The Advocate

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The Advocate



     Winter, 2008 Central Ohio Chapter Volume 18, Issue 3 Association of

     Rehabilitation Nurses FROM THE PRESIDENT…

     By: Norma Clanin MS, RN, CRRN

    Rehabilitation nurses have always known the value of the therapeutic

    rehabilitation milieu - the environment in

    which we practice. All hospitals, skilled care COARN Upcoming Education Events facilities and clinics are usually pretty good at Chapter Meeting

    “Neglect in Acquired Brain Injury” creating a physically accessible environment.

    Speaker: Sharon McDowell, MD Wide doorways, roll-in showers, accessible

    April 15, 2008; 6pm sinks, automatic doors, etc…are all easily Rothermich Room, Dodd Hall seen, measured, adjusted and created. What 480 Medical Center Dr can make rehabilitation so unique is the Columbus, OH 43210

    attitude of the staff and the social environment

    in which we provide care. It is an COARN Board of Directors environment where we provide superb President

    physical care, while, at the same time, Norma Clanin MS, RN, CRRN conveying that life has value. The patient President-Elect

    who has a brain tumor, the one who has had a Maureen Musto MS, RN, CRRN stroke, the person who has a spinal cord injury Treasurer

    - they are here on our rehab unit with life. Deb Thomas RN, CRRN Sometimes we do not know how long that life Secretary

    may continue; but for the present time, they Toni Grice RN

    are with us. Sometimes we know that the Directors

    person will most likely have a long, Lynne Genter MS, RN productive life ahead. As professional Patty Organ RN, CRRN rehabilitation nurses we convey caring and Sharon Scott RN

    hope to all; that they will be more

    Co-Editors independent tomorrow; that they will be able

    Maureen Musto MS, RN, CRRN to cope with our guidance; that they hopefully

    Cindy Gatens MN, RN, CRRN-A will be able to go home; that they will be able

    Submit newsletter articles to Maureen Musto to resume many of their former activities; that

    at they may marry and raise a family. We will


    teach them how. The milieu is therapeutic when it is planned and deliberate. All of our interactions with patients and families make an impact - good or bad; encouraging or discouraging. With length of stay on our rehabilitation units remaining relatively short in comparison with our patients' long journey of progress toward healing, it has become even more important to make every one of our interactions with patients deliberate. Catheterizations are not done without teaching something; patient turns always include comments about the condition of their skin and why and where we are checking; getting ready for therapy means always having the patient do what they can and try something they could not do yesterday; conversations include less social chit-chat and more teaching and guidance. What's the difference between a med-surg unit and a rehab unit? It is not the nursing skills you see being done - IT IS THE NURSES! Rehabilitation nurses create the milieu where our patients and their families can heal physically, emotionally and socially. Take pride in being a rehabilitation nurse - not everyone can do it and do it well!

Diabetes Education

     By Maureen Musto RN, MS, CNS, AP-BC, CRRN

    Diabetes is a condition that causes problems with insulin production or utilization. According to the American Diabetes Association (ADA, 2005), 7% of the United States population, 20.8 million people, have diabetes. Diabetes was the sixth leading cause of death listed on U.S. death certificates in 2002. The total estimated cost of diabetes in the United States in 2002 was $132 billion. Diabetes alone represents 11% of US health care costs with $40.3 billion spent for inpatient hospital care. Diabetes related hospitalizations totaled 16.9 million days in 2002.


    There are two main types of diabetes: Type 1 and Type 2. Type 1 diabetes accounts for 5% to 10% of all diagnosed cases of diabetes (ADA, 2005). Although the cause of Type 1 diabetes is unknown, it is thought to be the result of a genetic-environmental reaction (McCance & Huether, 2002). Type 1 diabetes develops when the body’s immune cells destroy beta cells in the pancreas. Beta cells make insulin, which regulates glucose. Therefore, those who are diagnosed with Type 1 diabetes will need insulin injections to prevent hyperglycemia and associated complications.

    Type 2 diabetes is more common and accounts for about 90% to 95% of all diagnosed cases of diabetes (ADA, 2005). Cellular resistance to the effect of insulin is a major factor in Type 2 diabetes (McCance & Huether, 2002). As the disease progresses there is some type of B-cell dysfunction. Risk factors for Type 2 diabetes include aging, family history, race/ethnicity, obesity, and sedentary lifestyle. Abdominal adiposity (waist-to-hip ratio greater than 1) appears to be the greatest risk factor. Individuals with Type 2 diabetes are often overweight, hyperlipidemic, and hypertensive.

