Sunday, July 10, 2016

PARADIGM BYTES July 10, 1016

PARADIGM BYTES

Newsletter for Paradigm 97
July 10, 2016

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


 This is an excellent site ....I suggest we all bookmark it.


Statistics:     Zika virus disease in the United States, 2015–2016

As of July 6, 2016 (5 am EST)
  • Zika virus disease and Zika virus congenital infection are nationally notifiable conditions.
  • This update from the CDC Arboviral Disease Branch includes provisional data reported
  •  to ArboNET for January 01, 2015 – July 6, 2016.


http://www.cdc.gov/zika/geo/united-states.html 
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Birth Defects
Zika virus can be passed from a pregnant woman to her fetus during pregnancy or

  around the time of birth. Zika infection during pregnancy is a cause of microcephaly, a
 severe birth defect that is a sign of a problem with brain development, and other severe fetal brain defects.
In addition to microcephaly, other problems have been detected among fetuses and infants infected with Zika virus before birth, such as miscarriage, stillbirth, absent or poorly 
developed brain structures, defects of the eye, hearing deficits, and impaired growth.
Although Zika virus has been linked with these other problems in infants, there is more to learn. Scientists continue to study the full range of other potential health problems that Zika 
virus infection during pregnancy may cause.
Guillain-Barré Syndrome
Guillain-Barré syndrome (GBS) is an uncommon sickness of the nervous system in which a person’s own immune system damages the nerve cells, causing muscle weakness, and sometimes, paralysis.
  • The Brazil Ministry of Health has reported an increased number of people who have
  •  been infected with Zika virus who also have GBS.
  • GBS is very likely triggered by Zika in a small proportion of infections, much as it is 
  • after a variety of other infections.
  • CDC is investigating the link between Zika and GBS.
Symptoms
The most common symptoms of Zika virus disease are
  • Fever
  • Rash
  • Joint pain
  • Conjunctivitis (red eyes)
Many people infected with Zika virus won’t even know they have the disease because
 they won’t have symptoms. The sickness is usually mild with symptoms lasting for 
several days to a week. People usually don’t get sick enough to go to the hospital, and
 they very rarely die of Zika.

Zika Transmission
With the recent outbreaks in the Americas, the number of Zika cases among travelers visiting or returning to the United States will likely increase. CDC can't predict how much
Zika virus will spread in the continental United States. To date, Zika has not been spread
by mosquitoes in the continental United States. However, lab tests have confirmed Zika
virus in travelers returning to the United States from areas with Zika.
Zika virus is spread to people primarily through the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus). A man with Zika virus can pass it during sex to his partners. Some non-travelers in the United States have become infected with Zika through sex with someone who has traveled to an area with Zika. Many areas in the United States have the type of mosquitoes that can become infected with and spread Zika virus. However, recent outbreaks in the continental United States of chikungunya and dengue, which are spread by the same type of mosquito, have been relatively small and in limited areas.

Not having sex can eliminate the chance of getting Zika from sex. Men who live in or 
travel to areas with Zika can avoid transmitting Zika to their partners by using condoms
 every time they have sex, or by not having sex. To be effective, condoms must be used correctly (warning: this link contains sexually graphic images) from start to finish,
 every time you have vaginal, anal, or oral (mouth-to-penis) sex.  

CDC and EPA Urge Puerto Rico to Consider Aerial Spraying as Part of Integrated 
Mosquito Control to Reduce Zika-Associated Birth Defects

 Acting on data from multiple scientific studies in Puerto Rico that show that Zika is spreading 
rapidly and is a major risk to pregnant women and their fetuses, the Centers for Disease 
Control and Prevention (CDC) and the Environmental Protection Agency (EPA)
 recommend the people and the government of Puerto Rico consider implementing aerial 
spraying as part of an integrated mosquito control program.
“Multiple independent data sources indicate that at current trends thousands of pregnant 
women in Puerto Rico will catch Zika,” said CDC Director Tom Frieden, M.D., M.P.H
. “The continental United States has been using aerial spraying for decades to reduce
 mosquito populations, and we urge the people of Puerto Rico to consider using the same proven and safe tactic.” 
“Our recommendations for mosquito control in Puerto Rico are the same as our recommendations for mosquito control elsewhere in the United States—integrated pest management,” said EPA Administrator Gina McCarthy. “An integrated and comprehensive approach includes reducing places where mosquitoes lay eggs, keeping them out of houses, 
and reducing the populations of both larval and adult mosquitoes by treating areas with EPA-approved products. We strongly encourage the people of Puerto Rico to consider aerial spraying as this approach is safe for people and a proven way of controlling the spread of mosquitoes that transmit diseases from Zika to dengue to chikungunya.”...
To read more of this press release, click here.


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FROM  THE MEMBERS

This letter was unexpected and  no exchange of moneys occurred.


RE: An open letter to Paradigm 97 subscribers

I have asked Frankie to throw modesty to the wind and to send this to the entire Paradigm 97 mailing list, and include it in the blog.  


I have wanted to write this each time I have received a newsletter for the past year. I simply did not make the time to do it. It is way past due. I am pretty wordy and want to keep it short, but summarizing 20 years is not a particularly easy task.

Paradigm 97 got its name because Frankie and another nurse started it in 1997. Easy enough. In those days, the Internet was in its infancy and all of us were AOL subscribers, primarily because that was the only ISP available. I live in an area with 2 major colleges and had a horrible time connecting on my dial-up line. (Dial up was also the only type of connection available at that time.) Once I connected, I left the connection open all day because it was likely I would not be able to connect again. It was horrible. The Internet has come a long way.

In 1997, we also used an AOL chat room for a variety of purposes, including presenting nursing information. As the Internet grew, so did our subscriber list. Members left AOL as more efficient services became available in their areas. The chat room went by the wayside, but Frankie continued writing the newsletter every month without fail. The other nurse retired from her job, and when she did she also retired from the newsletter, leaving 100% of the responsibility to Frankie. She has been the solo editor for many years now. 

Meeting a deadline and assembling a multi-topic newsletter requires a great deal of work and an incredible commitment. Frankie is not a young woman. Many of you are aware that she had a carotid endarterectomy several years ago, and recently had a pacemaker/defibrillator implanted. 

