ENDOCRINE EMERGENCIES 11 00 AM 12 00 PM

ENDOCRINE EMERGENCIES 11: 00 AM – 12: 00 PM Speaker: Laura Gasparis Vonfrolio RN, Ph. D has been a nurse for over 45 years in critical care nursing and has held CCRN and CEN certifications. She obtained and Associate and Bachelors degree in Nursing, MA from NYU in Nursing and a Ph. D in Nursing Education. Dr. Vonfrolio has held positions as a staff nurse, manager, staff development instructor and a tenured Professor of Nursing. She has published over 30 articles and authored 11 books including the Critical Care Examination Review and Emergency Nursing Examination Review Books, 12 Lead EKG Stat and 25 Stupid Things Nurses Do to Self Destruct & a monthly columnist for RN Magazine. She organized the “Nurses March on Washington DC” with over 35, 000 nurses protesting which has been the catalyst for nurse legislation for safe nurse patient ratio’s. She is the former

Everything You Always Wanted To Know About….

ADRENAL CRISIS Most common cause is ABRUPT WITHDRAWAL of steroids CHRONIC ILLNESS CHRONIC STRESS

ADRENAL GLANDS ADRENAL CORTEX & MEDULLA MINERALCORTICOIDS GLUCOCORTICOIDS

ADRENAL GLANDS MINERALCORTICOIDS ALDOSTERONE GLUCOCORTICOIDS CORTISOL

ALDOSTERONE SODIUM NA POTASSIUM K CORTISOL GLUCOSE

ADRENAL CRISIS NA K GLUCOSE

ADRENAL CRISIS TREATMENT MODALITIES STEROIDS NORMAL SALINE CALCIUM CHLORIDE INSULIN + GLUCOSE K-EXCELATE

HYPERKALEMIA Sine Muscle Weakness EKG Changes

HYPOGLYCEMIA CVS Tachycardia Palpitations Diaphoresis Irritable Restlessness CNS Confusion Lethargy Slurred Speech Seizure Coma

HYPOGLYCEMIA CVS Tachycardia Palpitations Diaphoresis Irritable Restlessness BETA-ADRENERGIC BLOCKER CNS Confusion Lethargy Slurred Speech Seizure Coma

MYXEDEMA COMA HYPOTHYROID PERSON TRAUMA INFECTION STRESS MYXEDEMA COMA

MYXEDEMA COMA HYPOTHERMIC HYPOVENTILATING HYPOACTIVE BS HYPOTENSIVE HYPONATREMIC

ATTRACTS WATER Pericardial Effusion Pleural Effusion Dilutional Hyponatremia

MUCOPOLYSACCARIDES Dilutional Hyponatremia Hypotension 280 240 280

Treatment for MYXEDEMA COMA SYNTHROID BLANKETS

THYROID STORM HYPERTHYROID PERSON TRAUMA INFECTION STRESS THYROID STORM

THYROID STORM TACHYCARDIA HYPERTHERMIA

THYROID STORM TACHYCARDIA CONGESTIVE HEART FAILURE PULMONARY EDEMA CARDIOGENIC SHOCK

THYROID STORM INDERAL PTU then METHIMAZOLE LUGOLS SOLUTION COOLING BLANKET No Aspirin!

Syndrome of Inappropriate ADH (SIADH) SIADH Too Much ADH Decreased Na Dilutional Hyponatremia Hypo-osmolar Decreased Osmolarity Decreased Urinary Output

Syndrome of Inappropriate ADH (SIADH) SIADH OAT CELL CARCINOMA VIRAL PNEUMONIA HEAD PROBLEMS Increased serum osmolarity, anesthesia, analgesics, stress

Syndrome of Inappropriate ADH (SIADH) SIADH Na+ Levels (Dilutional Hyponatremia) Serum Osmolarity Urinary Output Dilutional Hyponatremia SIADH!

