Chagas Disease & the Kissing Bug

 Chagas disease is a silent disease that is caused by Trypanosoma Cruzi, a parasite found in the Triatomine bug known as the kissing bug. It has that name due to its habit of biting faces at night. When they bite someone, they can suck blood for 10 to 20 minutes, fill up so much that their bodies look like a balloon, and their saliva also secretes allergens and irritants that cause swelling at the bite site. The transmission occurs when the bug gets full, it poops at the bite site, and they carry live parasites that, when they enter the broken, pierced skin by scratching the site, they quickly enter the bloodstream. They can stop at some point, enter the cell, reproduce, burst out of that cell, travel again into the bloodstream, and nest in the heart muscle, their favorite place because of the large quantity of blood available, and there they can live for years, causing dilated cardiomyopathy, which reduces the heart's ability to pump blood.

Trypanosoma Cruzi was detected 9 thousand years ago in mummies in the Atacama Desert.  

In 1909, Carlos Chagas, a Brazilian physician, scientist, microbiologist, and clinician researcher, after examining two year two-year-old little girl with fever, swollen lymph nodes, and enlarged spleen and liver, collected her blood and detected Trypanosomes identical to the ones in Triatomine bugs, "kissing bugs" that's why it was named after his last name, Chagas Disease.

As of now, there are no vaccines for Chagas disease, despite mice infected with Chagas disease having been treated with experimental vaccines; no humans have participated in trials yet. 

Treatment is available only efficiently during the acute phase, as of 2018 standard treatment for acute stage of Chagas disease is: benznidazole dose given 3 times a day for 60 to 90 days, with less side effects, and niturtimox, this last drug has more side effects reports, both drugs are provided by the CDC, thats why it is importnat to contact CDC for the infection and control.

Signs and symptoms. Acute phase: as soon as bitten by the kissing bug, it appears a swollen site and this is probably the most accurate sign; symptoms may or may not occur, which include headache, flu-like symptoms. Chronic phase, after 4 to 8 weeks after the bite, the Chagas disease develops, better saying the Trypanosome Cruzi chooses a place to reside, which can be in any organ, it takes years to cause damage. The heart is their favorite place to live. long-term symptoms are shortness of breath, chest pain, heart palpitations, fainting, arrhythmias, dilated cardiomyopathy, and heart failure. Most people don't even know they have Chagas disease until they feel so sick. 

Ways of transmission by the bite of the kissing bug are by blood transfusions ( Trypanosoma cruzi survives in refrigerated, frozen, and thawed blood), Organ donation, and vertical transmission, mother to baby during pregnancy. Other ways are oral contamination by fruit juices or contaminated food with these bugs.

Ways to avoid the kissing bug are living in well-built houses with no holes, cracks, applying screens on doors and windows, washing food well, and looking carefully if there are bugs in it. If the house is a log, barn, wood, or clay built with visible cracks, use a net over the bed during sleep. Insecticide spray is effective too.

How to test for Chagas? There are blood tests, ELISA or PCR, being more accurate and easier than the traditional Microscopy lab studies, the Machado Guerreiro test, EKG, imaging, such as X-ray, and other ways to detect Chagas disease.  It usually takes 10 to 20 years to detect any damage.

Trypanosoma Cruzi in blood smear:

Kissing bugs:

Net over bed:

Carlos Chagas:

For educational purposes only, source of information and pictures: Wikipedia and Texas A&M "Kissing bugs" and Chagas disease in the U.S./ Texas A&M, CDC websites.

#chagasdisease  #kissingbug

The Mortal gas: Carbon Monoxide

 Be aware that the invisible and mortal carbon monoxide gas can kill very quickly because it competes with oxygen in binding with hemoglobin ( our blood cells), and it binds with hemoglobin, and guess who wins the binding? Yes, believe it or not, Carbon monoxide wins over oxygen. Hemoglobin and carbon monoxide have a strong attraction for each other.

