MANNITOL ADMINISTRATION (PART TWO).

Mannitol (Osmitrol) is contraindicated in severe pulmonary oedema, severe heart failure, active intracranial hemorrhage, disruption of blood brain barrier, severe dehydration and anuria.

A TEST DOSE of Mannitol should first be administered in patients with renal impairment, to ascertain renal function and the ability of the kidneys to eliminate Mannitol and other toxic substances from the body.

A test dose of about 0.2-0.25g/kg body weight is usually administered between 3-5minutes. The nurse monitors patient’s urinary output every hour (urethral catheter must be passed to ensure this) for 3-4hrs. The urinary output must range between 30-50ml/hr. If patient does not make up to that range, the second test dose is given. If patient still does not make up to the set range, discontinue Mannitol, and call the attention of the physician to review the patient.

Mannitol crystalizes at low temperatures. Therefore the nurse must examine the mannitol solution in bright light to ensure it is clear and free of crystals. The infusion giving set to be used in administering Mannitol should have micro-filters to help in filteration of unidentified crystals. Also, the solution should be warmed close to body temperature (37 degrees celcius) if crystals are seen, to dissolve the crystals.

A large peripheral line or central line should be used to administer Mannitol, especially the concentrations of 20% and above, because of its high risk of venous irritation.

The nurse must constantly assess the cardiovascular, respiratory, neurological and renal function of a patient on Mannitol therapy, by monitoring patient’s blood pressure, heart rate and rhythm, respiratory rate and pattern, breath sounds, hourly urinary output, level of consciousness and the intravenous site (check for any sign of inflammation or irritation).

The nurse also monitors the Mannitol flow rate. Mannitol is usually infused over 30-60minutes. Proper documentation of all nursing activities must be done. Regular monitoring of serum electrolytes, blood urea nitrogen and creatinine must be ensured.

NOTE:
Do not administer Mannitol simultaneously with blood and blood products, to prevent hemolysis or pseudoagglutination. If it is very essential to do so, add 20mEq (same as 20mmol) of sodium chloride to one liter of Mannitol.

Other uses of Mannitol include:
1) Bladder irrigation especially in transurethral surgeries, to minimize the risk of intravascular hemolysis during surgery.
2)Inhaled Mannitol is a bronchoconstrictor used to test for bronchial hypersensitivity/hyperreactivity.
3) Mannitol helps in the measurement of glomerular filteration rate (GFR) because of its ability to pass through the glomerulus freely.

DOSAGE CALCULATION.
Example 1:
A test dose of 0.2g/kg of IV 10% Mannitol was ordered for a patient weighing 60kg.
i) Calculate the dosage of the drug.
ii) How many milliliter of the drug will the nurse administer?

i) Weight= 60kg
Test dose= 0.2g per kilogram
Test dose= 0.2g * 60 = 12g

Test dose = 12g of IV 10% Mannitol.

ii) Remember:
‘10% Mannitol’ means ‘Each 100ml of solution contains 10g Mannitol’

If ‘Each 100ml of solution contains 10g Mannitol’;
…………ml of solution will contain 12g Mannitol?

Simple calculation:
(100*12) ÷ 10 = 120ml

The nurse will administer 120ml of IV 10% Mannitol

Example 2:
IV 20% Mannitol 60g stat was ordered for a head injured patient with raised ICP in the emergency unit.
i) How many milliliter of the drug will the nurse administer?
ii) Assuming 20% Mannitol is out of stock, and the available concentration is 25% Mannitol. Calculate the amount of IV 25% Mannitol the nurse will administer, using the original order.

LET’S WORK IT OUT!
i) IV 20% Mannitol 60g stat
Each 100ml of solution contains 20g Mannitol (20% Mannitol);
…………ml of solution will contain 60g of Mannitol

= (100*60)÷20
= 300ml
The nurse will administer 300ml of IV 20% Mannitol

ii) Ordered concentration is 20%
Available concentration is 25%
Ordered dose is 60g

New dosage = (ordered concentration ÷ available concentration)*ordered dosage
= (20%÷25%)*60g
= 48g
The new dosage is 48g of IV 25% Mannitol.

