Western Nurse Magazine January February 2020 by ANF WESTERN NURSE MAGAZINE

January â&#x20AC;&#x201C; February 2020

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ANF PITCHES IN TO HELP FIRE RECOVERY PAGE 3

western nurse is the official magazine for ANF members in WA

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January – February 2020

FEATURED AND FAVOURITES 3 4 6 7 8 18 19

Secretary’s Report Fire Relief Internet Watch Mark’s Q & A ANF Out ‘n’ About Recipe Corner Pet Page

CONTINUING PROFESSIONAL DEVELOPMENT: CLINICAL UPDATES 12 14 16 17

Iron deficiency anaemia in children: Diagnosis and treatment Nursing management of peripherally inserted central catheters Zuclopenthixol Pregabalin – a medication update

LATEST NEWS AND RESEARCH 20 Across the Nation 21 Around the Globe 22 Research Roundup HOLIDAY ANF 23 ANF Holiday Apartments – book now! WIN! 23 Win ANF Ultimate Dance Packs!

Talk to us... It’s your magazine. We want your feedback and story ideas!

Secretary's Report State Secretary Mark Olson

Our members and ANF councillors have been asking how our organisation can help those affected by the fire disaster that has engulfed Australia in recent months. The ANF and its members have a history of pitching in when people are experiencing hardship – with generous donations in the past to the Victorian Bush Fire Appeal and the Lord Mayor’s fund for the Yarloop fire, and also to the tsunami appeal for Indonesia. Therefore, our Council has decided that the ANF will contribute $100,000 to the Red Cross Disaster Relief and Recovery Fund, to assist communities affected by the latest fires. The ANF always follows its members’ wishes and our members have let me know now, and in the past, that they expect the ANF to respond to these human crises, and we are more than happy to do so. As I write this, another crisis has been growing rapidly with the coronavirus epidemic. We have written on several occasions to the WA Health Minister about WA Health’s preparation and strategies for this outbreak, to protect both our members and the patients for whom they care, and as this edition was going to press, we were awaiting a detailed response. I’ll update you as usual directly via email as developments emerge – and I hope that by the time the next edition of western nurse comes round we will have some good news about treatment and vaccination for this lethal affliction.

Editor Mark Olson Phone 08 6218 9444 Freecall 1800 199 145 Email editorwesternnurse@anfiuwp.org.au Web anfiuwp.org.au

Australian Nursing Federation 260 Pier Street, Perth WA 6000

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January – February 2020 western nurse |

FIRE RELIEF

ANF members working at Joondalup Health Campus and their colleagues have raised more than $7000 to help firefighting efforts in WA and the eastern States. Claire Johnstone and her workmates at Joondalup Health Campus have seen firsthand the devastation wreaked by fires across Australia in recent months.

and Country Fire Authority in Victoria. This comes on top of the $30 million the Paul Ramsay Foundation donated to support communities affected by the recent bushfires.

A blaze in December threatened 6000 homes in Yanchep – burning through about 13,000ha in several days. Only the efforts of local firefighters saved the dwellings.

JHC chief executive officer Kempton Cowan said: “I’m really proud of the staff at JHC for digging deep to support what is, without doubt, a national tragedy.”

So, Claire, a clinical nurse manager, who has been an ANF member since arriving in Australia from Scotland more than seven years ago, suggested the proceeds of their ward’s Christmas raffle go to the Yanchep Volunteer Fire Service.

Additionally, in mid-January the hospital’s Supply Department also provided items to help wildlife affected by bushfires.

“A lot of people were affected locally, so many people working at the hospital and patients,” Claire said. “I even had to rush home from work one evening because one of my children rang me and said there was a fire, and that we would have to evacuate the house. We had to stay with friends overnight.

Medical supplies such as absorbent pads and cloths, plastic suture sets, kidney dishes, and IV starter kits were donated. 

“Back at work, I was already organising the ward Christmas raffle, where we raffle off a hamper and use the money for a charity. “So I asked the staff to donate the money this time to the local fire service who had done so much for the community – and they said yes!” They raised $2414 and recently presented a cheque for that amount to the fire service. Meanwhile, in January other Joondalup staff raised a further $4761 at an event during which meals and coffee were sold for a gold coin donation in the staff dining room. Parent company Ramsay Health Care matched the amount and proceeds went to the NSW Rural Fire Service

western nurse January – February 2020

JHC staffer Declan Ellery selling lunches for a gold coin donation to ANF members Hayley Morgan and Jenny Aslan, and their colleague Kate Fabbri.

JHC nurses, who are also ANF members, Laura Evans, Ashlee Hince, Sian Wright, Stephanie Guthrie, Fiona Timmons and Melissa Potter, look on as Claire Johnstone hands the donation to local firefighters

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AMAZING APPS + ONLINE NEWS

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RCH Emergency Nurse Practitioner The Royal Children’s Hospital (RCH) has a great collection of apps. This one provides in-depth guides on paediatric assessment, common diagnostic findings, and important red flags to watch for. It is suitable for any healthcare professional wanting to further their knowledge in paediatrics. Free

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western nurse January – February 2020

Heart of Gold Australia Embark on self-guided, interactive gold trails as you discover the story of a nation built on gold. The #heartofgold Discovery Trail in Perth will take you on a gold journey of discovery through Perth city, from Elizabeth Quay to The Perth Mint – complete with augmented reality, remarkable audio stories, fun widgets, vivid videos, timeless photos and interactive games. Information on school excursions and linked lesson plans are also available. Free

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Pinterest Remember pasting cut-outs of your favourite fashion, idols, hobbies and inspirations from magazines into a scrapbook? So do millions of other people which is why Pinterest is so popular. The beauty of the online version is you can check out other people’s ideas too. Free

FIVESuperSites Is My Airbag Safe?