Knowing that is very important to save yourself during a fire or in the event of a suspicious leaking gas. If you see people fainting on the floor, never enter the area unprepared. Make sure to breathe in with an oxygen tank. Now you're safe and good to go. Now that you have your oxygen tank ready, so you breathe oxygen through your oxygen mask, you can go and start rescuing people.

PROTECT YOUR OWN LIFE BEFORE TRYING TO RESCUE OTHER PEOPLE. Be prepared with oxygen tanks, know how to check if it's empty or full, have all the hook-ups ready, an oxygen mask, tubes, and the necessary tools to connect.

If you feel your life is in danger because you were breathing carbon monoxide, so you probably have carbon monoxide poisoning, go to an emergency department and they will collect your blood and see how much the danger is for carbon monoxide poisoning. Get a BLOOD TRANSFUSION, get your own blood type, and the same Rh. If you are Rh negative, only receive Rh negative. If you are O negative, receive only O negative, and so on. Some blood types are compatible to receive different blood without harm, usually, you receive your own type.

Breathing O2 helps, but O2 alone DOES NOT FIX THE PROBLEM. REMEMBER THE CARBON MONOXIDE IS ALREADY BOUND WITH YOUR BLOOD CELLS FOR THE NEXT THREE MONTHS (BLOOD CELL LIFETIME). BREATHING OXYGEN MAKES LITTLE DIFFERENCE IF THE LEVELS OF CARBON MONOXIDE ARE TOO HIGH, GET A BLOOD TRANSFUSION AS SOON AS POSSIBLE!!! 

How is it like to work in Home Care as a nurse?

Working as a nurse in home care is very nice and very rewarding, not much experience is required to get hired, you go through training and shadowing with either the family or the other nurses before starting to work on your own.

The advantages of working in home care are that you work at your own pace, you get to deliver excellent services, because you get to be your true ownself, away from the spotlight of criticism-biased eyes that often happens in stressful environments such as busy hospitals.

The charting program is pretty easy, called Kantime. The good thing about Kantime is that after submitting your chart, you can get a call from your case manager to improve it or correct it later, like time discrepancies, temperature values instead of 98.3F, which was accidentally entered as 983F, it's possible to correct later. The company provides a laptop with internet in it.

Flexible schedule, it's easy to get as many hours or fewer hours, it's easier to ask for days off, because there are more nurses available to pick up your schedule, you don't have to worry about finding someone to cover you, the company does all of that.

Another benefit is that you're not required to take 30 30-minute break, because the work environment is so chill, you only take about 6 to 15 minutes for lunch and still get paid for the full shift.

Working in home care as a nurse is very pleasant it doesn't even look like a job, it's so much fun, I have experiene in pediatric home care as a nurse and as a care giver in adult-elderly, both are very rewarding, as it may be that last day you see your client, make sure that that time that shift is the best of it, making your client feel happy, content, satisfied, entertained, loved, encouraged, gratefull with your services.

#homecare #pediatrichomecare #homecarenurse #homecarecaregiver

Skin Assessment

 Skin Assessment should be performed during admission and discharge to/ from the hospital, every shift, if Pt. conditions change, and at the emergency department. 

Complete assessment of the skin head to toe, paying attention to bony prominence because there can be the site for a pressure injury, aka bed sore. those are the most frequently bony prominences: 

*Sacrum/coccyx

*Buttocks

*Ischium

*Heels

Braden scale: Braden scale is a standardized and validated tool to determine pressure injury risk, It contains 6 items, sensory perception, moisture, activity, mobility, nutrition, and friction and shear. These helps in the decision-making and plan of care.

Assessing pressure related changes like temperature, cooler, warmer, blanch response, and pain or discomfort. Signs of pressure injury may include blanchable erythema, and or changes in tissue temperature or consistency.

"Blanchable" refers to an area of skin redness that turns white when pressure is applied, meaning the color disapears with pressure, while "non-blanchable" means the redness persists even when pressure is applied, indicating potentialtissue damage and often a sign of developing pressure ulcer. in dark skinn colors apply a wet wipe and use a tangential lighting, use a penlight to detect suspected erythema or color changes. 

