Sunday, January 11, 2015

Happy Birthday to us....18 years of PARADIGM BYTES Newsletters


PARADIGM BYTES

Newsletter for Paradigm 97
January 10, 2015
PARADIGM DEFINED:

1) an outstandingly clear or typical example or archetype. 2) a philosophical and theoretical framework of a scientific school or discipline within which theories, laws, and generalizations, and the experiments performed in support of them, are formulated.

Our website...... http://paradigm97.blogspot.com/Please copy, paste, and bookmark it.
MISSION STATEMENT
We believe that nurses need each other for support during the "lean and mean" days to help survive them. We offer research results and other ideas to enrich the nursing experience.
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SNIPPET

[ I have used this before, please allow one more time]
ABGs Made Simple (Wendie H. )

You want simple ABGs? Piece o' cake. People who have seen this before, well, just scroll on by. Newbies who want a brief ABG's refresher, take out your pencils and a piece of paper, cuz you'll need to do a bit of drawing .

I taught ABG interpretation for yrs in a way that made it pretty foolproof. You will make your own key to interpret ABG's, and will be able to reproduce it from memory any time you need to with very little trouble if you learn a very few **key concepts**, labeled **thus**..

Take a piece of paper. Make a big box on it, then draw vertical and horizontal lines on it so you have four boxes. I will try to make this come out, but...you should have

AB
CD

where the four boxes a,b,c,d are such that a is above c and b is above d. You don't need to label the boxes a,b,c,d, just get them in the right alignment. (This is WAY easier with a whiteboard bear with me).

*Inside* each of the 4 boxes write the following, down the left edge:
pH
CO2
Bic

Now, OUTSIDE the big box do the following: above the "A" box write "resp"; above the "B" box write "metabolic"

To the left of the "A" box write "acidosis" and to the left of the "C" box write "alkalosis"

Now you have a "resp" column and a "metabolic" column, an "acidosis" row and an "alkalosis" row. So you have respiratory acidosis and alkalosis boxes, metabolic acidosis and alkalosis boxes.

With me so far?

Now, you're going to label the PRIMARY DERANGEMENTS, so later you can tell what's the derangement and what's the compensation. OK? In the respiratory column, underline CO2's. In the metabolic column, underline the Bicarb's. That's because in **respiratory disorders, the CO2 gets messed up**, and in **metabolic disorders, the Bicarb is messed up**. You knew that, or could figure it out pretty quick if you thought about it, right? Thought so.

Now. You are going to put upward-pointing and downward-pointing arrows next to the pH, CO2, and Bicarb labels inside every box. Ready?

pH first. In the "alkalosis" row, make up arrows next to pH, because **pH is elevated in alkalosis (by definition)**. Put down arrows in the acidosis row's pHs, because **acidosis means a lower that nl pH**.

Remember that **CO2 is (for purposes of this discussion and general clinical use) ACID** and **Bicarb is ALKALINE** (this is the end of the key concepts. Not too bad, huh?). (oops, I forgot: **nls are generally accepted as pH 7.35-7.45, CO2 35-45 (nice symmetry there), bic 19-26**)

Now go to the box that is in the respiratory column and the acidosis row. Figured out that CO2 must be elevated? Good. Put an up arrow next to that CO2. Go to the respiratory alkalosis box. Figures that CO2 must be low to cause this, right? Put a down arrow next to that CO2.

OK, now go to the next column, the metabolic one. I think you can figure out what happens here: in the metabolic alkalosis box, put an up arrow next to the Bic, because high bicarb makes for metabolic alkalosis. Put a down arrow next to the Bic in the metabolic acidosis box, because in metabolic acidosis the bicarb is consumed by the acids (like, oh, ASA) and is low.

You are now going to put arrows next to the blank spots in your boxes that show compensatory movements. Ready? OK, what does your body want to do if it has too much acid? Right, retain base. Yes, of course if your body has too much acid it would like to get rid of it...but if it can't do that, then retaining bicarb is the compensation. So for every elevated CO2 you see, put an up arrow with its bicarb.( Chronic CO2 retainers always have elevated bicarbs, and this is why.) You will find an up arrow next to the CO2 in the resp/acidosis box.

So if your body is short on acids, what does it do? Right, excrete base. So put a down arrow next to the bicarb in the resp/alkalosis box, because chronic low CO2 makes the body want to get back into balance by getting rid of bicarb. However, remember that it takes a day or two for the kidney to do this job, and if you have nonfunctioning kidneys they won't do it at all.

