Ambulatory Care Nursing Certification

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 r e N u r s i ng
a t o r y C a
Ambul w
a t i o n R e v i e
Certif i c
s e S y l l a b u s
Cou r
 Ambulatory Care Nursing Certification Review Course

Course Overview
This course provides an overview of the potential content that may be tested on the
ambulatory care nursing certification exam. It is a valuable opportunity to reinforce your
knowledge of ambulatory care, identify your weak areas, and learn new information.
Interact with nationally recognized faculty and colleagues to discuss information related
to ambulatory care practice and the certification exam.

Course content is based on the test content outline for the ambulatory care nursing
certification exam. All topics will be offered in an interactive, case problem-solving style
to enhance critical thinking.

Learning Outcome
After completing the Ambulatory Care Nursing Certification Review Course, the learner
will be able to use the presentation to reinforce knowledge of ambulatory care nursing,
self-assess the content areas where they need further review, and use the content
presented as preparation for taking the certification exam.

Copyright 2019 American Academy of Ambulatory Care Nursing

Current copyright laws prohibit individual audio or videotaping, or duplication of this
handout without written consent from AAACN.
East Holly Avenue, Box 56
Pitman, NJ 08071
Phone: 800-AMB-NURS (262-6877)
Fax: 856-589-7463
E-mail: aaacn@ajj.com Web site: www.aaacn.org

REVISED 2019

1
 Ambulatory Care Nursing Certification Review Course ***** AGENDA
15 8:00 am – 8:15 am
20 8:15 am – 8:35 am
40 8:35 am – 9:15 am
9:15 am – 9:25 am
40 9:25 am – 10:05 am
110 10:05 am – 11:55 am
30 11:55 am – 12:25 pm
30 12:25 pm – 12:55 pm
12:55 pm – 1:40 pm
20 1:40 pm – 2:00 pm
30 2:00 pm – 2:30 pm
30 2:30 pm – 3:00 pm
15 3:00 pm – 3:15 pm
3:15 pm – 3:25 pm
15 3:25 pm – 3:40 pm
25 3:40 pm – 4:05 pm
35 4:05 pm – 4:40 pm
10 4:40 pm – 4:50 pm
10 4:50 pm – 5:00 pm
Exam Criteria and Certification
Ambulatory Care Nursing Overview
Clinical Practice:
• Plan of Care and Care Management
BREAK
Communication:
• Interpersonal Skills and Customer Service Skills
Clinical Practice:
• Clinical Practice
• Well Clients Preventive Care
• Acutely Ill Clients
• Clients with Chronic Conditions
• Clients with Terminal Illness
• Clinical Skills
Clinical Practice:
• Telehealth and Telephone Triage
Clinical Practice:
• Medication Management Systems
LUNCH
Communication:
• Documentation and Informatics
Education:
• Education
• Health Promotion
• Teaching and Learning Principles
• Disease/Injury Prevention
Systems/Legal/Regulatory:
• Regulations, Standards, Accreditation
Systems/Legal/Regulatory:
• Quality Management
• Operations
• Documentation
• Reimbursement
BREAK
Professional Role:
• Scope of Practice
• Ethics and Nursing Advocacy
Professional Role:
• Legal and Ethical Issues
Professional Role:
• Professional Development and Leadership
Questions & Answers
Wrap-Up/Evaluation
2
 CE Information and Disclosure

Requirements for Successful Completion

Attend 90% of the course offering in which contact hours are earned, complete the evaluation, and
submit.

Conflict of Interest Disclosure

No planner or speaker discloses an actual or potential conflict of interest in relation to the
presentation.

Sponsorship or Commercial Support Disclosure

This program has not received commercial support or sponsorship.

Learning Outcome
After completing the Ambulatory Care Nursing Certification Review Course, the learner will be able to
use the presentation to reinforce knowledge of ambulatory care nursing, self-assess the content
areas where they need further review, and use the content presented as preparation for taking the
certification exam.

Accreditation
This education activity offering for 7.9 contact hours is jointly provided by Anthony J. Jannetti, Inc.
(AJJ) and the American Academy of Ambulatory Care Nursing (AAACN).

Anthony J. Jannetti, Inc. is accredited as a provider of continuing education in nursing by the

American Nurses Credentialing Center’s Commission on Accreditation.

AAACN is a provider approved by the California Board of Registered Nursing, Provider Number CEP
5366.

3
 Ambulatory Care Nursing Certification Review Course
Faculty

Denise R. Hannagan, MSN, MHA, RN-BC, EDAC

Senior Healthcare Consultant
HDR, Inc.
Pasadena, CA
Email: denisehmsnmha@gmail.com

E. Mary Johnson, BSN, RN-BC, NE-BC

Career Coach for Nurses Consultant
Patient Navigator Consultant
Cleveland, OH
Email: emjrn2016@gmail.com

Susan M. Paschke, MSN, RN-BC, NEA-BC

Adjunct Faculty
Kent State University
Kent, OH
Email: susanpaschke@att.net

Christine M. Ruygrok, MBA, RN-BC

Associate Quality Administrator
Southern California Permanente Medical Group
Pasadena, CA
Email: christine.m.ruygrok@kp.org

HOW & WHERE TO TAKE THE EXAM

To download a registration catalog, including the application to take the exam, please visit
www.nursingworld.org/ancc or call ANCC at 800-284-2378 for more information.

CREDENTIAL YOU WILL EARN: RN-BC

4
 Content Overview
Ambulatory Care Nursing 2
Certification Review Course
Clarify information and requirements of the
certification exam
Exam Criteria and Certification
Discuss the testing, preparation process,
and test-taking tips

Intense review of content based on the test
1 content outlines from ANCC
American Academy of Ambulatory Care Nursing
Certification Review Course
Suggest study resources and references
FACILITATORS:
E. Mary Johnson related to ambulatory and telehealth nursing
Denise Hannagan
Susan Paschke
Christine M. Ruygrok

1 2

What is the difference

between American Nurses
3 4
ANCC and AAACN? Credentialing Center - ANCC
American Nurses American Academy of
Credentialing Ambulatory Care On the ANCC website you will find information on:
Center - ANCC Nursing - AAACN registration, eligibility, cost, and scheduling

provides experts to assist
Registration details

develops and oversees the
with writing test questions • Apply any time
certification exam
• Exam to be taken during a 90-day window

provides this certification

approves initial certification review course • Scheduled through testing sites in your local
process as well as the areas
renewal process
Review Course Facilitators
do not participate in the
175 questions specifically related to
writing of the test questions

ANCC Web Site – ambulatory nursing
on the ANCC examination
www.nursingworld.org
150 graded items - score is based on these

AAACN Web Site –
25 pretest items -no indication of which items
www.aaacn.org are not graded

3 4

5 Eligibility Requirements 6 Domains of Practice

Test content is divided into Domains of Practice

AD, Diploma, BSN or higher degree in
The domain that applies to the section will be
nursing
included in the title slide

Current active RN license Domains include:
Clinical Practice

Minimum of 2,000 hours of clinical practice
in ambulatory care and/or telehealth nursing Communication
within the last 3 years. Education
Professional Role

30 hours of continuing education in
ambulatory care and/or telehealth nursing Systems/Legal/Regulatory
within the last 3 years See ANCC Website for Test Content Outline

5 6

5
 7 Exam Questions Getting Started
Domains of Practice # of Questions Percent

Clinical Practice 76 50.67%

Communication 34 22.67%

Education 15 10%

Professional Role 9 6%

Systems/Legal/Regulatory 16 10.67%

TOTALS 150 100%

7 8

9 The Test and Tips for Testing 10

Certification

Time limit is 3 ½ hours
Results known immediately upon test completion
• Budget time to allow for return to skipped
questions
• Credential awarded: RN-BC
 Board Certified in

Questions can be marked to return to Ambulatory Nursing
them later
• Can change answers until test is submitted

See handout in syllabus for additional test Re-certification
taking tips, principles, and hints for
Certification must be renewed every 5 years
success: • Multiple options to renew
• Read each item carefully
• Pay attention to key words
• Answer every question – no penalty for guessing
• Select options that reflect nursing judgment

9 10

STUDY HARD
& Ambulatory Care
GOOD LUCK
Nursing Overview

You are on your way to becoming an

12
Ambulatory Care
Board Certified Nurse
RN-BC

11

11 12

6
 Content Overview
13

Discuss the characteristics of ambulatory
care nursing practice

Describe the role of the ambulatory care
nurse

Differentiate Ambulatory Care Nursing
from other specialty Nursing Practice(s)

Discuss ambulatory patient population
characteristics
Definition of
14 Ambulatory Care Nursing

Professional ambulatory care nursing is a complex,
multifaceted specialty that encompasses
independent and collaborative practice.
(3rd edition, AAACN Core Curriculum)
• INCLUDES:
Clinical, Leadership, Education and Research
Activities (AAACN/ANA, 1997)
• Applies clinical expertise rooted in nursing process
• Includes clinical, organizational, and professional
activities for individuals, groups, or populations who
seek assistance with improving health and/or seek
care for health related problems
• Nurses are accountable for care provided (Standards
of Care, Regulatory Standards and Nurse Practice
Acts)

13 14

Characteristics of Ambulatory Nursing Ambulatory Care Nursing

15 16
Defined in terms of:
Nurse autonomy, critical thinking, nursing Wellness or Functional Goals
process Patient expectations
Patient advocacy, ethics, holistic nursing Settings and encounters
care Sites include: hospital based, schools, retail based,
Patient and family decision making and care assisted living, workplace
providers
Cost aligns with effective ways to maximize wellness,
Skillful, rapid nursing assessment, patient prevent illness, and minimize symptoms of acute
education, patient engagement minor aliments
Long term relationships that promote patient/ Support patients and families in the management of
family trust chronic disease throughout the lifespan

15 16

Definition of Ambulatory Definition of

17 18
Care Nursing (AAACN/ANA, 1997)
Ambulatory Care Nursing
(AAACN/ANA, 1997)

Encounters are episodic

Conceptual framework is a
• Less than 24 hours in duration
• Occur singly or in a series guide/map that specifies:

Encounters may occur:
• Essential concepts and skills in an
• Face-to-face
area of practice
• Telehealth
• Email (MyChart©, patient portals) • Relationships between major content
• Other communication devices – smart and skill areas
phones, face-time, virtual clinics,
biosensors, apps, etc.

17 18

7
 Ambulatory Care Conceptual Framework Application of the Ambulatory
19 20
Care Conceptual Framework
(AAACN/ANA, 1997)

Design of ambulatory care delivery models

Assist in development of:

orientation programs for ambulatory
personnel educational materials

performance appraisal

certification testing material

providing clarity of nursing role and
dimensions vs. roles of other health care
providers

Act as a catalyst for further refinement of the
role

19 20

Challenges for Ambulatory Nursing Major Roles of the

21 22
Ambulatory Care Nurse
Evolve From:

Increasing volumes and patient acuity

Communication, collaboration, delegation

Care coordination, care management, Clinical Practice
continuity of care

Use of evidence based protocols
(algorithms, protocols, etc.)

Technology evolution – face to face
encounters vs. telehealth, patient portals, Professional Organizational
video virtual clinics, biosensors, mobile Development Operation
apps) Systems

Team member dynamics – overlapping roles

21 22

Clinical Role Dimensions Organizational/Systems

23

Communication using
24 Role Dimensions

Patient Education technology
Practice/Office Support
Delegation and
• Primary • Telephone triage Supervision
• Secondary • Virtual clinics
Healthcare Fiscal
• Tertiary Prevention
Ambulatory Culture
• MyChart Management

Advocacy
Collaboration with

Cross Cultural
• Compassion
Collaboration Competencies
• Caring healthcare teams and
• Emotional support patient
Conflict Management
Political-

Care Coordination/
Resource Identification
Informatics Entrepreneurial Skills
Transition Management
Appropriate referral
Patient Centered Care

Context of Care

Assess, screen, triage,
Regulatory
prioritize
Clinical procedures
Delivery Models

Independent Compliance

Outcome Management
Care of the Caregiver

Protocol
Interdependent
Advocacy
Development/Usage
Documentation
Priority Management
Legal Issues

23 24

8
 Professional Role Dimensions Characteristics of Ambulatory
25 26

Evidence-Based Practice Patient Populations

Leadership, Inquiry and Research Utilization
Patient / Family / Significant Other
• Initiates encounter/visit and often live in the

Clinical Quality Improvement
community

Staff Development/Self Care • Collaborate with interdisciplinary ambulatory

Regulatory Compliance/Risk Management care team regarding treatment regimen
• Manages and provides health care between

Ethics/Advocacy visits

Workload/Staffing • Controls health care decisions and has
choices

Patient Navigator
• Can have long term relationships with
ambulatory care providers

25 26

Ambulatory Care Ambulatory Patient Health Status –

27 28
Patient Populations Defined:
Chronically ill
major illness
• Obesity
• 78 million BMI > 30
Major illnesses • Diabetes
Terminally ill
• Leading cause of kidney failure –
• End-stage
amputations- lower limbs,
blindness liver disease
• Heart disease • Uncontrolled
Age • i.e. uncontrolled B/P, elevated LDL, diabetes
smoking and too much sodium • Cancer
• Stroke • ALS
• AIDS • End stage
• Chronically ill persons can have acute CHF
Type / Sources of reimbursement illness and/or exacerbations of chronic
disease
• i.e., diabetic with the flu who also
has hypoglycemia

27 28

Ambulatory Patient Health Status - age Future Opportunities for Nurses

29 30
in Ambulatory Care

Well or essentially
healthy Multiple diverse roles will result from
and will continue to evolve as health
• Well baby checks
Acutely ill but care systems adapt to today’s
• Women’s annual otherwise healthy challenges in health care delivery
• General physical (Paschke, Nursing Economics, 2017)
• School physical • Ear infection
• Appendicitis
American Academy of Ambulatory Care Nursing
• Upper Respiratory (AAACN)
• Pink Eye
Many Settings. Multiple Roles.
One Unifying Speciality!
Speciality!