This search tool tells you whether or not your vehicle is affected by the Takata airbag recall. Simply enter your vehicle registration plate details and location. Green means your vehicle is not affected, red means it could be. Advice is provided should your vehicle be at risk. ismyairbagsafe.com.au

StatPearls

Head here for free, peer-reviewed articles and activities. You’ll find a comprehensive database of multiple-choice questions with explanations. It’s really useful if you are looking for the answer to a clinical question. Accompanied by a collection of apps. statpearls.com

ResearchGate

If StatPearls is a one-stop shop for clinical evidence, ResearchGate is the platform for sharing and following research. Ask a technical question for answers from experts or start a scientific discussion with your peers. Set a profile and invite or follow other people’s research projects. Also comes with an app. researchgate.net

What Should I Read Next?

Ever finish a great book and feel empty, not knowing what to read next? WSIRN generates recommendations based on the mass opinions of readers. Now the technical description is out of the way, head to this site and enjoy what the generator spits out for you. Type in an author or book title and see what titles pop up - so cool! whatshouldireadnext.com

Rainy Mood

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Mark’s

CPD HOURS DUE SOON – KEY POINTS Once a year I like to give our members a brief general refresher on your Continuing Professional Development (CPD). It’s an important topic, given you can lose your registration if you haven’t fulfilled your CPD requirements and the Australian Health Practitioner Regulation Agency (AHPRA) audits you. Your hours will be due yet again in just a few months, so I hope this short general guide will give you some pointers. However, if you have more questions you can always write to us. Q: When are my CPD hours due each year? A: May 31. Q: How many CPD hours am I required to complete annually? A: Registered nurses (RNs) and midwives need to do a minimum of 20 CPD hours yearly. If you’re both a midwife and an RN you need to do a further 20 hours (40 hours total), though some CPD hours can count towards both nurse and midwife registrations. Q: I’m a nurse practitioner or a midwife practitioner. How many CPD hours do I need? A: You need an additional 10 hours on top of the CPD hours needed for your normal registration. Q: I have scheduled medicines endorsement. How many CPD hours do I need? A: You need an additional 10 hours on top of the CPD hours needed for your normal registration. Q: I’m on maternity leave, long service leave or other leave. Do I still need CPD? A: To retain your registration, yes, you need to complete normal CPD hours. Q: I work part-time. Do I still need CPD? A: Yes, you need to complete normal CPD hours.

Q: Where can I find and complete CPD modules easily? A: ANF iFolio has hundreds of quickly accessible Clinical Updates (CUs) across a range of topics that fulfil your AHPRA obligations. Your western nurse magazine also contains CUs. Q: How much does it cost to do ANF CPD units? A: You don’t pay anything! CPD units are included as part of your local ANF membership in WA. Q: Is there an evidence record of my CPD that I can show AHPRA if need be? A: iFolio has a convenient downloadable evidence record that lists everything AHPRA asks for on CPD. This includes your identified learning need, activity undertaken and reflection on the activity. The ANF evidence record also details other relevant CPD activities on it, not just iFolio modules. If you attend ANF seminars, education sessions or legal talks, these are automatically updated on your ANF iFolio, so you receive CPD credit that you can show AHPRA, all in one location. Q: I’ve been charged by the federal office for CPD units. Why is that? A: You signed up to the wrong provider! Save your cash – do your CPD with us, it’s free in WA with your local ANF membership. Q: What other types of activities are valid as CPD apart from ANF iFolio modules and ANF activities? A: Tertiary courses and other accredited study, conferences, short courses, workshops and even your mandatory competencies, as long as they are recognised as being related to your work, can count towards CPD and be recorded on your iFolio. The information provided in this column is general advice only. If you want information specific to your circumstances you should contact the ANF Helpline or send us your questions by email. January – February 2020 western nurse |

ANF Out 'n' About

SJOG Bunbury Bella Udeozo, Sinead Trewren and Louise Cruickshank, and from Bunbury Regional Hospital Rochelle Hawkins

SJOG Murdoch Deb Patman and Carmel Bourke

We’re always thrilled to see that our bags have been travelling the world! ANF member Gerry Coutinho knew what type of bag she needed when she was in Bali last year – an ANF one of course! Gerry told western nurse that in this holiday snap she was “sharing the ANF love in the rice fields of Bali”. Meanwhile, back on the home front in WA, this edition also displays photos taken of our members at St John of God Bunbury and Murdoch, Sir Charles Gairdner, Royal Perth, Margaret River and Kojonup hospitals. We also feature one of our numerous prizewinners, offshore medic Mark Welten, who won an ANF Jamie Oliver prize pack. Mark told

western nurse that he's been a member for many years. He started at Fremantle Hospital and is now working offshore as a medic, and “wouldn’t change it for the world”. Mark said all his mates will see this pic, and his “Jamie Oliver spoon is going straight to the pool room!” – we’d expect no less. We’ve got a huge schedule of workplace visits this year – both city and country – where we’ll be bringing out more goodies, including our much sought-after bags. And don’t forget that every photo published gets entered in a big prize draw at the end of the year, so make sure you come to see us when we turn up!

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western nurse January – February 2020

School of -

Nursing & Midwifery 3/1/20 2:52 pm

Gerry Coutinho was in Bali with the handy ANF shopping bag

SCGH Steve Chatterton

RPH Laura Sutherland

SJOG Murdoch Georgie Redgrave

Offshore medic Mark Welten won an ANF Jamie Oliver prize pack

SJOG Bunbury Dal Taylor and Chris Lancaster

ANF members receive 10% DISCOUNT on any online or instore purchase. Please enter or mention the code: ANF10. Excludes sales items.