    Chronic complications of diabetes may be manifested as problems with neuropathy, vascular disease, and infection (McCance & Huether, 2002). Vascular changes include microvascular disease (retinopathy and diabetic nephropathy) and macrovascular disease (coronary artery disease, stroke, and peripheral vascular disease). It is extremely important for those diagnosed with diabetes to maintain glycemic control to prevent these complications.

    Diabetes is an ever-growing problem in our society. Obesity and sedentary living are powerful determinants of diabetes (Wylie-Rosett, 2006). With obesity becoming more prominent, diabetes will be even more prevalent. Diabetic patients in the hospital setting often have a co-morbidity that is perpetuated by their lack of diabetes management. Cardiovascular, renal, and peripheral vascular diseases as well as infection are often the admitting diagnoses of these patients.

     Controversy has existed as to whether the hospital setting is the best place to educate the person with diabetes (Nettles, 2005). It can be argued that patients are unable to retain information in an acute phase of illness or that hospital staff lack the knowledge to educate. However, in the outpatient setting patient reimbursement for education is limited and the amount of education a patient receives is variable. Therefore, education should be provided in both settings.

    Research suggests that diabetes self-management education is associated with improved glycemic control in both Type 1 and Type 2 diabetes (Strine, 2005). Diabetes can be a progressive disease, and new management skills may need to be learned over time. The ADA recommends that education be provided on an ongoing basis, and that diabetes self-management education be an integral component of medical care.


    It has been estimated that 50 80% of people with diabetes have significant deficits in

    knowledge pertaining to disease management (Strine,, 2005). A Healthy People 2010 objective is to increase the proportion of people with diabetes who receive formal diabetes self-management education from 40% in 1998 to 60% by 2010.

    A task force made up of multiple organizations, federal agencies, and federally funded programs has established national standards for diabetes self-management education (Mensing,, 2002). This task force consisted of the following: American Diabetes Association, American Association of Diabetes Educators, American Dietetic Association, Veteran’s Health Administration, Centers for Disease Control and Prevention, Indian Health Service, National Certification Board for Diabetes Educators, Juvenile Diabetes Foundation International, and Diabetes Research and Training Centers. These organizations have come together to formulate standards in regard to diabetes self-management education, because it is the cornerstone of care for all individuals who want to achieve successful health-related outcomes. These standards were to be implemented in diverse settings and facilitate improvement in health care outcomes.

    According to a study done by Persell, et al. (2004), knowledgeable patients were more likely to perform self-management activities. If patients would manage their diabetes and maintain good glycemic control, the rate of diabetic complications should decrease. Studies have shown that systematic control of glucose levels, blood pressure, and cholesterol in patients with diabetes can reduce the risk of them developing complications and result in considerable cost savings to the health care system (Greusinger, 2004).


    American Diabetes Association. (2005). National Diabetes Fact Sheet, 2005. Retrieved

    February 13, 2006 from

    American Diabetes Association. (2005). Direct and Indirect Costs of Diabetes in the United

    States. Retrieved February 13, 2006 from

    Greisinger, A., Balkrishnan, R., Shenolikar, R., Wehmanen, O., Muhammad, S., &

    Champion, P. (2004). Disease Management, 7(4), 325-332.

    Nettles, A.T. (2005). Patient Education in the Hospital. Diabetes Spectrum, 18(1), 44-48.

    Mensing, C., Boucher, J., Cypress, M., Weinger, K., Mulcahy, K., Barta, P., Hosey, G.,

     Kopher, W., Lasichak, A., Lamb, B., Mangan, M., Norman, J., Tanja, J., Yauk, L.,

    Wisdom, K., & Adams, C. (2002). National Standards for Diabetes Self-Management

    Education. Diabetes Care, 25 (suppl. 1), s140-s147.

    McCance, K. & Huether, S. (2002). Pathophysiology The Biologic Basis for Disease in Adults th& Children. (4 ed.). Mosby Publishing: St. Louis, Missouri.

    Persell, S., Keating, N., Landrum, M., Landon, B., Ayanian, J., Borbas, C., & Guadagnoli, E.

    (2004). Relationship of diabetes-specific knowledge to self-management activities,

    ambulatory preventive care, and metabolic outcomes. Preventive Medicine, 39, 746-


    Strine, T., Okoro, C. Chapman, D., Beckles, G., Balluz, L., & Mokdad, A. (2005). The impact

    of formal diabetes education on the preventative health practices and behaviors of

    persons with type 2 diabetes. Preventive Medicine, 41, 79-84.


    Wylie-Rosett, J., Herman, W., & Goldberg, R. (2006). Lifestyle intervention to prevent

     diabetes: intensive and cost effective. Current Opinion in Lipidology, 17(1). 37-44.