Likewise in the metabolic/alkalosis box, a high bicarb makes your body want to retain acid, increasing CO2 being the fastest way to do that because all you have to do is hypoventilate, to bring your pH back towards nl. Put an up arrow next to the CO2 in the met/alk box. See the pattern here? Put a down arrow next to the CO2 in the met/acidosis box, because if your body has too much acid in it (think : ASA overdose? DKA?) it will want to get rid of CO2 to compensate, and the fastest way to do that is to hyperventilate. This is why patients in metabolic acidosis are doing that deep, rapid breathing thing (Kussmaul's respirations).

OK, I hear you wailing: but how do I know whether that elevated or decreased CO2 or Bicarb in my ABG report is primary or compensatory?

Well, now you have your key. So take your ABG reports and look at them. Say, try these. (Notice that O2 levels have nothing to do with acid-base balance ABG interpretation) (OK, if you are VERY hypoxic you can get acidotic...but you see that in the metabolic component, not the O2 measurement, because it's lactic ACID your body is making if it's working in an anaerobic way)

1) pH = 7.20, CO2 = 60, Bic = 40.

First thing to look at is the pH. 1) is acidosis, with a low pH. Look at your acidosis choices (you have two). Find the acidosis where both CO2 and Bicarb are elevated, and you find your answer: respiratory acidosis with metabolic compensation. This is what you see in chronic lungers who have had high CO2's for so long their kidneys have adapted to things by retaining bicarb. (It takes about 24 hrs for your kidneys to make this compensatory effort, so you can tell if your resp acidosis is acute (no or little change in bicarb) or chronic)). (Remember, your lungs' first and most important job is not getting oxygen in, it's getting CO2 out, and when chronic lungers have CO2 retention, they're really getting bad. People with acute bad lungs will often have low oxygens and low CO2's , because their ability to gain O2 goes first, and while they're trying to deep breathe their way back to a decent PaO2, they hyperventilate away their CO2. ....but I digress....)

2) pH = 7.54, CO2 = 60, Bic = 40
pH here? This is alkalosis, with a high pH.
The only box where pH is high and CO2 & Bic are both elevated is metabolic alkalosis with respiratory compensation. Sometimes you'll see this in people who have a bigtime antacid habit. Really. (You can get a short-term metabolic alkalosis with rapid severe vomiting, because the body's nl balance between acid and base has been disrupted due to a sudden loss of acid. Things will equilibrate pretty quickly, though, all things considered.)

So even though you have identical abnormal CO2's and Bicarbs, you can look in your boxes, find the match, and see what you have. Remember you underlined the primary disorder in each box?

Wanna try another one?

3) pH = 7.19, CO2 = 24, Bic = 12. Bingo, you found it: an acidosis where the CO2 and the Bic are both abnormally low. Only fits in the metabolic acidosis box, so you have a metabolic acidosis with a respiratory compensation effort. Incidentally, this is what you see in diabetic ketoACIDOSIS, when they come in huffing and puffing to blow out that CO2 because their ketosis is so high. Also you see this picture in ASA OD's, because this is acetylsalicylic ACID they ate, and the fastest way to get rid of acid is to blow it off via hyperventilation. Increasing your bicarb takes 24-48 hrs. Another quick way to get a metabolic acidosis is to poop out a lot of diarrhea, because you lose a lot of bicarb that way. Another classic place for this is in mesenteric artery thrombosis, in which you have a lot of ischemic bowel sitting in there screaming for oxygen and making lactic acid when it can't have any.

I know this is LONG, but trust me, you'll never go wrong with it, and you can recreate it anytime. It doesn't really even matter how you set up your boxes, so long as you have a metabolic and a respiratory axis and an acid/alkaline axis. Rotate your paper and you'll see what I mean.

Why don't I care about PaO2 here? Well, because ABG's mostly tell you about A/B balance and CO2 and Bicarb, that's why. Probs with them can be serious probs without any abnormality in oxygenation at all.

Remember that PaO2 (arterial oxygen, measured in torr or mmHg) is not the same as SpO2,( hemoglobin saturation, a percentage of red cells carrying oxygen). if you think they are, your pt could be in serious trouble before you do anything. There is a nomogram that shows you the relationship between arterial oxygen and saturation, which I regret I cannot reproduce here. But you can sketch out a basic version...

Draw a graph where sats are on the vertical (left) axis and PaO2's are on the horizontal (bottom) axis. Draw little shaded band across the top at the 95%-100% sat areas. That's your normal saturation. Draw a few dots there indicating a line of PaO2's of 80-100, because those are normal PaO2's.

