Western Nurse Magazine June - July 2022 by ANF WESTERN NURSE MAGAZINE

June-July 2022

incorporating western midwife

SEE INSIDE OUR SPECIAL 40 PAGE EDITION – 20 YEARS OF WAGE NEGOTIATIONS LIFT OUT

Secretary's Report

June-July 2022

ANF Assistant Secretary Janet Reah

FEATURED AND FAVOURITES 3

Secretary’s Report

The ANF Legal Team

ANF in WA Cuts Fees by 25%

11 ANF Out ‘n’ About 14 ANF Helpline 16 Internet Watch 17 20 years of wage negotiations 8 page lift out 28 Across the Nation 30 The Brain Buster Crossword 32 Around the Globe 34 Recipe Corner 38 Pet Page CONTINUING PROFESSIONAL DEVELOPMENT: CLINICAL UPDATES 26 Diabetic ketoacidosis – a clinical update 35 Methotrexate - a medication update 36 Iron - a medication update 37 Lactulose - a medication update WIN! 39 ‘Atlas Of The Heart’ and ‘Experiences of Health Workers in the COVID-19 Pandemic’ books

Front cover: Clockwise from top left - Fremantle nurses at Parliament House ANF rally in 2012, nurses at the ANF Geraldton Hospital Rally in 2013, Fremantle Nurses at the Dumas House ANF Rally 2001, KEMH nurses & midwives waiting for the bus to take them to the Challenge Stadium ANF rally in 2001, SCGH nurses at one of their hospital ANF rallies in 2013… and one of the ANF bees.

iFolio is a registered trademark

Firstly, I want to thank outgoing State Secretary Mark Olson for his 24 years of tireless service to ANF members in Western Australia and I look forward to building on his great work. These are the most challenging of times for all our members whether they work in the Public Sector, Private Sector or Aged Care and it will take all the unity of purpose to protect the achievements of the last two decades as well as gaining further improvements. My focus going forward is on wages, conditions and better workloads for all ANF members. When the McGowan Labor government came to power in 2017, WA nurses and midwives were the highest paid in the country. But as a direct result of his government’s policy of capping wage increases to $1,000 per year for four years we have been overtaken by every state and territory except Tasmania. This must change or we will be losing our local nurses and midwives to other states and be unable to attract any significant numbers to travel this side of the WA border. Even when NSW and Victoria recently announced $3,000 bonus payments in addition to higher yearly wage increases than what is being offered in WA, the WA Premier said: “there is a material difference between what occurred in our hospitals and what the workforce had to endure and what occurred in NSW and Victoria.” Clearly the WA Premier thinks there is nothing wrong with having a health system reliant on ANF members doing record numbers of double shifts, doing record levels of overtime and suffering record levels of unfilled vacancies each and every shift. And talking about workloads another attraction to work in other states are the legislated nurses/midwife-to-patient ratios in Victoria and Queensland. The newly elected South Australian government has also promised to introduce legislated ratios sometime during their four year term. For our part we have contributed heavily to the current independent review by Prof Phil Della which is a review secured by the ANF in the 2020 EBA negotiations. The outcomes of this review will form part of our campaign for legislated ratios in Western Australia because it is an essential part of protecting our workforce from the workload abuses of the last two years. I look forward to meeting more and more members during my workplace visits and working closely with you as we progress these important projects and campaigns. Janet

Janet Reah speaking with members at SJOG Subiaco

June-July 2022 western nurse |

ANF HAS YOU COVERED IN THE MOST IMPORTANT WAYS Last year over 500 ANF members needed a legal referral from the ANF Helpline to the in-house ANF Legal Team. With this number expected to increase by 100 members each year we take a closer look at this vital service provided free to ANF members’. The free ANF Legal Service In 2010 nursing and midwifery registration went national with the creation of Australian Health Practitioner Regulation Authority (AHPRA) and within 12 months it became clear to the ANF Council that members in WA were going to need a much more robust legal representation than ever before and so the ANF Council moved away from expensive law firms and created the ANF Legal Service: purpose built to provide free legal representation for ANF members in Western Australia.

Continuous Expansion of Legal Services

According to Belinda, it’s crucial that members have access to legal advice and representation, especially as so much of a nurse or midwife’s working life can be exposed to various legal processes. “A member may be confronted with an adverse patient event at any time in their daily working life,” Belinda explains. “Nurses and midwives are also heavily regulated as professionals by AHPRA and are subject to potential complaints to AHPRA and investigations,” Belinda said. This can be stressful at any time. Throw in a pandemic and the pressure grows tenfold. Belinda understands the legal process is a foreign one for nurses and midwives.

Starting with just one lawyer in 2011 the ANF Legal Service has continued to grow and develop to ensure all members have access to the right kind of legal representation when required. Last year there were 500 legal referrals and this number is increasing by 100 referrals each year. The all-female team currently consists of nine lawyers led by the ANF Director of Legal & Industrial Services Belinda Burke and they assist ANF members with work related legal matters including registration issues with or complaints made to AHPRA, disciplinary investigations, civil litigation, coronial investigations, court proceedings and complex industrial relations matters where legal proceedings may be anticipated or imminent.

western nurse June-July 2022

Belinda Burke

"As a lawyer, if I go into a hospital as a patient, the hospital environment is a very different one for me, I am unfamiliar with the sounds, equipment, and processes. I keep this in mind and understand that this unfamiliarity is shared by nurses and midwives whenever they step into a court room, or are the subject of a legal proceeding" Belinda said.

L-R: Michelle Nguyen, Jennifer Lee, Belinda Burke, Briana Kerr, Jane Lovett

Which is why the Legal Service is so important and which is why streamlining the service has been a priority for the ANF. Belinda recounts her arrival at the ANF in February 2000 when she first commenced work as the ANF Senior Industrial Officer. She says it was a challenge to organise legal assistance for members with lengthy processes in place. Members would contact the ANF to ask for help, then make an application for legal assistance. This would be referred to a committee of the Council of the ANF. If approved, funding would be allocated for assistance from an external law firm. However, the funding was limited. “There were no guarantees of ongoing funding,” Belinda explains, “and a member may only have sufficient funds allocated for just one component of their legal issues.” Perhaps one of the biggest issues though, was that there was a lot of red tape involved. “Each stage required internal ANF approval meetings and there were inherent delays.” This all changed with the creation of the in-house legal team in 2011. It meant that approvals could be made directly from the ANF Helpline where members can be referred immediately for legal assistance and receive timely and relevant legal assistance, prioritised according to the urgency of the situation. Indeed, it is not uncommon for a member to be facing two or three related but separate legal processes arising from the same incident. They now get a streamlined legal service which ensures seamless and integrated legal solutions to suit the nuances of their particular issues. Another challenge faced by members was the creation of AHPRA and the introduction of the Health Practitioner Regulation National Law (WA) Act 2010. According to Belinda, the legislation imposes a higher level of accountability on health professionals. “The legislation created a range of new reporting obligations in relation to relevant events which must be reported to AHPRA, and regarding conduct.”

Jennifer, Belinda and Michelle outside the Central Law Courts where the ANF Legal Team represents members in coronial inquests

June-July 2022 western nurse |

L-R: Jenny Morris, Jane Lovett, Belinda Burke, Brona McGovern, Donné Oosthuizen

“The introduction of this legislation has resulted, in our experience, in an increasing number of matters being investigated by the regulators and of course an increasing requirement for legal advice and representation for members,” Belinda said. Belinda says that AHPRA processes are generally taking longer than they have done so in the past. Before AHPRA was created, if a nurse was facing some form of suspension or serious sanction, the case would be relocated to, and dealt with swiftly by, the State Administrative Tribunal, because the Nurses and Midwives Act 2006 required it to referred there within 14 days. Now, there is no such timeframe and AHPRA and the Nursing and Midwifery Board of Australia can take is some cases up to two years to refer a matter to the Tribunal, with a nurse potentially suspended for the entire period while they wait. This, Belinda says, ‘along with the frustratingly long time AHPRA matters generally seem to take to be investigated, has been a retrograde consequence of the new regulatory scheme and a constant battle for the ANF Legal Service. Belinda also says the scrutiny of the practice of nurses and midwives has increased tenfold in her time at the ANF.

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Growing demand leads to streamlined access to services To ensure the most cost effective service and to stop legal costs blowing out, it was crucial that the ANF legal services were streamlined. The first step, according to Belinda, is identifying all the relevant work related legal issues that may be confronting the member, keeping in mind that one issue may involve multiple legal processes. “The death of a patient, for example, may potentially involve a request for a statement from or interview with the police, whether they are acting on behalf of the Coroner, or conducting a criminal investigation; a statement for the workplace, a workplace investigation which could be either a disciplinary investigation, or a sentinel event investigation; and even potentially an AHPRA matter.” As each issue is assessed and categorised, the relevant legal processes can be identified and dealt with accordingly, including any additional legal referrals for that member that may be required to appropriately deal with the matter. In addition, the legal priorities of the member are considered and the legal work sorted and coordinated in a manner that protects their legal interests to protect those of greatest significance for their professional situation.

“ ”

I am proud of my team, every single lawyer has one thing in mind – the best interests of the member they are assisting. Belinda Burke

Of course, there are also cost savings for members, with access to the ANF Legal Service covered in member fees. If members were to engage a lawyer privately to assist with either a Coronial Inquest or an AHPRA matter, it would be at their own expense. These matters can be lengthy and engaging a lawyer outside of the ANF Legal Service can quickly add up to ten’s of thousands of dollars.

Importantly, the ANF Legal Service is also the gatekeeper for matters that may fall under the ANF professional indemnity policy. ‘Clearly we assess each issue to determine whether a claim is warranted or whether a matter fits within the policy parameters. Where that is the case, we will initiate the process for a professional indemnity claim’ says Belinda.