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January – February 2020 western nurse |

ANF Out 'n' About Kojonup Hospital Cathy Stanton, Jean Daly, Jill Cavanagh, Diane House and Hannah Patterson

Margaret River Hospital John Dallimore and Sandy Znidarsich

RPH Nicola Mostert, Alison Willis, Roma Parikh, Eun Ah Seo and Soumya Sebastian

SCGH Charlotte Emmett, Holly Brown, Blake Mulraney, Mary Rodger and Tenri Mirzah

10 |

western nurse January â&#x20AC;&#x201C; February 2020

Margaret River Hospital Sarah Murphy, Barbara-Jane Forsyth, Candise Sullivan and Marina Ghirardi

SJOG Murdoch Valerie Joubert

NEW RELEASE Our members have been asking for more of the ANF's fob watch covers. The good news is we're releasing a new shipment in the next few months in all your favourite colours! Both the watches and the covers are FREE for ANF Members. If you don't have a fob watch already, order one now on your iFolio – it comes with a set of coloured covers. Just log on to your iFolio account and click ‘Resources’. The fob watches are under the heading ‘Merchandise’.

ifolio.anfiuwp.org.au

January – February 2020 western nurse |

CONTINUING PROFESSIONAL DEVELOPMENT

ANF iFOLIO CLINICAL UPDATE:

ANFClinical Updates Iron deficiency anaemia in children: Iron deficiency anaemia in children: Diagnosis and treatment 1 iFolio hour Diagnosis and treatment Read this article and complete the quiz to earn

Read this article and complete the quiz to earn 1 iFolio hour Iron deficiency occurs when iron absorption does not meet the iron requirements of the body.1 It is the most common nutritional deficit worldwide, the only one that is still prevalent in industrialised countries and the most common cause of anaemia in children of all ages.1 The World Health Organization (WHO) estimates that 80% of the world’s population is iron deficient and 30% have iron deficiency anaemia (IDA).1 Iron deficiency develops gradually with the initial imbalance depleting stored iron while blood haemoglobin levels remain normal.2 After iron stores are exhausted there is insufficient iron to support normal physiological functions and iron deficiency anaemia develops.2,3 Anaemia occurs when there is a decrease in either the number of red blood cells (RBC) or the amount of haemoglobin in the RBC.2,3 In Australia it is estimated that 8% of preschool children have anaemia which is defined as ‘a haemoglobin (Hb) concentration below the lower limit of the normal reference range, and varies according to age and sex.’ (See Table 1)4.

Table 1: Diagnosis of anaemia by haemoglobin level, age, and sex4

Age

Lower limit of normal range of Hb (g/L)

2 months

2 - 6 months

6 - 24 months

105

2 – 11 years

115

> 12 years

Female - 120

are both haematological, due to anaemia, and non-haematological, due to lack of oxygen supply to the muscles and brain.1 Their presentation can be subtle.1 Iron deficiency can cause: • Behavioural problems, including attentiondeficit hyperactivity disorder (ADHD) • Cognitive and intellectual impairment in children • Decreased aerobic sports performance • Decreased memory, impaired learning and concentration

In children, high-risk groups include;

• Developmental delay in infants - both motor and mental function

• Adolescents

• Fatigue

• Hospitalised and institutionalised patients

• Impaired immune function1,5

• Malabsorption disorders, e.g. coeliac disease • People on restrictive diets, e.g. vegetarians and vegans • Premature or low birth weight babies, toddlers, and preschool children • Refugees and recent migrants from developing countries • Some Aboriginal and Torres Strait Islander populations1,2,5

IRON METABOLISM Iron is a crucial component of haemoglobin (Hb), myoglobin, and other enzymes and plays a key role in respiration, energy production, deoxyribonucleic acid (DNA) synthesis, and cell proliferation.2,5 Over half of the body’s iron is found within the Hb.1 A further 25% is stored in readily metabolised ferritin in the liver and the reticuloendothelial system.1 Implications of Iron Deficiency Anaemia The clinical consequences of iron deficiency

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western nurse January – February 2020

CAUSES OF IRON DEFICIENCY ANAEMIA Inadequate dietary intake and increased demand for iron during periods of rapid growth are the most common causes of IDA in children and adolescents.5 Maternal IDA, multiple pregnancies, and early cord clamping at birth, place a baby at risk of iron deficiency anaemia early in life.1 Preterm and low birth weight babies are also born with low iron stores and undergo rapid catch-up growth, which means they are at risk of becoming anaemic in the first six months of age.1 Other factors that put children at risk include late or insufficient introduction of iron-rich solids, poor intestinal iron absorption, and increased iron loss due to bleeding.1

PRESENTATION The most common presentation of mild IDA in children is an asymptomatic, well-nourished infant/child with a mild to moderate microcytic-

Male - 130 hypochromic anaemia.3 As it progresses, IDA in infants and children typically presents as a subacute or chronic history of progressive pallor, fatigue, irritability, pica, reduced feeding, decreased activity, poor concentration, and/or worsening school performance.1-3

DIAGNOSIS Serum ferritin, with full blood count, is considered the most effective screening test to assess iron stores, however, serum ferritin is an acute phase indicator and a normal result does not exclude iron deficiency and concurrent assessment of C-reactive protein is recommended to exclude inflammation.6 A reduced serum ferritin (<20μg/L) indicates inadequate iron stores and serum ferritin <50μg/L may indicate iron deficiency in children with chronic disease or those in high risk population groups.6 Serum iron levels are variable and considered unreliable in diagnosing iron deficiency in children.6