Now draw a dot for SpO2 of 90 and PaO2 of about 75. Now, another dot showing SpO2 of 85 and PaO2 of about 60. Another dot: SpO2 of about 80 and PaO2 of about 55. Connecting all these dots should give you a sort of S curve, indicating that while the top is pretty flat in the PaO2 80-100, SpO2 95-100 range, PaO2 drops off like a shot at decreasing SpO2 levels.

Your pt with a sat of 85 is not doing OK, he's in big trouble. While a PaO2 of 75 torr isn't too bad at all, a SAT of 75% is heading for the undertaker unless dealt with.

Here's my very favorite ABG of all time: pH = 7.11, PaO2 = 136, PaCO2 = 96, bicarb = 36.

What happened to this lady? What will happen next?
Wendie

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EDITORIAL COLUMN

This section is for you to write in about your problems, your solutions, requests for advice. This is my third month of asking for participation.  If you are not interested, please write me and I will discontinue the Editorial Column. Frankie
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I have run this before in 04, and again in 06...but I think it is worth another appearance:
Recent surveys have provided a scientific rationale for IM site selection. The Ventro-gluteal is the only site that has not been associated with any adverse effects whatsoever. The ventro-gluteal site lacks major nerves and blood vessels, has well developed muscle mass, and is easy to locate.
Directions for this placement are as follows: place heel of NON-dominant hand over the patient's greater trochanter. Position the index finger on or toward the anterior superior iliac spine, then stretch the middle finger away from the index finger. The center of this V formed by the fingers and the iliac crest is the injection site. I strongly suggest that just before injection, a small tap by the nurse's finger will be a momentary distraction, and will help alleviate the pain of the injection.

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INTERESTING READING

Please remember that the REUTERS articles usually good for only 30 days

CDC: About 15% of middle-age and older adults have lung disease

CDC data showed almost 15% of adults ages 40 to 79 have a lung disorder, and more than one-third have moderate or severe respiratory symptoms. The data showed men and women had similar disease severity, and rates of lung diseases such as asthma and chronic obstructive pulmonary disease increased with age. HealthDay News(1/7)


While 10 percent of those people experience mild breathing problems, more than one-third of them report moderate or severe respiratory symptoms, the U.S. Centers for Disease Control and Prevention (CDC) reported.

"There are a huge number of Americans that experience lung obstruction," said Dr. Norman Edelman, a senior medical advisor to the American Lung Association, who was not involved in the research. "It's a major problem; it's the third leading cause of death in the United States."
People with asthma or COPD -- which includes emphysema and chronic bronchitis -- have reduced airflow and shortness of breath.
For the report, CDC researchers analyzed national survey data on adults ages 40 to 79 between 2007 and 2012. The research team looked at results of breathing tests or self-reported oxygen use to determine the prevalence of lung obstruction. http://r.smartbrief.com/resp/grmfDrrXoMmFnTykfDlkdwfCxptK?format=standard
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UCLA study: Non-drug treatment may reverse Alzheimer's LOS ANGELES --
Alzheimer's disease was officially recognized a hundred years ago, but there's still no effective treatment for it. Now researchers at UCLA say they've developed a program that shows for the first time memory loss being reversed.
It's not a drug; it's not a procedure; it is a novel, comprehensive and personal approach to treating memory loss associated with Alzheimer's. UCLA researchers spell out exactly what can be done to reverse what the disease does to the brain.
In the report provided by UCLA, Dr. Dale E. Bredesen explains how Alzheimer's is a complex disease affected by sleep, diet, even exercise.
"These all -- and other things -- all contribute to this critical balance in plasticity," said Bredesen.
Ten memory-loss patients, some with brain-scan-confirmed patterns of Alzheimer's, participated in a small UCLA trial called MEND (Metabolic Enhancement for NeuroDegeneration). ...
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Flu now Epidemic in U.S.,
(HealthDay News) -- The flu has reached epidemic levels in the United States, with 15 children dead so far this season, the federal Centers for Disease Control and Prevention reported Tuesday.
Every state will likely have flu cases within the next few weeks, and more deaths are expected, said Dr. Michael Jhung, a medical officer in CDC's influenza division.
"We are in the middle of flu season," Jhung said. "It's a safe bet that we are going to see flu activity continue to increase for a few more weeks. We are going to see every state in the country affected by flu." ...http://consumer.healthday.com/infectious-disease-information-21/flu-news-314/flu-now-epidemic-in-u-s-with-15-child-deaths-reported-695066.html

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(HealthDay News) --Treating children who have drug-resistant bacterial infections with high doses of the antibiotic vancomycin may raise the risk of kidney damage, a new study says.
Researchers said the drug should be used cautiously.
"Our results bear out the difficult balancing act between ensuring the dose is high enough to successfully treat these serious and, at times, life-threatening infections against the small but real risk for kidney damage," said the study's senior investigator, Carlton Lee, a pediatric clinical pharmacist at the Johns Hopkins Children's Center in Baltimore. ...
 