Seizure activity

Treatment Modalities for SIADH Treatment Get rid of the Oat Cell Carcinoma, Viral Pneumonia or Head Problems… Fluid Restriction Hypertonic Solutions 3 % Sodium Chloride No Hypotonic Solutions

Diabetes Insipidus (DI) DI No ADH Increased Na Levels Hypernatremia Hyper-osmolar Increased Osmolarity Increased Urinary Output (6 -24 L/day)

Diabetes Insipidus (DI) DI HEAD PROBLEMS DILANTIN

Diabetes Insipidus (DI) DI ADH Na+ Levels Serum Osmolarity Urinary Output (1. 001 -1. 005) Severe Hypovolemia SHOCK

Treatment Modalities for DI Treatment Give ADH (Pitressin) Give Fluids to Increase Intravascular Volume Monitor EKG for Ischemia Monitor Urine Specific Gravity

DKA vs HHNK DIABETIC KETOACIDOSIS HYPERGLYCEMIC HYPEROSMOLAR NON-KETOTIC COMA Who gets HHNK? …

HHNK ? OLD AGE DIET CONTROLLED DIABETICS TOTAL PARENTERAL NUTRITION PANCREATITIS

DKA HHNK BS 400 – 900 Dehydration (4 – 6 L) BS 1000 – 2000 Severe Dehydration No Insulin + Acidosis Kussmaul No Acidosis LTBB (6 – 8 L)

LTBB? Little ucky Tiny o Baby e Breaths reathing Not an approved abbreviation!

DKA HHNK INSULIN FLUIDS INSULIN • Insulin Drip NORMAL SALINE. 45% SALINE D 5 ½ SALINE

p. H. 1 K . 6 + Reciprocal Change In a state of acidosis, potassium will come out of the cell and hydrogen will go into the cell… + K (4. 5) H H + + H H + K (150) + + H K + + + K + H

p. H. 1 K + Reciprocal Change 7. 45 7. 35 7. 25 7. 15 7. 05 4. 5 5. 1 5. 7 6. 3 6. 9 . 6

AFTERNOON BREAK Thank You! Enjoy Your Lunch!

Intro slide Condition Critical: What We Need… What We Want! Speaker: Laura Gasparis Vonfrolio RN, Ph. D

Florence Nightingale RN Florence Nightingale

Well Behaved Women…

Well Behaved Women… Well Behaved Women Rarely Make History!

Burn out… Before you burn out… Anger You have to burn up!

Burn out… I AM A TROUBLEMAKER… CONTROVERSIAL… NO!

Short Staffing… Dissatisfied Nurses Controversial Debatable Disputable Poor Nurse: Patient Ratio’s Cheap Benefit & Retirement Packages Deaf Nursing Administrators Obnoxious Physicians

It”s Time To Call Into Question: Call into question: the state of healthcare and to fight for a more patient centered, humane system, and an environment that puts patients ahead of profits!

“The evil in our society… “The evil in our society is exemplified by profiteering in the healthcare system and the continuing oppression of nurses” Jo Anne Ashley RN, Ed. D 1976

Providing nursing care… Providing nursing care is: “Big Business” & “Valuable Commodity”

Nursing is the single most important factor in maintaining our healthcare system! Nursing is the single most important… Without the pooled energies of nurses, healthcare facilities across the nation would be forced to shut down. Hospitals as institutions, could not survive without nursing service!

Nurses have not been free to engage in anythingbut the task of keeping economic institutions operative- so that nursing service could be sold around the clock!

Defining The Problems • Staff Shortages • Lack of Time to Care for Patients • Unrealistic Workloads • Inadequate Pay & Inadequate Benefit/Retirement Packages • Lack of Understanding from Nursing & Hospital Administration • Lack of Respect & Poor Relationships with Physicians

Defining The Problems • Staff Shortages • Lack of Time to Care for Patients • Unrealistic Workloads

• • Feed Patients 8 x 15 min = 2 hrs x 2 = 4 hrs Medications 12 x 5 min = 60 min x 2 = 2 hrs Vital Signs 12 x 5 min = 60 min x 2 = 2 hrs Charting 12 x 10 min = 120 min = 2 hr Dressing Change 6 x 10 min = 60 min = 1 hr Assessing 12 x 5 min = 60 min = 1 hr Teaching 6 x 10 min = 60 min = 1 hr Special procedures (blood, trach care, suctioning) = 2 hr Medical Surgical Story PUT 17 HOURS WORTH OF WORK INTO 8 HOURS!

