Western Nurse Magazine January February 2018

January – February 2018

incorporating western midwife

THE MINISTER HAS SPOKEN

APPRAISALS HAVE BEEN ABOLISHED Public hospitals finally need to listen and get rid of them​ We're not going to stop till they're gone SEE PAGE 8

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Secretary's Report January - February 2018 on the

FEATURED

cover

8

4

Half Century of Nursing

8

Say No to Appraisals

14 Mark’s Q & A 21 Obituary: Beryl Grant Say No to Appraisals

28 NEW Jamie Oliver Recipes

FAVOURITES 6

Mark’s

Due to popular demand we’re bringing back Mark’s question and answer section as regular feature in western nurse. Tax deductions have been a common subject in many inquiries recently, so we’ll cover a repeatedly occurring question this edition.

Q:

A:

Can we claim home internet costs as a tax deduction because we have to do CPD each year, much of which is online; and I also often need to access work emails and often I do most of my mandatory competencies at home because work is too busy?

It’s a very good question given the amount of online learning now being done. And the answer is yes, a claim can be made – as long as the education is related to current employment, such as either keeping up-to-date or enhancing earning capacity. The education cannot be for a different field outside the scope of current work e.g. a nurse studying to be a doctor.

14

You may also be able to claim for some home office expenditure: Home office – You can claim the set rate of 45c per hour for heating, cooling, lighting; Mobile phone – percentage of bill for work purposes. You need to keep records for a 4-week representative period in each income year to claim a deduction of more than $50; Internet – percentage for work purposes; Specific office equipment – percentage claim based on work/private usage i.e. computer; Consumables – percentage based on work usage. i.e printer cartridges, paper, pens etc; You would need to ensure that any other people using the equipment, internet etc are factored into your calculations, so you only claim your own work-related usage as a deductible amount. 

Mark’s Q & A

Internet Watch

18 ANF Out ‘N’ About 22 Across the Nation 26 Around the Globe 30 Research Roundup 31 ANF Contact Details

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21

31 Win Blu-ray collections, ANF Holiday Unit Photo Comp

Obituary: Beryl Grant

I discussed this issue of renamed appraisals in my last editorial, but I will reiterate for the sake of these managers: The Health Minister has already abolished appraisals in public hospitals. Therefore, appraisals, renamed, new, or otherwise, should not be there at all – and no one should be bullying, pressuring or harassing our members into doing them.

Managers are saying these new appraisal/PD tools are just an opportunity for nurses to discuss their career path.

We say to those managers, why do nurses need to spend hours filling out a 10 or 20-page document every year that is kept on file just to have a chat about their career?

We know how such reviews have been used up till now – it’s been primarily bullying, not career counselling.

Our members are confident enough to ask if they want something, so let’s drop this excuse for bullying sessions.

Members are also telling us the managers who want to preserve appraisals are rolling out the same old lines – that appraisals or reviews, or whatever they’re calling them this week, somehow address bad work practices and maintain standards.

We say to those managers, if they are not performancemanaging bad work practices as soon as they occur under existing performance management mechanisms, and are instead waiting for a once a year chit-chat to do that, they should not be managers – because that’s dangerous.

And on the matter of standards, for the umpteenth time, annual appraisals do not enforce standards – nurses' and midwives' mandatory Continuing Professional Development (CPD), and annual audits by the Australian Health Practitioner Regulation Agency (AHPRA) are among the mechanisms whose specific purpose is ensuring best practice, and appraisals are not part of that.

Finally, if appraisals were necessary in maintaining standards, why were they often postponed or cancelled?

12 Serological tests for syphilis

What we do know is these appraisals have been used for years to bully staff, and we are going to put a stop to that bullying.

16 Drowning 24 Reviewing the basics

28

In recent weeks many of you will have received emails from me about how to deal with managers who are insisting you do some renamed form of a performance appraisal, usually under the guise of a new professional development (PD) tool.

CLINICAL UPDATES 13 Esomeprazole

NEW Jamie Oliver Recipes

State Secretary, Mark Olson

Again, we are currently working with the Health Department on the Declaration we created to be the modern workplace replacement for appraisals.

If you do feel you are being bullied, harassed or coerced into doing an appraisal by whatever label, you need to tell the ANF right away.

There’ll be more news in the next edition about ANF efforts to remove appraisals from the private sector.

January–February 2018 western nurse |

3

Maria Hopkinson at RPH in 1976 when RPH was dealing with paediatric cardiac patients

Maria Hopkinson retired from nursing last March after 42 years in RPH's Intensive Care Unit – and more than five decades in the profession. But the former Clinical Nurse Specialist didn't want to move into the next phase of her life without sharing her gratitude for having worked in "the best ICU I could have wished for".

Maria Hopkinson knew from the age of five she'd be a nurse.

While trying to master a tomboy stitch, also known as French knitting, during morning recess at primary school, she managed to get her needle impaled between her right eye and the bridge of her nose.

the past year – with lots of travel, language classes, and surprisingly, even more needlework, including studying it in Como, Italy – her overwhelming gratitude for a fantastic career is still fresh in her mind.

"It was in hospital that I observed what it was that nurses did, and from that time onwards, when grown-ups would ask what I wanted to be when I finished school, my answer was always the same – I wanted to be a nurse," Maria told

"For me the best thing about working at RPH in ICU was holistic patient care," Maria said. "The ICU at RPH admitted the sickest patients from all over WA. We worked as a team, and following a new admission, almost as fast as lightning, the patient was sorted.

But she couldn't have imagined back then she'd be still nursing aged nearly 71!

"I can now look back with admiration at the knowledge and clinical skills of ICU medical and nursing staff and say a silent 'Well done, team!'"

western nurse.

