RSSRecent Articles

Subscribe to Nurse Leader Insider!

Get expert advice, tips, and best practice strategies on nursing burnout, recruitment and retention, communication, leadership, and much more!

Subscribe to the Nurse Leader Insider for FREE now!

Patient Safety Movement Announces Progress Toward Goal, Change in Leadership

By Jay Kumar

This first appeared on PSQH on January 18, 2019.

Patient Safety Movement (PSM) has made major progress toward its goal of zero preventable deaths worldwide by 2020, even though it likely won’t achieve that goal, PSM founder and CEO Joe Kiani told attendees Friday at the group’s 7th annual World Patient Safety, Science & Technology Summit in Huntington Beach, California.

That said, PSM plans to continue to aggressively pursue its efforts to reduce and eliminate medical errors through aligning with healthcare leaders, doctors and nurses, patients and families, politicians and medical technology companies.

“Our goal of zero preventable deaths by 2020 is daunting,” Kiani said. “If we’re not going to get to zero, we at least have to give it our all. I’m going to give it my all. We have to…Don’t let your miracle of healing get hijacked by some medical error.”

Kiani announced that he is stepping down as PSM’s leader, with David Mayer, MD, vice president of quality and safety for MedStar Health and executive director of the MedStar Institute for Quality and Safety, taking over as CEO effective immediately. In addition, Michael A.E. Ramsay, chairman of the Department of Anesthesiology and Pain Management at Baylor University, will be the incoming chairman of the PSM Foundation board. Kiani, who is found and CEO of medical technology firm Masimo Corporation, said he will remain active in the group by serving on the board.

“I’m not quitting, I’m not leaving,” he said. “This is about the mission. I’m going to help you like the two of you helped me.”

Ramsay lauded Kiani’s efforts and urged attendees to keep moving forward. “For every life that’s lost, there’s probably 1,000 patients that have avoided harm,” he said. While PSM has been successful in raising awareness and spreading education, “we have a lot more to do.”

Asked if there will be a new goal after 2020, Ramsay noted that PSM initially began as a U.S.-focused effort, and now it has gone global. Kiani said the goal could be revised to zero deaths by 2025 or 2030, but nothing official was announced.

Mayer noted that PSM has created urgency in the healthcare industry to improve processes. Another big step forward was bringing patients and families into the effort. “It’s about the transparency,” he said. “It’s about learning from the event.”

“We’ve got to make our hospitals safe,” Ramsay added. “Families want to get to the safe place, and that’s home, not the hospital.”

What’s also necessary is to improve education in medical and nursing schools, Mayer said.

One of PSM’s major efforts is to create a series of 18 Actionable Patient Safety Solutions (APSS) that it has encouraged healthcare organizations to implement as they work to reduce preventable patient harm.

“We need to treat every death as a plane crash that you learn from instead of a car crash, where you say that happens,” Kiani said.

Even as he discussed the progress made by PSM over the last several years, Kiani voiced frustration at the apathy he still finds in the healthcare industry when it comes to making radical changes to reach the group’s goal of zero preventable deaths.

“One life is one too many that we lose, and we’re losing millions a year,” he said. “How can anyone not be willing to do anything and everything to stop reckless care?”

Eight new anticoagulant EPs added to NPSG

By Accreditation Insider

The Joint Commission announced revisions to its anticoagulant therapy National Patient Safety Goal (NPSG) on December 7. NPSG 03.05.01 has eight new Elements of Performance (EPs). The accreditor wrote that the changes are a response to a rise in adverse drug events tied to direct oral anticoagulants.

All the changes are listed in R3 Report 19 and will take effect on July 1, 2019. The update applies to all Joint Commission accredited hospitals, critical access hospitals, nursing care centers, and medical centers accredited under the ambulatory health care program.

The update comes nine days after The Joint Commission released updates to its suicide prevention NPSG. Those changes will also go into effect in July.