WANTED People to work long hours with frequent mandatory overtime. Few holidays and weekends off. Must be able to keep massive amounts of paperwork up to date while making split second, life or death decisions. Must be immune to verbal abuse and able to neutralize occasional physical assaults. Must display patience, kindness, understanding and caring even when personal life is coming apart at the seams. Must show no aversion to blood, vomit, oozing infections or human body wastes. Salary in no way commensurates with knowledge and ability. Only those interested in dealing with depressing situations on a daily

q. Over 2. 8 million registered nurses in the United States Over 2. 7 million RN’s q. Only 66% are working and… only 44% are working full time q. Only 10% of working nurses are “very satisfied” with their

Nursing Shortage Patently false and evade the real issues of why nurses leave nursing Pat excuse for every failure to render necessary care and for every vacancy that can’t be filled It is the ultimate answer that absolves the people who are responsible for creating the problem – shortage of nurses!

Nursing Shortage If the funds now spent fighting a losing battle to replace disheartened nurses with travel and agency nurses, were instead, devoted to improving job conditions, the nursing shortage could be solved!

Did I kill anyone today Did I Kill Anyone Today?

q 75% of RN’s feel that the quality of nursing care at their facility has declined q 68% citing staffing levels as a major factor to this problem 75% RN’s quality of care has declined

d o Go . … s w e N SEPTEMBER 20, 2015 PORTLAND, Ore. (AP) – A Portland jury has awarded more than $3 million to a nurse, saying she was wrongfully terminated by Legacy Good Samaritan Medical Center for complaining about cost-cutting measures. 75% RN’s quality of care has declined

Harvard School of Public Health Rese arch Stud ies Research Study Found A… Strong & Consistent Relationship Between Nurse Staffing & Patient Outcomes HIGHER NURSE STAFFING RATIOS Results In. . . SHORTER LENGTHS of HOSPITAL STAY

January 2006 The Journal of Health Affairs Resear ch Studie s “Adding to Nursing Staff Improves Safety and Quality in Hospitals” Research concludes that increasing the number of registered nurses and hours of nursing care per patient would save over 7000 lives and 4 million days of patient care in hospitals each year. The research also shows that greater use of RN’s results in fewer patient deaths, reduced lengths of hospital stay and

August 2005 Medical Care Resear ch Studie s “Improving Nurse to Patient Staffing Ratio’s as a Cost Effective Safety Intervention” Research showed when nurse staffing is improved, lives are saved in a cost efficient manner. February 2004 Medical Care “Nurse Burnout and Satisfaction” Patients were more likely to report high satisfactio with their care and nurses reported less burnout wh nurses worked in conditions with adequate staff.

March 2004 Agency for Healthcare Research “Hospital Nurse Staffing & Quality of Care” Research Studies January 2003 Medical Care “Fewer Licensed Nurses Leads to A Greater Number of Adverse Events” Both studies demonstrated that hospitals with a low nurse staffing levels have higher rates of poor patient outcomes

November 2003 Times New York National Academy of Science Institute of Medicine Research Studies Advised the federal government on healthcare urging reform to protect patients from the proven dangers of excessive nursing overtime and short staffing.

August 2002 JCAHO Resear ch Studie s “Nursing Shortage Poses Serious Healthcare Risk” Issued a report which focused on the severity of the current and future nursing shortage and its detrimental effect on patients. October 2002 JAMA “Hospital Nurse Staffing and Patient Mortality” Research by Linda Aiken RN, Ph. D found that for each additional patient assigned to a nurse, patient mortality rate increases by 7%.

May 2002 JAMA Resear ch Studie s “Nurse Short Staffing Leads To Deadly Complications” Needleman & Buerhaus found that nurses short staffing leads to deadly consequences for patients. September 2001 Effective Clinical Practice “ICU Settings With Fewer Nurses Are Associated With Significantly More Life-Threatening Complications” Research demonstrated that short staffed ICU resulted in a higher rates of patient complications.