She joined Royal Perth Hospital's Intensive Care Unit in 1975, becoming that ICU's first Clinical Nurse Specialist in 1986 – a position she held until her retirement on March 19, 2017, a month shy of her 71st birthday.

And though she's been enjoying life after nursing in

4|

western nurse January–February 2018

She said her 42 years in the RPH ICU were extremely happy ones: "I loved my work and the people I worked with. It was hard work, tiring and often very stressful. But the bond of teamwork and friendship amongst the staff held us together during difficult times.

Maria practicing needlework in Como, Italy

"I value the privilege of having been part of an expert team of people who have always provided, and continue to provide, a service of excellence in the care of the critically ill patient" an Operating Theatre Technique Course at The Royal Melbourne Hospital. She then worked in ICU at Guy's Hospital in London, and travelled extensively through the UK, Europe, Russia, Scandinavia, and the U.S.A, before starting at RPH's ICU in February 1975.

"I am what I am today, because of the opportunities provided there, for education and development, both professional and personal, and the experiences I had gained by managing staff and dealing with families in crisis situations.

She said conditions were poor when she first started in the profession 50-plus years ago, and she is grateful to the ANF for all its work in improving life for WA nurses and midwives.

"I value the privilege of having been part of an expert team of people who have always and continue to provide a service of excellence in the care of the critically ill patient.

"I would encourage all nurses to join the ANF, not only for personal benefit, but also for what the ANF has done for nursing as a whole. When I started nursing in 1964, pay was low, we worked six days a week, only had one day off a week, and had all our lectures in our own time," she said.

"I value the friendships developed and continued amongst the staff and myself – and I am grateful that I was once a nurse in the best ICU I could ever have wished for."

Maria first started nurse training in 1964 at Royal Adelaide Hospital, where she developed a taste for ICU, graduating in 1967. Because there were no ICU courses in Australia yet, she studied at Greenlane Hospital in Auckland, New Zealand, gaining a post-graduate ICU Certificate in 1968.

In 1969, Maria completed a Midwifery Certificate at King Edward Memorial Hospital, and in 1971 she finished

"The ANF fought for and won better conditions and wages for all of us, and we should be grateful for what it has achieved, and continues to achieve, for the welfare of the profession in WA." Maria added: "You never know when you'll need the ANF. I never needed anything of an industrial nature until the end of my career – thank God I was still a member when I did need them." 

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January–February 2018 western nurse |

5

InternetWatch AMAZING APPS + ONLINE NEWS

Australia Post Get the post office in your pocket. Track and manage your deliveries, pay bills and much more. Probably the most impressive feature? You can organise “safe drop” where eligible signature-on-delivery parcels will be left at your front door – or another safe place – if you aren’t at home. Free

Keeping Baby Safe Find information from the Keeping Baby Safe campaign featuring information on more than 30 products and what to look for when purchasing. It also includes information on warnings and dangers related to specific products that may be of interest to parents and carers.

Free. or Australian Competition and Consumer Commission website.

Eurovision Keep up to date with the Eurovision Song Contest.

You’ll get access to the Eurovision Facebook page, Twitter feeds, YouTube videos, Instagram photos and the Eurovision Wikipedia – all in one place.

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Draw Something Classic Here’s a popular drawing game. It’s a bit like ‘Pictionary’ but with an online competitor instead of paper and textas. It’s straightforward; pick from a list and draw a picture for your online partner to guess. Then their picture appears and you do the guessing.

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Express Plus Centrelink Aimed at making your dealings with Centrelink easier. With this app Centrelink says there is no need to visit an office or wait on the phone. You can report your employment income, view and update your family income estimate, check your payments and check the progress of claims.

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western nurse January–February 2018

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Jib Jab This one is gold. Fancy yourself as a dancing Elvis? A cute pug? How about as a cat using a laptop? From the folks that made ‘Elf Yourself’, insert a photo of your face, or anyone else’s and the app creates a hilarious GIF clip. Seriously laugh out loud stuff.

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Fender Tune Fender Tune is an accurate guitar tuner, featuring more than 20 tunings for acoustic, bass and electric guitars.

It’s easy to use for beginners and provides the tuning variety needed for guitar experts. Switch between auto, manual and chromatic mode and enjoy the pre-set tunings.

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Herbs Encyclopedia Herbs have been used in cooking and medicine for ages. Read about herbs and plants including health benefits, uses and classification. You’ll also find recipes and a list of harmful herbs if used incorrectly. Herbal interactions with medications is a must-see.

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UNO™ It’s time to shout ‘UNO’… at your device that is.

Play the beloved card game online with family, friends or other UNO™ fans. The same rules apply, play solo or in teams. Join a tournament or create a custom game. Free

FIVESuperSites Australian Dictionary of Biography

Here’s one for the inquisitive. This dictionary from the Australian National University (ANU) has information on all sorts of interesting Australians. From prime ministers, generals and bishops, artists, actors and authors, engineers and schoolteachers, to thieves and murderers. Perfect for school assignments. adb.anu.edu.au

Obituaries Australia

This is another site from the clever people at the ANU. Obituaries Australia is a digital collection of obituaries published in newspapers, journals, magazines and bulletins. Here you will find the life stories of Australians from the earliest times to the present. Fascinating stuff. oa.anu.edu.au

100 Common Myths & Misconceptions

We’ve all heard it – how chewing gum takes seven years to digest. Prepare to be mindblown... it doesn’t! “The truth is: Chewing gum is mostly indigestible, and passes through the digestive system at the same rate as other matter”, the site informs us.