The update requires impacted facilities to:

  • Have evidence-based protocols for starting, continuing, and reversing anticoagulant treatment
  • Establish processes for responding to adverse drug events and bleeding
  • Educate patients on anticoagulant treatment
  • Use devices desinged to reduce dosing errors, such as programmable pumps and pre-filled syringes

Before the Plane Crash

In January 2009, all eyes were focused on the Hudson River after a plane flying out of New York’s LaGuardia Airport struck a flock of geese and crash landed in the river. Thanks to fast acting by the pilots, all 155 passengers survived, with few major injuries, in the disaster dubbed “the Miracle on the Hudson.” However, trouble emerged in the aftermath when people tried to find out which hospital their loved ones had been sent to.

“Some of the patients went to New York and some went to New Jersey. And because of HIPAA laws, it was very difficult for airline authorities to get the names of who was where,” says Sharon Carlson, RN, director of Emergency Preparedness at Sharp HealthCare in San Diego, CA. “As a family member you can imagine your terror knowing that your loved one was in a plane crash and not knowing where they are. That’s a big issue we always have, reunifying people after a disaster.”

“Because of [the Miracle on the Hudson] we decided in San Diego that we needed to make relationships before an event happens,” she adds. “Get to know each other, work together, know each other by first name, know each other’s number.”

Using the lessons learned from the Hudson, Carlson and her health system joined a disaster partnership with their local airport, San Diego International (SAN.) The airport has been growing steadily over the past decade, with over 22 million people flying in and out of it in 2017. The airport partnership was started originally in 2010 by UC San Diego Health system.

The transportation administration requires SAN to conduct major disaster drills periodically. As part of the partnership, Sharp Healthcare is included in those drills, Carlson says. They practice their communication process once a year to ensure everybody is on the same page and that there’s been no changes in the contact information.

“We have a partnership with the airports, so they know who to contact at our hospitals,” she says. “And we’ve sent it through our compliance and legal departments, they know what kind of information we can give them.”

In the event of a plane crash or disaster, airport staff have a list of hospital contacts so they can reach out, then read names off the plane’s manifest and the hospital will be able to tell them which people on the list are there or not.

“We don’t give out conditions, injuries, or illnesses,” she says. “We just say if they’re here or not. Because the airline is wanting to tell the family members ‘ok, go over here, your loved one is at this hospital.’”

HFAP Ligature Standard Remain Same After CMS Memo

This first appeared August 23, 2018 in Hospital Safety Insider.

HFAP, one of the oldest accrediting organizations for U.S. hospitals, recently updated 13 of its standards to align with the expectations on ligature risk and other hazards that CMS outlined in a memo in December. The standards have been approved by CMS, but will not be revised again in light of the July memo, says Alise Howlett, AIA, CFPE, CHFM, HFAP’s emergency management, physical environment, and life safety standards advisor.

The July CMS memo states that surveyors would use Joint Commission ligature recommendations. Howlett says that the additional guidance is simply that, additional guidance.

The updated HFAP standards range from staff training on identifying patients for risk of self-harm to building safety policies and monitoring, from building security to life safety compliance, from privacy and safety concerns in a safe setting to requirements for environmental risk assessments.

“The HFAP standards have been approved by CMS and simply outline updates for accreditation expectations. They will be enforced per the direction of CMS which stated that AOs will use their judgment as to the identification of ligature and safety risks, what level of citation will be made for deficiencies, and the corrective action to be taken for mitigation and remedy. This is all outlined in QSO 18-21,” says Howlett.

HFAP was not part of The Joint Commission’s panel of experts, but “all accrediting organizations with deeming authority are working from the same playbook: the CMS regulations,” says Howlett.

IHI Launches Maternal Care Improvement Project

This first appeared August 22, 2018 on PSQH.