29 30

9
 31
Clinical Practice:
Any
Questions? Plan of Care and
Care Management

32

31 32

33 Content Overview 34 Case Management Defined:

Discuss care management, care
coordination, case management Collaborated process of
and disease management
assessment, planning,

Discuss healthcare resources and facilitation and
utilization options
advocacy for options

Define the roles of ambulatory care and services to meet
nurses in plan of care and care
management
individuals needs
(Laughlin, 2013)

33 34

35 Case Management Focus: 36

Community Expectations

Access to

Improve patient health healthcare
primary &
status and reduce specialties
utilization of expensive
health services
High- Reasonable

Targeted services Quality cost -
Care includes full
disclosure

35 36

10
 Primary Care Defined:
37 Continuum of Health Care 38

World Health Organization (WHO)
• Health care is central function

Definition: A concept involves a • Main focus of social and economic development
system that guides and tracts • Begins where people live and work
• Universally accessible to individuals and families in the
patients over time through a community
comprehensive array of health
Institute of Medicine (IOM)
services spanning all levels and • Integrates public and private models
• Primary care is central to the delivery of health service
intensity of care. • Preventive services must link with population-based
health programs
himss.org • Public health functions and community organizations
HIMSS.7 -- Ambulatory HIE tool kit must become partners in clinical interventions and cost
control

37 38

Continuity of Care: Gatekeeping Definitions of Care

39 40

Physicians control access
through medical orders
Primary Care – principle point
of contact within a health care

Payers control use by system - integrates primary
authorizing or denying
services services with other levels of care
• Primary care involves the widest

Care coordinators access and scope of health care
integrate interdisciplinary
• Continuity is a key characteristic
actions including appropriate
referrals to assist with the of primary care
plan of care

39 40

41 Definitions of Care (continued) 42 Mass Casualty Triaging

First responders using START

Secondary Care (Simple Triage and Rapid Treatment)
• Synonymous with hospital services to evaluate victims and assign them to
one of the following four categories:

Tertiary Care • Immediate (red)
• Highly specialized
• Highly technological hospital • Walking wounded/minor (green)
services • Deceased/expectant (black)

http://www.remm.nlm.gov/startadult.htm#more

41 42

11
 Understanding START Triage
Coordination of Care
43 Green = MINOR - Moving, Walking Wounded 44
Black = DECEASED - No Respirations after head tilt
Responsibility of primary care
Red = IMMEDIATE providers
 Breathing but UNCONSCIOUS

Integrates the timely, appropriate, cost-
• RESPIRATIONS over 30
effective use of health services across the
• PERFUSION - capillary refill >2 sec or
NO RADIAL PULSE - Control bleeding
care continuum
 MENTAL STATUS – unable to follow simple
Obtains/identifies resources to help individuals
commands obtain health, social, and support services
• Individually driven
• Applies at different points across the lifespan
• Includes provision for catastrophic and high cost
medical care

43 44

Primary Care includes: Care Coordination Model

45 46

Adult Medicine Coordination of Care includes:

Resource Utilization
Ob/Gyn
Transition Management

Case Management
Pediatrics
Disease Management

Family Medicine

45 46

Types of Management
47

Resource Utilization
Based on:
• Severity and acuity of
presenting situation
• Skill and competence
of the provider
• Type of therapy/
intervention required
• Consumer preference
• Resources available
• Need for subsequent
care
48 Types of Management

Transitional Management
Example: • The safe transfer of care from one setting
PCMH Patient Centered
Medical Home -
to another or different level of care. This is
 Provides care across key goal of ACO’s.
the continuum
 Payment based on
• Medication regime
quality vs. quantity • Visits scheduled and completed
of care
 EBP
• Hand off communication is written/printed
 Collaborates across Patient centered medical record,
•
settings
accessible at every visit

47 48

12
 Types of Management
49
Types of Management 50
Disease Management -
 Focus on chronic disease
management through education

Case Management to patients to prevent
Example:
exacerbations and further health

Manages and evaluates complications ACO Accountable Care
medical necessity,  Self management strategies
Organizations
 Provider groups,
 Comprehensive treatment plans
appropriateness and efficiency including PCP,
 Nurse as part of collaborative
of services under defined team specialists and
healthcare plan  Partnerships including community hospitals that accept
• Weight Watchers, silver responsibility for cost
sneakers, passport programs and quality of care
• Electronic tools- Healthbuddy delivered to specific
patient populations

49 50

Why is Disease Management effective? How does this happen?

51 52

Priority Management

Manage and direct patient access
Direct
Monitor flow for effective and efficient
Identify and
patient clinical outcomes
access assess

Assess and identify resources/referrals

Assist in navigating health care system
Health
Evaluation
Set plan and goals

Follow up of health care needs
Navigation of
Establish
health goals
Evaluate health status/outcomes
health
care/system and plan of
care

ADVOCATE FOR PATIENT

51 52

High-Risk Populations Self Management

53 54

Assisting the patient to deal with all that a chronic
illness entails.
Metabolic syndrome
• Symptoms
• Treatment
CHF • Physical consequences
• Social consequences
• Lifestyle changes
Diabetes mellitus
Skills required by the patient:
• Learning and acting upon knowledge and skills
to effectively manage chronic illness
COPD

Create and maintain new behaviors and lifestyles

Dealing with the emotional realities of chronic
Hypertension illness

53 54

13
 55
Core Patient Skills in 56
Utilization Management
Self Management Evaluation Process

Positive patient and healthcare
Hospital or Institution
provider relationship • Review of medical record to determine
length of stay

Problem solving

Decision making
Ambulatory
• Review of appropriate level of provider to

Action driven deliver care

Resource utilization • Review of level of care setting

Tools to guide goals and action plans • Review of best standardized care plans
based on EBP to manage patient with
chronic conditions

55 56

57
Levels of Prevention 58
Primary Prevention Involves

Health promotion interventions
Primary • Nutrition education
• Sex education

Specific protections
• Use of seat belts
Secondary • Avoidance of allergens
• Immunizations

May be directed at individuals, groups, or
populations
Tertiary
Targets well populations or those already ill

57 58

Secondary and Tertiary Prevention Role of Ambulatory Nurse in

59 60
Disease Management

Secondary Prevention involves:
• Early detection, diagnosis, and treatment
Advocate
 Mammography

Educate
 Colonoscopy

Encourage – Coach

Tertiary Prevention involves
Assist in problem solving
• Recovery, rehabilitation, and specific
measures to minimize disability and
Ensure patients are active in
increase functioning making decisions

59 60

14
 Implementation of Plan of Care The Goal of Care Delivery
61 62
Can it
be
done?

Right Right
Is plan Is there
success input from patient setting
based on Patient
the agreed and
goals? Family?

Right Right
Is timeframe provider care
identified
and
reasonable?

61 62

63 Any 64 Lets Take a Break

Questions?

63 64

15
 2
Content Overview

Define and discuss communication
Communication: process, techniques and barriers

Describe interpersonal skills that are

Interpersonal Skills
and Customer Service Skills essential to ambulatory nursing
practice
1

Identify techniques that promote
cultural competency in health care
settings

1 2

Communication How does effective

3 4

The exchange or transmission of thoughts, communication work?
opinions, information by speech, writing or

Sender transmits message in clear and organized
signs
form

Can be face to face, via electronic devices • Essential to follow the plan of care

Can be a document or message sharing news,
Confidence, competency, gestures and softness
views, opinions, information • Deliver the message with confidence – you are

Key - when 2 or more people interact, a First the expert
Impression is created for developing rapport
Receiver needs to show interest
and trust with patient caregiver and staff • Engagement is key

Learning differing techniques addressing
Skills to manage overall process of communication
various ages, developmental stages, cultures, • Diversion, reflection, active listening,
religions, socioeconomic status and gender – interviewing
leads to positive and impactful communication

3 4

Good Communication Includes

5 6
Characteristics of Expert

Presentation and assessment of information to Interpersonal Skills
receiver
• Skills to understand response received – can they
Rapid problem identification
restate or return demonstration?
(age, developmental stage are factors)
•Proactive
• Conducive learning environment
Courteous, customer-focused

Critical thinking – essential to determine patient’s communications
needs • Be in the “moment”
• What is the best channel for communication?
(dialogue, written material, pictures, social media)
• Focused

Technical know how
Active listening

• What type of access or skills does the patient have to

Abilityto quickly create an
technical resources?
*Required at all stages of life – consider audience being taught environment of trust

5 6

16
 Communication skills and considerations Communicating with Patients
7 8

Manage the overall process of communication by:

Expressive skills to deliver the message through:
Sensory Impairment - Hearing Loss
• Words
• Facial expression • Speak clearly at a slow to moderate
• Body language pace
• Maintain eye contact
• Look directly at the person while

Patient’s differing needs:
• Speak clearly
speaking
• Use plain language • Write down key words
• Use of assistive devices as needed
• Shouting distorts facial expression

Remember: High volume impaired population(s)
• Elderly
• Traumatic brain injury
• Stroke victims

7 8

Communicating with Patients continued Communicating with Patients continued

9 10
Sensory Impairment – Vision Cognitive Impairment
• Speak clearly and be explicit when • Depression
giving instructions/ directions • Dementia (caused by degenerative
• Consider room lighting brain diseases)
• Provide large print versions of • Apraxia (decline in motor activities)
material - use contrast - black ink on • Aphasia (difficulty in expressing
white background preferable thoughts and emotions, as well as
• Establish your exact location difficulty in understanding verbal
messages)
• Intellectual deficit

9 10

Communication Matters Nursing Assessment of

11 12
Communication
Why it matters:
Examples:
Content theme
• Test Instructions • What are the thoughts and
feelings being expressed
• Medication regimes

Communication patterns
• Life threatening diagnosis How are they being expressed
•
• Pediatric Instructions • Discrepancy in content, body
language, vocalization
• Genetic testing

What’s “not” being said

11 12

17
 Types of Behaviors: Communication Connecting Care Coordination
13 14

Aggressive behavior

Respect the patient/family in making decisions about
• Dominating / you statements / fixing blame
health care

Passive behavior

Clear delineation of the functions of each discipline
• Response that denies rights in order to avoid
conflict and team member

Multidisciplinary assessment, discussion of treatment

Assertive behavior (preferred)
options and agreement of a treatment plan, goals and
• Ability to say no
priorities
• Ask for what you need
• Appropriately express positive and negative
Measurement and documentation of collaborative
thoughts outcomes
• Initiate, continue and/or terminate interaction

13 14

Collaborative Practice Model Characteristics of a Collaborative Team

15 16

Goals, values, and mission agreed upon
Patient care requires a team of professionals

Nursing

Open, honest communication

Social Work
Roles and responsibilities defined

Physical Therapy
Tasks and time frames known

Pharmacy

Team norms and processes established

Respiratory Therapy
Examples:
Monitors to evaluate team performance
• Each has own scope of practice
• Metastatic
• Services may overlap
A unified front: mutual trust, respect, support
disease

Physicians have broadest scope
• Renal
Share responsibility and accountability
of practice and authority

Patient requirements dictate the
disease
Diversity in style and scope of practice valued
• Other
degree of involvement of various
Relevant information shared and discussed
chronic
team members, which can vary
illness
with each encounter

15 16

Communication Barriers
Conflict Definition:

17
Perception and Language Differences 18 • Tension arising from incompatible needs, in which the

Information Overload actions of one frustrate the ability of the other to achieve

Inattention a goal

Time Pressures
Sources of Conflict:

Distraction/Noise • Incompatible goals

Emotions • Different perceptions of facts

Poor memory/retention • Different behavioral expectations

Variance between verbal and body language • Competition for status

Deletion - leaving out parts of message • Lack of resources or “unfair” distribution

Communicating in a “round about way” - “Haven’t • Differences in styles of communication
you left yet?” • Varying beliefs about process for performing work

Recognition that family members are prohibited
from expressing themselves in their culture – (“We
Factors that influence conflict:
never discussed/talked about this.” Can create a • Gender
lifetime of communication difficulties.) • Cultural socialization
• Role socialization

17 18

18
 Approaches to Conflict Management
19
Avoiding 20

Competing Service Recovery

Accommodating

Compromising

Collaborating Actions taken
when customer

Conflict Management by Collaboration expectations not
• Recognize conflict exists met.
• Look for shared interests, goals, what satisfies
the majority Listening to the customer
• Clarify differences and value them Fixing the presenting problem
• Respect other’s point of view Going above and beyond
• Identify options for change Educate and Communicate so
• Implement will not reoccur
• Evaluate

19 20

21 22
Service Excellence Active
Listening

Setting
reasonable Honesty
Four key elements limits Nursing
Interventions for
Conflict
Management
Delivering the promise
Providing a personal touch
Going the extra mile Speaking Achieving
Resolving problems well clearly Calm

21 22

Cultural Competence Culture Awareness

23 24

Ability to develop an awareness of one’s
The way a person perceives the world
own self and existence without letting it
have undue influence on those from other
Serves as a guide for beliefs and
backgrounds practices

Components of Cultural Competence
Complex – usually unconscious

Cultural knowledge

Cultural skills
Why is this important?