MANAGEMENT Dietary advice Dietary changes are important for secondary prevention but will not treat frank iron deficiency.1 Advice includes increasing iron rich foods especially those rich in haem iron (animal sources).1-3,5 Vegetable sources of iron (non-haem iron sources) such as beans, dark green leafy vegetables, dried fruit and iron fortified foods such as cereals are not as well absorbed, notwithstanding the important part they play in a healthy diet.1,3,5 Oral supplementation Oral iron therapy is an effective first-line strategy for most patients with IDA and should both correct the anaemia and replenish iron stores.1,5 Adverse effects such as nausea, constipation, and abdominal pain reduce adherence and effectiveness.5 Other reasons for failure of oral

supplements include consumption of iron absorption inhibiters (such as calcium, fibre, tea, coffee and phytates found in cereals and legumes), hookworm infection, and vitamin B or folate deficiency.1-3,5 Parenteral supplementation Parenteral iron is used when oral therapy has failed or is contraindicated, when rapid iron replacement is required, or to avoid the need for transfusion.1-3,5 Intravenous (IV) iron infusion allows for rapid replenishment of iron stores with peak ferritin concentrations achieved seven to nine days after infusion.5 Haemoglobin rises within two to three weeks.5 Current IV formulations used for IDA in children are iron polymaltose, iron sucrose, and ferric carboxymaltose.6 Note that the use of ferric carboxymaltose and iron sucrose in children is an ‘off label’ use in Australia, however, the National Blood Authority, whilst acknowledging this, provides guidelines on their use in children based on high quality, current available evidence and best practice protocols.6 Intramuscular iron injection is not recommended for any population group.1,6 Precautions and adverse effects Hypersensitivity reactions (allergy and anaphylaxis) can occur with all IV iron formulations, meaning resuscitation facilities should be available.6 Reports of allergic and

anaphylactic reactions to iron polymaltose are more common.6 The risk is substantially lower with current nondextran formulations.5 Adverse events may be immediate or delayed and irreversible skin staining has been reported in the paediatric setting.5,6 Premedication with steroids and antihistamines may be considered.6 Oral iron supplements should be ceased prior to commencement of IV iron and should not be recommenced until at least one week after the last dose of parenteral therapy, if necessary at all.6 Nurses and midwives should not give IV iron unless competent to do so. Competency should include consent procedures. All local polices and guidelines for IV administration should be adhered to.

Table 2: Adverse effects of intravenous iron preparations5

Common

Uncommon

Rare

Dizziness

Abdominal pain, indigestion

Anaphylaxis

Flushing, sweating, faintness

Altered taste sensation

Malaise

Headache

Constipation, diarrhoea

High blood pressure

Fast heart rate, chest pain

Injection-site reactions (pain, bruising, extravasation, skin discolouration)

Fatigue

Nausea Transient low serum phosphate with ferric carboxymaltose

Fever, chills Hives, itch, red skin, rash, swelling under skin Hypersensitivity Hypotension Joint pain, back pain Muscle pain, muscle spasms Paresthesia Peripheral oedema Shortness of breath Vomiting, flatulence

Blood transfusions Blood transfusions are an expensive and potentially hazardous option for the treatment of IDA.1 Transfusions should be reserved for targeted management in patients with severe IDA compromising end-organ function or with serious, acute ongoing bleeding.3

INVESTIGATING THE CAUSE Iron deficiency is not an end diagnosis in itself and the cause of iron deficiency must always be investigated and once determined, addressed.1

REFERENCES 1. Gastroenterological Society of Australia. Iron deficiency – Clinical update. Mulgrave, VIC: GESA; 2015. 2. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2018. 3. Australian Red Cross Blood Service. Iron deficiency anaemia [Internet]. Last updated 22 Nov 2016 [cited Aug 2018]. Available from: https://transfusion.com.au/transfusion_practice/ anaemia_management/iron_deficienc y_ anaemia 4. The Royal Children’s Hospital Melbourne, Australia. Clinical Practice Guidelines: Aneamia. [Internet. Undated. [cited Aug 2018]. Available from: https://www.rch.org.au/clinicalguide/ guideline_index/Anaemia/ 5. Baird-Gunning J, Bromley J. Correcting iron deficiency. Aust Prescr. 2016;39:193–95. 6. National Blood Authority, Canberra. Paediatric and Neonatal Iron Deficiency Anaemia Guide. December 2017 [cited Aug 2018]. Available from: https://www.blood.gov.au/system/files/ Paediatric-and-Neonatal-Iron-DeficiencyAnaemia-Guide-Final-Dec17.pdf

January – February 2020 western nurse |

CONTINUING PROFESSIONAL DEVELOPMENT

ANF iFOLIO CLINICAL UPDATE:

Nursing management Nursing managementof ofperipherally peripherally inserted central catheters (PICC lines) inserted central catheters (PICC lines) Read this article and complete the quiz to earn 1 iFolio hour Read this article and complete the quiz to earn 1 iFolio hour

Peripherally inserted central catheters (PICC) are a type of central venous access device (CVAD). They are used in hospitals and community settings for patients with medium to long-term requirements for intravenous access. Management of PICC lines requires an understanding of the Australian National Safety and Quality Health Service (NSQHS) Standard Three: Preventing and Controlling Healthcare Associated Infections and advanced nursing competencies.1 All nurses and midwives must ensure they are working within their scope of practice and have the appropriate knowledge, skills, and competence to ensure high quality, safe care for patients with a PICC line.

CAUTION Note that local policies and state guidelines may vary, and all nurses and midwives are advised to check local policies.

WHAT IS A CENTRAL VENOUS ACCESS DEVICE?

There are many different types of PICC line catheters available, in varying sizes, with one or more lumens.1 Selection of an appropriate catheter will depend on product availability and indication for use. The catheter with the smallest gauge and minimum number of required lumens should be inserted to reduce the risk of phlebitis and infection.3 The insertion site of a PICC line should be accessible, in an area where asepsis can be maintained. Sites with any wounds or signs of bruising, infiltration, engorging, sclerosis, or phlebitis should be avoided.2 In the upper extremities, the median cubital, cephalic, basilic, or brachial veins are all an appropriate diameter for peripheral insertion (see Illustration 1). In neonates and young children, peripheral veins in other sites such as the head or lower extremities may also be considered.2 Illustration 1. Anatomy â&#x20AC;&#x201C; inserted in the basilic vein of the right arm and terminating in the superior vena cava.