A Growing Service ANF Assistant Secretary Janet Reah says the good news for members is that the ANF Council has put aside funds to employ at least one additional lawyer to the ANF Legal Service each year without increasing membership fees. “The additional lawyer is necessary because of the growing membership as well as the growing list of problems that are now being dealt with by AHPRA that may have previously been dealt with at the workplace level,” Janet said." And for the team themselves, they value their work and want to ensure nurses, midwives and carers are legally looked after. Michelle Nguyen is one of the senior lawyers who has been a member of ANF Legal Team for 10 years. “The most rewarding thing I have found about working with ANF members is being able to provide legal assistance, guidance and support to nurses, midwives and carers who find themselves

Mark Olson and Belinda Burke outside the Industrial Relations Commission in 2001 reading the outcome of the workload case Belinda ran as Senior Industrial Officer which delivered 400 extra nurses and regulation of nursing workloads for the first time in Western Australia

encountering legal issues that they have never had to deal with before in their career,” she says. “Through my work at the ANF I have become much more appreciative of our members and their work in our community.” The same goes for another 10 year legal team veteran and senior lawyer, Jennifer Lee. “My job has helped me gain a better insight into the challenges that our members face as health professionals and their valuable contribution to our health and safety,” Jennifer says. “What I find most rewarding about working with ANF members is being able to make a positive difference in their lives by advising and representing them on legal issues they are often dealing with for the first time in order to achieve successful outcomes.” Belinda is also proud to lead a team of professional, competent lawyers whose only focus is looking after the best interests of members. “I am proud of my team, every single lawyer has one thing in mind – the best interests of the member they are assisting” she says. ANF Assistant Secretary, Janet Reah says she would like to expand the range and extent of legal services the ANF offers to members in the future to include non-work related legal matters. “I feel there is a place for further legal services to members in the future and consider the ANF Legal Service to be in an ideal position to deliver these additional services,” Janet said. R: Janet Reah ANF Assistant Secretary and L: Rachael Heggie, the most recent addition to the ANF Legal Team

June-July 2022 western nurse |

ANF IN WA CUTS FEES BY 25% ANF Council responds to cost of living pressures while still expanding services

Most ANF members know the ANF fees have not changed for 18 years (not even for inflation) and so it was an extraordinary announcement from the ANF Council in June that ANF fees in WA will be reduced by 25% for the coming financial year. ANF Assistant Secretary Janet Reah said the Council wanted to let all ANF members know they understood the ever increasing cost of the cost of living pressures and were prepared to do something meaningful about it. Speaking to the Western Nurse soon after the Council decision Janet says the ANF Council knows that ANF members, like everyone in the community, are looking to cut back on household expenses wherever possible. She says the Council is sending a clear message that they

are making it even easier for all nurses and midwives to continue their membership of the ANF in Western Australia during these difficult times. Janet says there are three important things the ANF can do for members right now - campaign for better wages that at least keep up with inflation, continue to expand the services provided to ANF members keep the ANF fees as low as possible. “The Council has been keen to do its bit to help with cost of living pressures and so they looked at the financials and noted a much higher than expected income from the Holiday Units during the two years of border closures as well as significant savings generated in a range of other administration areas made it possible to achieve a fee reduction of 25%.” ANF Vice President and Wickepin Nurse/Midwife Kerry Lee says the Council first looked at whether the services expansion program for 2022 and 2023 would still go ahead with such a significant reduction in membership fees and the answer was a resounding yes.

“20 years of prudent financial management made it possible to not only cut the fees but to also continue adding services such as more lawyers for the ANF Legal Service and more features on the ANF app.” ANF Councillor Glenda Watson currently working at PCH says her main concern was the ANF still having sufficient funds to conduct its media and industrial campaigns for improvements to wages and conditions. Glenda Watson at work in the ICU at PCH

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“The cost of the fee reduction will be more than covered by the surplus the ANF Council delivered last year, which

privileged to work with a group of nurses and midwives who are always focused on how to best deliver better outcomes for members without increasing costs. “Even before I joined the ANF Council I was always impressed to see ANF fees staying the same price, year after year, and I would regularly point out to my colleagues around tax time each year this truly a truly remarkable achievement. But going the next big step and actually reducing fees by 25% is just incredible and something you will not see happening in any other organization… ever.”

Kerry Lee

means there is no need to cut anything in the budget for the coming 12 months and there is still plenty of money to run the upcoming Public Sector EBA as well as the current Ramsay EBA campaign and the many other private sector EBA negotiations due in the next 12 months.” Edgar Enad, currently working at Bethesda Hospitals and elected to the ANF Council in 2018 says he has been

How do ANF Services compare to other unions in Western Australia.

Ed Enad with Leanne Griffiths and Nick Webster

Despite ANF fees being less than half of those charged by other unions, the ANF still provides a much bigger range of service to its members. While all unions in WA provide industrial representation at the workplace and during wage negotiations, the chart below demonstrates the massive difference between the ANF and the other unions when it comes to other important services. The ANF offers even more services than listed below, but a comparison just in these key areas still emphasises how nurses, midwives and carers get the best value for membership fees.

ANF

United Workers

HSU

Teachers

FREE Legal Representation for work related matters FREE Lawyer for Coronial Inquests FREE Representation for Workers Compensation FREE Professional Indemnity Insurance FREE Journey Cover Insurance FREE Online CPD LOW cost Holiday Units FREE workplace legal talks FREE Clinical Reference Cards 24/7 Emergency Assistance June-July 2022 western nurse |

10% LIFE INSURANCE

LIFETIME DISCOUNT

ON LIFE COVER*

FOR ANF WA MEMBERS

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*Important information – Discount - ANF WA members are entitled to a 10% discount (which remains for the life of the cover) on NobleOak’s Premium Life Direct standard premium rates on term Life Insurance cover. ^NobleOak awards information found at https://www.nobleoak.com.au/about-us/award-winning-life-insurance/ #Feefo rating based on 305 service ratings over the past year (as at 9 September 2021). Legal statements. Premium Life Direct is issued by NobleOak Life Limited ABN 85 087 648 708 AFSL No. 247302. Address: 66 Clarence Street, Sydney NSW 2000. Phone: 1300 108 490. Email: sales@nobleoak.com.au. Cover is available to Australian residents and is subject to acceptance of the application and the terms and conditions set out in the Premium Life Direct Product Disclosure Statement (PDS). This information is of a general nature only and does not take into consideration your individual circumstances, objectives, financial situation or needs. Before you purchase an Insurance product, you should carefully consider the PDS to decide if it is right for you. The PDS is available by calling NobleOak on 1300 108 490 or from www.nobleoak.com.au. Clients should not cancel any existing Life Insurance policy until they have been informed in writing that their replacement cover is in place. NobleOak cannot provide you with personal advice, but our staff may provide general information about NobleOak Life Insurance. By supplying your contact details, you are consenting to be contacted by NobleOak, in accordance with NobleOak’s Privacy Policy.

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western nurse June-July 2022

ANF Out 'n' About

Bentley Touchstone CAMHS Pete Murray, Paul Hopkinson, Matthew Reichard

Hollywood Hospital Tiffany Smithwick and Leisa Munro

WINNERS of the ANF

Dalwallinu Hospital: Clara Nleya, Leonie Bryan, Eliza Berdin and Elize Pronk

Chocolate Giveaway

In this edition we’re featuring the winners of our ANF happiest group competition. We received lots of fantastic happy snaps of members with their Cadbury chocolates, thanks to Cadbury for their very kind donation to our hard working members during the pandemic. And the members featured in each of the winning happy group pics below, and on pg13, who received a nice $20 gift card in the post are… drum roll please…

Juniper Hilltop Melinda De Castro & Jacinta Terry Stacey

Armadale Kalamunda Group Sam Watadza, Jess Woods, Shannon Scari, Jane West, Linus Boon, Deb Jeavons

June-July 2022 western nurse |

We wanted to set the benchmark for the design and delivery of luxury apartment developments in Western Australia. So we did.

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western nurse June-July 2022

Find your dream home:

edgevl.com.au

ANF Out 'n' About Cont. WINNERS Looking forward to seeing you all soon, now that we’ve recommenced our workplace visits. We’ll bring plenty of ANF products, including our much sought-after bags. And don’t forget that every photo published in the Western Nurse magazine gets entered into a big prize draw at the end of the year, so make sure you come and see us.

Peelwood Family Medical Practice: Kylie Leech, Janice Mercer & Shelbi Carter

Rockingham General Hospital: Terri Paschini, Denise Bowman, Joanne Lovejoy, Raylene Reiners, Jody Callaghan (centre), Carol Baker & Pooja Sharma Southbank

Southbank Day Surgery: Seaeun Jang, Rosie Fleay, Fiona Zele, Daphne Tenger, Casey Gunnell, Kate Hapiuk and Rebecca Nitschke

SJOG Midland: Karen Boylen, Liz Housiaux, Carol Soutar, Emma Reid, Laura Hole, Phillipa Watson, Judy Payyappilly & Jayson Ayson

NMHS Mental Health: Tim Lister, Sam Gurusamy, Helena Bake & Simon Sullivan

June-July 2022 western nurse |

ANF Helpline Unique ANF Helpline in WA means greater convenience for members, better triage of issues and quicker service. ANF members do not wait on the phone when needing help with a workplace issue. Instead members can book an ANF Industrial Officer to call them back within a specific timeslot that has been selected by the member. The service has been evolving for the last few years and now other states branches of the ANF are starting to follow this model. ANF Assistant Secretary, Janet Reah tells members; “there is no need to sit on the phone for hours waiting for someone at the ANF to take your call as was the case many years ago. You book in a timeslot that suits you and one of our highly qualified ANF Industrial Officers calls you within that hour’s timeslot.” “There is no need to stress if you miss our first call, because our staff continue calling within that hour until they reach you. If for some reason you are not available within that hour, they will always send a follow up email directly to you to ensure you get your questions answered and the help you need.” The ANF Helpline has a straightforward triage system that enables the ANF Industrial Officers to gather the relevant information to meet your enquiry. “Sometimes the answer to a question is quick and other times it may take a little longer depending on the complexity of the issue and whether or not it requires a referral to the ANF legal department” Jeanet said. “Since the Industrial Officer knows which member the booking is for before making the call, they also know where that member works and will organise themselves to have the EBA and other relevant documents ready prior to making the call to help speed up the process.” It is important to remember any disciplinary action in the workplace can become an AHPRA complaint, or if suspended or terminated a reportable event for AHPRA. “AHPRA issues and legal matters are given priority, and legal referrals are completed the same day,” Janet says. Ms Reah says the level of complexity with issues on the ANF Helpline has risen quite markedly over the last decade because members have increasing access to wage rates, EBA’s and other

The ANF Helpline enquiries cover a wide range of issues including; • workload grievances • responding to allegations • statement for Coronial inquests • disciplinary processes • performance management • AHPRA investigations - including , immediate action against the member • registration and other legal issues, • in addition to enquiries related to basic entitlements such as overtime, ADOs, correct pay scales, long service leave and parental leave.

basic information using their ANF iFolio.

ANF developed surge capacity during COVID There have been times during the pandemic where the ANF had to increase the number of staff and available timeslots each hour so the ANF Helpline now has a permanent feature where the senior officer on duty can increase the number of timeslots, up to 12 an hour, and call up extra Industrial Officers for that period whenever there is a surge in demand. Janet says it is all about monitoring and matching demand so that resources are increased when needed. She says there was always an increases in member queries certainly occurred whenever there was a snap lock down or whenever the government made a significant COVID related announcement over the last 12 months. “We developed the surge capacity after reading the feedback from members. And that’s why it’s important members send us their views, particularly when they think the service should be improved or changed to allow greater flexibility,” Janet said.