The Institute for Healthcare Improvement (IHI) has begun a three-year project that aims to improve maternal outcomes for women and babies in the U.S. Supported by a grant from Merck for Mothers, the project’s goals are to spread the use of evidence-based care practices to reduce complications such as hemorrhaging, hypertension, and blood clots. It also plans to implement strategies to reduce disparities in maternal outcomes, and partner with women, their caregivers, healthcare providers, and community initiatives to better learn and address factors to improve health outcomes for mothers and newborns.

“IHI has proven experience in helping healthcare providers adopt and scale up best practices that save lives across whole systems, regions, and countries,” said Trissa Torres, MD, MSPH, FACPM, chief operations and North American programs officer at IHI, in a release. “We believe that by forging partnerships with others working on these problems and combining existing expertise with IHI’s improvement methodology, we can significantly improve care delivery outcomes for new and expectant mothers.”

Annually, an estimated 750 women die in the U.S. as a result of complications of childbirth, with more than 50,000 suffering serious complications, according to the IHI. African-American women have maternal mortality rates estimated to be three to four times higher than those of white women.

Merck for Mothers is a 10-year, $500 million initiative to help improve maternal mortality rates. The program began in 2011 and has expanded to more than 30 countries.

CDC says Heparin Syringes may have caused bloodstream infection outbreak

From PSQH Magazine

The Centers for Disease Control and Prevention (CDC) has confirmed 14 cases of bloodstream infections in children that may be linked to syringes of heparin and saline made by Becton Dickinson and Co., Reuters reported. The cases were caused by the same strain of the Serratia marcescens bacterium.

The infections occurred in seriously ill children who received intravenous medications through a catheter or central line in Tennessee, Colorado, Minnesota, and Ohio. No deaths have been associated with the infections and the number of cases is dwindling, the CDC said.

Health officials started testing the Becton Dickinson products after discovering the syringes had been used to treat several of the infected children. Saline or heparin are often used to flush central lines to keep them clear.

Reuters reported that so far, none of the Becton Dickinson products have tested positive for the bacterium. In April, Becton Dickinson recalled 949 lots of its BD PosiFlush Pre-Filled Heparin Lock Flush Syringes and Pre-Filled Normal Saline saline flush syringes sold between February and December 2017.

All of the recalled products were made at Becton Dickinson’s facility in Franklin, Wisconsin.

Lead the charge for change and innovation

As leaders in healthcare organizations, it is often a nurse manager’s responsibility to be a driver of change. And while effective leaders work hard to help release creative energy within their facilities, staff must understand what is valued in order to support this.

When attempting to create an environment that enhances change and supports innovation, consider the following questions:

  • Is there consistency in beliefs and assumptions among those who leave your facility?
  • Do staff members believe rewards are distributed equally?
  • Do management tempers frequently flare up?
  • Are management behaviors consistent, or do staff members always have to be alert for the decision of the moment?
  • Do you support innovation and change?
  • Is your approach consistent, or does it reflect the issue of the moment?

When trying to influence change it is also important to seek information and advice about best practices from outside your facility. If you are able to look objectively at yourself as a leader and at what you value, you will be more successful as a change agent.

What else should nurse managers consider when trying to create an environment that supports change?

Dealing with Difficult Patients: Helping patients sleep better

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

A cat eats and sleeps. Then maybe it plays with some string. A cat eats and sleeps. Then maybe it stretches. A cat eats and sleeps. Then maybe it curls up on your lap. A cat eats and sleeps.

If only our patients were cats, sleeping and eating without any concerns. Unfortunately, our patients are people. And many people suffer from two very common conditions: problems sleeping and problems eating. As a nurse, you need to have a tool kit of helpful hints and tricks to help your patients.

Catch up on your zzz’s
The normal sleep cycle is about one-and-a-half hours in length and includes passing through five stages of sleep: Stages 1, 2, 3, and 4 are sometimes called non-rapid eye movement sleep, and are followed by a period of rapid eye movement (REM) sleep.

Stages 1 and 2 are periods of light sleep during which eye movement, heart rate, and breathing slow down. Stages 3 and 4 are deeper periods of sleep. People awakened during these stages often feel disoriented and groggy. It is the deeper stages of sleep—REM sleep—that refresh the body. It is a time when breaths quicken, the heart beats faster, muscles become immobile, and the person experiences vivid dreams.