A CVAD is an intravascular access device or catheter that terminates at, or close to the heart, or in one of the great vessels.2 The great vessels include the pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, common iliac veins, or femoral veins. Types of CVADs include PICCs, tunnelled central venous catheters (CVC), percutaneous non-tunnelled catheters, and implanted ports (portacath, infusaport).

area surrounding the insertion site is cleaned with >0.5% chlorhexidine in 70% alcohol or 5% povidone iodine in alcohol (if chlorhexidine is contraindicated).1 Drapes are used to cover the entire patient, apart from the insertion site. Once inserted, the line is covered with a sterile occlusive dressing.1,4

PICC LINE DRESSINGS PICC line dressings are used to secure the catheter and protect the insertion site from infection.1,4 Sterile, transparent semi-permeable dressings are preferred as they anchor the catheter, can reduce bacterial colonisation, and allow visualisation of the insertion site.1,4 Chlorhexidine-impregnated dressings and sponges reduce the risk of exit site infection and catheter-related bacteraemia (see Image 1).1 More evidence is required to establish the safety of chlorhexidine-impregnated dressings and sponges in low birth weight neonates and these should therefore not be used in this patient group.1 Sterile gauze dressings are only indicated if there is a contraindication to transparent semi-permeable dressings, such as an allergy or excessive oozing, bleeding, or diaphoresis.1,4 Image 1. PICC line dressing

HOW IS A PICC LINE DIFFERENT FROM OTHER CVADS? A PICC line is a unique type of CVAD. It is inserted in a peripheral vein and terminates in the superior vena cava.2 Indications for a PICC line include medium-term (4 weeks to 6 months) administration of; -

Fluid or medication, including antibiotics and chemotherapy

Total parenteral nutrition And/or

Recurrent blood sampling3

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western nurse January â&#x20AC;&#x201C; February 2020

INSERTION All PICC lines are inserted under aseptic conditions with maximal barrier precautions in situ (including hair cap, mask, eye protection, sterile gown, and sterile gloves).1,4 A surgical scrub is required in preparation for the procedure.1 Assistants entering the sterile field should also don maximum barrier precautions including a surgical scrub.1 The

Transparent, semi-permeable, self-adhesive, polyurethane dressings and chlorhexidineimpregnated dressings are changed weekly, or more frequently if there are signs of dampness or soiling, loosening, or loss of occlusion.1 If gauze dressings are used (with or without semi-permeable dressings), they must be changed every 24 to 48 hours depending on local policy.1,4 Patients with long-term PICC lines, managed at home, may require less frequent dressing changes (up to every two weeks).1

Table 1. How to: Perform a PICC line dressing change5

DON’T

Observe the site daily

Fiddle with the dressing, lumens, or bungs on a regular basis

Perform hand hygiene prior to touching the PICC line

Touch the PICC line with soiled hands

Shower with PICC line covered

Swim or use a spa bath with a PICC line

Keep PICC line covered at all times

Let pets near a PICC line

Avoid rough, strenuous, or repetitive activity that involves the PICC line insertion site

Interact in environments that may expose a PICC line to dirt or infection

Attend appointments for regular dressing changes

Plan any dental visits with a PICC line in situ

All PICC line dressing changes are performed using aseptic technique with a sterile dressing pack, drape, and sterile gloves. Patients should turn their head away from the exit site or wear a mask.1 The specific steps to performing a PICC line dressing change are outlined in Table one. Refer to organisational specific guidelines for more information.

PICC LINE FLUSHES AND LOCKING OF PICCS Flushes are used to maintain patency of PICC line lumens and prevent mixing of incompatible solutions.1,3 Flushes are administered using sterile 0.9% sodium chloride applied in a pulsatile motion.3 The ideal volume and frequency of flushes has

Table 2: PICC line recommendations for patients1-3 Steps for performing a PICC line dressing. Note - Local policies should be checked Step 1

Confirm patient details, including allergies and appropriate indication for dressing change. Explain the procedure and obtain consent.

Step 2

Perform hand hygiene and don PPE as required.

Step 3

Measure external catheter length from point of exit to end of the bung. If there is more than a 2cm difference from documented length on insertion, inform the medical officer. Observe for signs of complications such as pain, redness, swelling or exudate.

Step 4

Perform hand hygiene and don non-sterile disposable gloves. Using aseptic technique open sterile dressing pack and all sterile items. Place plastic sheet from the dressing pack under the arm to protect against fluid run off.

Step 5

Remove existing dressing and adhesive stabilisation device with caution in order to avoid dislodging the catheter and prevent skin tears. Apply adhesive strip to hold PICC line in place (if required).

Step 6

Dispose of dressing and remove gloves (discarded waste). Perform aseptic hand wash for one minute and dry hands with sterile hand towel.

Step 7

Don sterile gloves.

Step 8

Remove chlorhexidine-impregnated gauze (if present) with sterile forceps. Discard forceps. Again, observe for signs of complications at the insertion site.

Step 9

Disinfect the insertion site with 2% chlorhexidine in 70% alcohol solution using concentric circles from the insertion site outwards. Repeat three times with a new gauze or sponge each time. Allow 30 to 60 seconds drying time in between.

Step 10

Use skin preparation to prepare the site for an adhesive device. Apply the adhesive stabilisation device as per manufacturer’s instructions (if using this).

Step 11

Apply appropriately sized chlorhexidine impregnated sponge.

Step 12

Remove the adhesive strip holding the PICC line in place (if used). Apply a large semi-permeable transparent dressing. The PICC line insertion site should be in the centre of the dressing.

Step 13

Prepare new bungs. Prime each bung with 0.9% normal saline using a 10mL syringe and leave syringe attached.

Step 14

Disinfect each old bung for 15 seconds with a separate 70% alcohol or 2% chlorhexidine in 70% alcohol swab for each one. If the PICC is valved, clamping of the lines is not required. If the PICC is non-valved, clamp each of the lines. Remove old bungs.

Step 15

Disinfect each new bung for 15 seconds with a separate 70% alcohol or 2% chlorhexidine in 70% alcohol swab for each one. Apply new bungs. Unclamp the line (if required) and flush with 0.9% normal saline using a pulsatile technique.