Cultural encounters
Increased diversity of populations

Cultural awareness
Racialand ethnic minorities may

Cultural desire
receive less routine care

23 24

19
 Cultural Barriers
25 Cultural Beliefs 26

Delays seeking care
Beliefs Affect:
Mistrust of the healthcare system

How and from whom a person will seek care
Lack of knowledge on use of health care

How self care is managed systems

How health choices are made
Language – need for interpreters

Time constraints of healthcare providers

How a patient responds to a specific therapy

Financial
www.deltaaetc.org

Personal beliefs

Misinterpretation of patient behaviors

25 26

Types of Cultural Differences

27 Influences of Health 28
Race Job-related abilities
Social Determinants of Health Gender Marital status

High quality education
Age Family status

Nutritious food
Religion

Decent and safe housing Values

Affordable, reliable public transportation Ethnicity
Clothing

Culturally sensitive health care providers Weight
Appearance

Health insurance Educational level

Clean water Personality traits
Physical

Non-polluted air Technical abilities
Mental
healthypeople.gov
Sexual orientation Generational

27 28

Elements of Cultural Differences Examples of Cultural Differences

29 30

Communication styles
Environmental Control
• Modify patterns of communication • Individual’s perceived ability to control
• Identify and avoid gestures that could be external occurrences
misinterpreted

Internal, external locus of control

Space
• Can be source of safety and security
• Physical distance, Distinct zones

Social Organization
Ethno pharmacology

• Who is primary decision maker? • Effect of cultural and genetic factors on

Time absorption, metabolism, distribution and
• Includes clock and calendar, orientation to past, elimination of pharmaceuticals – may be
present, future enzyme response (ultra metabolizers/poor
metabolizers)

29 30

20
 EXAMPLES: African-American Culture
31 32
Native American Culture
Health Beliefs and Values
Health Values and Beliefs

Religious beliefs and church affiliations
are sources of strength and affect ideas

Medicine and religion strongly interwoven about health and illness

Health results from being in harmony and
Alternative modes of healing include
universe herbs, prayer, and laying of hands

Do not believe in germ theory
Members are comfortable with close

Illness and pain are caused by something personal space when interacting with
that occurred in past or will happen in the family and friends
future Saunders Comprehensive Review for the NCLEX – RN EXAMINATION 2014

www.Healthzone.com- Delmar, Division of Thompson Learning

31 32

Hispanic/Latino-American Culture Muslim Culture

33 34
Health Beliefs and Values Health Beliefs and Values

Dramatic body language
Religious rules can pose risk factors
(gestures/facial) or verbal expression
Sensitive to contact with men who are not related -
may be used to express emotion or pain preference for same gender providers

Confidentiality is important
Duty to preserve life and prevent premature death –
In medical emergencies, – saving the life takes

Avoiding eye contact may indicate precedence over who intervenes
respect or attentiveness
Death is predestined by God

Comfortable with close proximity with
Little focus on preventive screening – may forego
family, friends breast or cervical cancer screenings due to modesty

Direct confrontation usually disrespectful issues

Politeness and modesty are important
Believe illness and death should be met with
patience, meditation, and prayer

NCLEX-RN, 6th edition, p 41

Important to discuss dietary requirements – avoid
pork and any medication that contains alcohol

Modernhealthcare.com, Selvam, A (2013, July 27)

33 34

Nursing Responsibility for

35 Chinese American Culture 36 Cultural Competence

Education
Health Beliefs and Values • Understanding key aspects

Request permission to touch patient • Use of web sites

before doing so • Research studies

Limit eye contact
Sensitivity and Appreciation

• Sexual preferences

Avoid gesturing with hands • Belief systems

Clarify responses to questions
Cultural Desire

• Internal motivation to want to know

Alternative methods of healing are often
used
Accommodation and adaption

NCLEX-RN, 6th edition, pl 41 • Collect relevant information
• Engage in cross cultural interactions

35 36

21
 Outcomes of Cultural Competence
37 38 QUESTIONS?

Mutual trust
and respect

Continued Values
learning of variation to
everyone benefit of all

37 38

39 40 CONTENT OVERVIEW

Describe the nursing process in the
Clinical Practice ambulatory setting, including
assessment methods and triage.

Discuss the nursing considerations
for well clients and for clients with
acute, chronic, or terminal conditions

Identify the knowledge and skills
necessary to perform onsite testing,
invasive and non-invasive
procedures.

39 40

THE APPROACH TO
ASSESSMENT OF ALL PATIENTS COLLECTING THE DATA:
41 42

Systematic approach to collecting data:
• Individual:
INVOLVES THE NURSING PROCESS
chief complaint, weight, BP, etc.
• Community:

health risks
• Assessment

environmental conditions
• Diagnosis

financial resources, etc.
• Planning and organizing
• Implementation
Includes subjective and objective data
• past medical history/EMR
• Evaluating responses • Patient stated history
• Reassessment and revision of the plan • Labs/diagnostic testing

Guides the development of the plan

41 42

22
 ASSESSMENT TYPES ASSESSMENT TYPES
43
Comprehensive 44
Problem-focused
• symptomatic call or visit (e.g. abdominal pain)
Provides baseline information as foundation of • Assessment of appropriate associated systems
care planning • Differential diagnosis
• new patients
Bowel patterns
• changes in condition/new problems
Left or right sided, upper or lower quadrant
• Pre-op or pre-procedure
Recent urination, pain with urination

LMP
Collects clinical data
head to toe assessment
Time-lapsed assessment or reassessment
body systems approach • management of chronic illness (e.g. hypertension,
diabetes)
Also includes psychosocial, emotional, and spiritual
Periodic assessment
assessments
Logs
 Evaluation of patient strengths:
Nutrition intake
family/caregiver support
Medications
financial resources
Exercise
emotional resources
Improvement/decline?

43 44

ASSESSMENT TYPES Review

45 46 Performing a Physical Assessment

Population assessment
Performed in order of:
• risk of lead poisoning or prevalence of
• Inspection
obesity
• Palpation

Age of buildings

Community programs • Percussion

Nutrition and Exercise • Auscultation

Ethnic/Culture Prevalence
Except for abdominal assessment which is:
• Inspection

Emergency assessment
• Unconscious/unresponsive patient • Auscultation

• Rapid assessment • Percussion

CALL THE CODE • Palpation

Initiate CPR (C-A-B!)

45 46

Nursing Diagnosis Planning

47 48

Analyze and interpret the data
Comprehensive, coordinated,
individualized plan

Needs
• Identify the client’s or population’s
Involves the patient and family
response
Jointly determine goals and
• Actual or potentially unhealthy activities desired outcomes

A nursing intervention can help to
change toward positive health
Reference resources and
determine what guidelines apply

Strengths
• Identify the client or population’s healthy
Apply critical thinking to
response determine priorities and

A nursing intervention can support or appropriate nursing interventions
strengthen healthy activities

47 48

23
 Implementation
49

Perform the nursing actions to resolve,
prevent, or manage problems

Includes independent and medically-
directed actions

Patient education and teaching
• Inform the patient about the nursing/
collaborative plan

Always consider patient support, comfort,
and safety

Some interventions may be delegated
49
51
Clinical Practice:
Well Clients Preventive Care
51
Screening Recommendations- Invasive Procedures
53

Mammography (USPSTF, 2014).
• recommended every 2 years for women
ages 50 to 74 yrs.

Pap smears (USPSTF, 2014)

Strongly recommends cervical cancer
screening in women with a cervix:

Women ages 21-65 every 3 years

Screening before age 21 not recommended
regardless of sexual history

And then Recommended annually until 2
or 3 consecutive cytological smears are
normal and then every 3 years up to age 65
53
24
Evaluation
50
Determine effectiveness of the interventions
and the degree of goal attainment
• Was the patient comfortable with the plan
and able to comply?

Was the outcome measurable?
• Nurse-sensitive outcomes

e.g., improved comfort
• Collaborative outcomes

e.g., improved serum glucose control

Revise the plan, as indicated
50
US Preventive Services Task Force
52 Recommendations
USPSTF The Guide to Clinical Preventive Services
• Evidence-based recommendations
• Published by the Agency for Healthcare Quality & Research
(AHRQ)
• Developed by an independent panel of experts in primary care
and prevention
• Reviews the evidence of effectiveness and develops
recommendations for clinical preventive services.
• Uses up-to-date relevant literature and quality of evidence
• Sometimes stir controversy with recommendations
• e.g., breast cancer screening
• TO ORDER:
• WEBSITE : https://ahrqpubs.ahrq.gov
• CALL 1-800-358-9295 to order the USPSTF Book
52
Screening Recommendations- Invasive Procedures
54

Colorectal screening (USPSTF, 2014)

Men and Women Ages 50-75
SCREENING OPTIONS:

Fecal occult blood testing (FOBT) annually

Flexible sigmoidoscopy every 5 years with
high sensitivity Fecal Occult Blood Test
every 3 years

Colonoscopy every 10 years

Begin earlier than 50 years and/or more
frequently with greater risk, family hx of first
degree relative colorectal cancer
54
 Well Patients
Screening &
Preventive
Care
Children Adolescents Adults Healthy People 2020
55 56

Statement of national health objectives designed
Development and behavior Lipid Disorders
to identify the most significant preventable
Sickle cell, PKU Depression, Suicide risk
threats to health and to establish national goals
High blood pressure Chlamydia, and other STD’s
to reduce these threats
Genetic anemia Alcohol use
Scoliosis Tobacco use
Created by scientists both inside and outside of
Blood lead level Violence Government, sponsored by Office of Disease
Vision Cervical Cancer Prevention and Health Promotion, U.S.
Hearing Prostate Cancer Department of Health and Human Services
Dental health Breast Cancer
Obesity Osteoporosis
Leading Health Indicators (LHI) are used to
Diabetes Dementia measure the health of the US over 10 years
• Each LHI has one or more objectives

55 56

Healthy People 2020 Healthy People 2020

Leading Health Indicators- LHI Leading Health Indicators- LHI
57 58

Access to Health Services Nutrition, Physical Activity and Obesity

Clinical Preventive Services Oral Health

Environmental Quality Reproductive and Sexual Health

Injury and Violence Social Determinants

Maternal, Infant and Child Health Substance Abuse

Mental Health Tobacco

www.healthypeople.gov www.healthypeople.gov

57 58

Sickle Cell Screening Depression Screening- Adolescents

59 60

Screening for all newborns
Screening of adolescents begins anywhere from the age of 12-18 for
mandated in all 50 states and major depressive disorder (MDD)
District of Columbia
MDD may be present when these symptoms cluster together and

Sickle cell anemia affects 1 in 500 persist for 2 weeks or more
African-American newborns born in • Symptoms:
US – smaller proportions in other
Persistent sadness, Irritability
ethnic groups.
Loss of interest or pleasure in most activities

Children with sickle cell anemia are
Social isolation
vulnerable to life-threatening
Decline in school work
pneumococcal infections.
Anger

Important to address with patient /
Sleep and appetite disturbances
caregivers

or non-specific pain
• Infection control
Patient Health Questionnaire for Adolescents [PHQ-A]
• Pain control
• Fatigue The Beck Depression Inventory-Primary Care Version [BDI-PC])
http://www.nhlbi.nih.gov/health/health-topics/topics/sca

59 60

25
 Suicide and Crisis
Suicide Risk Factors Intervention
61 62

Depression, other mental disorders, or substance
Assists clinicians in
abuse disorder
conducting a suicide

Certain medical conditions assessment using a 5-

Chronic pain step evaluation and
triage plan to identify risk

A prior suicide attempt factors and protective

Family history of a mental disorder or substance abuse factors, conduct a suicide

Family history of suicide inquiry, determine risk
level and potential

Family violence, including physical or sexual abuse interventions, and

Having guns or other firearms in the home document a treatment
plan.

