 20 years it has saved no lives? In terms of return on investment, there are many other concepts that will be more effective for more people, for much longer (even permanently). Lives are complex; save a life, and you’ve saved a father, grandfather, cousin and uncle in one go; you save a family’s grief, you save hardship, pain, anxiety, fear, and uncertainty. Faced with the choice between possibly saving one life and definitely saving 50, I’d go with the 50 every time. Yes, in health as with in everything, it is a numbers game.

Whatever a defib costs, it’s likely more lives can be saved by using the investment another way. I applaud the sentiment with which people campaign for more defibs, but the people in our communities need, and deserve, more than just that. Let’s aim bigger. Let’s live better. 

 

Santa is not a well man.

He’s been doing the same high-level stressful job for as long as anyone can remember, and now he’s doing it for our children. Yes he gets the best part of a year off, but just how long can he keep going?

I don’t want to appear preachy, but be aware that with his current lifestyle and obligations, Santa is not going to go on forever. Don’t be surprised if one year, you have to deliver all those gifts yourself and pretend it was Santa.

Just look at the evidence:

Ulcers:

  • Job in logistics – renowned for being a sector of decreasing returns, when taking into account tariffs, fuel and duty, and infrastructure
  • High public expectation, huge responsibility = massively unfair level of stress on one person
  • Dealing with animals, and therefore animal welfare people. Do you know the regulations for keeping working reindeer? Nope, neither do I. 
  • Dealing with elves; renowned for being tricky customers, these little chaps are hot on their ethnic minority, disability, and human rights laws. ‘Elf and Safety, mate. 

DVT:

  • Long periods of static position and limited leg room in sleigh. Plus, new sleigh models have a smaller parcel shelf, so smaller parcels may need to be suspended from ‘curry hook’ in passenger foot well.

Metabolic syndrome:

  • The classic combination of increased girth, increased blood pressure, high cholesterol and high glucose. Just look at the diet and lifestyle of this chap.
  • Mince-pies and clotted cream – diet high in sugar and saturated fat – hypercholesterolaemia and hyperglycaemia leading to increased risk of diabetes and cardiovascular events

Cardiovascular disease:

  • Excess fat in diet, being overweight, and not getting sufficient cardiovascular exercise to strengthen heart muscle contribute to risk of cardiovascular disease
  • High blood pressure and stressed lifestyle likely to cause complications.

Gout:

  • Excessive alcohol intake increases concentration of uric acid in blood increasing likelihood of developing gout
  • Obesity, high blood pressure, hypercholesterolaemia and decreased kidney function can all contribute to increased risk of gout

Chronic kidney disease:

  • Developing type 2 diabetes and having prolonged high concentration of glucose in blood over time can damage fine capillaries in kidneys, decreasing kidney function.

Type 2 diabetes:

  • Obesity through high-calorie diet – waist circumference now a risk factor for diabetes – due to increased percentage of body fat, likely increased insulin resistance, leading to over-production of insulin to compensate.
  • Likely impaired fasting glycaemia or early stages of diabetes, as has been overweight for a considerable  time. However, there has been no over-frequent incidence of Santa using people’s toilets, and he usually sticks to ‘just the one’ sherry at each house so unlikely to be experiencing osmotic symptoms of diabetes such as increased thirst or need to wee.
  • Night-time working and long hours have also been connected with developing type 2 diabetes (admittedly in Italian shift-workers) – and this chap must have the weirdest body clock ever.

Erectile dysfunction:

  • Sustained hyperglycaemia leads to damage of penile capillaries. Decreased incidences of nookie with Mrs Christmas may lead to marital problems.

Clinical depression:

  • Well if you had all that lot, there’d be a greater chance of being depressed, right?

 

Fifteen minutes to care?

Yesterday the Leonard Cheshire Disability organisation revealed that agencies and councils are often routinely scheduling 15 minute long visits for care staff to provide care for people in their own homes.

Fifteen minutes isn’t enough to take someone frail or unsteady to the loo, administer medication or make a simple snack, because as any nurse knows, it’s not just about that. It’s about providing company and a friendly face to someone who may not see another person from one day to another. It’s not enough time to make sure a person feels secure, has everything they need and is comfortable, and is safe to leave alone.