We will celebrate our 20th anniversary next year. Frankie has distributed the newsletter every month for the entire time. I try to send her articles of interest that cross my desk. Whether she uses them is her decision. I have told her not to credit me for them but she does so anyway. I am just the messenger. She researches most of the material herself. 

Frankie has done battle for the newsletter on a number of occasions. She has fought with AOL because they thought the newsletter was spam. She has fought with subscribers who felt she was stepping on their copyrights. In fact, she has fought many battles behind the scenes to keep this newsletter alive. There are several nursing websites that make millions of dollars of profit from advertising. Frankie has never made a dime for her commitment to all of us and to this newsletter. That is sad. Living on a retirement income is difficult at best.

I want to publicly thank Frankie for her hard work, dedication, and commitment, and hope all of you will do the same. We have all benefited from this newsletter in one way or another. 

The next anniversary will mean we have completed 20 years and are beginning our 21st year. Congratulations! So thank you Frankie, for your perseverance, dedication, devotion, and selflessness for ensuring this valuable information has been available to us for almost 20 full years. I appreciate the gift you have given us, and wish you all the best.

Barbara Acello, RN

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This from Tyree (TigerTyree@gmail.com) :

 Frankie    Do you have any nursing friends who are top notch in computer applications with use of dashboards or widgets for tracking patient referral work flow among groups working on the case?   Tyree

  


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



 Interesting facts about the nursing profession:
  • The nurse cap is patterned after a nun’s habit to keep the hair neatly in place. Although this clothing item has long been phased out as it is known to carry pathogens, some countries still use this as part of the female nurses’ outfit.
  • The most visits to emergency rooms occur during the warmer months of the year.
  • According to the latest data available to the World Health Organization, Finland, Norway, Monaco, Ireland and Belarus have, in that order, the highest ratios of nurses per capita of all nations, ranging from 2162 to 1182 nurses per 100,000 people.
  • Linda Richards was the first nurse to earn a Nursing diploma in the United States. She earned it in 1873 and the proof of her graduation is now displayed in the Smithsonian Institution in Washington.
  • James Derham, a black slave, was “owned” by several doctors working as a nurse. He bought his freedom using his nursing salary and he later became the first African- American physician.
  • The top occupational health concern of nurses is back injury. A survey done in 2011 shows that 59% of nurses are afraid they might have this.
  • The first Nursing school was established in India in 250 BC.
  • Japan’s exam for foreign nurses is so difficult that, according to the latest report, it has been passed only by 96 out of 741 test takers in the past five years.
  • The famous poet and essayist Walt Whitman served as a volunteer nurse during the Civil War in Fredericksburg, Virginia. His poem entitled “The Wound Dresser” got its theme from his nursing experience in the battlefield.
  • In order to give recognition to school nurses, January 27 is now celebrated as the National School Nurse Day.
  • May 8 is celebrated as the National Student Nurses Day.
  • According to the World Health Organization, Nepal is one of the countries with the lowest nurse per capita. It only has 5 nurses per 100,000 people.
  • Lucretia Lester was a well-known nurse and midwife who attended to 1,300 deliveries, with only 2 ending up unsuccessful.
  • The first hospital training ground for nurses was established in the Institute of Protestant Deaconesses in Kaiserwerth, Germany in 1846.
  • The UKCC or the United Kingdom Central Council has established the Nurses Registration Act of 1919 that ensures nurses get the proper and high standard of training.
  • The term nosocomial which means “hospital acquired” originated from a Latin term “nosocomium” which refers to men who tended the sick in ancient Rome.
  • The knights who were ordered by Pope Urban II to fight during the crusades became nurses to the ill and wounded. They decided to take this role for good thus they were called the Knight Hospitallers.
  • The American Nurses Association, first known as the Nurses Associated Alumnae, was started in 1898.
  • In a 2001 survey done by the ANA/NursingWorld.com, 59% of nurses expressed fear of getting a severe back injury as one of their top three occupational health concerns.
  • In 1947, Florence Blanchfield, a nurse, became the first female regular commissioned officer in the United States Army, assigned as the superintendent of the Army Nurse Corp.
  • 17th century shipwreck survivor Juan de Mena is considered the first nurse in the New World.
  • Mary Todd Lincoln, the wife of Abraham Lincoln, was a volunteer nurse during the American Civil War
  • Mary Seacole, a self-taught nurse, was famous for establishing a hotel for invalids close to the front during the Crimean War.
  • Florence Nightingale, the most famous nurse in modern history, was only a nurse for three years of her life
  • Saint Camillus de Lellis established a Catholic order called the Fathers of a Good Death in 1584 to tend to the terminally ill, and is also reputed to have designed the red cross on a white background symbol and to have developed the first ambulance
   
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Nurse humor and  abbreviations (non-kosher type):

Sign in the nurse' break room:   Effective immediately, your fifteen-minute breaks are being cut from a half hour to twenty minutes

---The Management



WNL:  within normal limits or we never looked

SGP:   Shallow gene pool

HI-5:   HIV positive
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  Thank you, Barbara (BAcello) for this article:


Nurses leaving Texas nursing homes for better pay ‘at McDonald’s or Wendy’s,’ advocates say

AUSTIN — Nurses and other medical staff are leaving their positions in Texas’ nursing homes because of low pay, advocates say, setting up the possibility for a nursing shortage in long-term care facilities as the state’s 65-and-over population booms in the next few years.
The state’s low Medicaid reimbursement rate contributes to the low pay, a dynamic that’s driving nurses out of nursing homes or out of the health industry entirely, said Julie Sulik, vice president of Clinical Services for Southwest Long Term Management.
“Sometimes they can go down to the drive-through window at McDonald’s or Wendy’s and make more money,” Sulik said. “Morale can be hurt when we have a hiring freeze or a wage freeze, because we can’t compete.”
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fact-of-the-day
Up to 40% of all hospital beds in the United States (except for those being used by maternity and intensive care patients) are being used to treat health conditions that are related to alcohol consumption.
According to the CDC, excessive alcohol use or alcohol abuse "led to approximately 88,000 deaths and 2.5 million years of potential life lost each year in the United States from 2006 – 2010". One in every ten deaths among working-age adults 20-64 years old was due to excessive alcohol consumption. Maybe you're thinking since you only drink a half-a-bottle of wine a night, we are clearly not talking about you but if you're a lady excessive drinking is 8 alcoholic drinks a week (and wine is considered a 5-oz pour) I know, I know. We were just as shocked. This message has been brought to you by your friendly worker bees. Source: Centers for Disease Control and Prevention.
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Your responsibilities under the Child and Family Services Act

The Child and Family Services Act (CFSA) recognizes that each of us has a responsibility for the welfare of children.