Each 100ml of solution contains 25g Mannitol (25% Mannitol);
…………ml of solution will contain 48g Mannitol
= (100*48)÷25
= 192ml
The nurse will administer 192ml of 25% Mannitol

Ogunlabi, David (RN).

Advertisements

MANNITOL ADMINISTRATION: AVOIDING ERROR

Mannitol is a 6-carbon sugar alcohol that is used as sweetener in foods. However, in medical practice, it is a non-electrolyte, obligatory osmotic diuretic. It is used in the management of raised intracranial pressure (cerebral oedema), raised intraoccular pressure (glaucoma), and to improve diuresis in the oliguric phase of acute renal failure.

It works by creating an osmotic gradient between the target tissues and the blood. When it is administered, it gets into the blood stream and increases the osmolarity of the blood, and exerts it hyperosmotic effect on the target site by causing the movement of water from that site (area of lower concentration) into the blood (area of higher concentration), and the kidneys eliminate the excess water.

Mannitol diffuses freely through the glomerulus still retaining its hyperosmotic state. It inhibits tubular reabsorption of water, and enhances the tubular excretion of sodium and chloride. This explains its diuretic effect.

Mannitol comes in different concentrations, 5%, 10%, 15%, 20%, 25%. These percentages are essential for accurate determination of the amount (in milliliters) the nurse will administer to the patient.

Before administering Mannitol, the nurse must ensure that the prescription is well written out by the physician.

For instance:
IV Mannitol 50g stat

The above prescription is not well written, because the concentration (percentage) is missing. So the nurse MUST insist on a complete prescription before administering Mannitol.

Now look at this prescription:

IV 20% Mannitol 50g stat

The prescription is now complete. So let’s see how to go about the calculation.

20% Mannitol simply means ‘Each 100ml of the solution contains 20g of Mannitol’.

And this is always written on the drug label.

The percentage (%) translates into the 100ml of the solution.
The ’20’ translates into the 20g of Mannitol

So if Each 100ml of solution contains 20g Mannitol (that is, 20% Mannitol),
How many ml of solution will contain 50g Mannitol?

Simple calculation is required:

(50*100)÷20
= 250ml

The nurse will administer 250ml of 20% Mannitol.

Let’s have a similar prescription with a different concentration:

IV 10% Mannitol 50g stat.

The same principle applies:

10% Mannitol simply means ‘Each 100ml of solution contains 10g Mannitol’

So if Each 100ml of solution contains 10g Mannitol,
How many ml of the solution will contain 50g Mannitol?

Simple maths!

(50*100)÷10
= 500ml

The nurse will administer 500ml of 10% Mannitol

Ogunlabi, David (RN)

USING WATER-FILLED LATEX GLOVES TO PREVENT HEEL ULCER: GOOD OR BAD PRACTICE?

Pressure ulcers are localised areas of tissue damage, usually over a bony prominence, which result from pressure or pressure in combination with shear (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel, 2009).

The heel is the most common site for pressure ulcer formation, after the sacrum (especially patients on supine or semi recumbent). Its vulnerability is due to the thin layer of subcutaneous tissue covering the calcaneous, thus exposing the small blood vessels to injury due to the pressure exerted on it. Diabetes (and other peripheral vascular diseases), immobility and other conditions that compromise circulation to the lower limbs, further contribute to heel ulcer formation.

The use of water-filled latex gloves is an age-long practice. However, it is now outdated.

Several studies have revealed that the pressure that the water-filled latex gloves exerts on the heel is higher than what is exerted when the heels are placed on the mattress. This higher pressure will impede blood flow (circulation) to that area, leading to the development of pressure sore.