So why’s it like that? Because social and nursing care is not appreciated, nor is it respected. The reason agencies and councils are unable to provide decent levels of care consistently is down to resources. Because resources are finite, we have to ration them. For as long as nursing and social care is not respected, it won’t be adequately funded. With nurses only being paid marginally more than unskilled workers, it’s clear to see that the problem is deeply embedded.

The fault is our own. For as long as we don’t speak out, for as long as we sideline nursing and social care in favour of funding more exciting issues, the sick, frail and vulnerable in society will not receive the care and respect they deserve.

Those who have grown up and grown old in the shadow of the NHS, will find in the words of a 94 year old I nursed, ‘It’s not there for me. I’m too old. I paid my taxes since I was 14, thinking the NHS would be therefore me when I needed it. I need it now, and they told me I’m too old.’

Why are fifteen minute care visits the norm? Because that’s all you need to accomplish the minimum. Surely we should want more than the minimum for the people who have no choice but to rely on it?

What’s the deal with diabetes?

Today Diabetes UK in partnership with Tesco is launching a campaign to raise awareness of the complications of type 2 diabetes. According to the charity only a third of us are aware of what could happen if our type 2 diabetes goes undiagnosed and/or untreated.

What is type 2 diabetes?

A person with type 2 diabetes is still producing insulin, but not enough, either because their pancreas isn’t releasing so much, or because they are becoming resistant to their own insulin, or both.

When we put on weight, our insulin resistance increases as well as blood pressure, and often cholesterol. All of these things can increase our risk of not only developing type 2 diabetes, but also our risk of strokes and heart attacks.

What problems does type 2 diabetes cause?

The increased sugar in your bloodstream can damage small blood vessels, this can cause blindness, chronic kidney disease (where kidney function is substantially decreased), it can also cause a loss of feeling and/or pain in the extremities caused by associated nerve damage. Many men with type 2 diabetes will also suffer from erectile dysfunction (sometimes referred to as ‘impotence’).

How can I protect myself from type 2 diabetes?

  • Diabetes UK has a handy online tool to help calculate your risk of type 2 diabetes. You can find it here:  http://riskscore.diabetes.org.uk/
  • Keeping healthy by eating a varied diet (which will reduce your risk of cancer and heart disease too).
  • Get some cardiovascular exercise (this is the sort that increases your heartrate); this improves your heart health, and burns calories, reducing your weight, your insulin resistance, your cholesterol and your blood pressure. Result!
Studio cycling is a great way to get fast results - and to maintain your fitness.
Studio cycling is a great way to get fast results – and to maintain your fitness.

Nurses’ Illustrated Physiology – McNaught & Callander

What a change to read a book with apostrophes in the right places and no barcode. It’s a bygone world. This is a lovely book.

Allodynia

Pain caused by innocuous touch

Symptoms of Diabetes

(Guide only, type 2 diabetes can be asymptomatic for years)

Symptoms Type 1 Diabetes Type 2 Diabetes
Onset Fast (days/weeks) Slow (months/years)
Thirst √ often profound
Polyuria/nocturia
Bedwetting in children  –
Lethargy/tiredness
Mood changes/irritability
Weight loss √++ √+/-
Visual disturbances
Thrush infections (genital)
Recurrent infections (boils/ulcers)
Hunger
Tingling/pain/numbness in extremities
Occasionally abdominal pain
Confusion If advanced √ Especially in the elderly
Incontinence √ Especially in the elderly
Glucosuria May be absent especially in the elderly or if there is a high renal threshold
Ketones in urine or blood May be present (ketoacidosis) Likely to be present

Thanks to Practice Nurse 41 8

Symptoms of TIA

Definite Probably Not Alarm symptoms (may require admission)
Slurring Dizziness Known AF; or high stroke risk
Clumsiness Confusion Recurrent TIAs; more than 2 in last 2 weeks
Tingling/numbness General weakness Patient on anticoagulant. May need brain scan
Visual disturbance ABCD2 score of 4 or more

Thanks to Practice Nurse 41 8

Risk Factors for CHD

  • Age
  • Gender
  • Ethnicity
  • Family history
  • Past medical history of CVA or MI
  • High total cholesterol or LDL
  • Low HDL levels
  • Hypertension
  • Sedentary lifestyle
  • Obesity
  • Diabetes mellitus
  • Excessive alcohol consumption