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(HealthDay News) -- Laboratory researchers say they've discovered a new antibiotic that could prove valuable in fighting disease-causing bacteria that no longer respond to older, more frequently used drugs.
The new antibiotic, teixobactin, has proven effective against a number of bacterial infections that have developed resistance to existing antibiotic drugs, researchers report in Jan. 7 in the journal Nature.
Researchers have used teixobactin to cure lab mice of MRSA (methicillin-resistant Staphylococcus aureus), a bacterial infection that sickens 80,000 Americans and kills 11,000 every year, according to the U.S. Centers for Disease Control and Prevention (CDC). The new antibiotic also worked against the bacteria that causes pneumococcal pneumonia. ...


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RANDOM FACT:
January: named after Janus, the god of doors and gates
February: named after Februalia, a time period when sacrifices were made to atone for sins
March: named after Mars, the god of war
April: from aperire, Latin for "to open" (buds)
May: named after Maia, the goddess of growth of plants
June: from junius, Latin for the goddess Juno
July: named after Julius Caesar in 44 B.C.
August: named after Augustus Caesar in 8 B.C.
September: from septem, Latin for "seven"
October: from octo, Latin for "eight"
November: from novem, Latin for "nine"
December: from decem, Latin for "ten"

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Bonus Fact:
The earliest Latin calendar was a 10-month one, beginning with March; thus, September was the seventh month, October, the eighth, etc. July was originally called Quintilis, meaning fifth; August was originally called Sextilis, meaning sixth.
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Moving Toward Blood Test for Many Cancers (HealthDay News) -- Researchers who identified more than 800 "markers" of cancer in patients' blood say their findings could potentially lead to a single blood test for many types of cancer.
All cancers produce markers -- or indicators -- in the blood, and having a blood test that can detect cancer in the early stages would improve treatment and save lives, the researchers said.
The findings stem from a review of 19,000 studies.
"This is a new approach to early detection and the first time such a systematic review has been done," study author Ian Cree, a professor at the University of Warwick, said in a Cancer Research U.K. news release.

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FDA warns Pfizer's antipsychotic could cause fatal skin reaction

(Reuters) - Pfizer Inc's antipsychotic Geodon and generic versions of the drug can trigger a potentially fatal skin reaction, the U.S. Food and Drug Administration warned on Thursday.
A new warning has been added to the drug's label to describe the condition - known as Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) - which may start as a rash and spread all over.
Other symptoms include fever, swollen lymph nodes and organ inflammation.
Geodon, known generically as ziprasidone, is used to treat schizophrenia and bipolar I disorder by reducing hallucinations, delusions and other psychotic symptoms.
While no deaths have been reported, the regulator reviewed six cases in whom the signs and symptoms of DRESS appeared between 11 and 30 days after ziprasidone treatment was initiated.
Last year, 2.5 million prescriptions for oral formulations of ziprasidone were dispensed, the agency said. ...
http://www.reuters.com/article/2014/12/11/us-pfizer-fda-antipsychotic-idUSKBN0JP1Q620141211?feedType=RSS&feedName=healthNews
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An overview of depression in women: Through the lifespan
Before reading the article, click here to take the pretest.
To provide a quick and useful review of depression in women, the authors provide up-to-date information about risk factors, diagnosis, screening techniques, and management, and they discuss special considerations and the relationship between depression and various life stages. In addition, the authors include their own helpful tips for the management of depression in women.
Key words: depression, major depressive disorder, premenstrual dysphoric disorder, antidepressants, depression and female life stages
Depression, which can occur at any time throughout the life­span, poses a major public health problem in the United States because of its high overall prevalence and associated disability.1,2 The prevalence of depression is higher in women than in men (21% vs. 13%).3 In addition, the prevalence of depression and treatment-seeking behaviors may differ among ethnic groups.4 The financial burden of depression was about $83.1 billion in 2000.5 Of the 2000 total, $26.1 billion (31%) were direct medical costs, $5.4 billion (7%) were suicide-related mortality costs, and $51.6 billion (62%) were workplace costs....
 