ANF Emergency Helpline Hotline 24/7 - After hours & weekends Another service unique to members of the ANF in Western Australia is the after-hours emergency service that starts from 5pm each day and goes through until 9am the following morning. This deals with matters that cannot wait until the ANF Office reopens such as police inquiries ( arrest, or forced questioning), death of a patient that involves the coroner or where an employer is demanding a member provide a statement about an incident at work. Another emergency situation is being locked out of your ANF holiday apartment. Janet Reah has taken over the after-hours phone from Mark Olson who fielded calls from members at all hours of the day and night for more than two decades. There is no other nursing union where you can ring up the State Secretary at any time of the day or night and it’s so important for members to be safe with the knowledge that the ANF is there for them in those after-hours emergencies.

The new ANF Membership Helpline Every day members contact the ANF about issues that are related to the ANF membership rather than a workplace issue so the ANF now as a dedicated Membership Helpline service for those matters – see details on next page.

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New ANF Helpline service during COVID In February the ANF Helpline reactivated the COVID Enquiries Support Team (CEST) that was first established at the beginning of the COVID lockdown in March 2020 to provide ANF members with speedy, accurate and up-to-date advice on COVID related questions. The size of team has increased to meet the challenges of 2022 and the hours have also expanded so it’s a now a 7-day a week service including public holidays. You can contact the CEST at any time, through the red ‘COVID’ tab on your iFolio or by sending an email to: COVID@anfiuwp.org.au . There are also links to the ANF COVID Enquiries Support Team on every page in the COVID section of your iFolio as well as on the regular iFolio Helpline page.

ANF COVID Inquiries Support Team – Janet Reah, Mark Olson, Kim Bohn and Harsini Kugan

The team suggest that if you do need a call back, it’s always useful to provide some idea of the question or the topic so the team can be better prepared to provide the answer when they call you. At the time of going to press over 1500 members had used this additional ANF Helpline service with frequent topics including:

• COVID Leave • PPE availability and fit testing

• Current and changing employment requirements, public health and social measures

• Distribution of Rapid Antigen Tests

• Private sector elective surgery

• Close contact rules

Need to talk to an ANF Industrial Officer about a workplace matter? The quickest way to get help and advice: Log in to your iFolio, and click the blue ‘Helpline’ tab in the top RH corner Select a ‘Date’, convenient ‘Time slot’, your ‘Preferred number’, and click ‘Request Booking’, then we’ll call you. Or you can now book a Helpline appointment on your ANF iFolio App. Simply click on ‘Helpline’ in the menu, then select ‘Industrial Officer’, then a ‘Date’, convenient ‘Time slot’, your ‘Preferred number’, and click ‘Request Booking’, then we’ll call you.

Need to update your Membership Payment or Contact details? The quickest way is to either: Simply log in to your iFolio, click ‘My Account’ in the top RH corner, then click on ‘Update Payment Type’ or ‘Edit card details’, or scroll down and click ‘Edit Account’ Or if you’d like the ANF Membership team to call you back’... log in to your iFolio, click ‘My Account’ in the top RH corner and under the heading ‘My Account’ click the blue ‘click here’ in the 3rd line: ‘If you have any questions about your ANF membership, click here and the ANF Membership Team will give you a call’, then we’ll call you Or you can now book a Helpline appointment on your new ANF iFolio App, simply click on ‘Helpline’ in the menu, then select ‘Membership’, your ‘Preferred number’, and click ‘Request Call Back’, then we’ll call you.

OR use the 24/7 email helpline service: anf@anfiuwp.org.au June-July 2022 western nurse |

AMAZING APPS + ONLINE NEWS

InternetWatch Daybreak

Daybreak is the companion app to Hello Sunday Morning and designed to help change relationships with alcohol. Whether your goal is to reduce your drinking, or complete abstinence, Daybreak is here to support you and your choices. Daybreak is a non-judgemental chatbased community where you can get the information and support you need to help achieve your goal. Free

Cricket Australia

We don’t like cricket. We love it! Here’s your one stop destination for live cricket coverage, breaking news, and video highlights. All forms of the game are included here including Tests, One day matches, and the Big Bash League. Free

Strava

Use your phone or smart watch to track your fitness activities. Record activity, map your favourite bike trail or run and analyse your training stats. Strike out on your own or mix up your run, swim, or ride with the world’s largest trail network it’s entirely up to you! Free

Audible

Audio books are perfect for when you’re on the bus, the train, walking or even while in the car. Owned by Amazon, Audible is a place to find audio books. You are welcome to register with a 30-day free trial and then if you prefer to continue with the service, subscribe for a monthly fee. Price varies

Pencil Sketch

Pencil Sketch is a photo sketch maker with heaps of sketch image filters that will make your photos extraordinary. It also allows you to make cartoon versions of your photos or ones that look like you drew them with crayon. Free

Spotify Greenroom

Spotify Greenroom is a new audio experience that lets artists and fans share their opinions. Fans and creators are brought closer together to communicate about the big moments, or sub-cultures they love. Free or log in with your Spotify account

Super Slime Simulator

Create realistic slime and play with it on your mobile device. Stretch your slime, squish it, knead it, pop it - just like you would with real slime. Enjoy that oddly satisfying feeling and get into the awesome colours, textures, and decorations. Free

Perth Trails

Here is a trail app with a difference. This one offers informative walking trails designed to showcase Perth history, heritage, art and cultural points of interest, curated by the City of Perth. The walking trails are suitable for people of all ages, from curious residents to seasoned travellers, and families alike. Free

Western Australia’s Drivers’ License

Here’s a great way to prepare for the Western Australia Drivers’ License test. The app contains questions that are very similar to the real test and are based on information from the latest Drive Safe Handbook. Free

SharkSmart WA

SharkSmart WA is Western Australia’s official source of shark activity information. It also includes beach safety features such as Surf Life Saving WA patrolled beaches to help you plan your trip to the beach. Free.

FIVESuperSites Hello Sunday Morning

The folks at Hello Sunday Morning aim to change the world’s relationship with alcohol, one Sunday at a time. Whether that means abstaining, taking a break, or simply understanding how to have a healthy relationship with alcohol, this registered charity is here to support you and your choices. Comes with a companion app called Daybreak. hellosundaymorning.org/

Canva

Canva is a graphic design platform for the masses, used to create social media graphics, presentations, posters, and the like. Or design something more personal, like an invitation or a flyer. The platform is free to use and offers paid subscriptions for additional options. canva.com/

OzHarvest

The food rescue organisation OzHarvest has made an appearance in the WN before, however it totally rates another mention based on their new initiative called ‘Use It Up!’ It’s a simple habit that will save food, money and the planet. Check out their website for more details and for instructions on how to get your hands on ‘Use It Up!’ products. ozharvest.org/

We Rate Dogs

The We Rate Dogs community is on a mission to celebrate good dogs, noting they’re all good of course. Here you’ll read their stories and help the ones who need us the most. Submit a photo of your good boi or gurl on their Twitter page for a rating. weratedogs.com/

The Hairstyler

Try over 12,000 hair styles before the scissors or hair dye is unleashed. You’ll be asked to upload a clear photo without glasses and with no hair on your face or neck. You’ll find the latest in hair trends here, even the good old mullet! thehairstyler.com/virtual-hairstyler

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western nurse June-July 2022

1990’S THE LOST DECADE The 1990s is largely remembered as the decade ANF members in the public and private sector lost a large number of conditions that drove many out of the industry and left the WA health system struggling to find nurses and midwives by the year 2000. It was the decade where the term “trade off” was increasingly used by governments and private sector employers alike when responding to wage claims by ANF members. That is, they would say if you want a pay rise then you need to trade-off conditions to pay for it. In November 1998, ANF members elected a new State Secretary who had a plan to recover these lost conditions in the new millennium with carefully structured media and industrial campaigns.

Some of the losses during this decade included: 1990 – Qualification allowance lost 1991 – Hourly on call rate lost 1991 – Senior Nurses excluded from overtime payments 1994 – RN’s and midwives lose automatic entitlement to 7 weeks annual leave with many members having their annual leave reduced by up to three weeks with the creation of the new category of “continuous shift worker” and the exclusion or many part time staff from pro-rata leave 1994 – Public Holidays – if you were part time and not a continuous shift worker, then you were not entitled to any public holiday leave unless you actually worked the public holiday 1992 to 1998 – ADOs for full time staff was lost at various at various public hospitals throughout the decade as hospitals moved to introduce shorter shifts where 70 hours worked over 10 days became the new normal for nurses entering the workforce particularly graduates. And in private hospitals they were lost altogether 1998 – ADOs lost for all part timers – and when the part time staff lost their ADOs many also lost 5% of their working hours 1998 – RN’s and Midwives lose penalties on sick leave 1998 – as the nursing shortage starts to bite, public hospitals decide pay out public holidays rather than allowing nurses to take them as leave Paid Maternity leave did not exist throughout the entire 1990s Rural gratuities did not exist throughout the entire 1990s Nursing career structure decimated with Clinical Nurses, Clinical Midwives, Nursing and Midwifery Educators significantly reduced in numbers.

Next up… the 20 year recovery… SPECIAL LIFT OUT June-July 2022 western nurse |

A NEW millennium brings recovery ANF State Secretary Mark Olson says the key feature of negotiations from the year 2000 onwards has been the recovery of lost conditions, the gains of conditions that did not exist previously, never giving up on claims no matter how long it takes to get there and a constant battle to keep the wages of nurses and midwives better than those in other states. The public sector EBA negotiations are not only important for those ANF members working in the public sector, they set the pay and conditions benchmarks for the private sector as well. Mark also says that negotiations never really stop with the signing of each new wage agreement. “Actions by governments between each EBA and other events means the ANF is constantly listening to members to establish the priorities for the upcoming EBA. We also use the time to bring matters to the attention of the media so that the public has some understanding of the issues faced by our members which is critical to retaining public support when holding stop work meetings or closing beds.”

ANF Members on the march in Bunbury 2001

Bed closure vote at Fremantle Hospital – February 2001

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western nurse June-July 2022

Rally at Challenge Stadium, May 2001

2000/2001 This campaign started in September 2000 and had two distinct phases. The first part was in the lead up to the 2001 state election where ANF members closed one-in-four hospital beds that helped to secure a minimum increase of 13.5% with further improvements to be negotiated after the election. Unfortunately, the incoming Labor Government continued to resist the other claims of ANF members and a second campaign was conducted by the ANF from February till June 2001 that achieved even higher wage increases and a suite of other recovered conditions.

FINAL OUTCOME 2001:

• Public sector nurses brought back into the

one agreement thereby ensuring that country public sector nurses would never again lag behind their colleagues working in Perth

• 18% wage increase over three years including 2 additional increments for Level 1 with flow on to Level 2 giving them a 17.1%. SRN positions were created giving them a further increase of 6% to 12% in 2002

• Night shift rate increased to 20% • Return of hourly on call rate • All nurses who had been employed on 70 hours

2002

Workloads case run by ANF in Federal Industrial Commission In the year following the 2001 EBA negotiation the ANF also conducted an Exceptional Matters Case in the Federal Industrial Commission where we successfully argued for nurses & midwives to have their workloads regulated with a benchmark minimum hours in accordance with the Nursing Hours Per Patient per Day model. This resulted in an initial increase of 400 extra nurses.