Check out the world’s most widespread myths, misconceptions and falsehoods. geekwrapped.com/myth-infographic

Department of Transport Direct Keep track of your demerit points and more at the Department of Transport. According to the department: “The information provided is based on traffic offence details supplied to the Department of Transport by the Western Australian Police. It may not include recent offences and does not include offences allocated to a served Notice”. transport.wa.gov.au

You’re Welcome – AccessWA

You’re Welcome is a guide for people with disabilities and for seniors. Use this site to find access details on more than 3000 businesses and attractions in Western Australia including accommodation, beaches and cafés. Detailed information is provided, such as the layout of toilets and bathrooms. accesswa.com.au

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January–February 2018 western nurse |

7

JUST SAY NO Annual performance appraisals have been abolished by the Health Minister in public hospitals. Yet some managers are still trying to coerce ANF members into doing them.

The ANF is not going to allow that to happen.

“ You no longer have to have an appraisal meeting with your manager – and if they try to force you, show them the Minister’s letter and tell them if they don’t like it, they can come and talk to me – Mark Olson – about it ”

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western nurse January–February 2018

When the ANF finally got a commitment from the WA Labor Party at the last State Election that Labor would abolish annual performance appraisals in public hospitals if they won, we never thought these dreaded tools of bullying would be gone overnight.

Instead, we have worked doggedly over the past year to make them history, including formulating with the Government a proper Professional Development Annual Declaration to replace appraisals.

Professional Development Annual Declaration Name: ________________________

HE no. _____________

This declaration is to be completed and returned to your Manager by 30 June each year.

1)

I have completed my NMBA Continuing Professional Development requirements  Yes

2)

I confirm that I have practised for at least 450 hours in the last 5 years for each profession I am registered in  Yes





3)

No

ANF State Secretary Mark Olson has been in communication with the Minister to address this serious matter, and the Minister has repeatedly reiterated his commitment to get rid of appraisals.

Mark has also been writing to individual members to inform them of their right to refuse to do these appraisals by another name.

“Some managers have even told our members: ‘We don’t care what the Minister or Olson say, we’re keeping appraisals and you will have to do them’.

We want to remind those individuals, you’re defying a Ministerial edict – that’s your boss, in case you’ve forgotten,” Mark said.

“And we want our members to know, you no longer have to have an appraisal meeting with your manager – and if they try to force you, show them the Minister’s letter and tell them they can come and talk to me – Mark Olson – about it.”

No

I have completed my Hospital Mandatory training requirements (include a copy of mandatory training checklist)



Yes



No

4) I have completed my ward/unit/area Specific Mandatory training requirements (include a copy of mandatory training checklist)

5)

Yes



No



Yes



No

I have completed my clinical competencies (include a copy of the competencies checklist)

6)



I request a meeting to discuss my professional development with my Manager (it is not a requirement of this declaration to meet with your Manager) 

Yes



No

Signed: _________________________ Date: __________________________

Then, on November 21 last year, Health Minister Roger Cook announced the “abolition of annual performance appraisals”.

Yet, some hospitals and individual managers have continued to try to force our members to do them under another name, usually labelled a professional development review or similar.

January–February 2018 western nurse |

9

Mark said work on the new declaration is progressing rapidly. “The beauty of the new declaration is it collects all information that indicate an individual has fulfilled their professional development obligations, but removes the need for the compulsory meetings with managers that nurses and midwives hated so much, because they were more often than not used for bullying,” Mark said.

“And despite what some managers are claiming, this interim period of deciding on the final form of the declaration with the Government does not obstruct the operation of hospitals in any way – staff can do their mandatory and clinical competencies, and other types of professional development and training. But you just no longer have to have an appraisal meeting with your manager.”

Mark said the managers who are defying the Ministerial edict have been rolling out the “same old lines” to defend their actions.

“(They) are saying these new appraisal/PD tools are just an opportunity for nurses to discuss their career path. We say to those managers, why do nurses need to spend hours filling out a 10 or 20-page document every year that is kept on file just to have a chat about their career?” Mark said. “We know how such reviews have been used up till now – it’s been primarily bullying, not career counselling.”

He added: “Our members are confident enough to ask if they want something, so let’s drop this excuse for bullying sessions”.

Mark also said the notion that these meetings “address bad work practices and maintain standards” was false and also disturbing, if managers depended on a once a year meeting to address issues of bad work practices.

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western nurse January–February 2018

“If (managers) are not performancemanaging bad work practices as soon as they occur under existing performance management mechanisms, and are instead waiting for a once a year chitchat to do that, they should not be managers – because that’s dangerous,” he said.

Mark added that nurses’ and midwives’ mandatory Continuing Professional Development (CPD), and annual Australian Health Practitioner Regulation Agency (AHPRA) audits were among the mechanisms whose specific purpose is maintaining standards and best practice – not appraisals.

He also said if appraisals were necessary in maintaining

standards, why were postponed or cancelled?

they

often

Mark said if you are being pressured to do an appraisal, in the first instance, tell your manager “no”, and suggest to them that you fill out the Professional Development Annual Declaration instead. You can find the declaration on iFolio, click on the employment tab, then click on special notices, and the declaration is on that page.

“But if that doesn’t work, and you feel bullied, harassed or coerced into doing an appraisal, under whatever name, call us at the ANF – we’ve got your back,” Mark said.

“There’ll be more news in the next edition about ANF efforts to remove appraisals from the private sector.” 

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January–February 2018 western nurse |

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update: Serological tests for Syphilis

Read this article and complete the online quiz to earn 0.5 iFolio hour

Syphilis is a sexually transmitted infection caused by the bacteria Treponema pallidum.