Pharmaceutical Product Recalls and Backorders

    By: Michael Ganio, BS, PharmD

     thOn February 28, 2008, Baxter International Inc. voluntarily recalled all lots and doses of heparin sodium products with the exception of premixed heparin infusion bags. Baxter implemented the recall in response to an increase in adverse event reports, including life-threatening hypotension. While reports of adverse reactions had been documented with the multi-dose vials, Baxter decided to take the extra precaution of recalling all heparin products. Baxter manufactures approximately half of all heparin vials supplied in the United States.

    While recalls this large are rare, drug recalls, shortages, and backorders are quite common. Some of the major reasons for shortages include issues with manufacturing, discontinuations by the manufacturer, and limited manufacturing capabilities.

    Manufacturing issues can occur when the supply of any material used in the production of the final medication is interrupted. This includes both active and inactive ingredients, chemicals used in the process, and even packaging equipment. Manufacturing can also be interrupted because of either chemical or biological contamination within the facility producing the medication.


    Some companies may decide to stop manufacturing a particular medication. If that company is the only producer of a medication, the medication is then no longer available. If there are a limited number of manufacturers of that product, a shortage may occur while the other producers increase their ability to manufacture more of the medication.

    In the event of a drug recall or shortage due to backorder, members of the health-care team should collaborate to determine the most appropriate alternative therapy for the patient. Several resources are available to help health-care providers:

The American Society of Health-System Pharmacists Drug Shortage website:

FDA Drug Shortage website:

Your institutional pharmacist is also a great resource for information regarding drug shortages.

Carbohydrate Counting

     By: Nicole Reed Benameur, R.D., L.D.

    and Breanne Shirk, OSU Medical Dietetics Intern; Winter 2008

What is carbohydrate counting?

    Carbohydrate counting can be used to track and balance the amount of carbohydrates in your diet in order to keep your blood glucose levels under control. Through the use of food labels and correct portion sizes, you can count the grams of carbohydrates in your diet. Foods are made up of 3 components: carbohydrate, protein, and fat. Carbohydrates affect blood glucose levels the most.


Which foods contain carbohydrates?

    ; Foods containing starch such as bread, bagels, biscuits, crackers, cereal, pasta, and rice.

    (Choose whole grain varieties more frequently)

    ; Starchy vegetables such as corn, peas, potatoes, and sweet potatoes. ; Dried beans and peas, including kidney and pinto beans and black-eyed or split peas. ; Fruits and fruit juice (canned, dried, and fresh).

    ; Milk and yogurt

    ; Sweets (cake, cookies, ice cream, jam, jelly, and sugar).

    ; Snack foods (popcorn, potato chips, pretzels).

How many carbohydrates do I need?

    The amount needed is based on your height, weight, and activity level. As a standard, women need about 45 grams per meal or 3 carbohydrate servings per meal. Men need about 60 grams per meal or 4 carbohydrate servings per meal.

    *****15 grams=1 carbohydrate serving*****

Why should I pay attention to serving sizes for carbohydrate foods?

    The amount of carbohydrate consumed can make a huge difference in your blood glucose. For example, if you eat more carbohydrates than usual at dinner, your blood glucose will most likely be higher than usual several hours later.

How do I know how many carbohydrates are in my food?

    Remember that 1 carbohydrate serving is equivalent to 15 grams of carbohydrate. For basic

    foods, you can refer to the chart below or read the Nutrition Facts on food labels.

    Carbohydrate Serving Sizes (approximately 15 grams)

Starch Group1 serving equals: Fruit Group1 serving

    ; 1 slice of bread or 1 biscuit equals:

    ; ? hamburger bun ; 1 small piece of fruit

    ; ? cup mashed potatoes/corn (~4oz)

    ; 1/3 cup cooked rice or pasta ; ? cup orange juice

    ; ? cup beans and peas ; ? cup canned fruit

    ; Approx. ? cup cereal (check food labels) ; 1 cup grapes (~17 sm.

    ; ? cup cooked cereal grapes) Other1 serving equals:

     ; ? cup dried fruit ; ? cup salad dressing Milk Group1 serving ; ? cup berries ; Unfrosted cake/brownie (2 equals: ; 1 ? Tbsp. 100% fruit inch square) ; 1 cup milk spread ; ? cup spaghetti sauce ; 1/3 cup dry milk ; 1 Tbsp sugar ; 6 oz. yogurt ; 3 cups popcorn ; ? cup ice cream

     ; 15-20 baked snack chips

    ; 9-13 snack chips 7

    ; 6 saltine crackers

    When looking at food labels, you first need to look at the serving size and compare that to the amount you are eating. Then, look for the grams of carbohydrate.