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Waiting Game: Women More Likely To Ignore Heart Disease Symptoms, Delay Seeking Medical Help Than Men

Grace Dierssen was a high-powered executive in a software development firm. Personal health came only second to her after family and career. So one morning when she developed sudden chest pains, exhaustion, and breathing difficulties, she attributed it to work stress and went about her chores. It's only when the pain got unbearable that she got herself admitted and found that she had suffered a heart attack.
Dierssen is not a solitary example. There are hundreds of women who develop similar heart attack symptoms as men but put off seeking medical help, consequently endangering their lives. This was the result of a study presented at the Canadian Cardiovascular Congress, where researchers used Dierssen as an example.
"The main danger is that when someone comes to the hospital with a more severe or advanced stage of heart disease, there are simply fewer treatment options available," said lead author Dr. Catherine Kreatsoulas in a statement. ...
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Life and death in the U.S.: Mortality data from the National Vital Statistics System (2012, most recent date)
78.8 years:
Life expectancy at birth for U.S. population—a record high
81.2 years:
Life expectancy for females
76.4 years:
Life expectancy for males
1.5%:
Percent decrease in infant mortality from 2011 to 2012 (to a historic low of 597.8 infant deaths per 100,000 live births)
1:
Heart disease is the leading cause of death.

RANDOM FACTS:
The largest recorded snowman ever built was in Bethel, Maine, in February 1999. The 113-foot, 7-inch snowman broke the previous record held by Yamagata, Japan, at 96 feet and 7 inches.
Bismarck, North Dakota, holds the record for the most snow angels at one time. On February 17, 2007, several schools joined forces to create 8,962 snow angels.

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Is It Safe To Eat Snow?
I'm sure you wouldn't think twice about catching a snowflake on your tongue, but using snow to make snow ice cream or melting it for drinking water might get you wondering whether it's safe or not
The Bottom Line Yes, you can eat snow! Snow is crystallized water, meaning it's actually more pure than most types of precipitation. If you think about how snow forms in the atmosphere, it's essentially frozen distilled water, crystallized around a tiny particle, so it might even be more pure than the stuff coming out of your faucet. Campers and mountaineers all over the world use snow as their primary water source without incident. Even if you live in a city, you can eat clean snow.

Snow does fall through the atmosphere before hitting the ground, so it can pick up dust particles and other impurities in the air. If the snow has been falling a while, most of these particles have already washed out. The biggest consideration for snow safety is where and how you collect the snow. ...
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Simple intravenous fluid could save many Ebola patients, specialists say
(Reuters) - Simple intravenous fluid drips could save the lives of many West African Ebola patients, but are being neglected because of a perception that there is no effective treatment for the disease, specialist doctors said on Friday.
"Ebola treatment centers must be more than just a setting for quarantine," Ian Roberts of the London School of Hygiene and Tropical Medicine and Anders Perner of Copenhagen University wrote in the journal The Lancet. "Patients will be reluctant to attend treatment centers unless the care they receive ... is superior to the care provided by family members."
West Africa's Ebola epidemic, by far the largest on record, has killed more than 6,000 of the 17,000 or so people infected so far, according to the World Health Organization. Guinea, Liberia and Sierra Leone account for all but 15 of the deaths....
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Quiz Time

Your patient experiences an anaphylactic reaction while receiving an infusion of a monoclonal antibody. Which response is correct?
a. Speed the infusion so it finishes more quickly.
b. Manage the patient symptomatically.
c. Premedicate the patient in the future.
d. Do not administer that medication to the patient again.
See the answer at end of Newsletter.

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Mediterranean Diet :
There are hints in a new study that eating the much-lauded Mediterranean diet may help boost longevity.
Researchers found that the regimen -- rich in whole grains, vegetables, fruits, legumes, nuts, fish and olive oil -- appears to be associated with longer telomere length, which are indicators of slower aging.
Telomeres are located on the ends of chromosomes -- much like the plastic tips on the end of shoelaces. According to geneticists, telomeres prevent chromosomes from fraying and scrambling the genetic codes they contain. These bits of genetic material naturally shorten with age, but they tend to shorten more slowly in healthy people.
Shorter telomeres have long been associated with a greater risk of age-related diseases and a shorter life span, experts say.
The new study was led by Immaculata De Vivo, an associate professor at Brigham and Women's Hospital and Harvard Medical School, in Boston. Her team looked at data from more than 4,600 participants in the ongoing Nurses' Health Study, which has been tracking the health of U.S. nurses since 1976.
RELATED: What You Didn’t Know About The Mediterranean Diet