Introduction

We all share a responsibility to protect children from harm. This includes situations where children are abused or neglected in their own homes. Ontario's Child and Family Services Act (CFSA) provides for protection for these children.
Section 72 of the Act states that the public, including professionals who work with children, must promptly report any suspicions that a child is or may be in need of protection to a children's aid society (CAS). The Act defines the phrase "child in need of protection" and explains what must be reported to a CAS. It includes physical, sexual and emotional abuse, neglect, and risk of harm.
This brochure explains the "duty to report" section of the Act and answers common questions about your reporting responsibilities. It also includes relevant portions of Section 72 for your reference. It does not provide specific legal advice. Please consult a lawyer or a CAS about any specific situation.

Who is a "child in need of protection"?

The Child and Family Services Act defines a child in need of protection as a child who is or who appears to be suffering from abuse and/or neglect. The Act clearly specifies how you can identify these children in Section 72 (1). (See pages 7 to 10). [CFSA s.72 (1)]   ...   (this is long...but well worth the read)
  http://www.children.gov.on.ca/htdocs/English/topics/childrensaid/reportingabuse/abuseandneglect/abuseandneglect.aspx
  
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 HHS clarifies rules for filming patients after hospital misstep


NewYork-Presbyterian Hospital will pay $2.2 million to settle federal allegations that the hospital violated two patients' privacy rights when it allowed television crews to film them without their permission. Health care providers are not allowed to invite film crews into treatment areas without first obtaining permission from all patients who are present, according to the HHS Office for Civil Rights.  



Can health care providers invite or arrange for members of the media, including film crews, to enter treatment areas of their facilities without prior written authorization?


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 FDA seeks more data on over-the-counter hand sanitizers


The U.S. Food and Drug Administration said it is seeking additional data to support the safety and effectiveness of certain active ingredients used in topical consumer antiseptic rubs, including hand sanitizers, that are sold over-the-counter.


The regulator's move comes more than a year after it asked for additional data to check if antiseptics used in healthcare settings were as safe and effective as they were once considered.

The action is part of a larger ongoing review by the agency after a lawsuit settlement with the environmental group Natural Resources Defense Council (NRDC) in 2013.
The group had sued the FDA, claiming the agency failed to regulate toxic chemicals found in antimicrobial soap and other personal care products. (reut.rs/292GT18)

NRDC's senior attorney Mae Wu said the FDA action was "long overdue". "We need to know whether these chemicals are safe and effective."

The FDA said on Wednesday its request would help ensure that regular use of these products do not present unknown concerns, and not that these products were ineffective or unsafe. (1.usa.gov/29c72zQ)

The agency said it does not require any hand sanitizers to be removed from the shelves at this time.

"We believe that the FDA has a wealth of data on hand sanitizers in their possession to judge them as generally recognized as safe and effective," the American Cleaning Institute (ACI) said in a statement.

"However, we will work to provide additional data as necessary to ensure the agency has the most complete, useful, and up-to-date information on these products," the statement said.

The ACI represents antiseptic ingredient and product makers such as Purell hand sanitizer-maker Gojo Industries Inc, Clorox Co (CLX.N) and Procter & Gamble Co (PG.N).

http://tinyurl.com/govounv

or

http://www.reuters.com/article/us-antiseptic-fda-idUSKCN0ZF1M2?feedType=nl&feedName=healthNews&utm_source=Sailthru&utm_medium=email&utm_campaign=US%20Health%20Report%202016-06-29&utm_term=US%20Health%20Report


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  U.S. approves first drug for psychosis linked to Parkinson's


Acadia Pharmaceuticals Inc's drug for psychosis linked to Parkinson's disease was approved in the United States on Friday, becoming the first treatment for the condition to get a nod in the country.
The U.S. Food and Drug Administration, however, asked Acadia to include a black-box warning, its strictest warning, on the drug's label for an increased risk of death associated with its use in older people. (1.usa.gov/1SPKUID)

An estimated 50,000 Americans are diagnosed with Parkinson's disease each year and about 1 million Americans have the condition, the FDA said in a statement, citing data from the National Institutes of Health.

The drug, Nuplazid, is expected to be priced at $13,500 per patient for a year and reach more that $1 billion in sales in 2021, according to Leerink analyst Paul Matteis.

http://www.reuters.com/article/us-acadia-pharm-fda-idUSKCN0XQ2L6?feedType=nl&feedName=healthNews&utm_source=Sailthru&utm_medium=email&utm_campaign=US%20Health%20Report%202016-05-02&utm_term=US%20Health%20Report

or
http://tinyurl.com/zo8s2le





  
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Aspirin Before Cardiac Surgery: Not Harmful, But Not Helpfu   

lDeath, thrombotic complication, and bleeding risk all unaffected in ATACAS trial  VE
Aspirin before coronary artery surgery appeared safe but not effective for patients whose age or comorbid conditions put them at higher risk for complications, the ATACAS trial showed.
The 30-day rate of death and thrombotic events (nonfatal myocardial infarction [MI], stroke, pulmonary embolism, renal failure, or bowel infarction) was 19.3% with preoperative aspirin and 20.4% without it(relative risk 0.94, P=0.55), Paul S. Myles, MPH, MD, of Monash University in Melbourne, and colleagues found.
"Major hemorrhage leading to reoperation occurred in 1.8% of patients in the aspirin group and in 2.1% of patients in the placebo group (P=0.75), and cardiac tamponade occurred at rates of 1.1% and 0.4%, respectively (P=0.08)," they reported in the New England Journal of Medicine.
"The absence of an adverse bleeding effect in this trial could be explained by patient selection, the low dose of aspirin used (100 mg), or the use of antifibrinolytic therapy in half the patients," they suggested.  ...  

 http://www.medpagetoday.com/Cardiology/Prevention/56385?xid=nl_mpt_DHE_2016-02-25&eun=g379846d0r 
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 Sedentary time tied to coronary artery calcium


(Reuters Health) - One reason being sedentary is so bad for health may be that it promotes “hardening” of the arteries with calcified deposits, a new U.S. study suggests.