CURRENT RESEARCH Aiken L. H, Sloane D. M, . et al, 2011 “The Effects of Nurse Staffing on Patient Deaths. ” Medical Care Aiken L. H, Sloane D. M, . et al, 2010 “Implications of the California Nurse Staffing Mandate for Other States. ” Health Services Resear ch Studie s Shekelle, P. 2013, “Nurse patient ratios as a patient safety strategy”. Annals of Internal Medicine, 158 (5) 404 -410 Duffin, C. 2014 “Increase in nurse numbers linked to better patient survival rates in ICU”. Nursing Standard, 28 (33) 10 -12 Park, S. , Blegen, M. , et al, 2015 “Comparison of Nurse Staffing Measurements in Staffing Outcomes”. Medical Care Phibbs, C. 2015 “The Impact of Nurse Staffing on Patient Outcomes” Healthcare Economics Needleman, J. 2016 “Nursing Skill Mix and Patient Outcomes”. Quality & Safety. West, E. , Barron, D. et al. 2014 “Nurse staffing & Mortality in the ICU”. International Journal of Nursing Studies 51(5) 781 -791

How are we supposed to make any progress with our heads thrust so deeply in the sand?

Newspaper clippings “Given recent and current criticisms of poor quality in healthcare, the public would do well to turn more of its attention to the developments in nursing and to the problems with which this group has to contend with. ”

• One in four nurses plan to leave their job within a year • 50% reported feeling exhausted and discouraged • 40% felt powerless to affect change necessary for safe patient care • 26% felt frightened for their patients • 24% felt frightened for themselves • 55% report that they would not recommend a career in nursing

25 State Laws enacted to address the nursing shortage – State laws to address nursing shortage Most of them designed to encourage individuals to go into nursing programs

Pouring water into a bucket… It’s akin to pouring water into a bucket that has a giant hole in its bottom and… wondering why it never seems to fill up!

Why are nurses dissatisfie d? 78% skipped meals/breaks to care for patients 65% unable to attend continuing education programs 58% worked voluntary overtime 33% worked mandatory overtime

Mandat ory Overtim e MANDATORY OVERTIME

Mandatory Overtime Use mandatory overtime as a staffing solution Is the result of poor hospital management with no regard for patient safety and nursing Jeopardizes the quality of patient care Still legal in 36 states! Other reasons nurses are dissatisfied…the list

Why are nurses dissatisfied? 51% experienced stress related illness 58% cite delays in providing basic patient care 50% believe patients 38% cite increased errors were discharged without (medications, diet, laboratory testing adequate preparation

Reasons Why We Do Not Retain Our Nurses POOR WORKING University of Penn, surveyed CONDITIONS: 44, 000 nurses and 2/3 stated that there Floating are insufficient nurses in their hospital to provide adequate quality Understaffing of care to patients. Frequent Overtime Inflexible Work Hours Hospital and Nursing Administrators Inattentive To The Needs of Nurses Physicians Are Disrespectful Over ½ the nurses surveyed – And Devalue Nursing 50% were verbally abused. Service Poor working conditio ns

Salary Many surveys show that over 65% Cheap Benefits & of nurses believe that they are being paid an unfair wage. Retirement Packages Salary Clerk $36, 600 -$40, 500 Registered Nurse $38, 790 -$59, 600 NONUNIONIZED Registered Nurse $52, 500 -$98, 000 UNIONIZED Security Guard $42, 000 -$49, 000 Maintenance Worker $46, 900 -$53, 000 Welder $48, 000 -$55, 000 Truck Driver $49, 000 -$52, 000 Carpenter $49, 900 -$55, 600 Painter $49, 600 -$56, 000 Electrician $55, 000 -$62, 500 Appraiser $57, 900 -$66, 900 Accountant $64, 000 -$71, 400

Hospitals need intelligent… Hospitals need intelligent, educated, and dedicated nurses, but nurses need support. It is time nurses were rightfully recognized, respected and…yes…. financially compensated!

If hospitals can pay travel and agency nurses $35 - $55 an hour… If hospitals can pay… Why not then, to the loyal, dedicated, hard working committed staff nurse employees?