Complete skin assessment include 

Skin Tones:  

*Pallor (paleness)

*Erythema (redness)

*Ecchymosis (bruising)

*Jaundice (yellow)

*Cyanosis (blue)

*Mottling ( spotty white)

Turgor:

When skin on the back of the hand is pinched, it should immediately return to normal. A variation of this may be indicative of dehydration or aging.

Temperature

Moisture

Skin Integrity:

* Intact

*Breakdown: open areas (skin tears, pressure injuries)

* Rash (fungal, bacterial)

*Moles, Freckles, variation in skin color or texture

Braden subscale: Sensory Perception

1) Completely Limited : unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body. Ex : comatose, sedated and intubated patient

2) Very Limited : responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. Ex: Spinal cord injury below the waist, stroke with hemiparesis.

3) Slighly Limited: responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment which limits the ability to feel pain or discomfort in 1 or 2  extremities. Ex: Patient has diabetes and has neuropathy (can't feel pain in their feet)

4) No Impairment: responds to verbal commands. has no sensory deficit to feel or voice pain or discomfort.

Braden Scale Mobility: 

1) Completely Immobile: Does not make even slight changes in body or extremity position with assistance

2) Very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3) Slightly Limited: Makes frequent though slight changes in body or extremity position independently.

4)No limitations: makes major and frequent changes in position without assistance.

Avoid : Egg mattresses, turning pacient onto a body surface that is still red from a previous episode of pressure loading.

Braden Scale Activity: bedfast, chairfast, walks occasionaly, no impairment. Avoid: long periods sitting, donut-type devices.

Braiden Scale Moisture: completely moist, very moist, slightly moist, rarely moist. Avoid hot water, plastic underpads, multiple layers of linens under patient, briefs in bed.

Recommended Interventions: turn and reposition every 2 to 3 hours, if unable to tolerate full turns, frequent micro turns every hour until stable. Heels if reclined, elevate off of footrest. Sacrum/lowe buttocks:consider application of multilayer foam dressing with silicone adhesive. Support surface: consider reactive overlay (specialty bed) or "sand bed" 

Braden scale Nutrition:

1)Very Poor: never eats a complete meal . Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly.. Does not take a liquid dietary supplement OR is NPO and or maintained on clear liquids or IVs for more than 5 days.

2) Probably Inadequate rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding.

3) Adequate eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutricional needs.

4)Excellent eats most of every meal never refuses a meal Usually eats a total of 4 more servings of meal and dairy products. Occasionaly eats between meals. Does not require supplementation.

Recommended Interventions: consult dietician if: NPO for more than 48 hrs, presence of stage 2 or greater pressure injury.

Braden Risk Category: Friction and Shear

Friction: occurs when the skin moves against another surface. Ex pulling a patient up in bed, pulling linens/tubes out from under patient, using elbows to push self up in bed.

Shearing: the pulling of two adjacent tissues in opposite directions,often resulting in tissue destruction Ex: High risk of shearing when HOB>30 degrees. Tissue and superficial fascia remain fixed against the bed linens while the deep fascia and skeleton slide down toward the foot of the bed causing deeper tissue injury.

Probem, potential problem, no apparent problem Avoid greater than 30 degrees head of the bed elevation.

Final notes: this entire presentation is from the mandatory courses provided by Ascension Seton, they are all standard tools to follow. The computer Cerner charting, program will give the score imediately when data is entered during charting. The only purpose of this presentation is educational purpose only.

 

How is a typical day of a nurse/ Brazilian nurse/ International nurse working at the IMC Intermediate care and Trauma MedSurg in the Hospitals in the USA

0615 Arrive at the Hospital. Go straight to the break room and put the lunchbag in the fridge, backpack in the locker, get flash light pen, pen, eraser pen, and stethoscope littmann out in the pocket or in the fannybag.