Research with middle-aged volunteers found that each additional hour of sedentary time was linked to 12 percent higher odds of having calcium buildup in the coronary arteries, an early sign of coronary heart disease.


“This is one of the first studies to help tease out the ways in which sedentary time relates to heart disease risk, by evaluating this early marker of atherosclerosis in the heart arteries,” said study coauthor Julia Kozlitina of the University of Texas Southwestern Medical Center in Dallas.


The researchers analyzed data on more than 2,000 participants in the Dallas Heart Study who had measures of physical activity based on wearable tracking devices and had coronary artery calcium scans.   ...  

http://www.reuters.com/article/us-health-sedentary-artery-calcification-idUSKCN0XJ2II

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 Who founded the American Red Cross?    

Clara Barton was nothing short of hardcore. She became a teacher at a time when women in teaching were greatly frowned upon. She was one of the first women to gain employment in the federal government. At age 60, when the rest of us are thinking retirement and 11 a.m. naps, Barton founded the American Red Cross and led it for the next twenty-three years. 
Source: The American Red Cross  
  
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Thank you, Barbara (BAcello)

Medicare Is Often Overbilled by Hospices, and Pays Twice for Some Drugs

Hospices often bill Medicare for a higher level of care than patients need, and Medicare often pays twice for the prescription drugs provided to people who are terminally ill, federal investigators say in a new report. The extra cost to Medicare was put at more than $260 million a year.


The investigators found that Medicare was paying hospices almost four times as much as it should have for some patients. The patients were receiving “inpatient care” when all they needed was less-expensive routine care in their homes, the report said.

Medicare now pays hospices an all-inclusive rate of $720 a day for inpatient care and no more than $187 a day for routine home care.





  
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Thank you, Barbara (BAcello)

8 latest healthcare industry lawsuits, settlements
By Ayla Ellison |  

From a Texas hospital suffering a setback in its lawsuit against a major insurer over network exclusion to a California hospital agreeing to pay $7.5 million to settle a data breach class-action case, here are the latest healthcare industry lawsuits and settlements making headlines. 

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Severe Depression Linked to Dementia in Seniors


(HealthDay News) -- Major and worsening depression may significantly increase seniors' risk of dementia, a new study suggests.
The research included close to 2,500 people in their 70s who did not have any signs of dementia at the start of the study. The participants were monitored for five years for symptoms of depression, and then for six years for signs of dementia.
Dementia developed in just over 21 percent of participants with serious and escalating symptoms of depression, compared to about 12 percent of those with consistently minimal symptoms of depression, the findings showed.
"Our results raise the possibility that older adults' cognitive [mental] health could be improved with interventions to reduce depressive symptoms, such as psychotherapy or other behavioral interventions, or medications," said study author Allison Kaup. She is an assistant professor in the department of psychiatry at the University of California, San Francisco.
"This is an important topic for future treatment studies to investigate," she said in a university news release.
Kaup said researchers can't rule out the possibility that depression might be an early signal of dementia or an emotional response to a decline in thinking and memory skills. And the association seen in the study does not prove cause-and-effect. ...    

https://consumer.healthday.com/senior-citizen-information-31/dementia-news-738/briefs-3-23-depression-dementia-jama-psych-ucsf-release-batch-2595-709334.html


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  What is the name of the galaxy closest to The Milky Way?


The galaxy Andromeda, The Milky Way's closest neighbor, is only about 2.2 million light years away. But like all good neighbors, it is quickly starting to invade our personal space, traveling at a speed of 670,000 miles an hour right to our front door. Give it 5 billion years and the two Space households will merge together as one.           Source: The Hubble Telescope's Official Site
 
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When seniors stop driving, social isolation looms  

(Reuters Health) - When elderly drivers have to stop getting behind the wheel, they run the risk of social isolation, especially if they don’t have an alternative transportation plan, a recent study suggests.

The study looked at driving habits and social activities, like visiting friends and family or going out to dinner or the movies, for more than 4,300 adults over age 65.

With wheels, older adults were much more likely to be out and about than their peers who never drove, the study found. But after elderly drivers lost the ability to hit the road, their participation in social activities declined to match their peers who never drove at all.

“Social participation in old age is linked with both physical and mental health benefits,” said study author Teja Pristavec, a sociology researcher at Rutgers University in New Brunswick, New Jersey.

“Older adults who remain engaged in social life report being in better health, experience lower mortality risk over time, and have lower rates of depression, dementia, and other cognitive impairments,” Pristavec added by email. “Transportation mobility is often crucial for such continued social participation.” ...  
http://www.reuters.com/article/us-health-seniors-driving-idUSKCN0YM2E3?feedType=nl&feedName=healthNews&utm_source=Sailthru&utm_medium=email&utm_campaign=US%20Health%20Report%202016-06-01&utm_term=US%20Health%20Report
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 Statistics   Facts on drug poisoning deaths from the Centers for Disease Control and Prevention:

81% Percent of poisoning deaths that are unintentional.

45 to 54 Age group with the highest drug poisoning death rate. 

70% Percent of opioid analgesic poisoning deaths in 2013 that involved natural and semisynthetic opioid analgesics 
such as hydrocodone, morphine, and oxycodone.


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 QUIZ TIME:

Which of the following can cause the oxyhemoglobin dissociation curve to shift to the right?
a. Alkalosis
b. Increased body temperature
c. Decreased 2,3-diphosphoglycerate (2,3-DPG)
d. Decreased partial pressure of arterial carbon dioxide (Paco2)


Answer at end of newsletter


   
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 The French Foreign Legion is a military service wing of the French Army established in 1831, unique because it was exclusively created for foreign nationals willing to serve in the French Armed Forces.


 Random Fact:

The original purpose of the Foreign Legion was to remove disruptive elements from society and put them to use fighting the enemies of France. Recruits included failed revolutionaries from the rest of Europe, soldiers from the disbanded Swiss and German mercenary regiments of the Bourbon monarchy, and troublemakers in general, both foreign and French.