In search of some rest
People of all ages can experience trouble sleeping. Parents complain that babies and children have erratic sleep patterns; teens are notorious for staying up all night and wanting to sleep during the day; adults complain of not getting enough sleep; and older adults complain that they have trouble staying asleep.

Activities that help promote sleep are the same throughout a person’s life­span. First, make sure your patients have careful and comprehensive assessments of their sleep problems. For example, if a person is having trouble sleeping because of allergies or enlarged tonsils and adenoids, these need to be addressed. People with restless leg syndrome or other limb movement disorders need to be evaluated and treated properly. Obstructive sleep apnea, a serious cause of sleep problems, also needs prompt attention.

Here is a list of hints that you can give your patients to help them sleep and feel rested in the morning:

Avoid stimulants. Cutting caffeine at least four to six hours before bedtime can help a patient fall asleep easier. Caution them to avoid using alcohol as a sleep aid. Alcohol may initially help a person fall asleep, but it also causes disturbances in sleep resulting in less restful sleep. Restrict nicotine, as it too is a stimulant.

Relax before bedtime.
Provide time for quiet activities in the hour before bedtime. Try reading something light or doing some light stretching. Many nurses use aromatherapy for its relaxant effect, and commonly used essential oils include oils of chamomile, jasmine, lavender, neroli, rose, and marjoram. Add a few drops to a warm bath or sprinkle a few drops on a handkerchief or pillow. It is important to understand the difference between essential oils and fragrances.

Other bedtime relaxation rituals that might work include asking the patient to gently wiggle his or her toes. You could also give him or her a head message, and/or ask the patient to apply lotion to his or her hands and feet.

Provide for a comfortable bedroom situation. Keep the patient’s bedroom as quiet, dark, and comfortable as tolerated. For many people, even the slightest noise or light can disturb sleep. Ear plugs and eye masks may help. Ideal room temperatures for sleeping are between 68°F and 72°F. Temperatures above 75°F or below about 54°F can disrupt sleep (Kryger et al.).

Eat right, sleep tight. Help the patient to eat sensibly during the day and to avoid heavy meals before bedtime. Foods high in tryptophan, such as milk, can promote sleep. The patient can also try a bit of carbohydrate in the form of cereal or a banana, and should avoid overeating, as this may cause indigestion.

Caution the patient to avoid drinking fluids after 8 p.m. Waking up to go to the bathroom may disrupt sleep and the patient may not be able to fall asleep again once disrupted.

Start a routine. Do not allow the patient to nap during the day. Waking up at the same time in the morning helps develop a sleep rhythm.

Just (help them) relax!
Progressive relaxation and relaxation breathing exercises can also aid in sleep. Progressive muscle relaxation (PMR) was described by Edmund Jacobson, MD, PhD, in the 1930s, and is based upon his premise that mental calmness is a natural result of physical relaxation. It is a deep relaxation technique that has been used to relieve insomnia as well as aid in the reduction of stress, anxiety, and pain. Simply stated, PMR is the practice of tensing (tightening) a muscle group and then releasing (relaxing) it, followed by moving on to another muscle group and repeating the process until you have systematically tensed and relaxed all muscles in the body.

Almost anyone can learn PMR. Usually it is best to start at the head or the feet. For example, start at the head and work down through all the body muscle groups, or start at the feet and work up to the head. Practicing relaxation breathing at the same time you practice PMR adds benefit.

Many people like to practice PMR in bed just before sleep, but it can be practiced in a sitting position as well. Sometimes PMR is a useful technique to use during long and tedious meetings.