Common symptoms of bronchiectasis

  • Cough with sputum
  • Wheeze
  • Shortness of breath/chest tightness
  • Minor haemoptysis
  • Blocked/runny nose
  • Facial discomfort
  • Chest pain (sharp or aching)
  • Tiredness
  • Difficulty concentrating

Taken from Independent Nurse 22/8/2011 p20

ABCD2 Scoring tool for calculating risk of CVA

Age >60 years 1 point
Blood pressure >140/90mmHg 1 point
Clinical signs Unilateral weaknessSpeech disturbance 2 points1 point
Duration of symptoms 0-59 mins60 mins or more 1 point2 points
Diabetes Diabetes 1 point

Score 4 or more indicates significant risk of CVA

Thanks to Practice Nurse 41 8 for this.

Symptoms of Influenza

  • Malaise
  • Fever (fast onset)
  • Shivering
  • Headache
  • Muscle aches/pains
  • Sore throat
  • Cough
  • Nausea
  • Loss of appetite

Symptoms of Prostate Cancer

  • Difficulty/pain on urination
  • Interrupted or weak flow of urine
  • Haematuria
  • Pain in lower back, hips or thighs

Treating Mild Hypoglycaemia

To raise blood glucose, take one of the following:

  • 100ml Lucozade
  • 150ml non-diet fizzy drink
  • 200ml smooth orange juice
  • 5-6 dextrose tablets
  • 4 jelly babies
  • 7 jelly beans
  • 2 tubes glucose gel

If blood glucose is still below 4mmol/l after 10 mins, or if patient doesn’t feel better, repeat one of the above treatments.

When feeling better, eat some starchy food such as a sandwich or a banana, monitoring blood glucose afterwards.

Symptoms of Hyperglycaemia

  • Frequent urination
  • Nocturia
  • Copious urine
  • Unusual bed-wetting
  • Excessive thirst
  • Difficulty concentrating
  • Thrush/genital itching
  • Slow healing wounds
  • Fatigue/lethargy

HbA1c Conversion

HbA1c DCCT (%) 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5
HbA1c IFCC (mmol/mol) 42 48 53 59 64 69 75 80

Coeliac Disease

This is an autoimmune condition triggered by the consumption of gluten found in wheat, barley, rye and occasionally oats. Frequently there is confusion of a patient’s symptoms, sometimes leading to a diagnosis of IBS or wheat intolerance. Untreated celiac disease can lead to increased risk of osteoporosis and small bowel cancer.

Symptoms of celiac disease include:

  • Nausea
  • Bloating
  • Flatulence
  • Constipation
  • Diarrhoea
  • Weight loss
  • Fatigue
  • Joint or bone pain
  • Mouth ulcers
  • Dematitis herpetiformis (a skin condition associated with coeliac disease)

Coeliac disease is diagnosed first of all with a blood test for immunoglobulin A or tissue transglutaminase amtonpdoes (tTGA). If this proves inconclusive. Endomysial antibodies may also be tested for, and later with an endoscopy and biopsy of the duodenum.

Gluten-free food including pasta, flour, biscuits, crackers and even breads and pizza bases are available on prescription.

SOFTMASH – mnemonic for assessing COPD

  • Symptoms
  • Occupation
  • Family history
  • Triggers, Treatment
  • Medications taken
  • Atrophy, Activity, Allergies
  • Smoking history, Socioeconomic status
  • History

Interpretation of ABPI

  • 1.3 or above may indicate arterial disease or calcification. Seek advice from tissue viability nurse
  • 1.0-1.3 normal arterial flow. Regular compression is probably safe, if not otherwise contraindicated
  • 0.8-1.0 Mild arterial disease, but sufficient for compression if not otherwise contraindicated
  • 0.5-0.8 Moderate arterial insufficiency. Seek advice from tissue viability nurse; reduced compression may be appropriate following specialist advice

Signs and Symptoms of Chronic Bronchitis

  • Cough
  • Increased production of mucus
  • Dyspnoea
  • Wheezing
  • Fatigue
  • Signs of global hypoxaemia

Taken from Nursing in Practice 62 p58