Infection is characterised by four phases including primary syphilis, two to three weeks after infection; secondary syphilis, weeks to months later; latent syphilis; and eventually, tertiary or late-stage syphilis. If left untreated, syphilis may result in multi-organ complications, including damage to the heart, brain, spinal cord and bones.1

SYMPTOMS OF SYPHILIS Individuals with primary syphilis may or may not develop symptoms. One or more small, painless ulcers may arise around the area of sexual contact. Often people fail to identify the ulcers before they self-resolve and never seek treatment.1 Symptoms of secondary syphilis are also difficult to detect. They include generalised flu-like symptoms, fever, rash and swollen lymph nodes. Latent syphilis may persist for years without symptoms.1 After prolonged infection, neurosyphilis may arise.

Neurosyphilis is an infection of the brain or spinal cord, which may result in symptoms including abnormal gait, numbness in the extremities, confusion, mental problems, headaches, neck stiffness, incontinence, tremors and visual disturbances.1

the high associated costs and complexity of testing, meant that treponemal tests were, and in many cases still are, mostly reserved for confirmation of syphilis, following a positive nontreponemal test. However, recent advances in diagnostic technology have made testing easier and expanded the use of treponemal tests in patient screening.2

following treatment and eventually revert to nonreactive. Individuals who have had treatment and present with a newly positive nontreponemal test may be experiencing a new infection, response to recent treatment, or treatment failure. They may also have reached a serofast state where they will continue to have low-level titers despite adequate treatment.2

ALGORITHMS FOR SEROLOGICAL TESTING

If neurosyphilis is suspected, a sample of the cerebrospinal fluid (CSF) is also required.2 CSF-VDRL tests are used in combination with CSF cell count and protein levels, as well as reactive serological tests to definitely diagnose neurosyphilis.2

Nontreponemal tests or newer versions of treponemal tests may be used for initial syphilis screening. If a nontreponemal test is positive, confirmation with a treponemal test is required.

In general, if a nontreponemal test is negative, no further testing is required. Unfortunately, there is a window period during early stages of infection in which detection may not be possible. Patients at high risk are advised to repeat the test within two to four weeks.2 If both nontreponemal and treponemal tests are positive, a diagnosis of syphilis can be confirmed.2 Patients with no past medical history of infection require treatment.

Individuals with a known history of syphilis and positive results are more difficult to manage.

Those with a prior infection will continue to have a treponemal positive serological test result, despite effective treatment. In contrast, nontreponemal test results should decline Nontreponemal (RPR) tests

Treponemal tests detect antibodies against specific treponemal antigens. Historically,

12 |

western nurse January–February 2018

REFERENCES 1. Jin, Jill. Screening for syphilis. JAMA. 2016 Jun 7;315(21):2367.

2. Hicks CB, Clement M. Syphilis: Screening and diagnostic testing. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 12, 2016).

Treponemal tests

Advantages

• Low cost • Easy to perform • Provides a quantitative measure that can be used to determine response to therapy

• More specific • May be used for rapid serological tests, as in those used for point of care testing • Newer versions may be less expensive than nontreponemal tests • May detect syphilis earlier

Disadvantages

• Non-specific and not definitive • Potential for false positives and false negatives • Dependent on the humoral immune response, may not detect early stages of infection

• Complex to perform (especially older versions) • Expensive (especially older versions) • Potential for false positives • Once positive, will remain positive despite treatment • Dependent on the humoral immune response, may not detect early stages of infection

Examples

• Rapid plasma reagin • Venereal Disease Research Laboratory (VDRL) • Toluidine Red Unheated Serum Test (TRUST)

• Fluorescent treponemal antibody absorption (FTA-ABS) • Microhemagglutination test for antibodies to T. pallidum (MHA-TP) • T. pallidum particle agglutination assay (TPPA) • T. pallidum enzyme immunoassay (TP-EIA) • Chemiluminescence immunoassay (CIA)

SCREENING FOR SYPHILIS Due to the lack of distinct symptoms associated with syphilis, asymptomatic screening plays an important role in infection prevention and control. There are two types of serological (blood) tests used to diagnose syphilis. As there is a potential for false-positive results with both types of tests, confirmation is always required.2 Nontreponemal (rapid plasma reagin or RPR) tests determine whether serum is reactive to cardiolipin-cholesterol-lecithin antigen. These tests are non-specific and cost-effective. They are generally used to screen for syphilis, but also produce a titer (bacterial concentration), which can be used to measure the success of treatment over time. 2

CONCLUSION Serological testing is an important screening tool for syphilis. However, results must be considered within a broader clinical context, which includes the presence or absence of symptoms, patient history and an appreciation for the potential variability in test results.

update: Esomeprazole

Read this article and complete the online quiz to earn 0.5 iFolio hour

Esomeprazole is a proton-pump inhibitor (PPI) primarily used to treat reflux oesophagitis (heartburn), peptic ulcers and complications associated with non-steroidal antiinflammatory drug (NSAID) therapy.1 It is the second most commonly prescribed drug in Australia and costs taxpayers $296,247,832 per year.2 While PPIs are the most effective treatments for upper gastrointestinal disorders, overuse is a concern. Appropriate use is required to help minimise adverse effects and control costs associated with treatment.3,4 Generic name Esomeprazole Trade name Esomeprazole AN, Apotex, GH, GxP, RBX, Sandoz, Nexazole, Nexium, Nexole Drug class Proton pump inhibitors

METHOD OF ACTION Gastric acid is made in the stomach for the breakdown of food. In some conditions, it can cause adverse symptoms such as heartburn, regurgitation, vomiting, haematemesis, and malaena.5 Proton pump inhibitors bind to hydrogen-potassium ATPase enzymes (proton pumps) on gastric parietal cells and suppress acid secretion in the stomach.1 They irreversibly inhibit active proton pumps for up to 48 hours.