Historically, the American film industry portrayed the Foreign Legion as having a reputation as a haven for cut-throats fugitives from justice. This image is largely out of date since the legion now conducts extensive background checks via Interpol.

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Bonus Fact:

Some Americans disagreed with the United States' initial refusal to enter WWI and so they joined the French Foreign Legion or the British or Canadian army. A group of U.S. pilots formed the Lafayette Escadrille, which was part of the French air force and became one of the top fighting units on the Western Front.
  
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 Question: Who wrote the poem "The Road Not Taken"?

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Answer: “The Road Not Taken" is a poem by Robert Frost, published in 1916 in the collection Mountain Interval. Frost claimed that poem was based on his friend Edward Thomas. Thomas and Frost became close friends and took many walks together. In Frost’s words, Thomas was “a person who, whichever road he went, would be sorry he didn’t go the other. The poem was intended by Frost as a gentle mocking of indecision. Frost commented that “The Road Not Taken” is “a tricky poem, very tricky” implying that people generally misinterpret this poem as evidence of the benefit of free thinking and not following the crowd, while Frost’s intention was to comment about indecision and people finding meaning in inconsequential decisions.
  
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 Tracheostomy care: An evidence-based guide to suctioning and dressing changes   Tracheostomy care and tracheal suctioning are high-risk procedures. To avoid poor outcomes, nurses who perform them—whether they’re seasoned veterans or novices—must adhere to evidence-based guidelines. In fact, experienced nurses may overestimate their own trach care competence. Tracheostomy patients aren’t seen only in intensive care units. As patients with more complex conditions are admitted to hospitals, an increasing number are being housed on general nursing units. Trach patients are at high risk for airway obstruction, impaired ventilation, and infection as well as other lethal complications. Skilled bedside nursing care can prevent these complications. This article describes evidence-based guidelines for tracheostomy care, focusing on open and closed suctioning and site care. 

Also: http://www.nursebuff.com/2014/06/tracheostomy-care/  (a step by step illustrated guide for nursing care of a tracheostomy---cleaning and suctioning)










 The following is long...but worthwhile double checking:   

Suctioning a trach tube

A trach tube may have a single or double lumen; it may be cuffed or uncuffed, fenestrated (allowing speech) or unfenestrated. Each variation requires specific management. For instance, before suctioning a fenestrated tube, you must insert a plain inner tube, because a suction catheter may puncture the small opening of the fenestrated tube. (See Trach tube positioning by clicking the PDF icon above.) Regardless of the type of tube used, suctioning always involves:
  • assessment
  • oxygenation management
  • use of correct suction pressure
  • liquefying secretions
  • using the proper-size suction catheter and insertion distance
  • appropriate patient positioning
  • evaluation.
Also, be sure to keep emergency equipment nearby. (See Be prepared for trach emergencies by clicking the PDF icon above.)

When to suction

Suctioning is done only for patients who can’t clear their own airways. Its timing should be tailored to each patient rather than performed on a set schedule. Start with a complete assessment. Findings that suggest the need for suctioning include increased work of breathing, changes in respiratory rate, decreased oxygen saturation, copious secretions, wheezing, and the patient’s unsuccessful attempts to clear secretions. According to one researcher, fine crackles in the lung bases indicate excessive fluid in the lungs, and wheezing patients should be assessed for a history of asthma and allergies.

Suctioning technique

Before suctioning, hyperoxygenate the patient. Ask a spontaneously breathing patient to take two to three deep breaths; then administer four to six compressions with a manual ventilator bag. With a ventilator patient, activate the hyperoxygenation button. Experts recommend using suction pressure of up to 120 mm Hg for open-system suctioning and up to 160 mm Hg for closed-system suctioning. For each session, limit suctioning to a maximum of three catheter passes. During catheter extraction, suctioning can last up to 10 seconds; allow 20 to 30 seconds between passes. For open-system suctioning, catheter size shouldn’t exceed half the inner diameter of the internal trach tube. To determine the appropriate-size French catheter, divide the internal trach tube size by two and multiply this number by three. A #12 French catheter is routinely used for closed suctioning. Premeasure the distance needed for insertion. Experts suggest 0.5 to 1 cm past the distal end of the tube for an open system, and 1 to 2 cm past the distal end for a closed system.

Liquefying secretions

The best ways to liquefy secretions are to humidify secretions and hydrate the patient. Do notuse normal saline solution (NSS) or normal saline bullets routinely to loosen tracheal secretions because this practice:
  • may reach only limited areas
  • may flush particles into the lower respiratory tract
  • may lead to decreased postsuctioning oxygen saturation
  • increases bacterial colonization
  • damages bronchial surfactant.
Despite the potential harm caused by NSS use, one survey found that 33% of nurses and respiratory therapists still use NSS before suctioning. Other researchers have found that inhalation of nebulized fluid also is ineffective in liquefying secretions.

Evaluation

When evaluating the patient after suctioning, assess and document physiologic and psychological responses to the procedure. Convey your findings verbally during nurse-to-nurse shift report and to the interdisciplinary team during daily rounds.

Trach site care and dressing changes

Tracheostomy dressing changes promote skin integrity and help prevent infection at the stoma site and in the respiratory system. Typically, healthcare facilities have both formal and informal policies that address dressing changes, although no evidence suggests a particular schedule of dressing changes or specific supplies for secretion absorption must be used. On the other hand, the evidence does show that:
  • secretions can cause maceration and excoriation at the site
  • the site should be cleaned with NSS
  • a skin barrier should be applied to the site after cleaning
  • loose fibers increase the infection risk
  • the trach tube should be secured at all times to prevent accidental dislodgment, using the two-person securing technique described below under “Securing the trach tube.”
Start by assessing the stoma for infection and skin breakdown caused by flange pressure. Then clean the stoma with a gauze square or other nonfraying material moistened with NSS. Start at the 12 o’clock position of the stoma and wipe toward the 3 o’clock position. Begin again with a new gauze square at 12 o’clock and clean toward 9 o’clock. To clean the lower half of the site, start at the 3 o’clock position and clean toward 6 o’clock; then wipe from 9 o’clock to 6 o’clock, using a clean moistened gauze square for each wipe. Continue this pattern on the surrounding skin and tube flange. Avoid using a hydrogen peroxide mixture unless the site is infected, as it can impair healing. If using it on an infected site, be sure to rinse afterward with NSS.