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Nerve Injuries During Venipuncture by Sue Masoorli, RN
What is the procedure if the patient- during venipuncture- states that it felt like an electric shock went down the arm? This feeling of shock is a classic symptom when a needle point contacts a nerve. This could result in a permanent nerve injury and perhaps a malpractice charge involving the nurse… and this is not uncommon.
Two nerves which are most often injured during venipuncture are the radial and median nerves. The radial passes along the thumb side of the arm from the shoulder down into the wrist area close to the cephalic vein; the cephalic vein is preferred in most instances. This distal three inches of the radial nerve, JUST above the thumb, is the area most injured during IV procedures.
The median nerve, the largest nerve in the arm, runs inside the antecubital fossa, passes through the forearm into the palm of the hand. When blood is being drawn from the antecubital fossa or when inserting peripheral IVs, this nerve could accidentally be contacted and injured. Also, insertion of IV catheters into the superficial veins of the inner aspect of the wrist above the palm can result in serious injury to the median nerve and carpal tunnel syndrome.
If the patient complains of a feeling of electric shock as the needle is being inserted, the appropriate intervention is to remove the needle immediately causing only minimal damage.and prevents permanent injury. However, if the nurse continues with the procedure, a permanent , progressive, and painful disability resulting in reflex sympathetic dystrophy or Complex Regional Pain Syndrome (CRPS) can result.
The patient’s symptoms can include: hypersensitivity to temp changes, a mottled and cold hand/ forearm, excessive nail and hair growth, and the inability to lift heavy objects. CRPS is diagnosed by nerve conduction studies and the patients’ history. Treatments can include long-term pain control with narcotics, multiple nerve blocks, implanted morphine pumps, TENS units, splints, and/or casts.
The Infusion Nursing Standards of Practice* can be used in court to determine if a nurse delivered appropriate infusion care to the patient. The standards state: “site selection should avoid areas of joint flexion”. The wrist and antecubital fossa are areas of joint flexion and insertion of peripheral IV catheters into these areas can result in the decision that there was a deviation from the standard of practice.
Also, nerve compression injuries can occur when an infiltration of a large amount of IV fluid enters the tissues creating compartment syndrome. The length of which determines the amount of nerve damage. If, when the patient complains of tingling, the infusion is not stopped, a fasciotomy is required to relieve the pressure and a second surgical procedure required to close the wound.
Nerve injury related to venipuncture is one of the most common areas of nursing malpractice and one in which the nurse is considered the primary defendant.
Therefore, anytime the patient complains of tingling or “electric shock” during venipuncture or IV infusion……..the infusion must be stopped immediately.
Reference: Nursing Spectrum, September 20, 2004 FL, p. 14.
* Infusion Nursing Standards of Practice 2000 11/12 (5).
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RANDOM FACTS:

In 1984, President Ronald Reagan designated the third Sunday in July National Ice Cream Day and designated July as National Ice Cream Month.
Industrial production of ice cream begun in 1851 in Boston, United States.
The largest worldwide consumption of ice cream is in United States where one average person consumes 48 pints of ice cream per year.
The biggest ice cream sundae in history was made in Edmonton, Alberta, Canada, in 1988, and weighed in at over 24 tons.
The ice cream cone's invention is linked to the 1904 World's Fair in St. Louis. An ice cream vendor reportedly didn't have enough dishes to keep up with the demand, so he teamed up with a waffle vendor who rolled his waffles into cones.
Immigrants at Ellis Island were served ice cream as part of the welcoming to America.