Having recently been released from prison or jail

Being exposed to others' suicidal behavior, such as that Suicide is the 10th leading
of family members, peers, or celebrities cause of death in the US.

61 62

Homicide and Domestic Violence

Obesity Screening
63 64

Screen all adults and children for obesity
Ask & Document:
Offer counseling and behavioral interventions to promote
sustained weight loss for obese adults

Central adiposity increases risk for cardiovascular
The Top Five Risk Factors and other diseases independent of obesity
Has the abuser:
Waist circumference can be a measure of central adiposity
1. Ever used, or threatened to use, a gun, knife,
Body Measurement:
or other weapon against victim? Body Mass Index (NHLBI, 2017)
2. Ever threatened to kill or injure victim?

Wt in kg/Ht 2 in meters
(document complete and accurate quotes of
Reliable and valid for identifying adults at increased
the threats) risk for mortality and morbidity
3. Ever tried to strangle (choke) the victim?  Normal BMI = 18.5 – 24.9
4. Is abuser violently or constantly jealous?  Overweight BMI = 25.0-29.9
5. Has abuser ever forced victim to have sex?  Obese BMI = 30.0-39.9.
 Extreme obesity = >40
http://justicewomen.com/tips_dv_assessment.html

63 64

Alcohol Misuse Screening Recommended Immunization Schedule

65  “Risky” or “hazardous” drinking 66
Tetanus, diphtheria, (Td) - one every 10 years
• Women: more than 7 drinks per week (1 per day) or • After age 19 it is recommended to exchange a Tdap in place
more than 3 drinks per occasion of one Td to boost the pertussis

Example:
• Men: more than 14 drinks per week (2 per day) or
more than 4 drinks per occasion  Patient age 30 = Td 1980, Td 1990, Td 2000, Tdap 2010,
Td 2020
 “Harmful drinking”
• Experiencing physical, social, or psychological harm
Human papillomavirus (HPV) – 3 doses through age 26
from alcohol use but do not meet criteria for • Start ages 11-12
dependence
Influenza – Annual
 “Dependence” • all ages >6 months (2016)
• Unable to control drinking; drinks increasing amounts;
Zoster – 1 dose > 60 yr.
experiences withdrawal symptoms if without
 Screening tools:
Measles, mumps, rubella (MMR) – 2 doses prior to school
entry
• National Institute on Alcohol Abuse & Alcoholism • Adults born during or after 1957, give >1 dose
http://www.niaaa.nih.gov/Publications/AlcoholResearch/
 Alcohol Use Disorders Identification Test (AUDIT) is
Varicella-
considered the most accurate alcohol screening tool. • If no immunity by 12 months – 2 doses
cdc.gov

65 66

26
 Recommended Immunization Schedule Childhood Immunizations
67
Meningococcal Vaccine 68
• 1 or more doses – provider recommendation
Live, attenuated vaccines
• All pre-teens and teens • A “live” weakened cultivated version of the
organism closely related but less dangerous
• First-year college students living in dormitories than the organism itself.
• Others at risk • alerts the immune system to produce a stronger

Pneumococcal polysaccharide antibody response

Herpes Zoster
• 2 doses between the age of 19-64
Varicella Study hint:
• After the age of 65 -1 dose
MMR •See early and late

Hepatitis A
Inactivated vaccines childhood
• Can be given at 12 months – adult
Are “produced” and contain toxoids, immunization
• 2 doses protein subunits, or killed organisms – schedules in
produce a weaker but still effective

Hepatitis B syllabus
antibody response •http://www.cdc.gov/va
• Can be given 1month – adult years
Influenza ccines/recs/default.htm
• 3 doses
Tetanus

polio

67 68

Vaccine for Children Program IM Injection sites for Infants to Teens

69 70 Age Needle Size Location

National Childhood Vaccine Injury Act of 1986
• Requires a Vaccine Information Sheet – VIS be Newborns 5/8” Anterolateral
(1st 28 days) thigh muscle
provided for immunization administration to
everyone prior to receiving the vaccine Infants 1” Anterolateral
(1–12 mos.) thigh muscle
• Includes the right to refuse
Toddlers 1” -1 ¼” Anterolateral
• Requires reporting of adverse event of (1–2 yrs) 5/8” – 1” thigh muscle
or deltoid muscle
vaccines and toxoids to U.S. Dept. of Health Can be dependent
of arm
on wt.
and Human Service
Children and Teens 1” -1 ¼” Anterolateral
(3–18 years) 5/8” – 1” thigh muscle
• Vaccines acquired through public purchasing or deltoid muscle
Can be dependent
must report adverse events to local, county on wt. of arm
and/or state health departments
Use 22-25 gauge needle depending on child size

69 70

Triage Assessment
71 72
Settings:
• Face-to-face
• Telephone
Clinical Practice:

Prioritization of Symptoms:
• Initial assessment
Acutely Ill Clients
Performed to identify immediate needs

Identify and refer to appropriate level of care

Appropriate level of care is based on:

• Needs of the client
• Personnel available and competency
• Technical resources available
• Provider resources for hands off

71 72

27
 Medical Emergencies Medical Emergency Assessment
73
Ensure staff orientation and education in handling 74
emergencies to include staff’s role during
CHEST COMPRESSIONS*
emergency
AIRWAY

BREATHING

Skills required (BLS, ACLS, PALS)
Perform in the order of: C-A-B

Competency assessment/re-assessment Although ventilations are an important part of resuscitation,
• Annual Mock Drills evidence shows that compressions are the critical element in

Age-specific medical equipment and medications resuscitation.
for emergency care 1. Check for responsiveness
• crash cart, resuscitation equipment 2. Check for breathing, absence of or abnormal

Ensure staff competence in recognizing acute 3. Call for help
changes 4. Check for pulse no longer than 10 seconds
5. Give 30 compressions

Complete documentation 6. Open the airway and give 2 breaths

Debriefing after event with staff 7. Resume compressions
*American Heart Association, 2010

73 74

Medical Emergency - Shock Medical Emergency - Shock

75 76

Caused by injury or condition that affects blood flow

Symptoms:

Severe allergic reaction, anaphylaxis
• Rapid, weak, or absent pulse

Significant blood loss
• hypotension

Heart failure
• Rapid, shallow breathing

Blood stream infections
• Cool, clammy skin

Dehydration
• Dilated pupils

Poisoning
• Confusion

Burns
• Anxiety

Can lead to organ failure and may be life-
• Loss of consciousness
threatening
• Dry mouth, decreased urine output

Requires emergency treatment/management

75 76

Communicable Disease
77 Medical Emergency - Shock 78
Modes of Transmission

Treatment:
Indirect contact:
• First Aid and/or CPR if necessary • Occurs when a pathogen can withstand the
environment outside its host for a long period of
• Epinephrine for anaphylaxis time
• Transfusion for hypovolemia • Ingesting food and beverages contaminated by
• Medications for cardiac symptoms contact with a disease reservoir

• Antibiotics for infection • The fecal-oral route of transmission, in which

sewage-contaminated water is used for drinking,
washing, or preparing foods

Examples - gastrointestinal diseases such
as cholera, rotavirus, norovirus,
cryptosporidiosis, and giardiasis.

77 78

28
 Communicable Disease Infection Control
80
79
Modes of Transmission Practices

Direct contact: • Hand Hygiene Compliance
• Hand contact in touching an takes at least 20 seconds
Prevent • Personal Protective
infected person Transmission Equipment (OSHA)
• Inhaling of infectious droplets • Standard Precautions
emitted by sneezing or coughing
• Intimate sexual contact

Examples: ringworm, AIDS, • Communicable diseases
• Blood/body fluids
trichinosis, influenza, rabies, Control • Knowing “dwell” time of
and malaria, West Nile virus. Exposure therapeutic/diagnostic time
something such as a PICC
Risks line, IV can remain until it
should be taken out, unless
earlier need to do so.

79 80

Lyme Disease Pediatrics -

81
Bacterial infection transmitted by bite of infected 82
Cephalohematoma
black-legged deer tick

Symptoms:
Hemorrhage of blood between the skull and
 Early – small red bump at site the periosteum that occurs during childbirth
• Rash (erythema migrans) – expanding red area with
clearing in center (bulls-eye pattern) – hallmark of the
May be caused by prolonged 2nd stage of
disease
• Flu-like symptoms – fever, fatigue, body aches
labor or forceps delivery
 Later – may occur weeks or months later
If severe, may lead to jaundice, hypotension,
• Rash (erythema migrans) in other parts of body
• Joint pain and swelling usually of the knees anemia
• Neurological symptoms – meningitis, Bell’s palsy, limb
numbness or weakness

Can take weeks to resolve
• Hepatitis
May need to rule out skull fracture
• Impaired memory

Treatment:
No treatment
 Oral or IV antibiotics
 Symptom management

81 82

Pediatrics –
83 84
Newborn Conjunctivitis

Red eye in a newborn caused by infection, irritation, or a
blocked tear duct
 May be caused by antimicrobial drops given at birth Clinical Practice:

Symptoms:
• Drainage from eye Clients with Chronic Conditions
• Red, puffy, tender eyelids

Treatment:
• Combination of topical, and either oral or intravenous
antibiotics
• Rinsing the newborn’s infected eye with a saline
solution to remove drainage

83 84

29
 Triage and Assessment of “Treat to Target”
85 Chronic Conditions 86

a therapeutic concept that considers well defined and
specific physiologic targets as aims in controlling the
pathophysiology of certain diseases
• Diagnosing the primary disease
a disease treatment strategy whereby an individual and
their health care provider set specific targets or goals for
improved health outcomes.
• Identifying secondary problems,
guides adjustments in the administration of an
intervention and facilitates target achievement
psychosocial

rationale for a specific target is based on
comprehensive, evidence based, generally accepted
• Treatment problems/effectiveness target values

Useful in treating:

Diabetes
• Self-management knowledge,
Cardiovascular disease (HTN, Hyperlipidemia)
behaviors
Rheumatoid arthritis

85 86

Endocrinology: Cushing Syndrome Endocrinology: Cushing Syndrome

87

Occurs when body is exposed to high levels of
cortisol produced by the adrenal gland over
extended time.

Signs and symptoms
• A fatty hump between shoulders
• A rounded face (“moonface”)
• Pink or purple stretch marks on skin.

Can also result in high blood pressure, bone
loss and diabetes.
http://www.mayoclinic.org/diseases-conditions/cushing-
syndrome/basics/definition/CON-20032115
88
Treatments for Cushing syndrome can return cortisol
production to normal and noticeably improve symptoms.

The earlier treatment begins, the better the chance for
recovery.

Treatment may include
• Surgical removal of growths or the adrenal gland(s)
• If external steroid use is determined to be the cause,
gradual tapering and removal of the steroid may be
recommended.
• Drugs that block the excessive production of certain
hormones may also be administered.
• Adrenal corticosteroid inhibitors block one or more
enzymes in the steroid synthesis pathway and are
used to treat Cushing syndrome.
http://www.mayoclinic.org/diseases-conditions/cushing-
syndrome/basics/definition/CON-20032115

87 88

Endocrinology - Addison’s disease Endocrinology - Diabetes

89

Also called adrenal insufficiency

Occurs when the body produces insufficient amounts of
cortisol and aldosterone produced by your adrenal
glands

Treatment

Oral corticosteroids: Prednisone, dexamethasone,
Hydrocortisone (Cortef), methlyprednisolone or
cortisone acetate

Corticosteroid injections

Androgen replacement therapy: To treat androgen
deficiency in women, dehydroepiandrosterone (DHEA) can
be prescribed
90

A disease marked by abnormal levels of sugar in the blood,
caused by the body's inability to produce or use insulin
properly.

If untreated, can cause problems with circulation, vision,
renal function and nerve damage.

Insulin is a hormone that helps move blood sugar into cells
where it's used for energy.

Insulin resistance is a condition in which the body is unable to
use insulin properly.

can lead to high blood sugar levels

closely linked to overweight and obesity

Significant hyperglycemia can lead to emergency
complications such as diabetic ketoacidosis or diabetic
hyperosmolar syndrome.

http://www.mayoclinic.org/diseases-conditions/addisons-
Persistent hyperglycemia increases risk for long-term

disease/basics/treatment/con-20021340 complications such as cardiovascular disease, blindness or
kidney failure.