0621 Find the assignment with 4 to 5 patients assigned, go to the computer, quickly read the main reason for Pt. being in the hospital, procedures done, medication times, and antibiotics next dose, next pain medication dose, allergies, past medical history,

0639 Clock in, get report from the night nurse, ask to spell out the abbreviations, ask again if he or she speaks too fast, write down really quickly everything. X4 X5 Shift change meet and greet Pt. update the board with the date, nurse, PCT, patient care technician, charge nurse names, phone numbers (work phones) plan of care, pain control, goals of the day, etc

0720 to 0930 Pass medications of the 7, 8, and 9 hour medication, Synthroid first is given 2 hours before breakfast. Insulin short-acting following the sliding scale, first need to know from PCT how much was the last glucose results, Insulin Glargine Lantus is long-acting and it is usually given by prescription certain units.

Beta-blockers (Metoprolol, Carvidelol) Always check blood pressure and apical pulse before administering, if lower than 50 hold, some recommend to hold if pulse is lower than 60 and Systolic pressure lower than 100, Digoxin hold if Pulse is lower than 60. Hold heparine and betablockers if there is surgery or call the anesthesiologist to ask first. Some medications are held before hemodilalysis, usually hypertension medication. 

Narcotics Oxycodone step one and step 2, Dilaudid, morphine, Tramadol after pulling from the BD Pyxis (an automated medication dispensing system) YOU HAVE 30 MINUTES TO ADMINISTER the narcotics, if waste get a nurse witness to witness, if Pt. refuses pain medication return medication back to Pyxis BEFORE THE 30 MINUTES. Pain scale must be moderate to severe and POSS score must be completed  1 for awake and alert, 2 for slightly drowsy. 

Antibiotics double check if it's the initial loading dose which is usually given in 6 minutes, maintenance dose is given over 2 or more hours. For Vancomicin runs for 4 hours, when trough level is due, collect blood for lab from a fresh vein, 30 minutes before the next dose. Laboratory says it's normal 10 to 20mcg/mL that number can vary depending on each hospital 

Heparine or Lovenox is given SC usually on the lower abdomen.

Tip: wake up Pt, do a quick assessment head to toe, ask about pain, if constipation, numbness and tingling check arms and leg strength, pulses, eyes, level of consciousness pulses, heart, lungs, sensibility on operated leg toes, arms fingers, color temperature. Ask pt. his/her name and date of birth, scan medication, give medication unwrapped in the medicine cup, explain each and what it is, its side effects, open the chart begin charting the assessment, Cerner or Meditech select only a few items of charting, just to set the time and register important information, charting completely after passing all medication is better so they dont't  get too late.Check orders constalty, refresh your screen every 15 minutes. Get help from your PCT with perineal care comfort care, check the skin while wiping with warm sponges no rinse sponges dry with towel,  turning Pt with two-person assistance, mornings go by very quickly.

1110 finish charting on Cerner or Meditech

1200 Pass noon medication rounding every room again, collect blood for lab studies, check lab results, eletrolytes results, administer Potassium if level is low, following the sliding scale the Potassium PO dose must be given with meals. 

1230 bathroom break drink water.

1100 or 1300 meeting with the interdisciplinary team.

8000 to 1230 answer calls and texts from work phone, if there is a surgery get informed consent signed by the Pt for surgery, explain risks, and consent for blood transfusions if needed and risks sign as witness, if Pt, needs further instructions doctoe can explain procedure again. All procedures are written without abbreviations, put it in the binder, delegate CHG bath.

13:30 take your lunch break, yes, finally another bathroom break warm up in the microwave, relax enjoy your lunch.

1400 pass medication, finish charting, discharge or admission.

1500, 1600, 1700 1800 rounding educating teaching Pt & passing medication fluids. collecting blood if necessary.

1800 Ins and outs. fluids, charting of food and beverage, urine output, and last bowel movement are usually done by the  PCT, nurses can do it too, beverage and urine output empty measure cup, , chest tube drainage, mark with sharpie pen last measurement on the device, JP drainage, on drains section.

1800 pass medication if any

1900 give Pt. report to the night nurse. see here an example of a bedside report.

!930 to 1945 clock out, go home, and get some sleep. You made it woohoo!

#MedSurg  #Progressivecare  #Nurse  #Braziliannurse  #Intermediatecare

 #TraumaMedSurg