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U.S. hospitals make fewer serious errors; 50,000 lives saved
(Reuters) - About 50,000 people are alive today because U.S. hospitals committed 17 percent fewer medical errors in 2013 than in 2010, government health officials said on Tuesday.
The lower rate of fatalities from poor care and mistakes was one of several "historic improvements" in hospital quality and safety measured by the Centers for Medicare and Medicaid Services. They included a 9 percent decline in the rate of hospital-acquired conditions such as infections, bedsores and pneumonia from 2012 to 2013.
Secretary of Health and Human Services Sylvia Burwell is scheduled to announce the data on Tuesday at the CMS Healthcare Quality Conference in Baltimore. It is based on a detailed analysis of tens of thousands of medical records, but because data was collected differently before 2010, it is not possible to compare pre-2010 figures to later ones. ...
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RANDOM FACT:
Winter solstice, which marks the beginning of winter is on December 20th. It is an astronomical phenomenon which marks the shortest day and the longest night of the year (for the Northern Hemisphere).
While it seems counterintuitive, Earth is actually closest to the sun in December, even though winter solstice is the shortest day of the year.
Winter in the Northern and Southern Hemispheres is caused by Earth's axis in that hemisphere being tilted away from the sun.
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HUMOR SECTION
Contrary to popular belief, most blondes do indeed know the value of a dollar. The other day a blonde from Atlanta had her car break down. The tow truck driver charged her $65.00 to take the car to the garage less than 10 miles away.
When she told her husband that evening, he said that the driver had taken advantage of her.
She said, "I thought so. But I made him earn it. I kept the brakes on all the way."
 
Postcard From Bubba

Dear Billy Joe,

I'm writin this real slow cause I know you can't read very fast.
We don't live where we did when you left, we read that most accidents
happen within 10 miles of home, so we moved.
I won't be able to send you our new address cause the last family that
lived here took the house numbers with them so they wouldn't have
to change their address.

This here new place has a washing machine. The first time mama used
it she put in four shirts and pulled the chain and we ain't seen them since.

It only rained here twice this week. Three days the first time and
five days the second time.
I know it is cold where you are so we're sending you a coat.
Mama said it would be too heavy to send in the mail with them
buttons on it, so we cut 'em off and put 'em in the pockets.
My sister had a baby this morning. I ain't heard whether it's a boy or girl
so I don't know if I'm an uncle or an aunt.

Uncle John fell in the big whiskey vat. When they tried to pull
him out, he fought them off, so he drowned.
We cremated him and he burned for three days.

Three of my friends went off the bridge in a pick uptruck.
One was driving, the other two was in the back.
The driver got out cause he rolled down the window
and swam to safety. The other two drowned,
they couldn't get the tailgate down.

Well, I hope this catches you up on things that are going on
around here.

Your cuz,

Bubba
I love this limerick:

There once was a lady from Niger,
who smiled as she rode on a tiger.
They returned from the ride,
With the lady inside -- and a smile on the face of the tiger.

~**~**~~**~~**~~**~~**~~

CEU SITES---(CME and CNE)
Those that are-----Free and Otherwise..........

NEW CME
Revised Pelvic Exam Guidelines Disputed CME/CE

Severe Peripartum Sepsis: Risk Factors Examined CME/CE

Antibiotic Prophylaxis Compliance in C-Sections CME/CE

Alarming Data on Prescribed Painkillers, CDC Reports CME/CE

Can Insurance Status Impact Cancer Outcomes? CME/CE

CE: Original Research: Staff Nurses’ Perceptions Regarding Palliative Care for Hospitalized Older Adults

O'Shea, Maureen F.
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2.5 CE Test Hours: Staff Nurses’ Perceptions Regarding Palliative Care for Hospitalized Older Adults

Contrada, Emily
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CE: Mild Traumatic Brain Injury

Hyatt, Kyong S.
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2 CE Test Hours: Mild Traumatic Brain Injury

Contrada, Emily


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WEBSITES/ LINKS
Always on the lookout for interesting websites / links. Please send them to:RNFrankie@AOL.com.
This is an excellent nursing site, check it out:http://nursingpub.com/

Decubqueen's website: www.accuruler.com.


The Nursing Site http://thenursingsite.com .


If you're buying a used car, it is recommended having a mechanic inspect it first. And screen the car's VIN through the free database at carfax.com/flood

Metric conversion calculators and tables for metric conversions
 
 
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MEDICAL RECALLS
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Valeant Pharmaceutical North America LLC Issues Voluntary Nationwide Recall of Virazole® (Ribavirin Powder For Solution) Due to Microbial Contamination December 31, 2014 - Bridgewater, New Jersey - Valeant Pharmaceuticals North America LLC (VPNA) is issuing a voluntarily recall of one lot of Virazole® (ribavirin powder for solution), 100 mL, 6g Vial, 4-pack to the user level. Inhalation of a non-sterile product with microbial contamination into the airways could increase the risk of respiratory infection. The risk is higher in patients who are immunocompromised (because of underlying disease), and are more susceptible.
Virazole is indicated for the treatment of hospitalized infants and young children with severe lower respiratory tract infections due to respiratory syncytial virus (RSV). Valeant has not received reports of adverse events or injuries, related to this recall.
Virazole is packaged in 100 mL, 6 g Vial, 4-pack NDC 00187-0007-14 which is to be reconstituted with 300 mL Sterile Water for Injection or Sterile Water for Inhalation (no preservatives added) and administered only by a small particle aerosol generator (SPAG-2). The affected Virazole lot is Lot No. 340353F with an expiration date of Oct-2018. Virazole was distributed in the U.S. and Australia. http://www.fda.gov/Safety/Recalls/ucm428683.htm