Here’s how to start PMR:

  • Inhale and contract all your facial muscles, squeezing your eyes together, puckering up your mouth, and scrunching up your face. Now exhale and relax your facial muscles.
  • Inhale and tighten your neck muscles, and then exhale and release.
  • Inhale and contract your upper chest and upper back, and then exhale and release.
  • Inhale and contract the muscles in your left arm and hand, and then exhale and release.
  • Continue working your way through your body, contracting each muscle group and then releasing.

During PMR, keep your breath calm and do not hold it. Breathe in when contracting or tensing your muscles, and breathe out during release. As you practice this technique on your own or with your patients, gradually pay more attention to the release of body tension, as well as emotional tension.

Relaxation or diaphragmatic breathing
Using the diaphragm and not the chest is the most efficient and relaxing way to breathe. Chest breathing elicits anxiety. Try it: Breathe only with your chest and see how you gradually become more and more anxious. Now, switch to breathing with your diaphragm, bringing in your breath through your nose, allowing it to slide through your chest without raising your chest, and continuing down to the area just above your navel. Some people have difficulty pushing out their abdominal area when inhaling and it may take some practice. But with practice, you and the patients you teach will find that it comes more naturally and that it results in a more alert and relaxed feeling.
To practice diaphragmatic breathing, try the following:

  • Put one hand on your chest and the other on your abdominal area. Spread your fingers open, put the little finger near the navel, and put the thumb near the end of the sternum.
  • Pay attention to your breathing. Breathe in slowly through your nose, allowing the breath to flow through the chest (keeping the hand over the chest still) and flow down toward the other hand, filling up the space under that hand.
  • Continue to breathe in and blow up that space below the diaphragm like a big balloon.
  • Now, exhale through the nose or mouth, sucking in the abdominal area to expel as much air as possible.
  • Do not hold your breath, but continue with an inhalation through the nose again. Repeat this process for five to 10 minutes to feel a relaxation response.

Caring for sleepwalkers
Most sleepwalkers are children, but occasionally a teen or adult will sleepwalk if he or she is sick, has a fever, is sleep deprived, or is under stress. Sleepwalkers tend to go back to bed on their own and don’t usually remember sleepwalking. However, sometimes nurses need to prevent injury and help a sleepwalker move around obstacles in their way. Sometimes nurses may need to help them find their way back to their bed, especially if they are in unfamiliar surroundings. Sleepwalkers may startle easily, so it is best to guide them back to bed gently without waking them.

 

Dealing with Difficult Patients: The importance of self-care

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Nursing is known as the caring profession. Nurses are known as caring individuals. Caring and anticipating needs are strengths of those in nursing. They are our best assets, and the assets most recognized by others.

But our greatest assets can also be our worst liabilities. In other words, caring has two sides to it: Caring for others is noble and fulfilling, but caring too much, or using up all of our energy caring without caring for ourselves, can leave us tired and drained.

In order to take care of challenging patients, we need to make time to take care of ourselves. Nurses who do not take care of their own health needs are often the ones most likely to have problems caring for challenging patients. We need to face up to the reality that spending our work life caring for others is a heavy burden, and we must take some time to recharge, and refill our cupboards. We need to address the emotional toll our work takes on us.

Rethinking stress

Stress can be emotional, physical, or spiritual. The first step in handling stress is to make sure that we understand how we cope with stress.

As nurses, we can make the assumption that our personal life and our work life cause us stress. There is really no need to make a list of our stressors—this might cause us more stress. But it’s safe to assume that we have stress. We have all developed methods to handle our stress: Sometimes we develop adaptive ways and other times we use maladaptive methods. Start by listing some coping methods and separating them into those that help and those that hinder you. Then do more of what helps, and systematically eliminate or change those that hinder.

Sometimes the way we look at things causes us increased stress. Here are some ways of thinking that add to stress. Do any of these ring true for you?

Extreme thinking: Sometimes we see things with no middle ground or no gray. It is all black and white, all or nothing, good or bad.

Overgeneralizing/blowing things out of proportion: Everything is a crisis. “No one here knows what he or she is doing.” “I never get a good assignment.”