89 90

30
 Diabetes: Assessment Diabetes: Assessment continued
91 92

Primary disease
Treatment problems and effectiveness
• Serum glucose • Hyper and hypoglycemia
• Hemoglobin A 1C
Signs and Symptoms
• Oral or insulin therapy

Secondary problems
Self-management knowledge and behaviors
• Retinal exam • Foot exam with • Diet
• Kidney function monofilament
• Sexual function
• Activity
• Infections • Glucose monitoring

Classic symptoms
• Skin and foot care

Associated risk factors are:
• Weight  Polyuria
Sick day knowledge
• BP  Polydipsia
Injection skills (if needed)
• Lipids  Hyperglycemia
• Smoking  Unexplained
weight loss

91 92

Plasma Glucose Cardiovascular – Heart Failure

93 94

Criteria for diagnosis of diabetes*
Inability of the heart to pump adequate supply of
blood to organs – Most often due to problem w/
• FPG >126 mg/dl on 2 separate occasions
left ventricle - blood begins to back up
OR

Right sided heart failure – (R) side not pumping
• Hemoglobin A1C 6.5% or higher to lungs as normal (often triggered by L sided
OR failure)
• 2-hour PG >200 mg/dl during an OGTT. • Leg edema, SOB, abdominal bloating,
excessive fatigue
OR

Left sided heart failure – (L) ventricle loses ability
• Symptoms of diabetes plus a random
to contract- blood backs up into lungs = moist,
plasma glucose concentration >200 mg/dl. wet
*American Diabetes Association
• Pillows to rest (orthopnea), SOB, pulmonary
(2017) edema

93 94

Heart Failure Diagnosis Cardiovascular - Stroke

95 96

A stroke occurs when a vessel in the brain ruptures or
is blocked by a blood clot

Echocardiogram

RISK FACTORS: smoking, hypertension, atrial

Ejection fraction: fibrillation
• measures amount of blood in left
Stroke types:
• Hemorrhagic (weakened blood vessel: bleed in brain)
ventricle after systole - determines how • Ischemic (blocked blood vessel )
well heart is pumping • accounts for 87 percent of all stroke cases

STROKE Symptoms:

Normal value – 55-70 • FAST (face drooping, arm weakness, speech

Less than 40 – may indicate heart difficulty, time to get help – 911)
• BEFAST includes balance and eyesight (vision
failure changes)
• tissue is treasure – 3 hr window- t PA-gold standard

More than 75 may indicate

Treatments:
hypertrophic cardiomyopathy
t PA

Angioplasty/stents

Carotid endarterectomy
**See appendix for Heart Failure causes, symptoms, meds
Rehabilitation
American Heart Association/ American Stroke Association – 2017

95 96

31
 Cardiovascular Metabolic Syndrome
97 Wellness/Prevention Education 98

a group of risk factors that raises

Lifestyle changes: risk for heart disease and other
• Quit smoking health problems, such as diabetes,
stroke and heart disease
• Maintain weight
• Track daily fluid intake
Requires at least three metabolic
• Limit alcohol intake risk factors to be diagnosed
• Manage stress
• Monitor B/P Source: National Heart, Lung and Blood Institute (2017)

97 98

Metabolic Syndrome Risk Factors Metabolic Syndrome

99
Excess fat in the stomach area (abdominal obesity) = greater 100

GOALS:
risk factor for heart disease than excess fat in other parts of the
body, such as on the hips • HTN

<130/85
RISK FACTORS:

high triglyceride level or taking medication to treat high • Smoking
triglycerides • FBS

<100 • Lack of exercise
• Triglycerides are a type of fat found in the blood
• HDL – “happy” • Insulin resistance

A low HDL cholesterol level or taking medication for low HDL

>50 for women • Obesity
cholesterol.
• HDL = "good" cholesterol - helps remove cholesterol from
>60 for men
current US
arteries • LDL – “lousy” obesity rates
• low HDL cholesterol level raises risk for heart disease

< 100
36% (2015 )

High Blood Pressure or taking medication for high blood • Triglycerides
50 %(2030 )
pressure

< 150
• over time, can damage the heart and lead to plaque buildup
• Waist circumference

High fasting blood sugar or taking medication for high blood

<35” for women
sugar
Source: National Heart, Lung & Blood Institute
<40” for men

99 100

Pulmonary Diseases Pulmonary Diseases

101
Air Flow Limitation 102

Screening tests – Spirometry
• associated w/ abnormal inflammatory response of the lung
assesses how well lungs work by measuring how much air is
• Usually progressive inhaled, how much is exhaled and how quickly it is exhaled
• Onset usually happens in 5th decade

Life style changes
• Associated symptoms: dyspnea, hypoxia, hemoptysis,
• Smoking cessation
productive cough
• Weight control

Chronic Obstructive Pulmonary Disease (COPD) • Nutritional support
• Emphysema- Abnormal enlargement of air spaces • Breathing exercises:
• Chronic bronchitis - airways that carry air in and out of • Pursed lip breathing : Pucker/ purse lips (think of whistling)
lung are partly blocked Conserves energy, calming, helps control SOB

Associated symptoms: constant and/or productive • Inhale, normal breath in-count 4,
cough, smokers cough, excess sputum, shortness of • Exhale – breath out count to 4
• Use when changing position or when breathing is labored- i.e.
breath (SOB), wheezing
getting up, rolling over, walking upstairs

Asthma- Chronic lung disease that inflames and narrows

Pulmonary Rehab
airways
• Reactive airway disease– airways react, swell and cause
Immunizations
chest tightness, SOB – difficulty breathing • Annual influenza
• triggers – exercise, pollen, cold, foods, odors/smells • Pneumonia

101 102

32
 Renal – Nephrotic Syndrome Renal – Nephrotic Syndrome
103 104

Causes increased protein excretion in urine
Diagnosis:

Caused by damaged glomeruli – inability to filter

Urine protein, albumin
waste and remove excess fluid

Blood protein levels

Symptoms:

Edema in ankles, feet, around eyes
Kidney biopsy

Foamy urine
Treatment

Weight gain due to fluid retention
Antihypertensives

Fatigue
Diuretics

Loss of appetite
Cholesterol reducing meds

Complications:
Anticoagulants

Blood clots

Corticosteroids to decrease inflammation

Hypertension

Acute/chronic kidney disease

103 104

Neurology - Dementia Neurology – Multiple Sclerosis

105

Alzheimer's Disease
• A progressive, degenerative disorder that
attacks the brain's nerve cells, or neurons,
resulting in loss of memory, thinking and
language skills, and behavioral changes.
• Most common cause of dementia, or loss of
intellectual function, among people aged 65
and older.
 Alzheimer’s Facts:

80% of communication is non-verbal

6/10 Alzheimer's patients wander

Visual field becomes narrower over time –
12x12
106
an Immune-mediated process – antigen unknown

body’s immune system creates abnormal response
against the central nervous system - nerve signals
interrupted between brain and other parts of the
body.

Myelin – fatty tissue surrounding nerves is affected –
myelin insulates the nerves/fibers

MS seems to be more prevalent farther from the
equator, possibly vitamin D related – more sunlight
exposure could be a possibility

Studies have shown smoking to increase the risk of
National developing MS - if stopped during the onset of MS,
Multiple
Sclerosis
can slow the progression
Society
See teaching plan in reference section

105 106

Musculoskeletal – Spine Curvatures Genitourinary System -

107
NO Cure 108

Impacts all age groups – affects 2-3% of the population (7 Testicular Cancer
million)

Onset is about 10-15 years of age, in both genders
Most common cancer in men age 15-34

Females progress to a curve magnitude that often
Can usually be cured
requires treatment

Impacts quality of life: limits activity, pain, reduced
Cryptorchidism (undescended testicle) may be a risk
respiratory function, self-esteem factor

Treatments often ineffective, invasive and expensive
Types:

Increase risk of x-ray exposure due to the frequency of
Seminoma
exams

Nonseminoma –grown and spread more rapidly

Three major types:

Lordosis - swayback, the spine of a person with lordosis
Symptoms
curves significantly inward at the lower back
Lump or swelling in testicle

Kyphosis - abnormally rounded upper back (more than
Dull ache in lower abdomen
50 degrees of curvature)

Scoliosis - sideways curve to their spine. The curve is
Sudden fluid buildup in scrotum
often S-shaped or C-shaped
Scrotal pain or discomfort

National Scoliosis Foundation

107 108

33
 Genitourinary System - Immune System –
109 110
Testicular Cancer Grave’s disease (hyperthyroidism)

Risks:
Immune system disorder

Undescended testicle
Result of overproduction of thyroid hormones

Symptoms include:

Family history of testicular cancer

Anxiety, irritability

White males

Fine tremor in hands or fingers

History or previous testicular cancer

Heat sensitivity

Treatment

Weight loss despite normal eating habits

Orchiectomy
Enlarged thyroid gland (goiter)

Adjuvant chemotherapy
Bulging eyes (exopthalmos)

Radiation
Fatigue

Treatment may cause infertility – consider prior
Palpitations
sperm banking
Thick, red skin on shins or top of feet

109 110

Immune System – Immune System - HIV Infection

111 112
Grave’s disease

Diagnosis:
Transmission: Course of Prognosis: Management:

Thyroid stimulating hormone (TSH) levels are low infection:
• Sexual • Strongly • Anti-

Radioactive iodine uptake contact • Brief mono- corre- retrovirals,
• Parenteral nucleosis-like lated • Prevent

Scans/imaging exposure to syndrome with opportunistic

Treatment: blood/ • Asymptomatic CD4-cell infections
selected seropositivity count (but no live

Radioactive iodine to destroy thyroid cells blood • Inversely virus
products • Symptomatic

Antithyroid medications seropositivity related vaccines)
• Maternal to the
transmission • Counseling

Beta blockers via breast
HIV load

Thyroidectomy (full or partial) milk and
perinatal
transmission
https://www.mayoclinic.org/diseases-conditions/graves-disease

111 112

Assessment Terminal Illness

113 114 Signs of depression and/or anxiety:
• sleep disturbance
• agitation
• restlessness
• excessive autonomic activity
Clinical Practice: Emotional
• weight change
• mood swings
Changes in
lifestyle imposed
strengths by illness
• spiritual • financial
Clients with Terminal Illness problems

Social supports Change in

Community
groups, support
problem-solving
groups ability
• Overwhelmed
• Disease related
Perception of
disease and ADL’s –
treatment independence
• Outward/social • Dependent on
perception others

113 114

34
 Terminal Illness Terminal Illness
115
Psychosocial Interventions 116 Psychosocial Interventions

Reduce anxiety
Palliative Care

take unhurried approach, discuss disease, • Focuses on relieving symptoms that are related to
support groups, recognize feelings of losing chronic illnesses
control, etc. • cancer, cardiac disease, respiratory disease, kidney
failure, Alzheimer’s and other dementias, AIDS,

Promote effective coping
Amyotrophic Lateral Sclerosis (ALS) and other

assist patient and family learning about disease neurological diseases.
and treatment, strengthening support system,
etc. • Can be used at any stage of illness — not just
advanced stages.

End-of-life choices

support patient and family to determine their • Treatments are not limited with Palliative Care
treatment goals. and can range from conservative to aggressive
and/or curative.

115 116

Terminal Illness
117 Psychosocial Interventions 118

Hospice care
• team-oriented approach to expert medical care, pain
management, and emotional and spiritual support Clinical Practice:
expressly tailored to the patient's needs and wishes
• Hospice Care is palliative by nature.
Clinical Skills
• curative treatment is no longer desired or beneficial –
goal is to promote comfort
• supports the patient and family while focusing on
relieving symptoms and offering comfort from pain,
shortness of breath, fatigue, nausea, anxiety, insomnia,
constipation, etc.
• treatments are limited and focus on relief of symptoms.