In the presence of PPIs, the body must activate resting proton pumps or synthesise new enzymes in order to stimulate acid secretion.1

INDICATIONS Major indications for the use of proton pump inhibitors include:1 Prevention and treatment of gastrooesophageal reflux disorder (GORD) A condition where food and acid from the stomach reflux into the oesophagus Zollinger-Ellison syndrome A rare condition where the stomach produces excessive amounts of acid Prevention and treatment of NSAID-induced gastric ulcers and upper gastro-intestinal (GI) symptoms Peptic ulcers with Helicobacter pylori infection Many peptic ulcers co-exist with a bacterial infection caused by Helicobacter pylori Esomeprazole may be administered in combination with antibiotics in order to treat the infection and ulcer at once Prevention of peptic ulcer re-bleeding Bleeding ulcers are generally managed with intravenous medications, followed by a longer course of oral PPIs to prevent re-bleeding

Esomeprazole is the S-isomer of omeprazole.1 Compared to omeprazole, it is equally safe and efficacious for the maintenance treatment of healed severe refractory ulcerative oesophagitis and may be more efficacious during the healing process.6 It is also more cost-effective for the treatment of gastric ulcers and ulcers associated with Helicobacter pylori infection.6

CONTRAINDICATIONS Absolute contraindications to esomeprazole include a known allergy to esomeprazole or omeprazole and co-administration with cilostazol (used in the treatment of peripheral vascular disease).1 All PPIs should be used with caution in individuals with known or suspected gastric carcinoma, hepatic impairment, or pregnancy (category B3).1

ADVERSE EFFECTS Complications associated with esomeprazole include headache, nausea, vomiting, diarrhoea, abdominal pain, constipation, and flatulence.1 Rarely, patients may experience confusion, alopecia, and microscopic colitis.1 Other potential risks include enteric infections and bone fractures.3 For example, there is significant evidence to suggest an increased risk of developing Clostridium difficileassociated diarrhoea with PPI use.3 One potential complication with the cessation of PPIs is rebound acid hypersecretion.4 This is an excessive production of gastric acid (beyond pre-treatment levels), which may occur after stopping a PPI. It can be difficult to manage and lead to chronic medication use.4 Evidence to support symptomatic rebound acid hypersecretion following the cessation of PPIs is inconclusive. Despite this, gradual weaning or on-demand use of PPIs is recommended to help prevent the onset of reflex-like symptoms after cessation.4

DOSAGE The recommended dose for esomeprazole differs based on the indication for use (see Table 1).

POTENTIAL FOR INAPPROPRIATE USE Long-term use of PPIs is only recommended for specific indications.3,4 Despite this, many Australians continue to use esomeprazole indefinitely. Patients often receive a prescription for a PPI without a confirmed upper GI diagnosis or an appropriate indication for use. Ongoing treatment may occur without re-evaluation. Many patients fail receive the appropriate education or do not comply with recommendations regarding step-down therapy to minimise use.3,4 When indicated, esomeprazole is a safe and effective treatment that helps relieve symptoms

and prevent complications associated with gastric acid secretion. However, excessive use in Australia is associated with the potential for adverse effects and high cost. Adherence to appropriate prescribing, follow-up and cessation of use is required to prevent harm.

Table 1. Adult Esomeprazole Dosage.1

Indication

Dose

Duration of treatment

GORD

20mg once daily (oral or intravenous)

4-8 weeks *May increase to 40mg once daily (oral) for a further 4 weeks, if required

ZollingerEllison syndrome

40mg twice daily Titrate based on gastric acid output

As per specialist

H. pylori eradication

20mg twice daily +clarithromycin 500mg twice daily +amoxicillin 1g twice daily

7 days

NSAIDassociated gastric ulcer

20 mg once daily (oral or intravenous)

4-8 weeks

NSAIDassociated upper GI symptoms

20mg once daily (oral)

4 weeks

Prevention of peptic ulcer rebleeding

IV infusion, followed by 40mg once daily (oral)

As per specialist

REFERENCES 1. Australian Medicines Handbook 2015 (computer program). Adelaide: Australian Medicines Handbook Pty Ltd; 2015 July.

2. The Pharmaceutical Benefits Scheme. Australian Statistics on Medicines 2014 [Internet].

Canberra: Commonwealth of Australia; 2016 Mar 7 [cited 2016 Jun 19]. Available from: http:// www.pbs.gov.au/info/statistics/asm/asm2014#_Toc425339267 3. Heidelbaugh JJ, Kim AH, Chang R, Walker PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therap Adv Gastroenterol. 2012 Jul;5(4):219-32.

4. NPS MedicineWise Professional. PPIs – too much of a good thing? MedicineWise News. Surry Hills: NPS MedicineWise; 2015 Mar 16. 6p.

5. NPS MedicineWise. Signs and symptoms of gastro-osophageal reflux disease (GORD) [Internet]. Surry Hills: NPS MedicineWise; 2015 Mar 30 [cited 2016 Jun 19]. Available from: http://www.nps.org.au/conditions/ digestive-system-problems/indigestion-refluxand-stomach-ulcers/heartburn-and-reflux/forhealth-professionals/signs-and-symptoms.

January–February 2018 western nurse |

13

Mark’s

Use of social media and its consequences at work is a big topic at a time when sharing thoughts and views, and photographs are second nature for many. Here’s a brief overview of some potential pitfalls – for more detail, the ANF can be requested to present its social media talk at your workplace.

Q: What’s the safest social media to post my

opinions on work if I don’t want to potentially offend my employers?

A:

None are “safe” if you’re posting opinion about work – a rule of thumb might be: If you’re not comfortable about seeing a particular opinion or photo of yours on the notice board at work, don’t post it on social media. Even using Messenger, which you might think is a personal communication tool, can lead to disciplinary action if work matters are discussed.

Q: But wouldn’t it be safe to make comments on A:

work practices or colleagues, or patients under an alias, or by having strong privacy settings?