Step 16

Write the date of the dressing on the border of the transparent film dressing and cover as appropriate. Remove sterile gloves and dispose of all waste.

Step 17

Perform hand hygiene. Measure external catheter length from point of exit to end of the bung and document accordingly. If there is more than a 2cm difference from documented length on insertion, inform the medical officer.

Step 18

Perform hand hygiene, check patient comfort, and document procedure.

not been determined. At a minimum, the volume of the flush should be equal to twice the volume contained in the catheter and any extension devices or needleless access devices. Between two to three millilitres is usually enough.1 In order to prevent excessive pressure (and catheter rupture), a 10mL syringe (or greater) should be used to administer intravenous fluids, medication, or flush into a PICC line.1 Locking is used to prevent occlusions with intermittent use of PICC lines. Locking is performed by applying positive pressure to prevent the backflow of blood, while clamping each of the lumens.1 There is mixed evidence to support the type of fluid that should be used to lock a catheter. Heparinised saline has been used but is incompatible with some solutions and is associated with complications including heparin-induced thrombocytopenia, altered coagulation, and bleeding.1 Sterile 0.9% sodium chloride is recommended unless the manufacturer outlines an alternative solution.1

RISKS ASSOCIATED WITH PICC LINES The primary risks associated with a PICC line include venous thrombosis and infection (central line-associated blood stream infections).3 Other possible complications include phlebitis, infiltration and extravasation, nerve injuries, occlusions, infection, air embolism, catheter damage, and malposition.2 Patients with a PICC line in situ should use precautions to reduce the risk of complications (see Table 2).1-3 Nurses should monitor for signs of exit-site infections (erythema, exudate, pain, redness, swelling), systemic infection (tachycardia, tachypnoea, hypotension) and patency of the lumen.1

REFERENCES 1. Queensland Government Department of Health. Guidelines: Peripherally inserted central venous catheters. Version 3.0. Brisbane: Department of Health; 2015 Jan. 28p. 2. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. Journal of Infusion Nursing. 2016 Jan;39(1S):S1-156. 3. Loveday HP, et al. epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection. 2014;86S1: S1-S70. 4. SA Health. Peripherally inserted central catheter (PICC) dressing management clinical guidelines. Version no. 1.0. Adelaide: Government of South Australia; 2017 Aug 1. 10p.

January – February 2020 western nurse |

CONTINUING PROFESSIONAL DEVELOPMENT

Zuclopenthixol Zuclopenthixol Table 1. Zuclopenthixol dosage and administration

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Indication

Formulation

Dosage

Administration

Acute psychoses or mania

Zuclopenthixol dihydrochloride (Clopixol)

10 to 50mg daily (maximum of 75mg)

Oral tablets

Zuclopenthixol acetate (Clopixol Acuphase)

50 to 150mg every 2 to 3 days*

IM injection

Chronic psychoses

Zuclopenthixol decanoate (Clopixol depot)

200 to 400mg every 2 to 4 weeks*

IM injection

*Lower doses may be required for the elderly

Generic name: Zuclopenthixol Trade name: Clopixol (Acuphase or Depot) Drug class: Antipsychotic

INDICATIONS Zuclopenthixol is an antipsychotic agent used to treat acute and chronic psychoses (schizophrenia), acute mania, and bipolar disorder.1,2 It comes in a variety of formulations. Zuclopenthixol dihydrochloride (Clopixol tablets) is the shortest-acting with a half-life of approximately 20 hours. Zuclopenthixol acetate (Clopixol Acuphase) is an intermediate injection (half-life approximately 36 hours) that may be used to treat mania, acute episodes of mental disorders, or worsening chronic conditions. Finally, zuclopenthixol decanoate (Clopixol Depot) is a long-acting injection, typically used to prevent acute episodes. It can be administered weekly to monthly with a halflife of 19 days.2 Zuclopenthixol is an older drug, first introduced in 1962. Although it is commonly used, there is limited research available regarding the efficacy of treatment compared to placebo. A systematic review of zuclopenthixol versus placebo for schizophrenia found only two eligible studies for inclusion.2 These randomised control trials were both focused on zuclopenthixol dihydrochloride (tablets), with a very small sample size (total population of 65 people) and were completed in 1968 and 1972, before many other antipsychotic agents became available. Findings suggest that zuclopenthixol is likely to improve global state (general state of wellbeing) but is also associated with a variety of side effects. Pragmatic evidence, from many years of use in practice, also supports these findings. However, without trial data it may be very difficult for clinicians and people with schizophrenia to decide which medication is best for them to take, and if the outcomes are worth it given the side effects of treatment.2

MECHANISM OF ACTION Antipsychotic agents are thought to work by blocking dopaminergic receptors in

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western nurse January â&#x20AC;&#x201C; February 2020

various parts of the brain and preventing the transmission of dopamine. All agents block D2 receptors. Some also block other receptors such as D1 or 5HT2 receptors, causing therapeutic and adverse effects.1 Zuclopenthixol blocks D2 and serotonin receptors, and has a high affinity for alpha-receptors, which may also cause antihistamine effects.2 Antipsychotic agents are associated with a wide range of precautions, complications, and adverse effects. As such, zuclopenthixol is an S4 (prescription-only) drug, typically prescribed by a psychiatrist.1,3

PRECAUTIONS Zuclopenthixol is contraindicated in patients with a known allergy, severe hypotension, low levels of consciousness, brain damage, low white cell count or previous blood dyscrasia, or pheochromocytoma.1,3 Caution should be taken when using in patients with hepatic impairment.1 Zuclopenthixol is not recommended during pregnancy or breastfeeding, unless absolutely necessary.3

ADVERSE EFFECTS Common adverse effects with an antipsychotic agent include sedation, anxiety, agitation, extrapyramidal side effects (see Box 1), orthostatic hypotension, tachycardia, blurred vision, mydriasis (dilated pupils), constipation, nausea, dry mouth, urinary retention, sexual adverse effects, weight gain, and hyperprolactinaemia (which has the potential to cause galactorrhoea, gynaecomastia, amenorrhea or infertility).1 Abnormal liver function may also occur.2 Box 1. Extrapyramidal side effects Extrapyramidal side effects are serious, dose-related adverse reactions associated with antipsychotic agents. They include dystonia (continuous or repetitive muscle spasms), akathisia (motor restlessness), parkinsonism (tremor, rigidity, bradykinesia), and tardive dyskinesia (irregular movements). Dose reductions may be required if symptoms persist.