It has also been observed in clinical nursing practice that majority of the patients whose heels are supported by the water-filled latex gloves eventually develop blisters in the heel, and when this blisters rupture, they form a very deep ulcer on the heel. The water in the latex gloves has also been observed to seep out on many occasions, creating an environment for pressure ulcer development.

It is therefore advised that patient’s calves be supported with soft pillow, and the heels suspended freely. This will relief the heels of the patient of any pressure whatsoever and improve patient’s outcome.

This should be combined with other methods of preventing pressure ulcers such as regular turning of patients/change in position, treatment of pressure areas, use of water bed, air bed and ripple mattress.

Ogunlabi, David (RN).

THE LADY WITH THE LAMP.

Florence Nightingale (1820-1910), the mother of modern Nursing, brought the nursing profession to limelight. She was a woman of impact, compassionate and dedicated to caring. A purpose-driven lady who dared to dream and against all odds, pursued her dreams passionately, and thus made an indelible mark in the sand of time.

She was the first nurse-theorist who, in her ‘Nightingale Environmental Theory’, explained how nursing care can be provided by utilizing the environment of the patient. She revealed how natural laws can be used to gain access to health. She stated that these natural laws (cleanliness, good ventilation, lighting, warmth, quietness, variety) can prevent diseases, accidents or death; and a deficiency in these factors can produce lack of health.

This theory was triggered by the series of events that occurred during the Crimean war of 1854-1856, when this young lady observed that the wounded soldiers died mysteriously after their transport to the Scutari hospital in Turkey (the closest hospital, located across the Black Sea). Nightingale visited the hospital and saw that the environment was a big mess: the blood-soaked uniforms of the soldiers were not changed after several days, the bed linens were dirty, the sewage system was bad, there was a terrible overcrowding evidence by bed space of 300-500 square feet, the environment was stuffy and choking, the water was bad, the dungs and carcasses of animals were found in the hospital environment. So she stepped into action. Nightingale mobilized 40 nurses to the hospital, and deployed other resources to tackle the identified problems. They opened the windows for good ventilation, changed the uniforms of the wounded soldiers, the sewers were flushed, the dungs and carcasses were buried, potable water was provided, eating utensils were supplied, the wounded soldiers were also treated.

Being a scientific nurse who was skilled and highly knowledgeable in research and statistics, she recorded the outcomes of her care; the mortality rate of wounded soldiers dropped drastically from 42.7% to 2.2%. She showed a causal link between sanitary reforms and the dramatic fall in mortality rate. What an achiever!

This theory set the stage for further nursing theories, and still remains integral part of nursing and health care till date. Nightingale made nursing attractive and famous. She displayed high intellectual prowess coupled with a compassionate attitude to the sick and dying. She laid a good foundation for the nursing profession by making it known that nursing is not just an art, but also a science.

This day, 12th May, the entire nursing community worldwide celebrate the birthday of this heroine and revolutionist who lived an impactful and purposeful life. She came to this world 199 years ago, lived for 90 years, and her works still speak. The light from the lamp is still beaming brighter and brighter.

*Ogunlabi David (RN)*

THEY CAME IN THROUGH THE WINDOW.

Shortly after my final qualifying examination in nursing school, I applied for a job in a private hospital. I was called for interview and was asked to start work the following day. It was an obstertric and gynaecology specialist hospital, so it was an opportunity for me to gather enough experience in that specialty. It was barely two weeks after resumption of duty that I started observing certain strange behaviours from two of the nursing staff. They were not familiar with the nursing process (a framework designed to provide systematic, individualized, client-centered and holistic care to patients), their communication skill (to patients and co-workers) was unprofessional, their nursing practice was obsolete and lacked scientific rationale. They were bold and fearless, damning the consequences for their actions. Their zeal was without knowledge. They looked more like apprentice. So I started some research to know who they really are. I later discovered they were not Registered Nurses (RN). I was shocked. So I have been working with quacks all these while? To cut the long story short, I resigned and got another job.