(10x7 hour shifts) offered full time hours + ADO’s

• All staff entitled to 10 days Public Holiday leave & pro rata for part time staff

• Paid parental leave for the first time – 6 weeks • Permanent night staff included in

definition of continuous shift worker

• Professional Development leave introduced – 2 day for metro and 4 days for rural

• Qualification allowance - one off payment • Various rural gratuity payments to assist recruitment in difficult to staff areas.

June-July 2022 western nurse |

ANF members rallied everywhere. Members from KEMH and SCGH gather at a rally outside the Royal Show in September 2004

2004/2005

2007/2008

This campaign was probably the most bitter, longest and hardest fought of all campaigns and lasted over a year during which nurses continued their campaign through a federal election in October 2004 as well as a state election in 2005. At one point the Labor government even put pressure on ANF members to vote for a NON Union agreement but it was rejected. Whilst there were no bed closures, there were plenty of hospital based stop work meetings, lots of ANF media stunts particularly in the lead up to the 2005 state election and lots of legal maneuverings by the government to undermine the ANF campaign and force ANF members to accept the lower pay increases already agreed to by other public sector unions.

As the state Labor government approached the 2008 state election, it was apparent early in negotiations by the reasonable responses to the ANF claims that they were keen to avoid a repeat of the bitter and protracted 2004 dispute. It was an opportunity for the ANF to secure some long sought after initiatives and showed that it is not always necessary to take industrial action to achieve an outcome - so long as the government has, in the back of their mind, the knowledge that a public ANF industrial and media campaign can be started at any time.

FINAL OUTCOME 2005:

• 14.7% wage increase over three years • Night shift loading on Sunday night

extended to 7.30am Monday morning

• Shift coordination allowance for level 1 nurses. ANF members rally at Parliament House – 2012

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western nurse June-July 2022

ANF members rally outside Parliament House 2012

FINAL OUTCOME 2008:

• Wage increase 17% for Level 1, 14.1% for all other categories

• Qualification allowance finally restored as a weekly allowance + ANF gets independent review panel

were the usual number of workplace meetings held and public awareness campaign but no industrial action. The government did try its best through the industrial commission to take a few conditions away from nurses and deny our country members access to the rural gratuities but they were unequivocally rebuffed by the ANF.

• Night shift increased from 20% to 35% • Evening shift increased from 12.5% to 15%

FINAL OUTCOME 2010:

• Parental leave increased from

• 12.75% over three years

6 weeks to 14 weeks.

• Major increases in rural gratuity payments • Sick leave days increased from 10 to 15

2010 The focus of this campaign was parking access and charges, rural gratuities tied to royalties for regions and additional sick leave. There

• ANF Qualifications list extended • ANF and/or members able to request

a review of the NHPpD for their ward or unit for increased staffing.

June-July 2022 western nurse |

ANF members at the Italian club in February 2013 voting to close 1 in 5 beds

2013

The “shake the tree” campaign This was the first campaign where everyone knew the date of the WA state election as it had been fixed in legislation to be forever held in early March. The public sector agreement did not expire until July 2013 but the ANF was keen to lock in a wage increase before the election because we knew the government was looking to force the ANF to trade-off conditions for a pay rise once the pressure of an election had passed and the government had secured another 4 year term. In the previous few years nurses and midwives had dropped down the national rankings compared to the other states while teachers, police and allied health workers climbed to the top of their respective interstate comparisons. So the focus of the campaign became getting the wages of nurses and midwives back to the highest in Australia (which we did) and to pick up a few more improvements in conditions along the way. The ANF campaign started with a rally at parliament house in September 2012 followed by ongoing work by the ANF in the media as well as many hospitals based meetings held across the state. 22 |

western nurse June-July 2022

The pointy end of the campaign came soon after the government launched its official state election campaign and three weeks out from polling day, ANF members met at the WA Italia Club and voted to close one in every five beds. The ANF also unleashed the two, seven foot high ANF Bee mascots who proceeded to disrupt just about every press conference held by the Premier, Colin Barnett and then Treasurer Troy Buswell. This was in addition to an extensive paid advertising blitz in print and on radio. A key feature of this campaign was the improvements in ANF communications that enabled the ANF to protect our members from the various legal threats that were made at the time to those closing beds that included dismissal as well as deregistration. After a week of closing beds in addition mounting pressure in the media, and despite the various legal threats and challenges to the ANF the government agreed to a 14.7% wage increase and for all other outstanding ANF claims to be decided by arbitration after the election with a guarantee of no lost conditions. FINAL OUTCOME 2013:

• 14.7% wages increase over three years with a

range of matters to be dealt with in formal hearings at the WA Industrial Commission (WAIRC)

2014/2015

ANF pursues further matters in the WAIRC The ANF Legal and Industrial Team spent a large part of 2013 and 2014 preparing then presenting our case for further improvements in conditions for our members. The hearings dragged on into 2015 as the government lodged appeals against the favourable outcomes form ANF and in the end the appeals were rejected and more conditions were improved. FINAL OUTCOME 2015:

• Return of ADOs for part time staff lost in 1998 • Allowance for authorised mental health practitioners

• Higher duties paid on shift by shift basis • Lead Apron allowance • Overtime rates for casuals • Pro rata long service leave after 7 years • Better access to purchased leave • Parking charges capped at CPI.

ANF members at the start of the “Shake the tree” campaign.

2016 This was probably the most uneventful wage negotiation ever as members accepted government wages policy of 1.5% per year for two years because it kept them as the highest paid nurses and midwives until at least 2017.

What a difference a decade makes - Mark McGowan supporting the nurses pay claim at Parliament House rally in 2012 and even wearing an ANF badge, in front of the ANF Banner… when he was Opposition Leader!

FINAL OUTCOME 2016:

• 3 % increase over two years

June-July 2022 western nurse |

2018 Not long after coming to office in 2017 the McGowan Government announced a new wages policy (that is, one they did not tell the public about prior to the election) limiting wage increases to $1,000 per year for all public sector employees. The government also made it clear that if any public sector union challenged the government $1,000 wages cap with any type of industrial action, the government would not hesitate to take matters to the WA Industrial Commission where losing conditions would become a likely outcome. As a result all public sector unions accepted the government wages cap of $1,000 per year for four years. In this context the ANF focused on low-cost and no-cost initiatives in the 2018 negotiations as well as additional staffing in 2020 negotiations. Prior to the 2018 negotiations the Health Dept had secretly removed a range of midwifery qualifications from the official list. These were eventually restored after a campaign by the ANF. However, this action by the Health Dept led to an insistence by the ANF that all qualifications attracting an allowance be listed in the EBA so they could never again be unilaterally deleted by the government.

FINAL OUTCOME 2018:

• $1,000 yearly pay increase • Cashing out leave more accessible • Better access to leave entitlements. • Mandatory online training to

be completed during work time

• Night shift staff protected from arbitrary

day rotations, they are not a requirement of employment but where it does occur, there has to be an education plan and it’s for a maximum of 2 weeks each year

• Qualifications cannot be removed from the approved qualification allowance list.

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western nurse June-July 2022

FINAL OUTCOME 2018:

• Wage increase of $1,000 each year for two years • Professional development leave that is not used to be paid out each year in July

• Casual loading increased from 20% to 25% + casuals get access to Long Service Leave

• Better access to purchased leave, deferred salary scheme and long service leave

• Recognition by the Health Minister that the

existing NHpPD formula can be converted to a transparent minimum number of nurses per shift which will form the benchmark for the review undertaken by Professor Della

• 400 extra nurses – over two years.

2020 and 2021 – Ongoing Campaign for more staff resulted in the government doubling the intake of graduates and increasing numbers in various wards and units.

Next time we shake the tree is in 2022.

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Nursing’s best kept secret Nurses working in prisons around WA say they love working in small nurse-led teams to treat people who are often disadvantaged. Accredited health centres in custodial facilities around the State employ hundreds of registered nurses who deliver important care to a diverse cohort of patients. For Ann, the Clinical Nurse Manager at Hakea Prison, the best part of the job is helping people address alcohol and other drug dependencies. “A lot of the people that we treat here have a problem with alcohol or drug abuse, and they often come from disadvantaged backgrounds,” she says. “While they’re in custody we have the opportunity to see them more regularly and build up trust so that we can really help them to start breaking those habits.” Delivering care to a range of patients with sometimes complex needs means no two days are the same. “It’s a primary care environment,” Ann says.

“If needed we can make referrals, but we also make clinical judgments about the kind of care that a patient needs. “It’s a fantastic environment to work in, you can learn so much.” Before starting prison nursing, Ann worked in hospital Emergency Departments and in acute surgical teams. “I’ve been working in the nursing team at Hakea for nine years now. “I feel supported and safe here. It’s definitely safer than working in an ED. “It’s nursing’s best kept secret! We work consistent shifts, it’s really flexible and accommodating and I work with the best team.” Are you looking for a change from traditional nursing roles? Head to the Department of Justice website for more information and to apply for positions open now.

GOVERNMENT OF WESTERN AUSTRALIA

Department of Justice Corrective Services

Are you looking for a change from traditional nursing roles? Visit the Department of Justice website for more information and to apply. www.justice.wa.gov.au/nurses June-July 2022 western nurse |

CONTINUING PROFESSIONAL DEVELOPMENT

ANFClinical Updates

ANF iFOLIO CLINICAL UPDATE:

Diabetic ketoacidosis: Diabetic ketoacidosis – a clinical update a clinical update

Read this article and complete the quiz to earn 1 iFolio hour

Read this article and complete the quiz to earn 1 iFolio hour Diabetic ketoacidosis (DKA) is a serious and potentially life-threatening complication of diabetes mellitus.1 DKA more commonly occurs in patients with type 1 diabetes, however it can also affect patients with type 2 diabetes.1 DKA is a complex metabolic disturbance characterised by hyperglycaemia, ketonaemia, and metabolic acidosis.2 It occurs as a result of insulin deficiency accompanied by an elevation of counterregulatory hormones, such as catecholamines, adrenaline, cortisol, and glucagon.2 Insulin deficiency may be absolute (during lapses in the administration of exogenous insulin) or relative (when usual insulin doses do not meet metabolic needs during physiologic stress).2,3 The annual incidence of DKA is 4-8 episodes per 1000 patient admissions with diabetes.4 Rates of admissions are increasing due to the increasing incidence of diabetes in the population.5 Diabetes is the fastest growing chronic condition in Australia; 280 Australians develop diabetes every day.6 While mortality from DKA remains relatively low in developed countries, less than 1%, it is the leading cause of death in patients with type 1 diabetes under 58 years of age.7 DKA is a medical emergency, it should be diagnosed promptly and managed intensively.7