DOSAGE AND ADMINISTRATION The dose and administration of zuclopenthixol is dependent on the indications for treatment. In patients with acute psychoses or mania, tablets or medium-term injections may be considered. Oral doses typically range from 10 to 50mg daily, spread over multiple doses. Zuclopenthixol acetate injections are administered intramuscularly (IM), as a course of treatment for up to a maximum of two weeks (see Table 1). For adults, the course consists of one 50 to 150mg injection every two to three days to a maximum of 400mg (up to four doses).1 For chronic psychoses, long-acting injections may be indicated. If an individual has never used long-acting antipsychotic injections before, it is important to test for adverse effects using a low dose (around 100mg). Regular doses of zuclopenthixol decanoate are between 200 to 400mg administered every two to four weeks. Lower doses may be required for elderly patients.1 Patients may need to alternate between oral tablets and intermediate and long-acting zuclopenthixol injections. Dosage of 40mg of oral tablets daily is equivalent to 100mg of zuclopenthixol acetate every two to three days. If changing to long-acting injections, the first long-acting injection should be given at the same time as the last intermediate injection, while tablets should be weaned during the first week post-injection.1

REFERENCES 1. Australian Medicines HandbookÂ 2017 (computer program). Adelaide: Australian Medicines Handbook Pty Ltd; 2017 Jan. 2. Lacey M, Jayaram MB. Zuclopenthixol versus placebo for schizophrenia. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD010598. DOI: 10.1002/14651858.CD010598. pub2. 3. NPS MedicineWise. Clopixol depot solution for injection [internet]. Surry Hills: NPS MedicineWise; 2017 May [cited 2017 May]. Available from: https://www.nps.org.au/medicalinfo/medicine-finder/clopixol-depot-solutionfor-injection#side-effects Accessed June 2017

CONTINUING PROFESSIONAL DEVELOPMENT

ANF iFOLIO CLINICAL UPDATE:

Pregabalin – a medication update Pregabalin – a medication update Read this article and complete the quiz to earn 0.5 iFolio hour

Read this article and complete the quiz to earn 0.5 iFolio hour Generic name: Pregabalin Trade name: Lyrica Drug class: Antiepileptic

INDICATIONS Pregabalin relieves pain, prevents seizures, reduces anxiety, and improves sleep patterns.1,2 It is used to treat focal seizures with or without secondary generalisation (spreading to involve the entire cortex) and neuropathic pain.1 It is listed on the Pharmaceutical Benefits Scheme (PBS, authority required) for patients with persistent neuropathic pain that cannot be controlled by other agents, such as tricyclic antidepressants (amitriptyline or nortriptyline).2

MECHANISM OF ACTION Pregabalin is similar to another antiepileptic agent called gabapentin. The exact mechanisms of action of both are unknown. They are structurally similar to the neurotransmitter gamma-aminobutyric acid (GABA) but do not seem to bind to these receptors or influence the action of GABA.1,2 Rather, they bind to calcium channels, reduce calcium uptake, and limit the release of neurotransmitters.1

PRECAUTIONS Caution is required when using pregabalin with some other medications as there is an increased risk of adverse events. Pregabalin is renally excreted; dose adjustments may be required for patients with renal impairment. Lower doses may also be indicated for elderly patients. There is limited data to support the use of pregabalin in pregnancy and medication is known to pass into breast milk. Expert advice is recommended.1

ADVERSE EFFECTS Pregabalin is generally well tolerated. Mild to moderate adverse effects are often dosedependent.2 Common adverse effects include dizziness, drowsiness, weight gain, dry mouth, headache, confusion, irritability, blurred vision, diplopia, ataxia, impaired balance, peripheral oedema and insomnia.1,2 Dizziness and drowsiness are the most common reasons why people may stop taking pregabalin despite ongoing neuropathic pain.2 More severe complications including depression, agitation,

hallucinations, and cognitive impairment may also arise with treatment.1 Routine monitoring for complications may be required.

PREGABALIN AND THE TREATMENT OF NEUROPATHIC PAIN

DOSAGE

Pregabalin has variable effects on neuropathic pain. A meta-analysis of randomised controlled trials found that pregabalin reduces pain in some patients with neuropathic conditions, when compared with a placebo.2 However, a recent randomised controlled trial found that pregabalin had no significant effect on leg pain for patients with acute or chronic sciatica, and many patients who take pregabalin for neuropathic pain experience treatment failure due to nil or minimal benefits and/or the onset of complications.1-3 Effective pain relief may take several weeks and results are often dose dependent.1 For instance, patients with diabetic neuropathic pain have reported limited effects with a dose of 150mg per day, but substantial benefits with between 300mg and 600mg per day.2 Patients who fail to experience pain relief despite compliance with the maximum dose of pregabalin should consider a combination treatment or cease treatment and try an alternative therapy.