Dressing the site

At least once per shift, apply a new dressing to the stoma site to absorb secretions and insulate the skin. After applying a skin barrier, apply either a split-drain or a foam dressing. Change a wet dressing immediately.

Securing the trach tube

Use cotton string ties or a Velcro holder to secure the trach tube. Velcro tends to be more comfortable than ties, which may cut into the patient’s neck; also, it’s easier to apply. The literature overwhelmingly recommends a two person technique when changing the securing device to prevent tube dislodgment. In the two-person technique, one person holds the trach tube in place while the other changes the securing device.

Review trach tube policy and procedures

To achieve positive outcomes in patients with trach tubes, keep abreast of best practices and develop and maintain the necessary skills. Every nurse who performs trach care needs to be familiar with facility policy and procedure on trach tube care. If your facility’s current policy and procedures don’t support evidencebased practice, consider urging colleagues and managers to conduct a patient-care study comparing different approaches to suctioning. Then follow the evidence by advocating for changes if necessary.
Selected references
Chulay M. Suctioning: endotracheal or tracheostomy tube. In: Wiegand DJ, Carlson KK, eds.AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA: Elsevier Saunders; 2010:62-70.
Dennis-Rouse MD, Davidson JE. An evidence-based evaluation of tracheostomy care practices.Crit Care Nurs Q. 2008;31(2):150-160.
Edgtton-Winn M, Wright K. Tracheostomy: a guide to nursing care. Aust Nurs J. 2005;13(5):1-4.
Harkreader H, Hogan MA, Thobaben M. Fundamentals of Nursing: Caring and Clinical Judgment. 3rd ed. Philadelphia, PA: Saunders; 2007.
Klockare M, Dufva A, Danielsson AM, et al. Comparison between direct humidification and nebulization of the respiratory tract at mechanical ventilation: distribution of saline solution studied by gamma camera. J Clin Nurs. 2006;15(3):301-307.
Kuriakose A. Using the Synergy Model as best practice in endotracheal tube suctioning of critically ill patients. Dimens Crit Care Nurs. 2008;27(1):10-15.
Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, Camera I. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 8th ed. St. Louis, MO: Mosby; 2010.
Smith-Miller C. Graduate nurses’ comfort and knowledge level regarding tracheostomy care. J Nurses Staff Dev. 2006;22(5):222-229.
Wiegand DJ, Carlson KK, eds. AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA: Elsevier Sauders; 2010.
Betty Nance-Floyd is a clinical assistant professor at the University of North Carolina at Chapel Hill School of Nursing.
 


RANDOM TIDBITS

 All of the Earth's continents are wider at the north, than at the south.

Any free-moving liquid will form itself into a sphere in outer space because of its surface tension.

It would take more than an hour for a heavy object to sink to the deepest part of the ocean.

Each year the moon's orbit moves about one and a half inches farther away from earth.

Over 50% of the world's population lives within 60 miles from a sea coast.

The strongest surface winds in the solar system are found on Neptune, where they have been measured at 1500 mph.

Mount Olympus on Mars is the highest mountain in the solar system.  It is 14 miles high and 388 miles wide.

Less than 1% of books published sell more than 50 thousand copies.

Beer is mostly water so the type of water used to make it can make a big difference in the taste.

Q is the only letter in the alphabet that does not appear in the name of any of the United States.

Schroinger's cat:  The phrase "Schrodinger's cat" describes a thought experiment in which a cat might be alive, dead, or somewhere in between depending on the outcome of some random preceding event.  Erwin Schodinger, the Austrian physicist, set forth the problem in quantum mechanics in 1935 in an effort to describe the uncertain state of a set of subatomic particles. 






                                                              ~~**~~**~~**~~**~~**~~
HUMOR SECTION

Thank you, Gerry (Decubqueen) ...keep sending them in, please.
  

POINTS TO PONDER

The location of your mailbox shows you how far away from your house you
can be in a robe before you start looking like a mental patient.

My therapist said that my narcissism causes me to misread social
situations. I’m pretty sure she was hitting on me.

My 60 year kindergarten reunion is coming up soon and I’m worried about
the 175 pounds I’ve gained since then.

I always wondered what the job application is like at Hooters. Do they
just give you a bra and say, “Here, fill this out?”

Denny’s has a slogan, “If it’s your birthday, the meal is on us.” If you’re
in Denny’s and it’s your birthday, your life sucks!

If I make you breakfast in bed, a simple “Thank you” is all I need ... not
all this, “How did you get into my house?” business!

The pharmacist asked me my birth date again today. I’m pretty sure she’s
going to get me something.

On average, an American man will have sex two to three times a week.
Whereas, a Japanese man will have sex only one or two times a year. This
is very upsetting news to me. I had no idea I was Japanese.

I can’t understand why women are okay that JC Penny has an older women’s
clothing line named, “Sag Harbor.”

I think it's pretty cool how Chinese people made a language entirely out
of tattoos.

What is it about a car that makes people think we can't see them pick
their noses?

Money can’t buy happiness, but it keeps the kids in touch!

The reason Mayberry was so peaceful and quiet was because nobody was
married. Andy, Aunt Bea, Barney, Floyd, Howard, Goober, Gomer, Sam,
Earnest T Bass, Helen, Thelma Lou, Clara and, of course, Opie were all
single. The only married person was Otis, and he stayed drunk.