PATHOPHYSIOLOGY Insulin reduces blood glucose levels by increasing the uptake of glucose from the bloodstream into the cells and decreasing hepatic glucose production by inhibiting glycogenolysis and gluconeogenesis.1,5 In DKA insulin deficiency leads to impaired glucose uptake and utilisation, increased gluconeogenesis, and accelerated glycogenolysis, resulting in hyperglycaemia.1,8 The increased concentrations of counterregulatory hormones activates hormone-sensitive lipase in adipose tissue, and the resulting enhanced lipolysis releases large quantities of free fatty acids and glycerol into the circulation.1,8 The free fatty acids are oxidised in the hepatic mitochondria to form ketone bodies (acetone, beta-hydroxybutyrate Concurrent with and acetoacetate).1,8 the increased production of ketones, the clearance of ketoacids β-hydroxybutyrate and acetoacetate is reduced, resulting in an accumulation of in ketoacids in the blood, a decrease in serum bicarbonate concentration, and the development of metabolic acidosis.8 The severity of hyperglycaemia and the high concentrations of ketoacids cause osmotic diuresis leading to hypovolaemia, which leads to further increases in counterregulatory hormone levels, further aggravating hyperglycaemia.8

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western nurse June-July 2022

As insulin also maintains potassium concentrations within the intracellular fluid, insulin deficiency causes potassium to move into the extracellular space leading to electrolyte imbalance.8

CAUSES AND RISK FACTORS The most common precipitating factors for DKA are inadequate or inappropriate insulin therapy and infection.1,2 Inadequate or inappropriate insulin therapy may occur due to missing or inadequate insulin doses, recent medicine titration, or undiagnosed or recently diagnosed diabetes.2,5 The physiologic stress associated with infection stimulates the release of counterregulatory hormones, causing insulin resistance, increased lipolysis, ketogenesis, and volume depletion, which may contribute to hyperglycaemic crises.2,5 Other precipitating factors for developing DKA include:1,2 • Acute illnesses, such as myocardial infarction, stroke, pancreatitis, acromegaly, Cushing’s syndrome, and hyperthyroidism • Bariatric surgery • Medications, such as corticosteroids, thiazide diuretics, second-generation antipsychotics, immune checkpoint inhibitor therapy, and sodium-glucose cotransporter-2 (SGLT-2) inhibitors • Eating disorders • Alcohol and illicit drug use.

SIGNS AND SYMPTOMS Common signs and symptoms of DKA include (see Illustration 1):2,9 • Increased thirst • Abdominal pain • Polyuria • Weight loss • Excessive tiredness • Nausea • Vomiting • Ketone breath (breath smells like sweet acetone) • Dehydration • Confusion • Reduced consciousness. Increasing acidosis is associated with Kussmaul respiration (rapid, deep, laboured breathing).1,2 Severe and prolonged DKA is also associated with hypothermia as a result of peripheral vasodilation.5

DIAGNOSIS The varied presentations of DKA can make diagnosis difficult.1 It is important to exclude other causes of ketoacidosis, such as alcohol ketoacidosis, lactic acidosis, uraemic acidosis, and starvation ketosis.1,2,7 DKA is generally diagnosed using a combination of preliminary clinical assessment and serological tests to measure glucose levels, ketone levels, and venous blood gas.1,2 Diagnosing DKA requires the presence of all of the following:2,7 Glucose: blood glucose level greater than 11mmol/L or known diabetes. Ketones: blood ketones greater than 3mmol/L or ketonuria on a standard urine dipstick. Acidosis: venous pH less than 7.3 and/or bicarbonate level less than 15mmol/L. Rarely, some patients may present with euglycaemic DKA and have a normal blood glucose level.2 Patients treated with SGLT-2 inhibitors are at increased risk of developing euglycaemic DKA.1 The presence of one or more of the following criteria may indicate severe DKA:2,7 • Blood ketones greater than 6mmol/L • Bicarbonate level less than 5.0mmol/L • Venous pH less than 7.0 • Hypokalaemia • Glasgow Coma Scale (GCS) score of less than 12 • Oxygen saturation below 92% on air (assuming normal baseline respiratory function) • Systolic blood pressure below 90mmHg • Pulse over 100 or below 60 beats per minute.

TREATMENT Treatment of DKA consists of fluid resuscitation and maintenance, insulin therapy, electrolyte replacement, and supportive care (see Table 1 for treatment pathway).1 The most urgent goals of treatment are rapid intravascular volume repletion, correction of hyperglycaemia and acidosis, suppression of ketogenesis, and prevention of hypokalaemia.3,7 Identifying and treating precipitating factors is also important.3 Ketonaemia and acidosis should resolve within 24 hours.7 Biochemical markers, ketones, bicarbonate, pH, glucose, and potassium, should be regularly monitored.2 The recommended metabolic treatment targets are:7 • Reduction of blood ketone concentration by 0.5mmol/L/hour • Increase in venous bicarbonate by 3.0mmol/L/hour

• • • •

Pyrexia Fatigue Confusion Decreased level of consciousness

Illustration 1: shortness of breath

1. Lizzo JM, Goyal A, Gupta V. Adult Diabetic Ketoacidosis. 2021 [cited 2021 Oct 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing LLC. Available from https://www.ncbi. nlm.nih.gov/books/NBK560723 2. BMJ Best Practice. Diabetic ketoacidosis [Internet]. London: BMJ Publishing Group Ltd; 2021 [cited 2021 Oct 23]. Available from: https://bestpractice. bmj.com/topics/en-gb/3000097/pdf/3000097/ Diabetic%20ketoacidosis.pdf

• Shortness of breath • Difficulty breathing • Dry mouth • Thirst

3. Diabetic Ketoacidosis (DKA). 2020 [cited 2021 Oct 21]. In: MSD Manual Professional Version [Internet]. Kenilworth (NJ): Merk Sharp & Dohme Corp. Available from: https://www.msdmanuals. com/en-au/professional/endocrine-and-metabolicdisorders/diabetes-mellitus-and-disorders-ofcarbohydrate-metabolism/diabetic-ketoacidosisdka

• Tachycardia • Arrhythmia

• Nausea • Vomiting • Abdominal pain

• Frequent urination

4. Lee MH, Calder GL, Santamaria JD, Maclsaac RJ. Diabetic ketoacidosis in adult patients: an audit of factors influencing time to normalisation of metabolic parameters. Intern Med J [Internet]. 2018 [cited 2021 Oct 23];48(5):529-534. doi: 10.1111/imj.13735

Ketones: blood ketones less than 0.6mmol/L.

• Reduction of capillary blood glucose concentration by 3.0mmol/L/hour • Maintain serum potassium concentration of 4.0-5.5mmol/L. Fluid resuscitation and maintenance Intravenous fluids (IV) should be started as soon as DKA is confirmed.2,10 The main aims of fluid replacement are restoration of circulatory volume, clearance of blood ketones, restoration of tissue perfusion, and correction of electrolyte imbalance.1,7 Intravenous fluids also dilute glucose levels and circulating counterregulatory hormones concentrations.1,2 Insulin therapy Insulin therapy should be started about one hour after IV fluid replacement is started as insulin may be more dangerous and less effective before some fluid replacement has been obtained.2 Insulin therapy suppresses ketogenesis, reduces blood glucose, and corrects electrolyte disturbances.7 Insulin therapy should be commenced as a fixed rate intravenous insulin infusion (FRIII) at a dose of 0.1units/kg body weight, or according to local protocols.10 Caution should be exercised if the dose is calculated to exceed 15units/hour.10

Acidosis: venous pH greater than 7.3 and/or bicarbonate level greater than 15mmol/L. A supplemental glucose or dextrose infusion may be administered concurrently as a substrate for the insulin to reduce the risk of hypoglycaemia.7 Electrolyte replacement Hypokalaemia and hyperkalaemia are common in DKA.1 While serum potassium is often high on admission, insulin therapy causes an intracellular shift and lowers potassium levels, potentially resulting in severe hypokalaemia.1,7 Hypokalaemia is also commonly associated with hypomagnesemia.1 Electrolytes should be monitored supplemented as required.10

and

PREVENTION The risk of DKA can be decreased by patients with diabetes:11 • Regularly checking blood glucose levels • Following their treatment plan • Staying hydrated

The FRIII should be continued until the following targets are achieved:10

• Checking with a health professional before taking new medicines

Glucose: blood 14mmol/L .

• Developing and following a plan for when they are ill.

glucose

level

REFERENCES

less

than

5. Broadley L, Clark K, Ritchie G. Prevention and management of hyperglycaemic crisis. Nurs Stand [Internet]. 2019 [cited 2021 Oct 16];37(7):75–82. doi: 10.7748/ns.2019.e11387 6. Diabetes Australia. About Diabetes [Internet]. Diabetes in Australia; c2021 [cited 2021 Oct 23]. Available from: https://www.diabetesaustralia.com. au/about-diabetes/diabetes-in-australia/ 7. Joint British Diabetes Societies for Inpatient Care. The Management of Diabetic Ketoacidosis in Adults [Internet]. London (UK): Joint British Diabetes Societies for Inpatient Care; 2021 [cited 2021 Oct 16]. Available from: https://diabetes-resourcesp ro d u c t i o n . s 3 . e u - we s t - 1 . a m a zo n a w s . co m / resources-s3/public/2021-06/JBDS%2002%20 DKA%20Guideline%20amended%20v2.pdf 8. Dhatariya KK, Glaser NS, Codner E, Umpierrez GE. Diabetic ketoacidosis. Nat Rev Primers [Internet]. 2020 [cited 2021 Oct 24];6(40). doi: 10.1038/ s41572-020-0165-1 9. Ray-Barruel G, Kerr K. Avoiding diabetic ketoacidosis in perioperative and procedure settings. Aust Nurs Midwifery J [Internet]. 2021 [cited 2021 Oct 16];27(2):28-30. Available from: https://anmj.org.au/avoiding-diabetic-ketoacidosisin-perioperative-and-procedure-settings/ 10. Government of Western Australia WA Country Health Service. Adult Diabetic Ketoacidosis (DKA) Guideline [Internet]. Perth (Australia): Government of Western Australia; 2019 [cited 2021 Oct 16]. Available from: https://www.wacountry.health. wa.gov.au/~/media/WACHS/Documents/Aboutus/Policies/Adult-Diabetic-Ketoacidosis-DKAGuideline--South-West.pdf?thn=0 11. National Health Service. Health A-Z [Internet]. Diabetic Ketoacidosis; 2019 [cited 2021 Oct 23]. Available from: https://www.nhs.uk/conditions/ diabetic-ketoacidosis

Table 1: Treatment pathway7

Fluid replacement

Insulin therapy

Biochemical markers

GCS

Precipitating factors

Complications of treatment

0-1 hour

Commence IV fluid replacement

Commence FRIII

Initial assessments Establish monitoring regime

Initial assessment

1-6 hours

Continue IV fluid replacement

Continue FRIII

Ensure parameters improving Avoid hypoglycaemia

Regularly assess GCS score

Identify and treat as necessary

6-12 hours

Continue IV fluid replacement

Continue FRIII

Ensure parameters improving Avoid hypoglycaemia

Regularly assess GCS score

Continue to treat as necessary

Assess for complications (fluid overload, cerebral oedema)

12-24 hours

Continue IV fluids Move to variable rate if patient not eating infusion if patient not and drinking eating and drinking and no ketonaemia

Ensure parameters normalised or improving

Regularly assess GCS score

Continue to treat as necessary

Re-assess for complications (fluid overload, cerebral oedema)

June-July 2022 western nurse |

LATEST NEWS AND RESEARCH

AroundtheGlobe UNITED KINGDOM

NZ nurse who cared for COVID+ UK PM quits in protest over wages and conditions A nurse credited with helping to save the life of British Prime Minister, Boris Johnson, has quit the UK’s National Health Service due to his lack of “respect” for frontline staff. Jenny McGee was one of two intensive-care nurses who cared for the PM round-the-clock at St Thomas’ Hospital, central London, when he contracted COVID-19.