There have been cases where employers have tracked down offending employees despite them having a pseudonym, and privacy settings can still allow “friends” to see your post, and that can be shared. Therefore, any time an opinion is “published” to others online, there’s a risk it will be seen by those for whom it’s not intended. And even when you take a post or photo down immediately, like on Snapchat, there will be a page impression somewhere on the Net, or someone may take a screenshot.

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Q: What about “likes”, are they an issue?

A: They can be, because if you are liking a contentious issue, a workplace matter or even what you might think is a funny medical-themed meme (pictures with often humorous captions), you can run into trouble with your boss, so think before you like.

Q: I’ve got a strong opinion on a general

health issue such as vaccination, why can’t I post that view?

A: Posting a view when you are identified as a medical professional can be seen as giving medical advice.

You’re not allowed to express to patients at work medical views that are contrary to accepted good medical practice, so think of social media in the same context. AHPRA has a social media policy which is a good guide and the ANF can provide more information as well. And when in doubt about whether something should be posted, don’t post.

The information provided in this column is general advice only.

If you want information specific to your circumstances you should contact the ANF Helpline or send us your questions by email.

WANT MORE WORKLIFE BALANCE? Book an ANF holiday unit on your iFolio.

January–February 2018 western nurse |

15

update: Drowning

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

Drowning is respiratory compromise that occurs as a result of submersion or immersion in liquid.1 It may be fatal or non fatal, deliberate, imposed or accidental and is a leading cause of death worldwide. In 2012, approximately 372 000 people died from drowning and for every death that occurs, there are four cases of non-fatal drowning.2,3 The pathophysiology of drowning is generally well understood. Respiratory impairment causes hypoxaemia (a low concentration of oxygen in the blood) and multi-organ injury, with a particularly negative effect on the brain.1 Ideal care begins long before presentation to the emergency department.

Pre-hospital management including early rescue, resuscitation and advanced life support, is required to optimise outcomes for drowning victims.1

RISK FACTORS Risk factors for drowning include age, sex, socioeconomic status, substance use and underlying medical conditions (see Table 1).

Children aged under five years are most at risk of drowning and have the greatest mortality rates worldwide.3 Table 1. Risk factors for drowning.3,4

Young age Male sex Low socioeconomic status Lack of childhood supervision Alcohol use Inadequate water safety knowledge Failure to use floatation devices Underlying medical conditions e.g. epilepsy, cardiomyopathy, cardiac arrhythmias

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PATHOPHYSIOLOGY OF DROWNING

During submersion or immersion, all individuals initially swallow, spit or hold their breath to prevent exposing their lungs to liquid.1,4 When a breath is ultimately required, liquid enters the airways and stimulates a cough response and fluid aspiration.1 Aspiration damages the airways by removing surfactant on the surface of the alveoli and disrupting the alveolar capillary membrane. Shifting of fluid, plasma and electrolytes across the alveolar-capillary membrane leads to excessive pulmonary oedema, atelectasis and impaired gas exchange.1 Damage to the lungs results in severely impaired lung compliance, similar to that of acute respiratory distress syndrome (ARDS) and ultimately causes failed ventilation and perfusion.3

Table 2. Predictors of positive outcomes following drowning.1

Early access to basic and advanced life support Mild hypothermia during drowning Limited duration of submersion Nil signs of brain-stem injury such as impaired levels of consciousness, altered respirations, or abnormal heart rate

Acute deterioration as a result of drowning occurs predominantly as a result of hypoxaemia.1 Lack of oxygen to the brain causes a loss of consciousness, impaired respiratory drive and apnoea.1 Build up of lactic acid throughout the body leads to severe metabolic acidosis, as well as stimulation of the inflammatory response, cardiac dysfunction, renal impairment and neurological dysfunction.3 The cardiac rhythm changes from tachycardia to bradycardia, pulseless electrical activity and eventually, asystole.1 For those who survive, treatment may range from cardiopulmonary resuscitation to airway protection, respiratory support and correction of acidosis.

Following the identification of a drowning victim, emergency medical services must be notified as early as possible. Conscious victims should be transferred to land and offered basic life support. Unconscious victims may benefit from resuscitation as soon as possible, regardless of the location.

In-water resuscitation is limited to ventilation.1 Those with isolated respiratory arrest will often respond quickly to rescue breathing.

Chest compressions are not effective in water. Therefore, if there is no immediate response to ventilation efforts, victims must be transferred to land to commence CPR.1 As cardiac arrest following drowning generally occurs as a result of pulseless electrical activity, defibrillation is often not required. Epinephrine (1mg or 0.01mg/kg body weight) may be considered if a qualified responder is present for administration.

PRE-HOSPITAL MANAGEMENT

HYPOTHERMIA

Effective pre-hospital management is important to ensure positive outcomes following drowning (see Table 2).3 Key aspects include early rescue and resuscitation with basic and advanced life support, as indicated.1 The morbidity and mortality of drowning is related to the duration of submersion. At 0-5 minutes of submersion, the risk of death or severe neurologic impairment after hospital discharge is 10%, while after 25 minutes, the risk is nearly 100%.1

Drowning victims often experience hypothermia as a result of prolonged exposure to cool liquids and hypoperfusion.1,4 Mild hypothermia may be neuroprotective as low body temperatures reduce oxygen and adenosine triphosphate consumption and delay cellular anoxia.1 While mild hypothermia may be beneficial, severe hypothermia is associated with metabolic and cardiovascular complications.4 Rewarming may be indicated in some cases.