The whole essence of sharing the above piece is to clearly bring to light what the Nursing profession stands for. Nursing is both an art and a science. It is a full blown profession. It is not (and will never be) apprenticeship. Nursing cannot be taught by one doctor in his hospital or clinic. The best of medical doctors cannot impact Nursing knowledge, skills, ethics and values because they are not trained to do so. We don’t do “freedom” in Nursing. That term is alien to us. Anyone who wishes to be a nurse should go to a nursing school that is accredited by the Nursing and Midwifery council of the country, or better still go to any University offerring Nursing as a course and accredited by the University Commision of that country. Any other route is mere waste of time, money and effort.

Don’t be deceived, it is not everybody you see in the usual white nurses uniform or scrub that is a nurse. And that is why you must always ask, “Are you a registered nurse?”, and watch out for the reaction and response. Don’t be afraid to ask. It is your right. Some came in through the window; they do not have what it takes to enter through the door. They are thieves. Their mission is to STEAL, KILL AND DESTROY. Our dear country is still suffering from the havocs these folks have wrecked and still wrecking through their ignorance.

But is it fair to heap the whole blame on them? What about their trainers? I dare to say those who train them are like them. They (their trainers) are in a dire need of slaves who will run errands for them, wash their cloths, fetch water and carry out other hospital and domestic works. They could even shout on them and slap them when they misbehave. And after an agreed number of years, they gather family and friends together celebrating MEDIOCRITY disguised as “freedom”. They have even stepped up now; it is has been rebranded as “graduation”.

There is hardly any private hospital you go in this country that these QUACKS are not found. The hospital owners are their automatic employer. They also go from house to house, doing private practice. Quacks are toxic to the society, so they are not wanted. Some quacks have made several attempts to sneak into government hospitals but were detected and ejected. Some sneaked in successfully but the periodic verification of results exposed them.

Hospital owners, in a bid to minimize cost, employ these QUACKS and pay them peanuts and eventually turn them to their slaves, running all kinds of errands. This is the perspective of a nurse by an average nigerian. What a wrong misrepresentation! So what you watch in nollywood is a reflection of the ignorance of a large percentage of the populace. It is a big shame on a country like ours.

Please, if you have friends and families who are already into quackery or who planning to plung into it, discourage them from doing so because it is a disservice to humanity. They administer drugs without sound knowledge of pharmacology. They dress wounds without any knowledge of aseptic techniques. Their first line of management has always been copious and liberal intravenous fluid administration irrespective of the disease condition. We have lost counts of the number of lives their actions and inactions have claimed. Parents, stop sponsoring your children to kill. Stop supporting them to cut short precious lives. Encourage them to go to school to receive proper training so that they can be productive, serve humanity and save lives. By so doing, your own lives too will be secured. You never can tell if you will end up in their hands when in serious danger. You reap what you sow.

COMPASSION FATIGUE (Part 1)

We have not been directly exposed to the trauma scene, but we hear the story told with such intensity, or we hear similar stories so often, or we have the gift and curse of extreme empathy and we suffer. We feel the feelings of our clients. We experience their fears. We dream their dreams. Eventually, we lose a certain spark of optimism, humor and hope. We tire. We aren’t sick, but we aren’t ourselves.”
– C. Figley, 1995

There are usually two sides to the nurse-client relationship: it can be very satisfying/fulfiling and at the same time, extremely distressful. The fulfilment one gets when a patient who used to be deeply unconscious, gradually regains consciousness; the joy of seeing our patients smile following a significant improvement in health status; the inner tranquility of giving one’s best to patients after each shift; the privilege to help patients go through devastating experience and come out strong: these and many others culminate into satisfaction, which is key to the well being of the nurse. It boosts self esteem, rejuvenates energy reserves and encourages better performance. Other factors that bring satisfaction include: a healthy and friendly work environment, good and fair supervision, good leadership, professional competence, regular promotion at work, adequate staffing and availability of equipment and work tools.