117 118

Noninvasive Procedures Blood Pressure Measurement

119 120

Height, weight
Appropriately sized cuff
• Bladder encircles 80 – 100% of arm

Head circumference, infants/children • Width 40% of circumference

plot on growth chart

Bare, non-constricted upper arm

12 Lead EKG

note placement of leads
Locate radial pulse, pump up rapidly to ~ 30 mm
Hg above radial pulse disappearance

Visual Acuity – Snellen at 20 ft,

wear correction if the patient requires
Release pressure slowly

refer for further evaluation if 20/40 or greater

Listen for the First two consecutive sounds =

BMI= Weight (kg) Systolic BP
Height(m) 2

Disappearance of sounds = Diastolic BP

119 120

35
 Blood Pressure Measurement continued
Fecal Occult Blood

Collect 2 separate samples from 3 separate bowel movements
121 122

Diagnosis of Hypertension :
Do not collect if:
In children: • Hematuria

Diastolic BP > the 95 %ile for age, sex, height • Rectal bleeding
In adults: • Menstruating

Systolic BP > 140 mm Hg, or a diastolic BP
Restrictions: (Can cause False positive results)
>80mm Hg
7 days prior avoid:

Measured on at least 2 separate occasions
• ASA, steroids, NSAIDs, iron supplements

May repeat after 5 min. of sitting quietly

5 days prior avoid:

Prior to measurement: • Vitamin C (dietary and supplements)
• Avoid caffeine and tobacco for 30 min. prior to
measurement
3 days prior do not consume:
• Quiet environment for 5 minutes • Red meats Black grapes
• Feet flat on floor/back and arm supported • Broccoli
• Manometer at eye level – calibrate BP cuff annually • Cauliflower Raw fruits or vegetables

121 122

Peak Flow Meter Pulse Oximetry

123
Teach the patient and caregivers/family 124

Determine the patient’s personal best

Measures arterial oxygen saturation
• Determined over a period of 2-3 weeks when feeling best

Based on height & age

Procedure:

Disposable or reusable spectrophotometric probe

perform standing up x 3 on patient’s finger, toe, earlobe, or nose -

Patients and Caregivers use to guide their home care measures amount of infrared light absorbed

Nurses can use as a tool to triage patients on the phone

What does it mean?
Leave probe on for 75 seconds
• Green:

80 -100% - good control of asthma
Normal SaO2 > 95%
• Yellow:

50 – 80% - caution, take quick relief medicine & seek PCP
Critical value SaO2 < 93% (ACLS)
care

consider oxygen therapy
• Red:

< 50% - danger, take quick relief medicine, & seek emergency
medical care if not returned to yellow or green immediately Reference: Emergency Severity Index, version 4, 2005

123 124

Nebulizers Defibrillators
125 126

Treatment for asthma and other respiratory
Review organization policy and manufacturer
conditions recommendations for maintenance and frequency

delivers liquid medication in mist form
Daily/shift checks

more effective way to deliver the medication
Plugged in/ready for use
than an inhaler which requires taking deep
breaths
Charges and delivers energy

can deliver short-acting or long-acting asthma
Record results
medication
Supplies

more than one medication can be given in the
Appropriate age related
same treatment

Sufficient number

Maintenance

Expiration dates/ condition of supplies

Single use chambers/mouthpiece

Competency review

Cleaning/disinfecting

125 126

36
 Automatic External Defibrillator
Invasive Procedures:
127 (AED) 128
Glucose Meters

a portable device that analyzes the heart rhythm and
can deliver an electric shock to the heart to try to restore Key points:
a normal rhythm Check expiration date on strips
Rotate sites used

used to treat sudden cardiac arrest (SCA).
Clean site prior to use

Use of AED: Obtain enough blood to fill test strip area

Taught with CPR classes Repeat test for unusual results

Voice prompts and screen displays assist use Quality controls
per manufacturer recommendations and organization

Untrained can use safely policy

Maintenance Checks Types:

Plugged in/ready for use 1. Liquid controls

Supplies available for adults/peds 2. Electronic checks

Competency review 3. Comparison to lab test
Competency review- required annually

127 128

129
Cleaning 130 Disinfection vs. Sterilization

Removal of visible soil and material, Disinfection Sterilization
organic and inorganic, from objects and
Eliminates many or all
Destroys or eliminates all
surfaces microorganisms, except forms of microbial life
bacterial spores, on
By physical or chemical

Normally is accomplished manually or methods
inanimate objects.

Pressurized steam
mechanically using water with detergents or
Usually by liquid

dry heat
enzymatic products chemical or wet

EtO gas
pasteurization
Hydrogen peroxide gas

Essential before high-level disinfection and plasma
sterilization
liquid chemicals

129 130

Types of Disinfection Types of Sterilization

131 132

High Level Disinfection:

kills all microorganisms except large numbers
All require • Steam Sterilizers
of bacterial spores cleaning/organic Autoclaves

Low Level Disinfection: matter removal • Dry heat sterilizers

Can kill most vegetative bacteria, some fungi, prior to processing Hydrogen peroxide gas
and some viruses plasma

Choice of disinfectant, concentration, and exposure
All require use of • Ethylene oxide gas
time is based on the risk for infection associated with chemical or Requires aeration
use of the equipment
biological • Chemical sterilants

Chemical compatibility after extended use with the
indicators to Time sensitive
items to be disinfected also must be considered
monitor Glutaraldehyde

Some devices can be difficult to clean and high-level Peracetic acid
disinfect because of intricate device design effectiveness

131 132

37
 Sterilization, Disinfection, or Cleaning? Triage Scenario

Critical items - enter sterile tissue or the vascular system, require
133 134 Source: ESI, v. 4 2005
cleaning and sterilization
• Surgical instruments Patient
• vascular catheters “I was shoveling snow and Assessment
• Implants
• intra-uterine devices may have overdone it,” • Appropriate level of

Semi critical items - contact mucous membranes or non-intact reports an obese, 52-yr-old care
skin, do not penetrate skin or enter sterile areas, require
cleaning and high level disinfection
male. He tells you his pain • Vital signs
• Respiratory equipment is 10/10, is nauseated. His • Subtle cues
• flexible endoscopes
• Laryngoscopes
skin is cool and clammy. • What do the history and
• Specula VS: combined signs and
• ET tubes

Noncritical items - contact intact skin, but not mucous
BP 86/50 symptoms indicate?
membranes, require cleaning HR 52 & Irregular • Should nurse be
• Stethoscopes worried about this
• Bedpans
RR 24
patient?
• BP cuffs
• Crutches
• environmental items

133 134

Triage Scenario QUESTIONS?

135 Source ESI, v.4 2003 136
Patient Assessment
12-year-old girl brought in by • What are concerns as
her mother, Mom states the RN triaging the
daughter has been weak and call?
vomiting for 3 days. Child
states she feels “thirsty all the • History of being
time and my head hurts.” “thirsty and lethargic”
Vomited once today. Denies suggests what
fever, abdominal pain, possible nursing
diarrhea. No significant diagnosis?
PMHx. The child is awake, • Should nurse be
lethargic, and slumped in concerned about this
chair. Color is pale, skin warm child?
and dry.

135 136

138
Content Overview
137

Describe skills necessary to provide

telehealth nursing services to
Clinical Practice: patients.

Discuss assessment skills for
Telehealth and Telephone Triage telehealth nursing practice.

Identifydocumentation requirements
and concerns in telehealth nursing
practice

137 138

38
 What is Telehealth? What is Telehealth Nursing?
139 140

the delivery, management and coordination of health
services that integrate electronic information and
telecommunications technologies to increase access,
care and services within the scope of
improve outcomes, and contain or reduce the costs of nursing practice incorporating
healthcare AAACN Core Curriculum, 2013
telephone or other

umbrella term used to describe services delivered across telecommunication technology to
distances by all health related disciplines
remove time and distance barriers
Technologies Used: for the delivery of nursing care
• telephone
• computer

includes provision of patient care,
• Email health education, patient advocacy,
• EMR portals and coordination of services
• virtual clinics/interactive video transmissions
• direct link to health care instruments
• transmission of images and teleconferencing

139 140

Core Dimensions of Telehealth Assessment

141 Telehealth Nursing Practice 142

Systematic assessment
Rely upon auditory, verbal and emotional

Identify and prioritize need and acuity cues communicated through speech

Use evidence-based techniques/ instruments

Identify expected outcomes

Identification of appropriate level of care

Coordination of care
Timely response to phone messages is

Health teaching/health promotion essential to patient safety

Documentation
Caller’s perception of the nurse’s caring and

Use of technology confident attitude often is basis of trust and

Evaluation of quality open disclosure about concerns, condition

Confidentiality and compliance

141 142

Assessment Tips What is Telephone Triage?

143 144

An interactive process

Talk to the patient whenever possible
between nurse and patient

Treat each caller like the first call of the
day
that involves identification of
the nature and urgency of the

Avoid being judgmental
patient’s health care needs

Clarify what the caller is saying/asking and determination of the

Use open-ended questions when appropriate disposition
appropriate

143 144

39
 Clinical Decision Support Tools
based on pattern recognition, encouraging the RN to use critical-thinking Clinical Practice Guidelines
145 skills, context, and pattern matching to determine a disposition
146

“statements that include recommendations,
• Set of rules for • Plan for

ALGORITHM
• Recommended

PROTOCOL
GUIDELINE

solving a carrying out

intended to optimize patient care, that are informed
practice to direct
the nurse in problem in a a patient’s by a systematic review of evidence and an
developing an finite number treatment assessment of the benefits and harms of alternative
individualized plan of steps regimen
care options" (IOM)
of care • Flow chart of
clinical • Actions are
recommendations for clinicians about the care of
• Flexible, allows questions, scripted, to
some discretion, usually be followed patients with specific conditions based upon the
use of nursing answered by the without best available research evidence and practice
judgment and patient with a deviation
experience while yes or no,
experience.
retaining a guiding
AHRQs National Guideline Clearinghouse is a public
standard of care, decisions in a
step-by-step, resource for summaries of evidence-based clinical
implementation, or
use logical practice guidelines.
sequence in
• Disadvantage: lack order to reach a
Available on mobile or tablet devices
of consistency final disposition

See reference information in appendix

145 146

Why use Protocols in Telehealth?

147 148
How to Use Protocols

Provides standardization and structure

Meets goal of providing safe, effective care and
Use the protocol that best matches the
appropriate disposition of patient health problems patient’s presenting problem

Eliminates common practice errors
If patient presents with multiple symptoms,
use the protocol that has the highest

Provides legal protection likelihood of leading to an appointment

Ensures documentation ease, efficiency, and
retrievability
Ask the patient which symptom is the most
bothersome

Meets accreditation standards

147 148

Dispositions Legal Issues linked to Telehealth

149 Emergent 150
• Severe, life-threatening symptoms
It is a “Formal Nurse-Patient
• Suicide prevention Relationship”
• 911
• Poison control
• Rape crisis
Still requires the nurse to practice
Urgent within scope of practice
• Seen as soon as possible at most appropriate site – usually
within 1-8 hours
Acute
Safeguards
• Seen within 8 to 24 hours or given a next-day appointment
Decision Support Tools
Non-acute
• Come in as appropriate - usually can be managed with
Documentation
telephone advice and/or an appointment at a later date
Quality Assurance
Cardinal Rule of Triage:
Accountability
When in doubt, always err on the side of caution

149 150

40
 Strategies to Control Legal Risks
151 152 Questions?

3 R’s - Right care, Right place, Right time

Consistency with prioritizing calls

Formal training for telephone nurses

Adequate resources and appropriate
protocols

Provisions to serve patient population

Written assessment and triage protocols

Documentation based on nursing process
and protocols

Quality Improvement measures

151 152

Medication Management
154

Clinical Practice:
Discuss National Patient Safety

Goals related to medication
Medication Management Systems management

Describe strategies for medication

153 reconciliation

153 154

National Patient Safety Goals - NPSG Brown Bag Assessment

155
Improve safety of using medications 156

Review all medications the patient is using, including herbals,
• Labeling medications vitamins and OTC
• Date, time, concentration, initials

New patients or patients taking new drugs
• LASA medications
• Side effects common with new drug
• Do Not Use Abbreviations
• Expected time frame for therapeutic levels to be achieved
• Tall man lettering
• DOBUTamine DOPamine
Assessment completed on new patients or those mentally
compromised

Medication reconciliation • Determine use of drugs and document
• Compare current and new medications  Discuss with provider medication list
• Communicate to next provider

Discard any unused medications
• Provide reconciled med list to pt
• Include short term medications and OTC
Develop education and adherence plan
• Educate on basic knowledge, purpose, side effects and

Resources: reactions including OTC and herbals, medication
• ISMP.org - Institute of Safe Medication Practice assistance device: pill dispenser, alarm clock
• Jointcommission.org • Instruct to use one pharmacy for all prescriptions

155 156

41
 Side Effects of Select Herbal Products Polypharmacy
157 158

Use of multiple medications often to treat more than

Ginkgo biloba: Bleeding
one condition

St. John's wort: Gastrointestinal disturbances, • Becomes expensive
allergic reactions, fatigue, dizziness, confusion, dry • Can lead to death
mouth, photosensitivity

Most common result of polypharmacy is adverse

Ephedra (ma huang): Hypertension, insomnia, drug reactions
arrhythmia, nervousness, tremor, headache,

Polypharmacy is most common in the elderly
seizure, cerebrovascular event, myocardial
infarction, kidney stones
Patients self medicate with OTC products, vitamins
and herbals

Kava: Sedation, oral and lingual dyskinesia,
torticollis, oculogyric crisis, exacerbation of
Patients seek care from multiple providers for multiple
Parkinson's disease, painful twisting movements of conditions
the trunk, rash
Lack of coordination in care

Source: American Family Physician
Direct–to-consumer marketing

157 158

Medication Resource Guides Medication Management

159 160

INCLUDES:
On-line hospital or clinic formulary

Medication security
Physician Desk Reference (PDR)
Sample Medications

Drug Voucher Programs
Nursing Drug Handbook
Disposal of expired medications

Labeling of vials once opened
Pharmacist / Clinical Pharm D.