Joy of getting older: If I do something stupid,
I won't remember long enough to stay embarrassed
 ************************












The ultimate stain remover that actually works on a seriously set in stain!   Never buy oxyclean again!
The mixture is:
1 tsp. Dawn dishwashing detergent
3-4 tablespoons of hydrogen peroxide
couple tablespoons of baking soda.
Scrub on with a scrubbing brush
**********************************

Death Risk With Off-Label Oral Ketoconazole Use, FDA Warns

The US Food and Drug Administration (FDA) is warning clinicians against the off-label prescribing of ketoconazole tablets (Nizoral, Janssen Pharmaceuticals) to treat skin and nail fungal infections because the risk for serious liver damage and death outweighs the benefits.
In July 2013, the FDA removed skin and nail fungal infections as indications for ketoconazole tablets in light of possible adverse events, which also include adrenal gland problems and harmful interactions with other drugs. The agency revised the label to warn that patients with no obvious risk factors for liver disease had developed serious hepatotoxicity after taking the drug, leading to liver transplants or death in some cases.
However, clinicians have continued to prescribe ketoconazole tablets for skin and nail fungal infections despite the label change, according to an FDA safety review. Such infections were the only diagnoses cited for the tablets during 2014 and the first 6 months of 2015, according to a database of physician surveys. For the last 12 months of that period, US outpatient retail pharmacies dispensed ketoconazole tablets to roughly 217,000 patients.
The FDA has received one report of a fatality related to oral ketoconazole since July 2013. The patient died of liver failure after taking the tablets for infected nails.
"Healthcare professionals should use ketoconazole tablets only to treat serious fungal infections when no other antifungal therapies are available," the FDA said in a news release. In contrast, skin and nail fungal infections are not life-threatening, so the risks that come with oral ketoconazole outweigh the benefits. Clinicians can turn to other prescription and over-the-counter treatments for these infections.
The FDA notes that topical versions of ketoconazole applied to skin or nails have not been linked to liver damage, adrenal problems, or drug interactions.  ...     http://www.medscape.com/viewarticle/863550

************

Treat high LDL cholesterol in CKD, even with inflammation 

SAN DIEGO – Among patients with chronic kidney disease, LDL cholesterol level was positively associated with risk of atherosclerotic vascular events, regardless of baseline inflammation, according to a large, randomized study.
In addition, lowering LDL cholesterol with ezetimibe/simvastatin was similarly effective in the presence or absence of inflammation.

“There has been substantial interest in the relationship between LDL cholesterol and outcomes in the general population, and in particular among people with kidney disease,” study author Dr. Richard Haynes of the Nuffield Department of Population Health at the University of Oxford (England) said in an interview in advance of the meeting.
“Previous studies have found a paradoxical increased risk of death at low cholesterol levels, which may be due to another disease process – such as inflammation – both lowering cholesterol and increasing the risk of death, thereby creating a false association,” he explained  ...

http://www.anticoagulationhub.com/single-article/treat-high-ldl-cholesterol-in-ckd-even-with-inflammation/3590a4bb395daa705c871019fb46805c.html?utm_source=Hubs_ANTI_eNL_121915&utm_medium=email&utm_content=Treat+high+LDL+cholesterol+in+CKD%2C+even+with+inflammation
or:  http://tinyurl.com/pkkjmrx

**********************

  Preventing Nurse, Patient Injuries Subject of New Bill
 Medscape Medical News
US Rep. John Conyers Jr (D-MI) is working with the US Senate to develop The Nurse and Health Care Worker Protection Act, which would provide a national standard for nurses and other healthcare workers when lifting patients.
Rep. Conyers, the American Nurses Association (ANA), and other healthcare safety experts spoke at a briefing on Capitol Hill on May 12. They called for healthcare employers to "implement common-sense, comprehensive programs to protect healthcare workers from career-ending injuries, and safeguard patients from falls," according to an ANA news release.
"Nurses and healthcare workers experience the highest rate of nonfatal occupational injuries and illnesses, including the manufacturing and construction industries. Every day, nurses and other healthcare workers suffer debilitating musculoskeletal disorders due to manually lifting patients," Pamela F. Cipriano, PhD, RN, NEA-BC, president of the American Nurses Association, told congressional officials.
"In no other profession would we ask workers to lift 90 pounds or more without mechanical support. Nurses and healthcare workers should not be the exception," she said.  ...     
http://www.medscape.com/viewarticle/845224
*********************

FDA approves new drug to treat multiple sclerosis.

The U.S. Food and Drug Administration approved Zinbryta (daclizumab) for the treatment of adults with relapsing forms of multiple sclerosis (MS). Zinbryta is a long-acting injection that is self- administered by the patient monthly.
Zinbryta should generally be used only in patients who have had an inadequate response to two or more MS drugs because Zinbryta has serious safety risks, including liver injury and immune conditions. Because of the risks, Zinbryta has a boxed warning and is available only through a restricted distribution program under a Risk Evaluation and Mitigation Strategy.

The boxed warning tells prescribers that the drug can cause severe liver injury, including life-threatening and fatal events. Health care professionals should perform blood tests to monitor the patient’s liver function prior to starting Zinbryta, monthly before each dose, and for up to six months after the last dose.

The boxed warning also highlights other important risks of Zinbryta treatment including immune conditions, such as inflammation of the colon (non-infectious colitis), skin reactions, and enlargement of lymph nodes (lymphadenopathy).
Additional highlighted warnings include hypersensitivity reactions (anaphylaxis or angioedema), increased risk of infections, and symptoms of depression and/or suicidal ideation.

The most common adverse reactions reported by patients receiving Zinbryta in the clinical trial that compared it to Avonex include cold symptoms (nasopharyngitis), upper respiratory tract infection, rash, influenza, dermatitis, throat (oropharyngeal) pain, eczema, and enlargement of lymph nodes. The most common adverse reactions reported by patients receiving Zinbryta when compared to placebo are depression, rash, and increased alanine aminotransferase.
                       For more information, please visit: Zinbryta.  '

(http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm504000.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery)

or

http://tinyurl.com/jaszwcs 



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

CEU SITES---(CME and CNE)
Those that are-----Free and Otherwise..........Go to www.sharedgovernance.org for access to a free continuing education module about shared governance, written by Robert Hess, Forum’s founder, and Diana Swihart, Forum advisory board member.
Please follow me on Twitter as Dr Robert Hess. info@sharedgovernance.orgwww.sharedgovernance.org 


 Pay Only $34.99 for a full year of CONTACT HOURS 
www.nurse.com for CNE offerings.
~~**~~**~~**~~**~~**~~
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.



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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******************************************************


  FDA MedWatch - Zecuity (sumatriptan) Migraine Patch: UPDATED Drug Safety Communication - FDA Evaluating Risk of Burns and Scars

UPDATED 06/13/2016: Zecuity manufacturer Teva Pharmaceuticals has decided to temporarily suspend sales, marketing, and distribution to investigate the cause of burns and scars associated with the Zecuity patch.  Health care professionals should discontinue prescribing Zecuity, and patients should stop using any remaining patches and contact their prescribers for an alternative migraine medicine.  Please refer to the Dear Health Care Provider letter and the updated Drug Safety Communication for more information.