    Nutrition Facts

    Serving Size: 6 crackers

    Total Carbohydrate: 15g

     One carbohydrate serving: 6 crackers

    If the total carbohydrate is greater than 15 grams, simply divide the total number (in grams) by 15 to determine what serving size is equal to one carbohydrate serving.

    Nutrition Facts

    Serving Size: 4 cookies

    Total Carbohydrate: 30g

     One carbohydrate serving: 2 cookies (15g)

What about the other food groups?

    Non-starchy vegetables: Foods such as broccoli, carrots, onions, spinach, tomatoes do not provide a significant amount of carbohydrates (5 grams or less per serving). Thus, foods in this group should not be limited.

    Meat group: This group includes meat, fish, poultry, and cheese. The meat group does not contain any carbohydrates. However, the fat content can vary so you want to choose low-fat meats such as skinless chicken breast, turkey or fish. Also, avoid those high in fat such as bacon and sausage. Cooking methods can also determine the amount of fat (i.e. bake instead of fry).

    Fat group: Fats do not contain any carbohydrates; however, they are high in calories. It is important to choose healthy fats, such as canola and olive oils over butter.

    Fiber: A high fiber diet can help control your blood glucose. Fiber is found in fresh fruits and vegetables, whole grains, beans, and lentils. Choose these high fiber foods as your carbohydrate servings instead of fruit juices and white bread.

*Information adapted from OSUMC One Source Handout “Carbohydrate Counting”


    Penne with Chicken and Vegetables

    This tasty meal provides protein, carbohydrate, and veggies all in one dish.


Number of Servings: 6

    Serving Size: about 2 cups


    Cooking Spray

    Olive oil 1 Tbsp

    Uncooked penne pasta (100% whole wheat) 9 oz

    Boneless, skinless chicken breasts cut into 1-inch strips 1 lb Broccoli florets 2 cup

    Medium red bell peppers, sliced into thin strips 2 peppers Medium yellow squash, sliced 2 squash

    14 oz. can no-salt added diced tomatoes, juice drained 1 can White wine ? cup

    Dried basil ? tsp

    Dried oregano ? tsp

    Salt ? tsp

    Ground black pepper ? tsp

    Grated Parmesan cheese ? cup


    1. Cook pasta according to package directions, omitting salt.

    2. Coat a large nonstick skillet with cooking spray. Over medium-high heat, cook chicken

    strips for approx. 3-5 minutes or until done. Remove from pan and set aside.

    3. Add olive oil to pan. Sauté broccoli, red peppers, and squash 3-4 minutes. Add tomatoes,

    wine, herbs, salt, and pepper. Cook for 5-7 more minutes.

    4. Toss chicken and vegetable mixture with drained, cooked penne pasta. Sprinkle with

    Parmesan cheese.

Nutrition Info:

    2 starch, 2 vegetable, 2 lean meat

Amount per serving:

     Calories 333 (calories from fat 61)

     Total Fat 7g (sat. fat 2g)

     Cholesterol 51mg

     Sodium 250 mg

     Total Carbohydrate 40g

     Dietary Fiber 5g

     Sugars 6g

     Protein 28g Taken from:



    By: Michele Rinkes RN, CRRN

    In the Ohio legislature, House Bill 346 the safe staffing bill, is before the House Health

    Committee. Nurses make up 54% of the health care workforce. Factors that affect a nurse’s performance significantly impact the health care system as a whole. This bill would require hospitals to establish a nursing care committee made up of a significant number of staff nurses to determine staffing recommendations as developed by ANA. It would take into consideration patient acuity and the hospital’s ability to provide additional nurses when patient’s needs unexpectedly exceed the planned workload for direct patient care nurse. You can show your support for this much needed bill by writing, calling or E-mailing your congressman. If you need help with this, go to

    Of particular interest to rehab nurses is the issue of Consumer-Directed care, the proposal whereby the disabled would be able to choose and train their own providers to perform certain health maintenance activities including self-administration of medications. Nurses want input to make this as safe as possible. The legislation that comes out of this will serve as a template for other organizations such as the Department of Aging.

    Two Mid-Ohio nurses, Linda Wagner and Elaine Haynes have been named to the Nursing Education Study Committee. This committee is charged with finding ways to get the dollars that were set aside by HB 119 to support graduate education for nurse educators.

    Nationally, Congress passed legislation to offer regulatory relief for long-term care hospitals by permanently setting the inpatient rehab facilities compliance threshold at 60%. This would allow hospitals to continue using co morbidities to determine whether a patient qualifies for inpatient rehabilitation.

     ndNurses Day at the Statehouse is April 2.Register on the ONA website. It will probable

    sell out quickly.

    The general Election is in November. Be a knowledgeable voter and get out and VOTE!


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