28 day expiration
Online drug information databases
Protocols to refill prescriptions

Standing orders/protocols
National Pharmacy Database

159 160

Medication Management continued Medication Management continued

161

Scheduled Drugs

Schedule I:

No currently accepted medical use in the US, high
potential for abuse

Heroin, LSD, marijuana (some states), Ecstasy

Schedule II:

high potential for abuse which may lead to severe
psychological or physical dependence

hydromorphone (Dilaudid®), methadone
(Dolophine®), meperidine (Demerol®),
oxycodone (OxyContin®, Percocet®), and
fentanyl (Sublimaze®, Duragesic®). Vicodin,
morphine, opium, and codeine

Includes methylphenidate (Ritalin) and
amphetamine (Adderal)
162

Schedule III:

Less potential for abuse than Schedule II but
may lead to moderate or low physical
dependence or high psychological
dependence.

Tylenol with Codeine, Ketamine, anabolic
steroids (depo-testosterone)

Schedule IV:

Lower potential for abuse than Schedule III

alprazolam (Xanax®), carisoprodol
(Soma®), clonazepam (Klonopin®),
diazepam (Valium®), lorazepam (Ativan®),
midazolam (Versed®), temazepam
(Restoril®), and triazolam (Halcion®).

161 162

42
 Medication Management continued
163

Schedule V:

low potential for abuse relative to
substances listed in Schedule IV and
consist primarily of preparations
containing limited quantities of certain
narcotics.

cough preparations containing not
more than 200 milligrams of codeine
per 100 milliliters (Robitussin AC®,
Phenergan with Codeine®)
Medication Management continued
164

Identifying Drug Seeking Behaviors
• Often request specific controlled
substance
• Reluctant to try different medication
• May exaggerate problems or symptoms

Setting limits using behavioral contracts
and offering referral to resources

Documentation of refills

Prescription Fraud
• Photo Identification of patient

Termination of Care based on behaviors

163 164

Complementary & Complementary &

165 166
Alternative Medicine Alternative Medicine
Practices used Alternative
independently Medicine
Goals are similar to that of conventional medicine
or in place of
conventional
• pain reduction
medicine • enhancing mood
• Wellness
• disease prevention
Practices employed
• stress reduction
in conjunction with • improved ADL’s
or to complement
Complementary conventional
Medicine medical treatment

165 166

QUESTIONS?
167 Examples of CAM Therapies 168

Naturopathic products

Yoga

Meditation

Acupuncture

Chiropractic care

Massage

Homeopathic medicine

Chinese medicine

Cupping

167 168

43
 169
Lunch Time!
Let’s Take 45 minutes!

169

44
Another random document with
no related content on Scribd:
Ils se dressaient grotesquement sur les chevilles
Et tentaient de leurs mains sans ongles de frapper,
Ou rampant sur le ventre ainsi que des chenilles
Ils se pressaient avec effort pour s’étouffer.

Mais la Parque toujours touchait les petits êtres

Et tranquille marchait vers le soleil couchant
Et toujours par milliers ceux qui venaient de naître
Affluaient à ses pieds comme l’herbe des champs.

Et je lui dis: «Ceci n’est qu’ortie et qu’ivraie:

Dans cet endroit maudit pourquoi porter tes pas
Puisque l’enfance humaine est une grande plaie
Qui coule et s’agrandit et ne guérira pas?»

Et la déesse alors au fond de la vallée

S’arrêtant, me montra dans un entassement
Effroyable, au milieu des formes emmêlées,
Un visage, rien qu’un, mais sensible et charmant...

Et le soleil mourant sur cette maladie

De la terre éclaira dans l’humus qui poussait
Un œil déjà bleuté par la naissante vie,
Un tremblotant éclat d’âme qui paraissait.

Et la Parque me dit: «Tout le mal de la terre

Est payé par un seul, s’il est vraiment humain.»
Et je la vis partir tranquille et solitaire
Parmi le flot montant des monstres enfantins.
 LA RÉGION DES ÉTANGS

J’atteignis vers le soir la plaine des étangs.

Un vent glacé soufflait parmi les vastitudes,
Mes pieds s’enchevêtraient aux herbages flottants.
J’allais vite et j’étais ivre de solitude.

De longs roseaux vivants cherchaient à me saisir.

Des plantes se collaient avec leurs fleurs gluantes.
Vers moi de toutes parts comme un vaste soupir
Montait la fade odeur des choses croupissantes.

Un souffle gras sortait de ces stagnations,

Une buée épaisse, animée, une haleine
Qui semblait le ferment des putréfactions
Millénaires, dormant sous ces mares malsaines.

Et j’entendis, venant d’en bas, parler la voix

Et je vis émerger la face aux gros yeux glauques:
«L’escalier spongieux, dit-elle, est près de toi.
Descends parmi la vase et les eaux équivoques.

«Viens dormir avec nous au fond des lits tourbeux

Dans l’émanation des poisons délétères.
Viens rejoindre ce soir les hommes sans cheveux
Qui sont jusqu’à mi-corps enfoncés dans la terre.

«Avec les serpents d’eaux, les vers et les têtards

Tu joueras dans les végétaux des marécages,
Oubliant parmi les parfums des nénufars
Qu’il est un ciel immense où passent les nuages.

«Tu nous seras pareil, sans espoir, sans amour,

Tu connaîtras, vautré dans la vase éternelle,
Le bonheur de l’aveugle et l’ivresse du sourd
Et tu ne sauras plus les choses qui sont belles.»
Alors je vis des bras tendus pour me saisir
Et des milliers de blancs visages apathiques.
Et le peuple de ceux qui n’ont plus de désir
Sortait de l’eau couvert de plantes aquatiques.

Et j’avais déjà mis le pied sur l’escalier

Qui plongeait en tournant dans une boue épaisse,
Je voyais des palais informes, des piliers
Parmi les joncs sans sève et les herbes sans sexe,

Lorsqu’un grand vent passant à travers les marais

Me souffla des odeurs de forêts aux narines
Et je m’enfuis vers l’horizon où je voyais
Des sapins s’accrochant au ciel sur des collines...
 LES ESCLAVES

Je les voyais marcher, enchaînés, deux par deux,

S’arrêtant quelquefois pour manger des écorces.
Alors, un cavalier courait à côté d’eux
Et d’un grand coup de fouet leur déchirait le torse.

Ils étaient las, pelés, exsangues et spectraux.

Les femmes les suivaient, à des bêtes semblables.
Comme un long bêlement humain et lamentable,
Une plainte montait de ce triste troupeau.

Les enfants suspendus aux mamelles taries

De leurs mères, tombaient au milieu des cailloux
Et les gardiens, riant de leur propre furie,
Les traversaient avec leur lance d’un seul coup.

Et quand le lieu devint comme un chaos de laves

Et de rocs, où croissaient quelques palmiers roussis,
L’homme au turban rayé, le conducteur d’esclaves
Arrêta le cortège et cria: «C’est ici.

«Vous ne sortirez plus de cet enfer calcaire.

Le ciel vous roulera ses simouns sablonneux.
Vous n’aurez pour boisson que les sucs de la pierre,
D’implacables soleils vous brûleront les yeux.

«Vous vous dessécherez comme des chrysalides.

L’éternel manque d’eau vous plissera le corps.
Vous ne verrez passer dans les azurs torrides
Que les corbeaux venant pour dévorer les morts.

«Nous placerons sur vos échines excédées

Des fardeaux écrasants, des blocs cyclopéens.
Et vos filles seront devant vous possédées,
Serviront de jouet lubrique à vos gardiens.»
Et moi sur la hauteur d’où je voyais la scène
Je criai: «Vous seriez, esclaves, les vainqueurs.
Que ne lapidez-vous ces tourmenteurs obscènes?
Faites-leur expier votre sang et vos pleurs.»

Et le maître éclata de rire. Les esclaves

A quatre pattes accouraient baiser ses pieds.
Et lui négligemment parmi ces faces hâves
Promenait comme un soc ses éperons d’acier.

Et le vent, agitant les palmiers squelettiques,

Soulevait par moments son burnous de couleur,
Le faisait ressembler sur le soir désertique
A quelque grand oiseau de proie et de malheur.
 LE PALAIS DES ROIS

Le seuil de cuivre feu avait cent trente marches

Et dix mille guerriers levaient leurs sabres plats.
La porte était immense et s’ouvrait comme une arche
Et les rois revêtus d’or safran étaient là.

Des chœurs retentissaient comme pour des obsèques,

Les bannières claquant comme des oiseaux fous,
On voyait flamboyer les mitres des évêques
Et les juges avaient des visages de loups.

Et derrière ondulaient sous la géante abside

Des rivières de cavaliers aux flots profonds.
Des rayons s’échappaient des armures splendides,
Les cuirasses luisaient sur les caparaçons.

Et les clefs et les sceaux et les mains de justice

Damasquinés de talismans et de bijoux,
Reposaient sur la pourpre à côté des calices
Portés par des hérauts chevelus, à genoux.

Et les chevaux piaffaient sur l’or des mosaïques

Et devant la splendeur d’un si grand appareil
Les pauvres un à un venaient, microscopiques,
Jusqu’au palais de feu beau comme le soleil.

Et les bourreaux joyeux avec leurs longues armes

Coupaient les têtes à grands coups sur l’escalier,
Et les rois quelquefois s’esclaffaient jusqu’aux larmes
Et les rires faisaient cogner les cavaliers.

Les membres confondus et les têtes coupées

Élevaient jusqu’au ciel leur amoncellement,
Les évêques parfois avec leurs mains trempées
D’eau bénite, aspergeaient le monceau gravement.
Et mon cœur soulevait mon étroite poitrine
De terreur en marchant vers le seuil à mon tour,
Je me sentais devant ces puissances divines
Plus frêle qu’un oiseau, moins qu’une plume lourd.

Devant les cavaliers et les rois formidables,

Les juges monstrueux et les bourreaux géants,
Je n’étais, moi porteur d’une âme pitoyable,
Que fragment de poussière et reflet de néant.

Je ramassai pourtant un caillou, ma sagesse

M’enseignant de lutter jusqu’au dernier moment,
Et je le lançai loin, de toute ma faiblesse,
Vers le palais des rois recouvert d’ornement.

Et voilà que soudain du monument de gloire

Il ne resta plus rien au choc de mon caillou
Qu’un coin de chapiteau, que l’os d’une mâchoire,
Qu’une mitre d’évêque avec tous ses bijoux.

Et j’ai craché sur ces débris et ces poussières

Et j’ai d’un coup de pied lancé la mitre aux cieux,
Car l’homme pauvre et seul et qui porte une pierre
Est plus fort que les rois et plus puissant que Dieu.
 L’INVASION DES INSECTES

J’arrivai dans la ville où régnait la paresse...

D’étonnantes chaleurs tombèrent des cieux lourds.
Le soleil sur le port fit vautrer les pauvresses.
On ne versa plus d’eau sur les dalles des cours.

Les végétations brusquement se séchèrent.

Les bouches des égouts empoisonnèrent l’air.
Les femmes dans les lits parfumés s’enfoncèrent
Sous la possession des forces de la chair.

Elles n’allèrent plus dans le quartier des bouges

Offrant leurs peignoirs de couleurs et leurs bas bleus,
Mais elles étalaient par terre leur corps rouge
Qu’humectait le désir et que gonflait le feu.

Et ce fut tout à coup une étrange naissance

D’insectes, dans le linge et les bois pourrissant,
Mille pullulements d’une vermine immense,
La vaste éclosion d’êtres buveurs de sang.

Les dormeurs épuisés eurent au crépuscule

Le grouillement d’un peuple gris parmi leurs draps.
On entendit le crissement des mandibules
Qui hérissaient les poils, pliaient les cheveux gras.

Des suçoirs aspiraient dans les poches rougeâtres

Le suc des hommes las qui ne résistaient plus.
Quelques-uns essayaient en vain de se débattre,
Les insectes sur eux montaient ainsi qu’un flux.

Les élytres vibraient dans les barbes vivantes,

Les œufs multipliés éclataient sur les corps.
Les dards aigus vrillaient les prunelles démentes
Et les germes actifs remuaient dans les morts.
Toute la ville fut pompée et dévorée...
Des hommes en fuyant coururent dans la mer.
Alors, un remuement obscur, une marée
De vase, les rendit à l’océan des vers.

Cela n’avait été prédit par nul prophète...

Les soleils infernaux ne se couchèrent pas...
Tout se passa sans cri, sans tocsins et sans glas...
Le peuple en ce temps-là fut mangé par les bêtes...
 L’ÊTRE MAIGRE AUX MAINS IMMENSES

Et j’ai vu l’être maigre avec des mains immenses.

Il était recouvert d’écailles de poisson,
Il était étendu dans le sable d’une anse
Et le trou d’un rocher lui servait de maison.

Il m’a dit: Vois mon corps qu’un mal affreux dévaste.

Mon cœur atrophié ne bat plus sous mon sein.
Si mes mains à ce point sont ouvertes et vastes
C’est qu’un siècle durant je les tendis en vain.