AUDIENCE: Internal Medicine, Pain Management, Neurology, Pharmacy

ISSUE: FDA is investigating the risk of serious burns and potential permanent scarring with the use of Zecuity (sumatriptan iontophoretic transdermal system) patch for migraine headaches. Since marketing of the Zecuity patch began in September 2015, a large number of patients have reported they experienced burns or scars on the skin where the patch was worn. The reports included descriptions of severe redness, pain, skin discoloration, blistering, and cracked skin. As a result, FDA is investigating these serious adverse events to determine whether future regulatory action is needed, and will update the public with new information when the FDA review is complete.

BACKGROUND: The Zecuity patch contains the active ingredient sumatriptan, a prescription medicine used to treat acute migraine headaches in adults. The patch delivery system is designed to deliver a dose of medicine by way of a single-use, battery-powered patch that is wrapped around the upper arm or thigh. It should remain in place for no longer than four hours.

************************
 Guidance for Industry: Enforcement Policy Regarding Investigational New Drug Requirements for Use of Fecal Microbiota for Transplantation to Treat Clostridium difficile Infection Not Responsive to Standard Therapies

FDA is issuing this guidance for immediate implementation in accordance with 21 CFR 10.115(g)(3) without seeking prior comment because the agency has determined that prior public participation is not feasible or appropriate because the guidance deals with an urgent issue affecting patients with life-threatening infections with Clostridium difficile.
FDA invites comments on this guidance. Submit one set of either electronic or written comments on this guidance at any time. Submit electronic comments to http://www.regulations.gov. Submit written comments to the Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. You should identify all comments with the docket number listed in the notice of availability that publishes in the Federal Register. FDA will review any comments we receive and revise the guidance when appropriate.
Additional copies of this guidance are available from the Office of Communication, Outreach and Development (OCOD), (HFM-40), 1401 Rockville Pike, Suite 200N, Rockville, MD 20852-1448, or by calling 1-800-835-4709 or 301-827-1800, or e-mail ocod@fda.hhs.gov, or from the Internet athttp://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/default.htm.



http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Vaccines/ucm361379.htm

***************************
URGENT – Voluntary Market Withdrawal – April 21, 2016: Octagam [Immune Globulin Intravenous (human)] 5% Liquid Preparation]

  April 21, 2016
PRODUCT / LOT NUMBER / Expiration:
Octagam [Immune Globulin Intravenous (human)] 5% Liquid Preparation
Lot Number K551A8441
Expiration Date: December 17, 2017
MANUFACTURER:
Octapharma USA, Inc.
Vienna, Austria
REASON:
Effective immediately, Octapharma USA Inc. is initiating a voluntary market withdrawal of Octagam 5% [Immune Globulin Intravenous (human)] 5% Liquid Preparation] that is labeled with lot number K551A8441. Although there have been no reports of serious injury at this time, Octapharma has determined, through consultation with the public health authorities at FDA, the most prudent course of action is to suspend further administration of this Octagam from this production lot.


http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/Recalls/ucm497244.htm                                                                                                            
*********************************

URGENT Recall for Leukotrap RC System with RC2D Filter

Product IDDescriptionLot #
129-62Leukotrap RC System with RC2D Filter1656076
129-63Leukotrap RC System with RC2D Filter1656083 and 1656084
MANUFACTURER:Haemonetics Manufacturing Inc.
Covina, CA
REASON:Haemonetics Corporation is voluntarily recalling three lots of its Leukotrap RC System with RC2D Filter (Reorder #129-62 and 129-63).
Haemonetics has received reports of higher than expected residual WBC associated with lot numbers 1656076 (129-62) and 1656083 (129-63). Further, although they have not received reports, they have determined through their investigation that Reorder# 129-63, lot# 1656084 may also be affected by this issue and are recalling this lot as well.
Use of this lot may result in a higher than expected level of leukocytes in transfused blood. Blood products processed with these lots should not be re-filtered and should be labeled as non-leukoreduced.
Please discontinue the use of these lots and return any unused product to Haemonetics. Contact your local customer service representative to coordinate the return and the shipment of replacement product to ensure a seamless exchange of goods.
This recall applies ONLY to the product IDs and lot numbers listed above. No other products or lots are affected by this action. 

http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/Recalls/ucm506109.htm

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                                                                 ~~**~~**~~**~~**~~**~~
ADVERTISEMENTS
from the members
This ad is from Decubqueen (Gerry)..........Accuruler for accurate wound measurement designed by nurses, for nurses. Now carrying wound care and first-aid supplies at prices you can afford.

 ~~**~~**~~**~~**~~**~~
NEW MEMBERS
Please send the prospective members' screen names and first names to me: RNFrankie@AOL.com

no new members this issue


~~**~~**~~**~~**~~**~~
NOTICE:

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



~~**~~**~~**~~**~~**~~
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)


~~**~~**~~**~~**~~**~~
PARADIGM 97 CO-FOUNDERS:
MarGerlach @AOL.com (Marlene) and RNFrankie @AOL.com (Frankie)

~~**~~**~~**~~**~~**~~
DISCLAIMER: The intent of this PARADIGM BYTES Newsletter is to provide communication and information for our members. Please research the hyperlinks and information provided by our members. The articles and web sites are not personally endorsed by the editors, nor do the articles necessarily reflect the staff's views.

~~**~~**~~**~~**~~**~~
THOUGHT FOR THE DAY


I am a most unhappy man. I have unwittingly ruined my country. A great industrial nation is now controlled by its system of credit. We have come to be one of the worst ruled, one of the most completely controlled and dominated governments in the world -- no longer a government by free opinion, no longer a government by conviction and the vote of the majority, but a government by the opinion and duress of a small group of dominant men.


-- Woodrow Wilson 1919
  



Hope to hear from you..... Frankie


 b. Causes of a shift to the right include increased body temperature, acidosis, exercise, and increased 2,3-DPG or Paco2 levels.
Learn more by reading the continuing nursing education article “Decoding the oxyhemoglobin dissociation curve.”
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