Following severe accidental hypothermia, prevention of further heat loss and early rewarming has been associated with improved outcomes.5 Passive rewarming prior to hospital may occur through drying and the use of blankets. Once in hospital, active rewarming techniques include warm intravenous fluid administration, ventilation with warm air, peritoneal and pleural lavage with warmed saline and cardiopulmonary bypass.6

HOSPITAL MANAGEMENT Many patients who present to hospital with non-fatal drowning exhibit few symptoms.

Awake and alert individuals with a cough, poor oxygen saturations, or rales (crackling or rattling in the chest) on auscultation may require administration of oxygen and frequent monitoring.4 Those with neurological dysfunction, severe hypoxaemia or cardiovascular compromise often require more invasive interventions such as intubation, mechanical ventilation and supportive treatment in an intensive care environment.4 Oxygen is administered to maintain saturations of 92-96%.1 When intubation and mechanical ventilation are required, lung protective strategies including maintaining tidal

volumes of 6ml/kg (ideal body weight) and the administration of positive end-expiratory pressure (PEEP) help to reverse atelectasis and hypoxaemia.6 Drowning victims who receive adequate treatment tend to recover quickly. In general, patients should remain mechanically ventilated for at least 24 hours regardless of progress, as there is a potential for further deterioration.1 Acidosis as a result of drowning often resolves spontaneously or with supportive therapy.

Relevant treatments including managing hypotension (primarily with crystalloid fluids), optimising electrolytes, and renal replacement therapy, may be initiated as required.4,6 Although infection may occur following drowning, prophylactic antibiotics are not recommended.1

PREVENTION The best treatment for drowning is prevention. At the beach, the majority of drowning incidents occur as a result of rip currents. Swimming in designated areas and staying away from rip currents is important.

Barriers, such as fences, are useful for limiting unsupervised access to water and are a legal requirement for backyard pools in Australia.

Public awareness campaigns, childcare and swimming lessons with an emphasis on safety also help to reduce the risk of young children drowning.1,3,4

REFERENCES 1. Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med 2012;366:2102-2110.

2. Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta: Centers for Disease Control and Prevention; 2009. Available from: http://www.cdc.gov/injury/wisqars.

3. World Health Organization. Drowning [Internet].

Geneva: World Health Organization; 2016 Sept [cited 2016 Sept]. Available from http://www. who.int/mediacentre/factsheets/fs347/en/.

4. Papadakos P, Gestring M. Encyclopedia of Trauma Care. Berlin: Springer-Verlag Berlin Heidelberg; 2015. Drowning. 103p.

5. DuCharme M, Steinman A, Giesbrecht G. Pre-hospital management of immersion hypothermia. In: Bierens JJ, editors. Handbook on drowning. Berlin: Springer-Verlag Berlin Heidelberg; 2013 Oct 26. 5p.

6. BMJ Best Practice. Near drowning [Internet].

London: BMJ Publishing Group Ltd; 2016 May 31 [cited 2016 Sep]. Available from http://bestpractice.bmj.com/best-practice/ monograph/657/treatment/step-by-step.html.

January–February 2018 western nurse |

17

ANF Out ‘N’ About

Child and Adolescent Community Health Midvale

Happy New Year to all our Out ‘N’ About readers – and to celebrate the start of 2018, we’ve picked a grand total of 75 prize winners from last year’s photos!

Of those 75, 15 of you will soon have an iPad Mini heading your way, either in the mail or when we visit your workplace.

A further 60 lucky members will receive a special ANF backpack, which is a great prize in itself, but also contains goodies including a gift voucher.

And don’t worry if you didn’t win this time round, because the competition has already re-started for 2018!

Additionally, we have the terrific members’ ANF Holiday Unit Photo Competition running right now.

That’s where you can win wonderful prizes just for uploading your favourite vacation snap at the ANF Holiday Units in Kalbarri or Margaret River. See your iFolio for more details.

We hope you enjoy our latest Out ‘N’ About spread, which also shows the members who’ve won the mini iPads on Page 20.

From the Out ‘N’ About Team, we wish you a terrific summer and see you soon at our ANF visits.

Fremantle Hospital Irene Phenk and Amy Banham

Fiona Stanley Hospital Lee Browes, Kate Pedersen, Haley Wilkinson and Doffitha Mathew

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Fiona Stanley Hospital Elissa Spackman, Vanessa De Graaf and Jeanie Hammond

title to run here

Joondalup Health Campus Sheila Vickery and Aggie Doyle

King Edward Memorial Hospital Lauren Papalia and Kirsten Blacker

King Edward Memorial Hospital Sarah Wickham and Claer Blackman

Fiona Stanley Hospital Elaine Anson and Janet Dillon

St John Of God Murdoch Wagaye Kebaswele, Anne Kauki and Lalaine Altizo

EXCITING OPPORTUNITY FOR REGISTERED NURSES Hannah’s House is seeking enthusiastic and passionate Registered/Enrolled nurses with a minimum of 2 years’ experience, preferably in paediatrics or critical care, to provide in home care to children with complex care needs.

Positions are casual and offer a flexible and reliable roster. We are a growing service, and are keen to develop a competent team to move forward.

For more information call

Susan King on: 0413 372 943 or email your CV to info@hannahshouse.org.au

Seeking Trainer/ Assessor - Diploma of Nursing The Institute of Health & Nursing Australia is a nationally Registered Training Organisation (RTO). We are currently seeking full-time, part-time and casual Nursing Trainers and Assessors (Nurse Educators) to join our Academic Team to deliver a Diploma of Nursing program in our Perth campus.