Mr Johnson said he only pulled through thanks to their care and made a video thanking them personally, but is facing fury from nurses after offering a one per cent pay rise. Ms McGee refused to take part in a Downing Street photo opportunity in July as nurses struggled under terrible COVID conditions noting: “Lots of nurses felt the government hadn’t led very effectively, the indecisiveness, so many mixed messages. It was just very upsetting. At that point, I didn’t know how to describe the horrendousness of what we were going through.” 

INDIA

Chennai nurse braves fire to save newborns A nurse has received high honour for bravery in fighting a fire threatening a neonatal intensive care unit (NICU) at one of Chennai’s busiest maternity hospitals. Indian news reported scrub nurse, P Jayakumar, had finished his shift and single-handedly responded to the fire at the Government Kasturba Gandhi Hospital for Women and Children. “I was only thinking of the babies because if it entered the NICU, it would have created a big disaster because neonates can’t tolerate that type of hazardous fog. They will collapse in ten seconds,” he recalled. It was reported – “When he found the source of the fire his anxiety gripped him more. The floor below the source of the fire was the manifold room where additional oxygen cylinders were stored due to COVID-19. This was a second potential disaster. The NICU staff had locked themselves from the inside, switched off all power and oxygen lines and began manual hyperinflation and ventilation for the babies.” “36 infants, 11 children, who were kept in incubators and their mothers were saved due to Mr Jayakumar’s actions,” an official statement said. 

UNITED KINGDOM

Scientists prove bat-like echolocation benefits blind A UK study has found people can be taught to echolocate like bats and dolphins, paving the way for the visually-impaired to navigate with a click of their tongue. Researchers found the technique could be taught in 10 weeks saying patients with sight loss should be prescribed the training to improve mobility and independence. Clicking sounds are used with echoes activating the brain to create three-dimensional ‘images’ in the mind.

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Researchers at Durham University looked into factors of learning the technique with 12 blind and 14 sighted participants aged between 21 and 79. The researchers found participants improved considerably on all measures, and in some cases performed comparatively with expert echolocators after training. The study, published in the journal PLOS One, is described as one of the most significant in improving mobility and independence for the visually impaired. 

USA

Forensic nursing breakthrough to aid sexual assault cases Skin cells left behind by perpetrators of groping can be used to build DNA profiles and successfully prosecute cases, according to a Brigham Young University (BYU) nursing professor. Dr Julie Valentine, who is also a certified sexual assault examiner, had research published in the latest edition of the Journal of Forensic Nursing. “What is new about this is we have really found that we can utilize (sic) touch DNA in sexual assault cases and that’s a big deal,” she said. “That really opens up a whole avenue for achieving more justice in these cases.” A breakthrough case in Utah from 2011 got her invested in the science. “The nurse knew about touch DNA in theory but what we didn’t know is in practise would it actually work,” Valentine said. The nurse collected skin cells from a victim of groping which allowed a lab to develop DNA profile leading to successful prosecution. 

Don’t ignore persistent cold and flu symptoms Especially if you’ve had exposure to asbestos or industrial dust through your work, home or community The Asbestos Diseases Society of Australia Inc is urging all Australians to be aware that early symptoms of asbestos diseases often present like a cold or flu. What are the warning signs? • shortness of breath • persistent coughs • rapid weight loss • chest or abdominal pains • blood in the sputum • multiple antibiotic treatments For a screening appointment, call (08) 9344 4077. For any workplace or community concerns, contact WorkSafe on 1300 307 877.

dedicated to community support and public health since 1979 mesothelioma • asbestosis • silicosis • lung cancer

219 MAIN ST OSBORNE PARK WA 6017 | (08) 9344 4077 |

WWW.ASBESTOSDISEASES.ORG.AU June-July 2022 western nurse |

INGREDIENTS • For the buffalo cauliflower • 1 head cauliflower, cut into drumstick-like pieces

Corner

• 1 cup soy or almond milk • 1 tsp cornstarch • 1 cup all-purpose flour

BUFFALO CAULIFLOWER RECIPE Fans of the low-carb dishes, rejoice. This easy buffalo cauliflower recipe will amp up your way of preparing vegetarian meals that don’t bore the tummy. It’s practically easy to make if you’ve got an air fryer at home. Get your day off to a good start with this super-satisfying air-fried cauliflower with a delicious buffalo sauce plus an easy ranch dressing!

• 1 tsp garlic salt • ½ tsp salt • 1 tsp smoked paprika • 1 tsp onion powder • ½ tsp freshly ground black pepper • ½ cup buffalo hot sauce • 2 tbsp vegan butter, melted • 1 tsp white vinegar • For the ranch dressing • ½ cup mayo (or vegan mayo) • ¼ cup soy milk

EQUIPMENT • Air fryer,

• small and large mixing bowl,

• ¼ cup freshly chopped coriander

• measuring cups,

• small and medium-sized saucepan, whisk & wooden spoon

• 1 tsp cumin

• measuring spoons,

• 1 tsp garlic powder

INSTRUCTIONS 1

Make the ranch dressing, if using. Whisk together the mayo, soy milk, coriander, cumin, and garlic powder in a bowl. Add a pinch of salt and season to taste, if needed. Set aside. Heat the milk and cornstarch together in a medium saucepan for four minutes, then set aside to let cool.

3 Whisk together the flour, garlic salt, paprika, onion powder, black pepper and salt in a large bowl. 4 Dip the cauliflower into the flour, then into the thickened milk mixture, then back into the flour. Tap off as much of the excess flour as you can, then place in a single layer in the bottom of your air fryer. Repeat with the rest of the cauliflower; knowing that you may have to work in two batches depending on the size of your air fryer. 5 Place the air fryer tray into the base and set to 7 minutes at 200C (400F). Let cook, then flip and shake halfway through cooking. 6 While the cauliflower is cooking, heat the butter, buffalo hot sauce, vinegar in a small saucepan over medium heat. 7 When cauliflower is done, toss with the melted buffalo sauce and serve immediately with the ranch dressing.

Recipe and image supplied by Kitchen Warehouse

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western nurse June-July 2022

CONTINUING PROFESSIONAL DEVELOPMENT ANF iFOLIO CLINICAL UPDATE:

Methotrexate for the treatment of rheumatoid arthritis: a medication update update Methotrexate - a medication Read this article and complete the quiz the to earn 0.5to iFolio hour Read this article and complete quiz earn 0.5 iFolio hour Brand name: Methoblastin, Methotrexate, Trexject1 Drug class: antimetabolites, disease-modifying antirheumatic drugs (DMARDs)1,2,3

MECHANISM OF ACTION

Methotrexate ameliorates symptoms of inflammation and suppresses immune responses.1 However, the mechanism of its immunomodulatory effects is unclear.1

ADMINISTRATION

Methotrexate is administered orally, or by subcutaneous or intramuscular injection.1

INDICATIONS

Methotrexate in indicated for severe, recalcitrant, active rheumatoid arthritis in adults unresponsive to, or intolerant of, other treatment options.2,3,4 Note: methotrexate is indicated in a number of other conditions, such as psoriasis, Crohn’s disease, juvenile idiopathic arthritis, and as a cancer treatment.2,3,4

CONTRAINDICATIONS

Methotrexate is contraindicated in patients with:1,2,3 • • • • • •

Hypersensitivity to methotrexate Severe hepatic impairment Severe renal impairment Severe acute or chronic infections Evidence of immunodeficiency syndromes Psoriasis or rheumatoid arthritis with peptic ulcer disease or ulcerative colitis • Alcoholism or alcoholic liver disease • Bone marrow depression or pre-existing blood dyscrasias.

Methotrexate is also contraindicated for women who are pregnant or planning a pregnancy, or who are breastfeeding.1

INTERACTIONS

Methotrexate has a number meaningful drug interactions.

clinically

Colestyramine interferes with enterohepatic recycling of methotrexate and may decrease its concentration and efficacy.5 Concurrent use of colystyramine and methotrexate should be avoided.5 Ciclosporin may increase the efficacy of methotrexate and lead to increased renal or hepatic toxicity.5 If they are used concurrently, the patient should be carefully monitored and the dose of either or both drugs adjusted if necessary.5

avoided if possible.5 If they are used concurrently, the patient should be closely monitored for adverse effects and the methotrexate dose reduced if necessary.5 Trimethoprim and sulfamethoxazole may increase methotrexate toxicity (bone marrow suppression).5 Concurrent use of trimethoprim and/or sulfamethoxazole and methotrexate should be avoided if possible.5 If they are used concurrently, the patient should be monitored for haematological toxicity and other adverse effects.5 Live vaccines should not be administered to patients taking methotrexate.2,5 As methotrexate is an immunosuppressant it may reduce the immunological response to the vaccination, and severe antigenic reactions may occur.2,5 The significance of some interactions varies according to the methotrexate dose.2,5 Some drugs such as ciprofloxacin and levetiracetam increase methotrexate concentration and the risk of toxicity but only when high doses of methotrexate are given, such as for cancer treatments.2,5 Potential interactions at the low doses administered for the treatment of rheumatoid arthritis are not clinically meaningful.2,5 Other drugs such as penicillin, proton pump inhibitors, and nonsteroidal antiinflammatory drugs (NSAIDS) are unlikely to have clinically meaningful interactions with methotrexate at the lower doses associated with rheumatoid arthritis, however the evidence is not clear.2,5 Until the situation is clearer, caution should be exercised when using these medications concurrently with methotraxte.2,5

hypoplasia of skull bones, wide fontanels, shallow supraorbital ridges, prominent eyes, low-set ears, maxillary hypoplasia, short limbs, talipes, hypodactyly, and syndactyly.7 Women using methotrexate should use effective contraception and discontinue treatment at least three months before a planned pregnancy.7 Methotrexate should not be used while breastfeeding.7,8 It is excreted in breastmilk and may accumulate in the infant’s tissues.7

ADVERSE EFFECTS

The most common adverse effects associated with methotrexate include nausea, vomiting, diarrhoea, mucosal ulcers, malaise, alopecia, leucopenia, thrombocytopenia, photosensitivity, infection, and increased aminotransferases.1 Other adverse effects include anaemia and oligospermia.1 Rarely, methotrexate is associated with severe skin reactions, pneumonitis, pulmonary fibrosis, hepatotoxicity, and anaphylactoid reactions.1 Concomitant treatment with folic acid may decrease the incidence or severity of adverse effects (folic acid should not be taken on the same day as methotrexate).2,3,4

REFERENCES 1.