Si mes yeux sont couverts d’une peau membraneuse

C’est que j’ai répandu des milliers de pleurs.
J’écoute la marée, éternelle berceuse,
Refrain toujours nouveau de la vieille douleur.

Elle vient vers celui qui n’a pas vu sur terre

La face du pardon et du soulagement,
Elle connaît le mal, son sens et son mystère
Et monte comme lui quotidiennement.

Et j’entends dans sa voix la voix des mauvais hommes,

De ceux que si longtemps jadis j’ai suppliés.
A présent le sel pur et les algues m’embaument...
Malheur, malheur à ceux qui n’ont pas eu pitié!...

Malheur aux durs, aux furieux, aux égoïstes,

A ceux qui font semblant d’être aveugles et sourds,
A ceux qui m’ont tendu le morceau de pain triste,
Malheur aux généreux qui donnaient sans amour.

J’ai trouvé près des mers ton sentier, solitude,

Bordé de corail rouge et de pétoncles clairs,
Et mon corps rabougri par les vicissitudes
Mange le coquillage et s’enivre de l’air.
Mais, ni mon lit marin rempli de zoophytes,
Les vents de l’au-delà lourds d’aromes puissants,
Ni ma grotte verdâtre avec ses stalactites,
Ni les soleils du soir me transfusant leur sang,
Ne pourront me donner l’aliment de mon âme,
Ce que j’ai désiré, espéré, mendié,
Le repos, la chaleur, le breuvage et la flamme...
—Malheur, malheur à ceux qui n’ont pas eu pitié!...
 L’AGNEAU DÉSESPÉRÉ

L’agneau sur le rocher semblait un bloc de laine.

A côté les torrents descendaient vers les plaines
Et les forêts roulaient leurs vagues vers les monts.
Et je vis l’hippogriffe à tête de lion
Qui bondissait dans la lumière violette...
Et l’agneau se dressa, divin, devant la bête,
Il la prit par les reins, la tordit puissamment,
Puis, ayant labouré sa gorge avec ses dents,
Malgré la gueule en flamme et le dard de la queue,
Au loin la projeta dans un lac dont l’eau bleue
Éclaboussa d’azur les couloirs de rochers.
Mais quand l’agneau neigeux voulut se recoucher
Il tachait les cailloux de sa laine sanglante.
Il courut vainement parmi les jeunes plantes,
Les traces ne faisaient que s’étendre, le sang
Était sur lui plus clair et plus éblouissant.
Et dans le soir qui devenait couleur de soufre,
Je vis sur l’horizon, courant au bord des gouffres,
Franchissant les lacs morts et les puits de granit
Comme pour se baigner aux ondes de la nuit,
L’agneau rouge, l’agneau dément, l’agneau de flamme,
L’agneau désespéré par le sang, ô mon âme!
 LA RENCONTRE DU SQUELETTE

Sous les figuiers géants, au fond de la vallée,

Parmi les flots de sable et les roches gelées,
Le puits me regardait, glauque et prodigieux,
Ainsi qu’un œil dans un visage de lépreux.
Sur l’antique margelle expirait le soir morne.
On était sous le signe froid du Capricorne.
Par des traces de pas j’avais été conduit
Et ces traces de pas s’arrêtaient à ce puits.
Et je savais qu’au loin mouraient les caravanes...
Il n’était ni fagot, ni vase, ni cabane,
Rien d’humain où mon âme aurait mis son espoir
Et je posai mon front sur la pierre pour voir...
Alors je vis sortir du puits un long squelette
Qui se tint devant moi, triste, branlant la tête
Et montrant ses os nus comme la vérité.
Il ressemblait un dieu du monde inhabité.
Des herbes lui faisaient une couronne noire,
Et voilà qu’une dent tomba de sa mâchoire,
Les phalanges se détachèrent de la main,
Le fémur se plia sous le poids du bassin,
Il se désagrégea, devint de la poussière...
Et l’ombre vint dans la montagne solitaire.
«Ah! que ne suis-je encor avec mes compagnons!
Quelqu’un m’appellerait peut-être par mon nom,
J’aurais un peu de vin au fond d’une outre, encore
De la chaleur sous un burnous multicolore...
Au moins je serais mort au chant des chameliers!»
La nuit morte gelait les branches des figuiers
Et je vis que la trace à peine saisissable
Des pas, allait plus loin dans la nuit, dans le sable...
 LA MONTAGNE DES BÊTES

De partout, près de moi, sur les monts fabuleux,

Les loups pelés montaient par les rochers galeux.
Je voyais sur le bord des crânes plats et chauves
Bouger comme du sang la flamme des yeux fauves,
Je touchais les poils durs et les dents de métal,
Pesant la solitude et la peur et le mal
Et l’amour de la nuit qui possèdent les bêtes.
Sur un tronc dépouillé pleurait une chouette.
Près d’un trou d’eau verdi, dans le creux du ravin,
Un crapaud regardait avec ses yeux éteints.
Des scorpions tendaient le crochet de leur queue
Et des vers déroulaient leur dos d’écailles bleues.
Des milliers de fourmis sortaient des fourmilières.
Des vipères posaient leur front triangulaire
Sur mes pieds, des têtards dansaient dans mes cheveux
Et des germes sans forme éclataient hors des œufs.
«Je veux vivre avec vous, ô frères taciturnes,
Pleurer vos morts, compter vos naissances nocturnes,
Participer, moi, l’homme, à l’obscur idéal
Que verse la nature au cœur de l’animal.
Donnez-moi vos chaleurs, vos bontés et les lampes
De vos yeux, animaux, peuples de ceux qui rampent,
Car venant de plus loin, d’un plus triste chemin,
Vous voyez dans la nuit mieux que les yeux humains...
Vous êtes le sel noir mais de pure substance
Et la rédemption des choses, le silence
Qui doit parler et la beauté qui doit surgir.
Voici venir le temps, bêtes, de repartir.
Puisque l’homme a failli, vous êtes la jeunesse,
Il faut recommencer la course de l’espèce...»
 LE NAGEUR

Pour aller jusqu’à l’île où sont les fleurs géantes

Et les cigognes d’or dans les arbustes nains,
Où les magnolias ont l’air d’adolescentes,
Où dans le port étroit dorment les brigantins,

J’ai nagé à travers les courants et les barres,

Enivré par l’écume et nourri par le sel;
L’épave m’a cogné, j’ai heurté des gabarres
Et vu les cachalots jouer dans l’archipel.

La mousse et le lichen m’ont couvert d’une robe,

Le crabe m’a mordu, l’espadon m’a piqué.
Suivi par les requins j’ai vu monter les aubes,
De nacre et de corail j’étais le soir casqué.

J’ai frôlé des pontons qui servaient à des bagnes

Et les forçats de loin m’ont lancé leur boulet.
J’ai troué des typhons hauts comme des montagnes
Et les vents furieux m’ont donné des soufflets.

Quand j’ai passé le long de leurs coques énormes

Les vaisseaux de haut bord ont tiré le canon.
Empoignant les cheveux d’herbages équivoques
J’ai saisi des noyés mangés par les poissons.

Je me suis débattu parmi les pieuvres bleues

Qui me fixaient avec mille yeux surnaturels,
Et les baleines du battement de leur queue
M’ont projeté dans leur jet d’eau plein d’arc-en-ciel.

Mais toujours je fendais allégrement la lame,

Sûr que je ne serais ni noyé, ni mangé,
Et porté sur les flots par la force de l’âme
L’infini de la mer me semblait sans danger.
Et lorsque j’émergeai couvert de coquillages
Et d’algues et pareil à quelque crustacé
Sur l’île merveilleuse et le divin rivage,
Mon corps marin par l’air terrestre fut glacé.

Et mes yeux n’avaient vu jamais de paysage

Plus désolé. Le sol était pauvre et crayeux.
Les grandes fleurs semblaient faites de cartilages
Et leur exhalaison était un souffle affreux.

Des squelettes de pélicans sur des eaux ternes

Claquaient du bec, non loin d’un cratère fumant.
Un soleil jaune ainsi qu’une horrible lanterne
Se balançait sur des collines d’ossements.

Alors j’ai dit: J’ai fui les grottes et les criques

Pour cela! Trahison de l’idéal humain!
J’aurais pu m’endormir sur les eaux magnétiques,
Chevaucher l’hippocampe ainsi qu’un roi marin.

Que le poulpe m’aspire et le crabe me ronge!

Je descends dans l’azur des abîmes profonds
Pour dormir à jamais dans un linceul d’éponges
Auprès de la méduse aveugle des bas-fonds...
LA DESCENTE AU PARADIS
 LA DESCENTE AU PARADIS

Le lac miraculeux brillait dans les couloirs

De galets bleus et de rochers météoriques.
Des monts de fin du monde au loin fermaient le soir
Et je suis descendu dans l’abîme conique.

Des gerbes de mica jaillissaient par milliers,

Près de moi s’éployaient des arbres de porphyre,
Le soufre et le salpêtre humectaient l’escalier,
Je voyais aux parois des laves froides luire.

Et tout au fond du gouffre, au cœur des minéraux,

Parmi les champs de houille et les forêts de schiste,
Sous l’ardoise pareille à d’aveugles vitraux,
La porte d’or massif était splendide et triste.

Elle tourna pour moi silencieusement.

Je me remémorai le regard de ma mère.
Je vis les rochers noirs et leurs entassements
Et quittai le chaos fraternel de la terre.

—Que d’azur! j’en étais entièrement baigné.

C’était un printemps clair, éternel, immuable,
De parterres taillés, de sources ineffables
Et tout était choisi, sans défaut, ordonné.

Et les roses semblaient des citrouilles parfaites

Par la dimension et l’absence d’éclat
Et le parfum de ces énormes cassolettes
Était comme un parfum de tisane et d’orgeat.

Les bienheureux marchaient en mornes théories,

La vierge sans désir baissant encor les yeux,
L’épouse vertueuse avec sa peau jaunie
Et l’enfant nouveau-né dont le corps est glaireux.
Et je pus contempler leur laideur étonnante.
Ils n’étaient éclairés par aucun sentiment.
Quelques femmes montraient des poitrines pendantes.
Les groupes se croisaient géométriquement.

Ils goûtaient, sans regret des choses de la vie,

Avec affection et se tenant les mains,
Aux bords des purs ruisseaux et des calmes prairies
Les plaisirs innocents et les bonheurs divins.

«Quoi, pas même une femme et pas même une vierge,

Ai-je dit, qui malgré les azurs bleus trop clairs,
Parmi ces corps pétris dans la pâte des cierges
Ne sente le plaisir lui tourmenter la chair.

«Pas même un chérubin, qui par sa grâce double,

Son torse féminin, ses hanches d’Adonis,
Rappelle le péché délectable et son trouble
Et ses remords autant que l’amour infinis.

«N’est-il pas quelque coin où des fleurs en désordre

Sont rougeâtres avec d’émeraudes lueurs,
Ou des femmes aux bras mêlés jouent à se mordre,
Tordant avec orgueil leur corps plein d’impudeur?»

Alors je me souvins des mortes admirables,

Et des chers compagnons que j’avais tant pleurés,
C’étaient des désireux et des insatiables,
Au cœur toujours ouvert et toujours déchiré.

Et je les vis... Leurs yeux, leur forme et leur image,

Mais ils avaient perdu ta lampe, ô souvenir!
Une béatitude emplissait leur visage,
C’était là la splendeur peut-être de mourir.

Mais ils étaient pour moi plus morts que les cadavres
Que l’on voit dans les lits, déjà décomposés.
De leur morne bonheur ils étaient les esclaves,
Ils ne possédaient plus le secret du baiser
Ils ne possédaient plus le secret du baiser.

Ils avaient oublié l’amère connaissance.

Ils n’avaient plus au front le sceau de la douleur,
Ils n’avaient plus au cœur le mal de l’espérance,
Jamais plus de leurs yeux ne couleraient des pleurs.

Et j’ai fui vers la porte ouverte sur le gouffre

Vers l’obscur escalier où le salpêtre luit,
Et j’ai baisé l’ardoise et caressé le soufre
Et joui des clartés qui tombaient de la nuit.

Et j’ai crié: «Seigneur, ton amour est sans charme!

La souffrance est trop belle, on ne peut l’oublier.
Si la vertu de Dieu ne peut verser des larmes,
Je préfère le mal qui connaît la pitié.

«Je crache sur tes lis et vomis sur tes palmes.

Ta clarté n’est pas faite avec du vrai soleil.
A tes rêves trop bleus dans les jardins trop calmes
Je préfère le cauchemar de mes sommeils.

«Je préfère la chambre étroite où je me couche

Avec le linge impur et les bouquets flétris,
La triste odeur des corps, le goût humain des bouches,
Mon paradis mauvais plein d’ombres et de cris.

«Je préfère la femme au regard immodeste,

Les peines de mes soirs, le plaisir déchirant,
Le fumier familier où croît l’arbre terrestre
Et le vice fécond qui m’a fait le cœur grand.»