The recommended dose for pregabalin depends on patient characteristics, such as age and renal function, and the indication for treatment. For adults with focal seizures, an initial dose of 75mg twice daily is recommended. If seizures persist, doses may be increased to up to 150mg or 300mg twice daily. Changes should be made at weekly intervals to allow enough time for therapeutic effects to be realised.1 There are no widespread treatment regimens for patients with neuropathic pain. Drug therapies should be used in combination with other physical, psychological, and social interventions.2 Tricyclic antidepressant agents may be considered first line. Gabapentin may also be used. Pregabalin should be considered when other drug therapies are unsuccessful.2 For adults, initial doses of 75mg at night are recommended. This may be increased to 150mg once daily or 150mg to 300mg twice daily at weekly intervals, as required.1 Some patients may prefer to divide doses unevenly as a greater dose at night time may help to improve sleep and prevent drowsiness throughout the day.1 Regardless of the indication, lower doses of pregabalin (25-75mg daily) are recommended for elderly patients and those with renal impairment.1 When stopping treatment, it is important to wean pregabalin rather than ceasing immediately. Abrupt cessation has the potential to cause anxiety, insomnia, headaches, sweating, nausea, and diarrhoea.1

REFERENCES 1. Australian Medicines Handbook 2017 (computer program). Adelaide: Australian Medicines Handbook Pty Ltd; 2017 Jan. 2. NPS Radar. Pregabalin (Lyrica) for neuropathic pain [Internet]. Surry Hills: NPS MedicineWise; 2013 Apr 4 [cited 2017 Jul 7]. Available from: h t t p s : / / w w w. n p s . o r g. a u / r a d a r / a r t i c l e s / pregabalin-lyrica-for-neuropathic-pain#wheredoes-it-fit 3. Mathieson S, Chiro M, Maher CG, McLachlan AJ. Trial of pregabalin for acute and chronic sciatica. N Engl J Med. 2017; 376:1111-20.

January – February 2020 western nurse |

Corner

AVOCADO SMOOTHIE BOWL

INGREDIENTS

INSTRUCTIONS

All green, silky, and smooth, this avocado smoothie bowl is a filling and nutritious breakfast choice. It’s packed with good fats and fibre – plus it’s easy to make. In fact, it’s ready to eat within a few minutes! Top with your choice of fruits, nuts, and seeds for an Instagram-worthy dish.

• 120ml (½ cup) coconut water

1. Place coconut water, avocado, spinach, hemp seeds, and mango into the blender in the order listed above, then secure lid.

EQUIPMENT • Vitamix Ascent A3500i High Performance Blender or any blender • Digital scale • Measuring jug • Measuring cups • Measuring spoons

• 150g (1 cup) frozen mango

• ½ avocado, pitted and peeled • 30g (1 cup) spinach • 1 tbsp hemp seeds

• 2 tbsp fresh blueberries • 2 tbsp unsweetened flaked coconut

OFF When you spend over $50

4. Top with blueberries and coconut flakes. You can also cut a kiwifruit in two as an extra topping for a refreshing breakfast bowl. Serve immediately.

ANF15 Present this voucher in-store or enter promo code at online checkout to redeem this offer

Limit of one use per customer. Cannot be used in conjunction with any other promotion. Excludes appliances and attachments, gift cards, price matching, workshops and VIP Points. Valid until 20/5/2020.

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western nurse January – February 2020

3. Blend for 1 minute, using the tamper to press the ingredients into the blades.

Recipe adapted from Vitamix, supplied by Kitchen Warehouse.

ANF MEMBERS

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2. Select Variable 1, turn machine on, and slowly increase speed to highest speed.

PetPage

EMAIL US YOUR FAVOURITE SNAP OF YOU AND YOUR PETS TO WIN PRIZES! Keep those pet photos coming, because we love them and so do our readers! We have a bonus competition this edition, separate to our normal comp – the details are in the Pet City ad below. And the good news is, if you’ve already sent in an eligible snap (both you and your pet in the pic and 1mb-3mb in size), you’re also in the draw for the new competition! This edition of Pet Page features ANF member Raelene Rowley with Nugget, her ISA Brown hen. “Nugget lives with two Australorp hens in our suburban backyard and they give us two or three eggs each day,” Raelene told western nurse. “The kids love them. Caring for them and listening to them cluck together is a lovely relaxing way to spend downtime.”

Mike Coates with Larry

Raelene Rowley with Nugget

Natalie King is pictured here with Yoda, a six-month-old pug, and Toby, her “loyal blue heeler”. Natalie said: “Toby has the best smile to greet us whenever we come home. He loves the beach, swimming, bush walks and his new brother Yoda. Yoda is playful, cute and cheeky and he loves his big brother.”

Natalie King with Yoda and Toby

Mike Coates said his ginger kitty Larry is his “best mate and keeps me company and wakes me every morning for brekkie!” Jane McRobert with Millicent

Jane McRobert’s poochie pal Millicent needs to keep up with current affairs while snuggling. “I’m trying to have a lie down and a read of the paper after a hard day’s work, while she feels the need to not only join me, but to be on me,” said Jane. Don’t forget, to be eligible for a prize, members have to be in the photo with their pet and the photo needs to be about 1mb in size, but no bigger than 3mb. Also include your name, your pet’s name and no more than 50 words about your special friend. Email the photo of you and your pet(s) to: editorwesternnurse@anfiuwp.org.au and if we publish the pic, you win a prize, including special ANF pet tags! See you next edition!

DOGS

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C AT S

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BIRDS

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SMALL ANIMALS

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REPTILES

•

FISH

EXTRA PRIZES – PET CITY GIFT CARDS FOR 100 MEMBERS!

As special bonus for our Pet Page readers, we’re offering additional prizes for 100 lucky members – $15 Pet City gift card. All you have to do to be eligible is email a photo of you and your pet(s) to editorwesternnurse@anfiuwp.org.au – it’s just like your normal Pet Page entry but with way more chances to win. Don’t worry if you’ve previously sent through eligible pet pictures, you’ll also be considered for this bonus prize. Remember, both you and your pet(s) need to be in the pic and it should be 1mb-3mb in size. Please also include your name, your pet’s name and no more than 50 words about your special friend.

petcitywa.com.au

@petcitywa January – February 2020 western nurse |