Methotrexate. 2020 [cited 2021 Jan 6]. In: Australian Medicines Handbook [Internet]. Adelaide (Australia): Australian Medicines Handbook. Available from: https://amhonlineamh-net-au/ chapters/rheumatological-drugs/immunomodulating-drugs/immunosuppressants-rheumatology/methotrexate-immunomodulator

Methoblastin. 2020 [cited 2021 Feb 14]. In: MIMS Online database [Internet]. North Sydney (Australia): MIMS Australia. Available from: https://www.mimsonline.com.au/ Search/ AbbrPI.aspx?ModuleName= Product%20Info&searchKeyword=methotrexate&PreviousPage=~/Search/QuickSearch. aspx&SearchType=&ID=10420001_2

Trexject. 2020 [cited 2021 Feb 14]. In: MIMS Online database [Internet]. North Sydney (Australia): MIMS Australia. Available from: https://www.mimsonline.com.au/Search/ AbbrPI.aspx?ModuleName= Product%20Info&searchKeyword=methotrexate&PreviousPage=~/Search/QuickSearch. aspx&SearchType=&ID=28860001_2

DBL Methotrexate Injection. 2020 [cited 2021 Feb 14]. In: MIMS Online database [Internet]. North Sydney (Australia): MIMS Australia. Available from: https://www.mimsonline. com.au/ Search/AbbrPI.aspx?ModuleName=Product%20Info&searchKeyword=methotrexate&PreviousPage=~/Search/ QuickSearch.aspx&SearchType=&ID=10430001_2

Drug interactions: Methotrexate. 2020 [cited 2021 Feb 20]. In: Australian Medicines Handbook [Internet]. Adelaide (Australia): Australian Medicines Handbook. Available from: https://amhonline.amh.net.au/interactions/methotrexate

Principles of immunomodulatory drug use for rheumatological diseases in adults. 2020 [cited 2021 Feb 10]. In: eTG Complete [Internet]. Melbourne (Australia): Therapeutic Guidelines Limited. Available from: https:// tgldcdp-tg-org-au/viewTopic?topicfile=principles-immunomodulatory-drug-use-rheumatological-diseases-in-adults&sectionId=rhg3-c04-s4#toc_d1e47

DOSAGE

The dose of methotrexate is initially 10-15mg once a week, with the dose adjusted according to the response.1 The usual maintenance dose is 10-25mg once a week (maximum 25mg if administered by injection, 30mg if administered orally).1 Methotrexate should be taken on the same day each week.1 Regular monitoring of disease activity should be undertaken, and the methotrexate dose adjusted if necessary to remain in the therapeutic range.6 Oral and parenteral methotrexate are not bioequivalent.1 As bioavailability is higher with parenteral administration, if changing from oral to parenteral administration the patient should be carefully monitored and consideration should be given to reducing the dose.1

PRECAUTIONS Renal impairment

Nitrous oxide may increase the incidence of methotrexate’s adverse effects.5 Concurrent use of nitrous oxide and methotrexate should be avoided if possible.5 If they are used concurrently, the patient should be closely monitored and calcium folinate rescue considered.5

If creatinine clearance (CrCl) is 10-50mL/ minute, the adult dosage should be reduced.1 Methotrexate is contraindicated if the patient’s CrCl is less than 10mL/minute.1

Methotrexate. 2020 [cited 2021 Jan 6]. In: Pregnancy and Breastfeeding Medicines Guide [Internet]. Melbourne (Australia): The Royal Women’s Hospital. Available from: https:// thewomenspbmg.org.au/ medicines/methotrexate

Pregnancy and breastfeeding

Probenecid reduces methotrexate’s renal excretion and increases its toxicity.5 Concurrent use of probenecid and methotrexate should be

Methotrexate should not be used during pregnancy.7,8 It has been associated with fetal malformations including microcephaly,

Drug use in pregnancy and breastfeeding. 2020 [cited 2021 Feb 10]. In: eTG Complete [Internet]. Melbourne (Australia): Therapeutic Guidelines Limited. Available from: https:// tgldcdp-tg-org-au/quicklinks?type=Pregnancy%20and%20 breastfeeding&bf=breastfeeding_m.htm

June-July 2022 western nurse |

CONTINUING PROFESSIONAL DEVELOPMENT

ANF iFOLIO CLINICAL UPDATE:

Iron: a medication updateupdate Iron: a medication 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

Brand names: Ferrous fumarate Ferro-tab1

• Iron should be administered at least six hours before or two hours after dolutegravir.

Iron polymaltose - Maltofer, Ferrosig, Ferrum1

Intravenous iron supplements may decrease the absorption of oral iron supplements.4 Oral iron supplements should not be administered for at least five days after the last dose of intravenous iron therapy.4

Ferrous sulfate - Ferro-grad, Ferrovance, FerroLiquid1 Iron sucrose -

Venofer1

Ferric carboxymaltose - Ferinject1 Ferric derisomaltose - Monofer1 Drug class: endocrine and metabolic1

MECHANISM OF ACTION Iron plays a crucial role in oxygen transport, oxidative metabolism, cellular proliferation, and many catalytic reactions.2 Iron supplements replace the body’s iron stores and encourage erythropoiesis (the development of mature red blood cells) and oxygen transportation throughout the body.3

ADMINISTRATION Iron supplements are generally administered orally.1,3 However, iron supplements may be administered by intravenous injection or infusion when oral supplements are ineffective, inappropriate, or not tolerated.1,3,4 Intramuscular administration is no longer recommended due to severe injection site pain, skin staining, and inconsistent absorption.3,5

INDICATIONS The only indication for iron supplements is the prevention and treatment of iron deficiency anaemia.1

CONTRAINDICATIONS

Iron is contraindicated in patients with:4,6 • Hypersensitivity to iron • Anaemia not caused by iron deficiency • Evidence of iron overload, such as haemochromatosis and haemosiderosis • Evidence of disturbance in the utilisation of iron.

INTERACTIONS Iron has a number of clinically meaningful drug interactions. Antacids, calcium, proton pump inhibitors, H2receptors antagonists, and tetracyclines may decrease the absorption of oral iron supplements.5,7 Administration times should be separated by as long as possible to minimise interactions.7 Iron supplements affect the absorption of levodopa, carbidopa, quinolones, eltrombopag, bictegravir, oral bisphosphonates, thyroid hormones, penicillamine, tetracyclines, and dolutegravir.7 Administration times should be separated by as long as possible to minimise interactions: 7 • Doses of iron and quinolone, bictegravir, oral bisphosphonates, penicillamine, or tetracyclines should be separated by at least two hours • Doses of iron and eltrombopag should be separated by four hours • Doses of iron and thyroid hormones should be separated by four to five hours

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western nurse June-July 2022

DOSAGE The dosage and duration of iron supplementation should be individualised to the patient based upon the extent of iron deficiency.1 Iron dosage is express in terms of elemental iron (1mg elemental iron is approximately equivalent to 3mg ferrous fumarate, 3.7mg iron polymaltose, 3mg dried ferrous sulfate, 5mg liquid ferrous sulfate).1 Treatment of iron deficiency anaemia1

Adult

oral 100-200mg elemental iron daily or IV dose in accordance with local protocols

Child

oral 3-6mg/kg (maximum 100200mg) elemental iron daily or IV dose in accordance with local protocols

Prevention of iron deficiency anaemia1 Pregnant adult

oral 60-120mg elemental iron daily

Child 4-12 months

oral 1mg/kg elemental iron daily

Child >12 months

oral 1-2mg/kg (maximum 15-30mg) elemental iron daily

Gastrointestinal tolerability of oral iron supplements may be increased by starting at a low dose and gradually increasing after two to four weeks, by divided doses, by alternate day dosing, or by taking supplements with food.1,5 To prevent teeth discolouration liquid oral supplements may be diluted with water, consumed through a straw, and followed with a drink of plain water.1 Patients receiving intravenous iron should be closely monitored for adverse effects for at least 30 minutes after administration.1

PRECAUTIONS Hepatic impairment Ferric carboxymaltose should be used with caution in patients with hepatic impairment.4 Ferric carboxymaltose should only be used if the expected benefit is considered to outweigh the potential risk, and the patient’s liver function is closely monitored.4 Pregnancy and breastfeeding Oral and intravenous iron supplements have been shown to be safe and effective in the treatment of iron deficiency anaemia in pregnancy.8,9,10,11 However, oral supplementation is preferred during the first trimester due to limited evidence in the use of intravenous supplements.8,9,10,11

Oral and intravenous iron supplements are safe to use while breastfeeding.8,9,10,11

ADVERSE EFFECTS The most common adverse effects associated with oral iron supplementation are gastrointestinal, such as nausea, vomiting, bloating, constipation, abdominal pain, diarrhoea, and black discolouration of the faeces.1 Liquid oral supplements are also associated with black discolouration of teeth.1 Intravenous iron is generally well tolerated.5 Adverse effects associated with intravenous iron are nausea, vomiting, taste disturbance, injection site reactions, headache, fever, arthralgia, myalgia, blood pressure changes, chest pain, tachycardia, bronchospasm, rash, and hypophosphataemia.1 Rarely, intravenous iron is associated with anaphylactic reactions.1,3