Mind reading/fortune-telling: You predict the future in a negative way: “This is going to be another rotten day.”

Jumping to conclusions without enough evidence or guessing about what other people are thinking about us: “They don’t know what it is like to work on the floor. This is just one more thing they thought up to make our days difficult.”

Personalizing: Jumping to a conclusion that something is directly connected to you: “Everyone knows I’ve been off work because I can’t cope.”

One way to reduce your stress is to change the way you look at things. Try these alternatives and see how they work for you:

Change extreme thinking into reality thinking. Look for the gray between the black and white.
Stop overgeneralizing and recognize that what is happening now is only what is happening now. Nothing lasts forever. Look for times when good things happen to you, such as when you do get a good assignment.

Stop mind reading. Ask for clarification and details. Check out the facts. What does the policy say? What does the procedure mandate?

Gather your data before making a conclusion. We all know we need to make a comprehensive patient assessment before a diagnosis can be made. Use the same principles when coming to a conclusion (diagnosis) about a situation that has caused you discomfort.

Come to grips with the reality that the world doesn’t revolve around you. Yes, sorry to say, most of the time other people are so concerned about themselves that they don’t even think about how their actions might affect you.

Change stress into relief

In her article “Break the cycle of stress with PBR3,” Becky Graner, MS, RN, IAC, shares a simple tool that aids in stress relief. PBR3 stands for pause, breathe, relax, reflect, rewrite. Let’s see how it works. Adhere to the process in the following table the next time you are in a stressful situation at work, or just before going in to take care of a patient who presents a challenge to you.

Pause: Simply stop thinking. You can continue doing something such as walking down the hall, washing your hands, or another activity that has become automatic for you. Simply stop your thoughts.

Breathe: Stop the chatter in your mind by paying attention to your breathing. Just focus on your breaths and count, say a prayer, or repeat an affirmation to yourself. Don’t try to control your breath. And don’t hold your breath.

Relax: Simply taking a pause and a few breaths, particularly diaphragmatic breathing, takes you out of a reactive state and into a more relaxed state. When you are relaxed, your thinking will clear.

Reflect: Debrief yourself. What was going on that led up to the situation that bothered you? If you felt angry, what was the feeling behind the anger? Was your response out of proportion to the situation? Were you thinking the worst?

Rewrite: Check yourself to find out where you may have been taking things too personally, making assumptions, or doing some of the other automatic thinking processes that cause more stress than not. Rethink or rewrite these into more realistic assumptions. Using humor, empathy, or compassion may soothe you.

Reference
Graner, B. “Break the cycle of stress with PBR3.” American Nurse Today, (2)5:56–57.

 

Dealing with Difficult Patients: High-octane energy

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Mania or an elevated mood is hard to miss. People who are manic have lots to say; have lots of places to go; have a wealth of ideas to share; and just don’t have enough time to explain all of their theories, schemes, and plans. Much like the Energizer Bunny, people with mania keep going and going, often after all of those around them have dropped with exhaustion, or walked away seeking quiet and solitude.

People with mania, especially those who have hypomania (a milder form of elevated mood and elation), love their episodes when they can say “I get so much done,” “I become super creative,” or “I am on the top of my game.” An episode can go something like this:

At first, when I’m high, it’s tremendous . . . ideas are fast . . . like shooting stars you follow until brighter ones appear. All shyness disappears, the right words and gestures are suddenly there . . . uninteresting people and things become intensely interesting. Sensuality is pervasive. The desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria. You can do anything . . .

But then things take a turn:

The fast ideas become too fast and there are far too many of them. Overwhelming confusion replaces clarity . . .  you stop keeping up with it—memory goes. Infectious humor ceases to amuse. Your friends become frightened. Everything is now against the grain. You are irritable, angry, frightened, uncontrollable, and trapped (Spearing).

And therein lies the problem: While in manic episodes, people deplete all of their own bodily reserves, and the reserves of others. Those caring for the manic person become exhausted themselves, generally depleting all of their emotional as well as physical energy reserves.