Specific proposals for compensation Pay More $! Wage increase to those who do not need benefits Allow older nurses to work fewer hours and receive full time pay hours * age 45+ work 36 hours, paid for 40 * age 55+ work 32 hours, paid for 40

Specific proposals for compensation Higher differentials for evening and night shifts as well as weekends and holidays Offer a referral bonus to nurses who recruit their experienced colleagues Allow nurses to exchange unused sick days for a cash bonus or for additional vacation days

Specific proposals for compensation Develop a competitive benefit and retirement package & better health coverage Flexible scheduling options Reimburse for continuing education

Remember…. Yo u’re Worth It!

TYPE OF CARE Sign the petition for national nurse patient ratios. We need it to render safe patient care! Laura Gasparis Vonfrolio RN, Ph. D www. GREATNURSES. com RN to PATIENTS Intensive/Critical Care Neo-natal Intensive Care Operating Room Post-anesthesia Recovery Labor & Delivery Pediatrics Emergency Room Trauma ER Step-Down Units Telemetry Units Medical-Surgical 1: 2 1: 1 1: 2 1: 4 1: 1 1: 3 1: 4 1: 5 www. Nurse. Patient. Ratios. Legislation. com Sign the petition today!

Unionization and the impact of collective…

I believe that sooner or later nurses will organize themselves in unions to protect themselves against the injustices of low pay, overwork, overtime without pay and other intolerable working conditions. Anyone who works in a hospital has as much right as any other worker to a decent standard of living. AJN 1955 Hospitals have no more right than industry to offer sub – standard wages and working conditions and

Academia Nursing Journals Professional Organizations Unions have a critical role to play in solving the shortage of nurses. Unions provide the best avenue to improving pay and staffing levels in the face of management teams driven by cost-cutting strategies.

Beyond their impact on wages & staffing, unions play a critical role in providing nurses a meaningful voice That is on the job… heard!

Nurses It is documented that to truly improve the working conditions and facilitate an effective recruitment and retention strategy, employees must have a meaningful say

The Journal of Nursing Administration, JONA March 2002 “Nurses Unions Decrease Patient Mortality Rate” found that hospitals with unionized nurses had significantly Unions lower impactmortality the quality of care by rates. negotiating increased staffing levels that improve patient outcomes and raising wages, thereby decreasing turnover, which contributes to improved patient care. The authors conclude that having a union promoted stability in staff, autonomy and collaboration.

Hospital Giant Community Health Systems Ordered to Pay $2 Million For RN Fired, Defamed for Patient, Union Advocacy February 2015 WASHINGTON - A civil jury has ordered an Ohio hospital, part of one of the most notorious anti-union hospital chains in the U. S. , to pay over $2 million in damages for its actions against Ann Wayt, an Ohio registered nurse it fired, illegally sought to have her nursing license revoked, and then defamed in retaliation for her outspoken patient advocacy and support for her union. NNOC/NNU Co-President Malinda Markowitz, RN praised Wayt for “standing up for herself, her family, and her colleagues against the harassment and attacks by a multi-billion corporation on their right to form a union. ”

March

Either you can hang together…

Impossibility of effective patient advocacy in non-union workplaces How can you function as a patient advocate, if you fail to maximize the influence you can have over patient care in the March

March

Nurses should not have to fight daily to secure quality care and safe environment for our patients… Nurses should not have to hear that we are resistant to change and that we should “embrace change”.

The current battle… The current battle in healthcare and within nursing is NOT about nurses unwillingness to change… …it is about nurses unwillingness to give second rate care!

The only change nurses are resisting is the wholesale dismantling of their profession which is designed to exploit patients in the name of profit! The only change…

Patients are placed in more jeopardy… Patients are placed in more jeopardy when nurses passively continue to work in spite of poor nurse: patient ratios, inadequate supplies, inept physicians and a staff that is overworked!

Power and freedom are never given to oppressed groups. Power and freedom must be taken! Conformity, cooperation and lack of questioning of established policies are never avenues to progress! Power and freedom…

Silence is consent

Our lives begin to end the day we become silent about things that matter. Martin Luther King Jr.

Solutions for the Nursing Profession * Rise Up Above Our Fear * Raise Our Consciousness * Bring Issues To Light QUESTION AUTHORITY *Take Action…Collectively TALK ONE-ON-ONE GET PEOPLE INVOLVED FIND THE NATURAL LEADERS

IT IS TIME FOR NURSES TO ROAR! It is time for nurses to roar!

