Blog post #6

One new thing I have learned in this module.... I was interested to see there were so many distinctions for mal-ware and mal-users. I previously would have classified anyone doing wayward things to/with a computer as either a hacker or an unauthorized user, and I thought that any program that went on a computer and did bad things was a virus. I don't know that it will make a difference, but I'm glad to know the difference.

Another thing that impressed me was the information that any computer is vulnerable to attack. I have a MacBook, and have always had a sense of security, because there just aren't Mac viruses. After this module, I thought about it, and realized there are many more Macs out there than there used to be, and people are probably starting to target them. So I downloaded the McAfee virus detection program for MacIntosh computers - FYI, this is available for free to University of Utah students through campus software licensing.

Decision Support

How did the readings influence your perception of your own clinical decision-making?

In many ways the readings validated my methods of decision making. I tend to rely on multiple methods to guide my practice - intuition, objective data, subjective data, decision support tools, consultation with colleagues - I could go on. In reflection, I often avoid heuristic means of judgement. 

I used to work in a microbiology lab, and identification of organisms can take days, and is reliant on microscopic appearance, gross morphology on an agar plate, biochemical tests, smell, etc. I had a close call with misjudgement early in my micro career. I had an organism growing on an agar plate which grossly resembled Staphylococcus aureus. The confirmatory test for S. aureus is a coagulation test using a rapid reagent (you mix a clump of the bacteria with the reagent, and the reagent coalesces into gray particles). After happily confirming the bacteria as S. aureus, I stamped out a plate of antibiotic disks - and was very surprised the next day to see that it was resistant to vancomycin - something which would be an incredible, CDC reportable occurence with a S. aureus strain. I reflected (before calling the CDC) and knew where I went wrong - I had never done a gram stain on the original isolate. The young colonies "looked" like S. aureus - but if I had done a microscopic examination, I would have seen gram negative rods - the isolate was, in fact. Escherichia coli!! Fortunately this did not result in an adverse outcome - the antibiotics the physician was using to treat the reported "S. aureus" were also effective against E. coli, but it could have had serious consequences if, for example, the patient had a CNS infection which was incorrectly treated, even for a day. 

I never, never, never relied on my "gut" again, and instead relied on the tried and true step by step methods for identification, and that methodology has carried forward into my nursing practice as well. For example, I could never be an ER or OR nurse. Instead I am drawn to specialties such as post-partum care, hospice, oncology - where I can make methodical decisions and take my time. 

Blog Post Module 4

And boy, does my current position ever involve teaching! I work in nutrition support, and we have patients who either transition home from the hospital on enteral/parenteral nutrition, or they are started on nutrition therapy directly in the home. I am mostly in charge of the outpatient clinic, and a large part of my role is teaching patients and their caregivers how to use the enteral feeding pump, and care for feeding tubes, or to care for central lines, administer TPN. Along with that I also teach them signs and symptoms to monitor - depending on the type of nutrition, things like feeding intolerance, infection, electrolyte imbalances, etc. If patients are on TPN long term I will teach them and their care givers how to change their central line dressings, as well.
I tried to think of a healthcare job that doesn't involve teaching - and there isn't one. We are either teaching patients, teaching each other or teaching the next generation of whatever we are. Doctors teach nurses. Nurses teach doctors. Laboratory scientists teach doctors and nurses (I have done a lot of that, as well). Even if we are in a position that is far from patient care, like informatics :) we will be involved with teaching other people how to use new technology.
Maybe a really sour anesthesiologist, who refuses to take students - that health care worker might not be involved in teaching - but I still think they would need to pass some information on to their patient at some point...

Module 3 - Information Retrieval

I did a search for information related to obesity and food deserts. In my search using the electronic index CINAHL, I was able to refine my search several times to achieve an adequate number of results without having information overload. I used the subject headings and initial search results to further guide my use of search terms, and ultimately had 196 articles.

When I used the guideline index, I had no "hits" using any of the search terms that I used in my database search. I think this is related to my topic - I was looking for background information that might further guide research, rather than a defined clinical problem with an intervention. In fact, the problem I am looking into is one of community resources as it relates to a disease, and there are likely no guidelines for that kind of problem.