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12/23/2014 Hospira Announces Voluntary Worldwide Recall of 10 Lots of Mitoxantrone Due to Confirmed Subpotency and Out-Of-Specification Impurities

FOR IMMEDIATE RELEASE – December 23, 2014 – LAKE FOREST, Ill. – Hospira, Inc. (NYSE: HSP), announced today it has initiated a voluntary recall of 10 lots, identified below, of MitoXANTRONE (both human and veterinary), due to confirmed subpotency and elevated impurity levels.
Risk factors associated with these types of out of specifications may include the potential for decreased potency which can lead to decreased effectiveness, additional dosing and the potential for cumulative impurity toxicity requiring medical intervention. To date, Hospira has not received reports of any adverse events associated with subpotency and impurities for these lots. http://www.fda.gov/Safety/Recalls/ucm427952.htm

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12/11/2014 Baxter Voluntarily Initiates U.S. Recall of Two Lots of Sodium Chloride Injection, USP Due to the Presence of Particulate Matter

FOR IMMEDIATE RELEASE – December 11, 2014 – DEERFIELD, Ill. – Baxter International Inc. announced today it voluntarily initiated a recall in the United States of two lots of 0.9% Sodium Chloride Injection USP in 100 mL MINI-BAG PLUS Container to the hospital/user level. The recall is being initiated as a result of two complaints (one per lot) of particulate matter that was identified as a fragment of the frangible from the vial adapter. The issue was identified upon standard visual inspection prior to patient administration.
Intravenous administration of a solution containing sterile particulate matter may lead to adverse health consequences. The extent and severity of harm depends on the size, number, and composition of the foreign material, and the patient's underlying medical condition. In the absence of in-line filtration, particles may cause: local vein irritation, inflammatory reaction, aggravation of preexisting infections, allergic reactions, and systemic embolization (blockage of blood vessels, which can result in stroke, heart attack, or damage to other organs such as the kidney or liver). There have been no reported adverse events for the affected lots.
0.9% Sodium Chloride Injection USP in 100 mL MINI-BAG PLUS Container is a sterile, nonpyrogenic solution for intravenous administration after admixture with a single dose powdered drug. This recall affects the following lots of 0.9% Sodium Chloride Injection USP in 100 mL MINI-BAG PLUS Container: ...
http://www.fda.gov/Safety/Recalls/ucm426879.htm
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ADVERTISEMENTS
                                                                   from the members
This ad is from Decubqueen (Gerry)..........AccuRuler Accurate wound measurement designed by nurses, for nurses. Now carrying wound care and first-aid supplies at prices you can afford.
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NEW MEMBERS
Please send the prospective members' screen names and first names to me: RNFrankie@AOL.com
                                                          No new members at this time. 

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NOTICE:
 
Change of Addresses:

I attempt to send newsletters to your email addresses on file and if the newsletters are rejected THREE consecutive times, I must then delete the email address until you contact me with an updated email address. So, be certain to let me know when you change your address. RNFrankie@AOL.com

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EDITORIAL STAFF:
GingerMyst @AOL.com (Anne), GALLO RN @AOL.com (Sue), HSears9868 @AOL.com (Bonnie), Laregis @AOL.com (Laura), Mrwrn @AOL.com (Miriam), and Schulthe @AOL.com (Susan)

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PARADIGM 97 CO-FOUNDERS:
MarGerlach @AOL.com (Marlene) and RNFrankie @AOL.com (Frankie)
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THOUGHT FOR THE DAY
Truth is incontrovertible, malice may attack it and ignorance may deride it, but, in the end, there it is.
Sir Winston Churchill
Answer to Quiz Time:

Correct answer: d. Two types of infusion reactions may occur in patients receiving monoclonal antibodies—anaphylaxis (a hypersensitivity reaction) and cytokine-release syndrome. A patient who has had anaphylaxis should never receive that medication again.
(In my opinion, the patient should be instructed to inform all health care providers in the future, about this anaphylaxis history)

Hope to hear from you..... Frankie
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