Making sense of manic patients

Don’t panic: When we are faced with dealing with a manic patient who is out of control, it can easily make us feel out of control too. Here are a few things to keep in mind:

  • The patient is being controlled by his or her disease. Control of behaviors and feelings is simply not possible.
  • The patient lacks any insight into his or her behavior. People in manic states do not realize they are sick, and they are unaware of the consequences of their behavior. They reject any idea that any illness is involved, and they find excuses to try to make sense of what is going on around them.
  • The patient with mania becomes frustrated, often with others who cannot keep up with him or her. The patient may lash out and show his or her frustration in inappropriate ways. It often appears that the patient knows exactly how to push your buttons, or knows the exact things about which you are most sensitive.
  • The patient with mania is hyperalert. People in manic states are hypervigilant and are often aware of things going on in the environment that others do not pick up on.

Ways to prevent cycling
When working with manic individuals, you need to help them prevent the exhaustive cycles they live through. Although that is not always possible, you can help them identify and attempt to avoid the triggers that may lead to a mood swing. One of the most important aspects of managing manic episodes is to stick to a routine.

You can also help patients:

  • Set realistic goals. Having unrealistic goals can set up the individual for disappointment and frustration, which can trigger a manic episode. Advise the patient to do the best he or she can to manage his or her symptoms, but expect and be prepared for occasional setbacks.
  • Get help from family and/or friends. Everyone needs help from family and/or friends during a manic episode, especially if he or she has trouble telling the difference between what is real and what is not real. Having a plan in place before any mood changes occur can help the individual’s support network to make good decisions.
  • Make a healthy living schedule. This is important for those with mood swings. Many people with manic episodes find that sticking to a daily schedule can help control their mood. Some examples include regular meal times, routine exercise or other physical activity, and practicing some sort of relaxation each night before bed. Also, you can help to provide a balanced diet for the patient, focusing on the basics: fruits, vegetables, and grains, and less fat and sugar. Exercise uses up some energy and helps a person sleep better. Help the patient develop an exercise plan that fits his or her lifestyle. While in the hospital, taking walks around the unit during the day may benefit the patient.
  • Get enough sleep. Getting a good night’s sleep may be a challenge for a person with mania. Being overtired or getting too much or too little sleep can trigger mania in many people. While the patient is under your care, make up a schedule for rest and relaxation before sleep. Have the patient go to sleep and get up at the same time every day, and relax by listening to soothing music, reading, or taking a bath. Do not allow the patient to watch TV in his or her room.
  • Reduce stress. Anxiety can trigger mania in many people. Ask the patient what helps him or her relax. It might be calming music or a meditation tape. Avoid those things that hype people up, such as watching violent shows on TV or listening to loud music. Helping the person reduce stress in general at home and at work might help prevent episodes. Advise the patient to ask for help: A young mother may ask her spouse, family, or friend to take care of some of the housework. If the person’s job is proving to be too much, he or she can scale back some responsibilities. Doing a good job is important, but avoiding a manic mood episode is more important.
  • Avoid stimulants, alcohol, and drugs. Many people with mania may turn to substances to try to avoid a manic episode, or stimulating substances to elevate their mood. Up to 60% of people with mood disorders also have substance abuse problems. This self-medication may give them some temporary relief, but it will make their condition worse over time. Tell the patient to eliminate the use of caffeine, alcohol, and recreational drugs (Spearing).
  • Stick with treatment. It’s essential for people with mania to continue their medication and get regular checkups. It can be tempting to stop treatment because the symptoms go away. However, it is important to continue treatment as prescribed to avoid taking risks or having unpleasant consequences associated with a manic episode. If the patient has concerns about treatment or the side effects of medicines, talk with him or her and caution the patient not to adjust the medicines on his or her own.

Reference
Spearing, M. (2002). “Bipolar Disorder.” National Institute of Mental Health. Available at www.nimh.nih.gov/publicat/bipolar.cfm.

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.