REFERENCES

1. Iron. 2021 [cited 2021 Aug 10]. In: Australian Medicines Handbook [Internet]. Adelaide (Australia): Australian Medicines Handbook. Available from: https://amhonlineamh-net-au/chapters/blood-electrolytes/drugs-anaemias/other-drugs-anaemias/iron 2. Yiannikourides A, Latunde-Dada GO. A Short Review of Iron Megabolism and Pathophysiology of Iron Disorders. Medicines [Internet]. 2019 [cited 2021 Aug 30];6(85). doi: 10.3390/medicines6030085 3. Nguyen M, Tadi P. Iron Supplementation. 2021 [cited 2021 Aug 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing LLC. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK557376 4. Ferinject. 2021 [cited 2021 Aug 31]. In: MIMS Online database [Internet]. North Sydney (Australia): MIMS Australia. Available from: https://www.mimsonline. com.au/Search/FullPI.aspx?ModuleName=Product %20Info&searchKeyword=Ferric+carboxymaltose&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=91220001_2#Top 5. Iron deficiency. 2021 [cited 2021 Aug 31]. In: eTG Complete [Internet]. Melbourne (Australia): Therapeutic Guidelines Limited. Available from: https://tgldcdptg-org-au/ viewTopic?topicfile=iron-deficency#toc_ d1e234 6. Maltofer. 2021 [cited 2021 Aug 31]. In: MIMS Online database [Internet]. North Sydney (Australia): MIMS Australia. Available from: https://www.mimsonline.com. au/Search/FullPI.aspx?ModuleName=Product %20Info&searchKeyword=maltofer&PreviousPage=~/Search/ QuickSearch.aspx&SearchType=&ID=6800001_2 7. Drug interactions: Iron. 2021 [cited 2021 Aug 30]. In: Australian Medicines Handbook [Internet]. Adelaide (Australia): Australian Medicines Handbook. Available from: https://amhonline.amh.net.au/interactions/iron 8. Ferric carboxymaltose. 2020 [cited 2021 Aug 31]. In: Pregnancy and Breastfeeding Medicines Guide [Internet]. Melbourne (Australia): The Royal Women’s Hospital. Available from: https://thewomenspbmg.org.au/ medicines/ferric-carboxymaltose 9. Ferrous fumarate/sulfate. 2020 [cited 2021 Aug 31]. In: Pregnancy and Breastfeeding Medicines Guide [Internet]. Melbourne (Australia): The Royal Women’s Hospital. Available from: https://thewomenspbmg.org.au/ medicines/ ferrous-fumarate-sulphate 10. Iron polymaltose. 2020 [cited 2021 Aug 31]. In: Pregnancy and Breastfeeding Medicines Guide [Internet]. Melbourne (Australia): The Royal Women’s Hospital. Available from: https://thewomenspbmg.org.au/ medicines/iron-polymaltose 11. Iron sucrose. 2019 [cited 2021 Aug 31]. In: Pregnancy and Breastfeeding Medicines Guide [Internet]. Melbourne (Australia): The Royal Women’s Hospital. Available from: https://thewomenspbmg.org.au/ medicines/ iron-sucrose

ANF iFOLIO CLINICAL UPDATE:

Lactulose: a medication update Lactulose: 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 Brand name: Actilax, Dulose1

INTERACTIONS

Drug class: Osmotic laxative1

Lactulose is not known to have any clinically meaningful drug interactions.1,3

MECHANISM OF ACTION Lactulose (also known as 1,4 beta galactosidase-fructose) is a nonabsorbable disaccharide comprised of galactose and fructose.2 It is metabolised by bacteria in the colon, causing an increase in intraluminal gas formation and osmolality which stimulates peristalsis and reduces intraluminal pH.2 The reduced pH promotes an increased uptake of ammonia by colonic bacteria, and causes a reduction in the intestinal production of ammonia.2 Lactulose also inhibits intestinal glutaminase activity, blocking the intestinal uptake of glutamine and its metabolism to ammonia.2

ADMINISTRATION Lactulose is generally administered orally or via nasogastric tube.1 However, lactulose may be administered rectally if there is a significant risk of aspiration or the oral route is not available.1,2

INDICATIONS

DOSAGE Lactulose dosage should be individualised to the patient according to the clinical response.3 Small regular doses provide better symptom control for chronically constipated patients than intermittent large doses.4 Dosage for rectal administration should be in accordance with local protocols.1 Constipation1 Adult

oral initially 15-30mL daily in 1-2 doses, usual maintenance dose 1025mL daily

Child <1 year

oral initially 5mL daily in 1-2 doses, usual maintenance dose 3-5mL daily

Child 1-6 years

oral initially 10mL daily in 1-2 doses, usual maintenance dose 5-10mL daily

Child 7-14 years

oral initially 15mL daily in 1-2 doses, usual maintenance dose 10mL daily

Hepatic encephalopathy1

Indications for lactulose are:1,3 • Chronic and habitual constipation • Treatment of acute hepatic encephalopathy • Prevention and treatment of chronic hepatic encephalopathy.

CONTRAINDICATIONS Lactulose is contraindicated in patients with:1,3 • Hypersensitivity to lactulose • Galactosaemia • Disaccharidase deficiency • Gastrointestinal obstruction • Digestive perforation. Lactulose is also contraindicated in patients who require a low galactose diet, or who are on a galactose, lactose, or fructose free diet.1,3

Adult

oral 20-30mL every 1-2 hours until laxative effect is achieved, reduced to 20-30mL 3 or 4 times daily according to clinical response to produce 3-4 soft stools daily or rectal 60mL undiluted or 300mL diluted with 700mL water or sodium chloride 0.9% given as enema retained for 30-60 minutes and repeated every 4-6 hours until oral route is available

Taking lactulose orally mixed with fruit juice, water, or milk may increase tolerability.1

associated with fetal harm or adverse pregnancy outcomes.5 However, high doses or prolonged use may result in maternal adverse effects.5 Occasional short-term use of lactulose for the treatment of constipation is also considered safe while breastfeeding.1,5 Systemic absorption of lactulose is low and is unlikely to cause adverse effects in the breastfed infant.5

ADVERSE EFFECTS Adverse effects commonly associated with lactulose are diarrhoea, flatulence, cramps, bloating, increased bowel sounds, and abdominal discomfort.1,3 Diarrhea is dose dependent; its severity may be decreased by reducing the lactulose dose.2 Lactulose is infrequently or rarely associated with nausea, vomiting, anorexia, increased thirst and, with prolonged use or excessive doses, electrolyte imbalances.1

REFERENCES

1. Lactulose. 2021 [cited 2021 Aug 18]. In: Australian Medicines Handbook [Internet]. Adelaide (Australia): Australian Medicines Handbook. Available from: https://amhonlineamh-net-au/chapters/gastrointestinal-drugs/ laxatives/osmotic-laxatives/lactulose 2. Mukherjee S, John S. Lactulose. 2021 [cited 2021 Aug 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing LLC. Available from: https://www.ncbi.nlm.nih. gov/books/NBK536930 3. Actilax. 2021 [cited 2021 Aug 28]. In: MIMS Online database [Internet]. North Sydney (Australia): MIMS Australia. Available from: https://www.mimsonline.com.au/ Search/FullPI.aspx?ModuleName=Product %20Info&searchKeyword=lactulose&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=28630001_2

Pregnancy and breastfeeding

4. Functional gastrointestinal disorders. 2021 [cited 2021 Aug 18]. In: eTG Complete [Internet]. Melbourne (Australia): Therapeutic Guidelines Limited. Available from: https:// tgldcdp-tg-org-au/viewTopic?topicfile=functional-gastrointestinal-disorders

Occasional short-term use of lactulose for the treatment of constipation is considered safe during pregnancy.1,5 Systemic absorption of lactulose is low and use during pregnancy has not been

5. Lactulose. 2021 [cited 2021 Aug 28]. In: Pregnancy and Breastfeeding Medicines Guide [Internet]. Melbourne (Australia): The Royal Women’s Hospital. Available from: https://thewomenspbmg.org.au/ medicines/ lactulose

PRECAUTIONS

June-July 2022 western nurse |

PetPage KEEP EMAILING THOSE PHOTOS OF YOU AND YOUR PETS TO WIN PRIZES! Pet Page this time round has yet another great array of characters from the animal world – courtesy of their ANF member owners. Dushica Poposki with Marly

Natalie Buswell with Onyx Natalie Buswell is pictured here with her dog Onyx. Natalie said ”We moved to Newman, out in the Pilbara, about a three years ago and we are loving life. Onyx’s favourite part is the dog park which is called the ‘Dingo Park’.”

Amanda Bath with Storm Dushica Poposki is pictured here with Marly, her 15 month old Labrador. Dushica said “Marly is my biggest emotional support after a long working day. He is a gentle giant with a big heart who loves to play with kids and chase cats! Giving me kisses is his passion!”

Jo Llewellyn with Watermark Limerick And finally we have Jo Llewellyn with Watermark Limerick. Jo said ”Watermark Limerick is a 11 year old Gypsy Cob. He loves nothing more than cuddles with his favourite human and food... he loves food... He says he’s not fat, just well built! [Like a tank]. There aren’t many of these fantastic horses in Australia so he’s pretty special.”

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western nurse June-July 2022

ANF Member Amanda Bath is pictured here with Storm, a very happy smiling border collie. Amanda told the western nurse ” Storm loved competing in agility and we worked very closely as a team, winning many rosettes.”

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!

PRIZES

Enter to WIN WIN one of 30 hardcover books of ‘Atlas Of The Heart’ – Brene Brown In Atlas Of The Heart, Brown takes us on a journey through eighty-seven of the emotions and experiences that define what it means to be human. As she maps the necessary skills and an actionable framework for meaningful connection, she gives us the language and tools to access a universe of new choices and second chances - a universe where we can share and steward the stories of our bravest and most heart-breaking moments with one another in a way that builds connection. Book description by Penguin Random House UK

Develop

long term professional relationships

with your patients

WIN one of 20 paperback books of ‘Experiences of Health Workers in the COVID-19 Pandemic, In their own words’ – Marie Bismark, Karen Willis, Sophie Lewis and Natasha Smallwood Experiences of Health Workers in the COVID-19 Pandemic shares the stories of frontline health workers—told in their own words—during the second wave of COVID-19 in Australia. The book records the complex emotions healthcare workers experienced as the pandemic unfolded, and the challenges they faced in caring for themselves, their families, and their patients. The book shares their insights on what we can learn from the pandemic to strengthen our health system and prepare for future crises. Book description by Routledge Taylor & Francis Group

Nursing Careers at Ability WA Our Benefits

Generous leave provision

Professional Development Leave 3.5 days per year

By switching their natural gas to Kleenheat, Janet

A comprehensive remuneration package

WINNERS

Kleenheat is proud to announce the winners of their January 2022 “Squeeze out the savings” offer, Janet Russell and Debbie Radisich!

and Debbie can save money on their gas bills. Just for choosing Kleenheat, both winners walked away with a Nespresso DeLonghi coffee machine and pod pack.

Clinical Supervision and Support Debbie Radisich

Salary packaging Free onsite parking

Kleenheat customers have access to plenty of great offers and partnership giveaways for the Good Food and Wine Show, Perth Garden & Outdoor Living Festival and so much more!

On the job training Opportunities to develop your leadership skills

Kleenheat are always thinking about gas, so their customers don’t have to. ANF members can enjoy an exclusive discount when they switch their natural gas to Kleenheat. Visit Kleenheat.com.au/ANF to sign up today.

view our careers page at www.abilitywa.com.au

Janet Russell

June-July 2022 western nurse |

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Western Nurse Magazine June - July 2022

Articles inside

Pet Page

Iron - a medication update

Methotrexate - a medication update

Recipe Corner

Around the Globe

Across the Nation

Internet Watch

ANF in WA Cuts Fees by 25

Secretary’s Report

20 years of wage negotiations 8 page lift out

ANF Out ‘n’ About

The ANF Legal Team

Diabetic ketoacidosis – a clinical update

ANF Helpline