Antinursi ng Admi nistra tion Dysfunctional Nursing Management

Antinursi ng Admi nistra tion Nursing leaders have failed both their profession and the society by conforming and being cooperative in a system that abuses nurses and fails to provide safe nursing care.

Antinursi ng Admi nistra tion Anti-Nursing Administration? YOU BET I AM!

Antinursing Administrat ion You are guilty… For every great nurse that has left this noble profession because of the frustrations of not being able to provide safe patient care in this profit driven healthcare system.

Antinursing Administ ration You are guilty… For every patient that suffers complications, such as atelectasis, decubiti, infections, bleeding, for it is YOU, that approved inadequate staffing.

Antinursing Administ ration You are guilty… For patient deaths, for it is YOU that leaves critically ill patients at the hands of overworked nurses and inexperienced personnel.

Antinursing Adminis tration You are guilty… For the degradation and demise of this great profession, for it is YOU that allowed hospital administrators to slash nursing budgets replacing nurses with unlicensed workers.

nurs ing Ad min istra tion You are guilty… For allowing this system of “so-called” healthcare to continue. For YOU are not banding together with other nursing administrators to insure safe nurse patient ratios, eliminate mandatory

“I am convinced that the perpetuation of traditional supervisory roles in nursing contributes to the abuse of nursing power. Nursing administrators do not always identify with those who make up the ranks of nursing – they more often identify with the powers that be in medicine and hospital management. ” Jo Ann Ashley RN, Ed. D, 1973

Magnet Status $ $ $ $$ $ It is unfortunate that hospitals must pay hundreds of thousands of dollars to an outside $ agency… $ $ Only to learn that the goal was always within their grasp for free … and that all it ever required was the will to change and insight enough to see

Mag net Statu s Public relations gimmick to avoid safe staffing levels Big hype and cash machine for the failing ANA Shouldn’t all hospitals be expected to have the highest standards of nursing care provided to patients?

Media & Nursing And Social Reeducation Public Awareness Teaching of Political Activism in Nursing Schools

“Educating Hannah” Hannah Story

Develop coalitions Contact newspaper, radio, TV, tell them about the corporate takeover of hospitals that are promoting the downsizing of nursing and compromising patient care. Actively campaign your legislators to establish mandates for safe nurse patient ratios and protection for nurses who speak out against unsafe patient care environments.

Develop coalitions Set up a “Patient Safety” campaign let the public know what a lack of nursing care mea (complications, longer recoveries, increase risk of mortality) Set up a “Patient Hotline” number and encourage the public to report managed care failure and unlicensed personnel errors.

When the healthcare system becomes. . When the healthcare system becomes the primary threat to quality patient care, advocacy, must move from the bedside into

Additional Solutions for the Nursing Additional Solutions For The Nursing Profession

Law Degree LAW DEGREE Mary Smith RN, BSN, JD Staff Nurse Patient Care Attorney

Nu rsi ng Co rp or ati on s NURSING CORPORATIONS All the nurses of Open Heart Unit the: Surgical ICU - Medical ICU Coronary Care Unit Neonatal ICU - Pediatric ICU Labor & Delivery Unit Emergency Department Operating Room - PACU Form a corporation and market your nursing services back to the hospital as a group – autonomy and professional respect!

Professional Rights… PROFESSIONAL RIGHTS and IES RESPONSIBILIT

You have the right to be treated with respect Professional Rights… You have the right to an equitable wage You have the right to act in the best interest of your patients You have the right to a

You have the right to ask for what you want… Professional Rights… You have the right to ask for what you need… It is for your well -being and the safety of your patients! AMEN!

When you go out in the nursing world, hold hands before crossing the street and stick And together! when you go forth in righteous anger to speak, on behalf of your patients and your own rights as a human being and Let anger make a professional… your posture straight, your voice firm and confident and your message so compelling … that it cannot be ignored!

Have a Safe Trip Home! Cars aren’t the only ones recalled by their Maker! God Bless America Laura Gasparis Vonfrolio RN, Ph. D WWW. GREATNURSES. com