When I searched google, using the final terms of my database search, I had 831,000 "hits" - this is pretty broad! In addition, many of these results were from questionable resources (ie, www.obesitymyths.com). Google has a "google scholar" function that might be useful - for example, my research question might have relevant information in fields like sociology that may not be available in CINAHL or MEDLINE. And general Google searches might reveal information that would be helpful later (such as, what is the public perception of the problem, what are people doing to solve the problem - evidence based or otherwise, what resources are out there for this problem). I have used Google searches at work when database/guideline searches have not given me enough information. For example, a couple of weeks ago I was working with my supervisor to defend the use of a particular step in the central line dressing change, and was unable to successfully find enough information on MEDLINE or in the guidelines to justify our rationale for keeping that particular step, but a Google search led me to an FDA document highlighting the reasons behind the intervention.

So, I think that use of search strategies needs to be tempered by what the researcher needs - is it a purely nursing/allied health problem (some are), might other disciplines yield additional information regarding the problem, what are the standards in place right now surrounding the problem, what are the lay person's perceptions of the problem?

Module 2 Healthcare Information and Devices

What is one way you could become involved in designing, selecting, evaluating, or implementing an information system in your workplace?


I have actually done this already. The department in which I work has an outpatient program where we monitor patients who are at home on either enteral or parenteral nutrition. We watch labs, provide phone calls, and sometimes have patients come in for a clinic visit. We often make changes to their regimen based on observed or reported data and information. 
Prior to when I started my job, the charting for these clients was done on paper. We had large bulky charts with hand written clinic notes, medications, notes from phone calls and tracking sheets for laboratory data. I am not a paper person, so I implemented the use of a pre-existing information system available at my facility to store free-text progress notes, assessments using templates and clinic visits using a SOAP form with areas to enter height, weight and other vital signs. The SOAP form also pulls in medications, problems and allergies entered by other providers, making med-rec a quick process, as well as flagging drug interactions when we prescribe new medications for our patients. The laboratory and radiology data have always been available in this computer system.
Unfortunately, while I have made a brave start, there are people in my department who won't "let go" of their paper - every clinic note and phone assessment now gets printed and put into the bulky patient chart, as well as being available in the computer. We are also still transcribing lab values and radiology information from the system into the paper chart.
In addition, we have demographic sheets in the charts with basic patient information, names and phone numbers for other providers, access device and current nutrition regimen. I have been trying to convert this to an electronic record for a year - the information on the paper gets crossed out, whited out, written over until it is often illegible, and we have no way of tracking history of nutrition regimen or access device. I tried making an excel worksheet but it still didn't fit my vision. I would rather use database software - but I need to get access to the software and help building a secure database. My preference would be to get a practice management system, but I haven't managed to sell that to my supervisor - the cost is a big factor there.
My vision is still a work in progress, andI am leaving my current position soon. I am not sure where the department will be in the future, but my hope is that I have planted the seed that there are better and more efficient ways of harboring patient information that bulky paper charts!

Nursing 6004 - Module 1, introduction

Hi everyone. First of all, about the blog name - I apologize. I already had this blog set up a couple of years ago, with the intention of sharing my yarn-crafting projects with people online. As you can see, that didn't happen, so it has been languishing, blank and unused, for some time. Perhaps this class will be an inspiration to me, and I can start posting photographs of fabulous hats and scarves when we are done!

About me - I am in the Acute Care DNP program. I have worked in maternal-newborn care, hospice, and right now I work in Nutrition Support Services (which is to say, I do nutrition assessments, recommend tube feeds, and write TPN orders). I am hoping to work in Oncology and/or Palliative Care as a practitioner.

I am pretty passionate about IT, and computers. My father was early on the IT scene (mid-80s), and set up/managed networks for government entities such as the Department of Justice and the Navy, so in some ways it is in my blood. I was actually torn, when I was applying to graduate school, between DNP and Nursing Informatics, and I can't promise that I won't go back later for more graduate fun..

I think that knowledge about computers and information technology is vital to healthcare. Use of computer charting is already helping to streamline and consolidate patient information. Computer provider order entry is a simple way to reduce mistakes caused by hand-written orders. If we could all get on the same system, computer technology will be a great way to have someone's medical information follow them between provider systems - to avoid needing to fill out medical history forms ad nauseam, to prevent duplicating prescriptions or drug interactions, etc.

In my current practice, we have an outpatient clinic where we see home patients who are on TPN or enteral feeds. We provide a lot of follow up in the form of phone calls, clinic visits, and manage labs and medications as they pertain to medical nutrition regimens. Before I started working in the department, the charting for clinic visits, phone calls, labs, medication reconciliation was all on paper. I quickly changed the department over to computer charting, which has not only made things more legible, but allows other providers who are in our system to see what we are doing.

I look forward to this course, because I think that there is always so much more to learn about IT - it is growing at an exponential rate!

Sandra J.