However, being constantly exposed to several traumatizing events in the course of caring for the patient can cause a distressing emotional response by the nurse. This results from her empathy (compassion), thereby sharing/bearing patient’s suffering and feeling their feelings. This weighs her down and drains her energy reserves, thus lacking the capacity to care and show compassion. The cumulative effect of these events results in compassion fatigue (CF). It is also referred to as secondary traumatic stress(STS) because it results from the patient’s distress (primary stress). It is also called, “the cost of caring”.

Considering the strategic roles nurses play in patient care, the intimacy, the trust, the good rapport established with the client and the empathy; our emotions get so involved that we begin to feel their pains and bear their hurts and sufferings, though subtly. The nurse working in the emergency unit gets exposed to a lot of traumatizing and life threatening events. The palliative nurse who gives end-of-life care to her patients cannot help but sympathize with these dying patients. The nurse who takes the delivery of a still birth is touched deeply and tries to give comfort to the parents even though she is also in need of help. The shock of suddenly losing a patient and the pain of breaking the news to the relatives of the client. These experiences have the capacity to cause a shift in the world view of the nurse. This concept is termed “vicarious traumatization”.

.….to be continued.

Ogunlabi David (RN).

LOADING DOSE ALONE IS NOT ENOUGH.

Training and development, though often used together, are not the same. Training is short term, development is long term. Training is the foundation, development is building on the foundation that was laid. Training is time bound, development is for a lifetime. Training is usually aimed at a group, development is about an individual (it is personal).

We get trained in our nursing schools and universities to become certified as PROFESSIONAL NURSES. This training impacts us with the basic and fundamental knowledge and skills, which equips us for service. We can liken training to the loading dose of a medication; and development will be the maintenance dose. Truth is, what keeps us potent, sharp, competent, proficient and vibrant in nursing practice is not just what we are trained to do, but much more, what enhances them. So development is an enhancer, a sharpner, a fan (fanning our skills to flame).

Our motive for studying and reading very hard in school must be checked. Examination has been identified as the key reason why students read. Take away examination factor, a lot of students will naturally loose interest for books. This is posing a threat to the glorious emergence of nurses and nursing. The minds of our nursing students have been conditioned to read just to pass examination. Alas, when such students later become nursing staff, they lack the drive for self-development. Ideally, as one climbs up the rungs of professional ladder, one’s level of knowledge ought to increase proportionately. But reverse seem to be the case as you hear older nurses asking the younger ones to remind them of the current trend of practice, claiming they left school a long time ago (a sign that the axe is blunt). This fits perfectly into the frame of training void of development.

The older and more experienced nurses should be looked up to by the younger ones for knowledge, insights and clarifications. This will remain a mirage if we do not deliberately and proactively embrace DEVELOPMENT in our career. Development should be a part of the routine activities and responsibilty of the employer. But it is unfortunate that many health facilities rarely have a structure that motivates knowledge-seeking behaviours of its employees. Nurses are therefore encouraged to take the initiative by doing the needful: organize teachings, attend seminars and workshops (of course, not without a cost), conduct research, take advantage of every opportunity to learn new things. Clinical handover and ward rounds are good period to impact knowledge and learn new things.

Take some time off work to advance in your career development. Career progression can be very fulfiling and it boosts self esteem. A lot of nurses are bitter for this same reason, so be wise. After your Masters degree, please go for your phD. Keep moving, don’t be discouraged. Take courses from other fields that are related to nursing. Don’t be too rigid. Take courses on management and leadership, research, psychology, to mention a few. Mandatory courses should be attended with a good and ready heart.

Remember, the loading dose alone isn’t enough to get rid of micro-organisms, you need the maintenance dose also.

#davidthenurse