Minimum skills and experience required · Bachelor or Master Degree in Nursing · Certificate IV in Training and Assessment - TAE40110 or TAE40116 · Minimum one year's experience in a clinical setting, as RN Div 1 Additional skills and experience advantageous for this role · Current experience in teaching nursing or other related health courses · In-depth understanding of ASQA/ANMAC regulatory guidelines and standards Candidates should submit expressions of interest to srijana@healthcareers.edu.au

January–February 2018 western nurse |

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ANF Out ‘N’ About WINNERS

SCGH Heather Simmonds, Denise Fairclough, Bronwyn Innes and Natalie Goodman

Graylands Hospital Monet Tombides and Jessica Murray

SJOG Midland Shelle-Ann Elliott, Lucy Brown, Isabel Brawn, Kennedy Ogbonna

RPH Kayleigh Morrison and Joelle De Robertis

Geraldton Regional Hospital Kahla Dumbris

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Fiona Stanley Hospital Ancy Georgekutty and Karen Mattioli

An

Liƒe

Extraordinary In Memoriam: BERYL GRANT AO, OBE Past President of Royal Australian Nursing Federation in WA Born: Subiaco, WA: 11 September 1921 Died: Balcatta, WA: 4 November 2017 eryl Grant spent her life fighting to improve conditions for women and children.

Despite losing her parents at a young age, and having to leave school at age 14 to work as a clerk, in her 21st year she was on her way to a nursing career, during which she energetically advocated for women’s and children's rights. She was accepted for general nursing training at the original Perth Children’s Hospital in November 1942, and later had midwifery training at King Edward Memorial Hospital.

She is extremely well known for her role as inaugural Matron at Ngala in South Perth from 1959-1980 – one of few places where unwed mothers could seek assistance and care in WA in her time – and she was involved in various government bodies dealing with the welfare of mothers and children. She also chaired the WA Panel into Prostitution in 1990.

As President of the Royal Australian Nursing Federation in WA, as the ANF was known then, Beryl pushed for nurse education to be recognised by universities, saying in Ian Tanner’s biography that: “Originally nurses were treated as handmaidens to the doctors … I thought nurses should have the same opportunities and standing as physiotherapists, occupational therapists, pharmacists, and all other members of the health team”.

The National Library of Australia lists her accolades across a long and distinguished career, including that “whilst at Ngala she was awarded, in 1968, a Winston Churchill Fellowship to travel overseas to study in particular crosscultural adoptions, fostering and single mothers” and in 1976 her being “awarded an Order of the British Empire (OBE) for services in this area”. In 2000, Beryl was also appointed an Officer of the Order of Australia (AO) for service to nursing and to the community by supporting and developing services and programs for children and families, particularly in rural and remote areas.

Beryl always felt she had a responsibility to contribute to positive social change, recalled her friend of more than 40 years, former RANF State Secretary Wilma Gardiner.

“Beryl was somebody that people looked up to. She brought a lot of presence to the causes she involved

Beryl Grant with friend Wilma Gardiner (left)

herself with, she was extremely well known across all walks of life, and she was deeply respected,” Wilma told western nurse in January.

“She had a great sense of humour, but she was also someone you had to know for a long time before you called her Beryl. Most people called her Miss Grant for years, until either you got the courage to ask if you could call her Beryl, or she said something. She had time for people, but didn’t give it away lightly. She was a very good cook, and kept in touch with people, including former employees.

“She was very Scottish in attitude, and she did have a very funny side – I remember it was the 2000s in the Perth Concert Hall, and it was a graduation ceremony, and she was guest speaker. She grabbed everyone’s attention by saying ‘I’m going to talk about the F word’ – which prompted an audible intake of breath across the auditorium. I don’t know if it was ‘friendship’ or ‘faith’, or whatever that she ended up talking about, but she certainly grabbed their attention – that was her sense of humour.”  January–February 2018 western nurse |

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AcrosstheNation NEWS, VIEWS AND GOSSIP FROM ALL OVER AUSTRALIA

start regular exercise is in latemiddle age, when the heart still has plasticity and this applies to people right around the world including Australia.” 

NATURAL THERAPIES CHOPPED FROM PRIVATE HEALTH COVER AUS Naturopathy and yoga

HEART FAILURE RISKS STILL REVERSIBLE IN MIDDLE-AGE VIC Middle-aged and unfit – don’t despair, you still might be able to reverse heart failure risks by doing regular aerobic exercise.

A study of 53 healthy but sedentary adults who did aerobic exercise consistently for two years, saw “significant improvements in how their body utilised oxygen and had decreased cardiac stiffness … both markers of a healthier heart”.

Melbourne’s Baker Heart and Diabetes Institute researcher Dr Erin Howden, who is the study’s first author, said these outcomes reversed “decades of a sedentary lifestyle on the heart for most of the American-based study participants”.

“Low fitness in middle age, in people right around the world, is a strong predictor of future risk of heart failure and is associated with increased cardiac stiffness, a potential precursor to heart failure,” she said. “However, waiting until heart failure develops or older age cements the effects of a sedentary lifestyle …by then it may be too late to reverse any damage.

“This study demonstrates that prolonged (2 years) exercise training, initiated in middle age, can forestall the deleterious effects of sedentary aging by reducing cardiac stiffness and increasing fitness.

“We’ve also found that the ‘sweet spot’ in life to get off the couch and

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are among natural therapies and practices that won’t be covered by many private health insurance funds from April next year.

The Federal Health Department confirmed to The West Australian newspaper in January that 16 items will no longer be funded under health insurance policies where government rebates apply, but insurers can still offer them as incentives.

Alexander technique, aromatherapy, Bowen therapy, Buteyko, Feldenkrais, herbalism, homeopathy, iridology, kinesiology, naturopathy, reflexology, rolfing and shiatsu will be excluded, as will yoga, Pilates and Tai Chi. Health Minister Greg Hunt referred to coming changes last October, after a Commonwealth review queried the benefits of most natural therapies.

A Health Department spokeswoman confirmed to The West that the therapies would be removed from private health insurance packages, saying: “Commonwealth funding is typically only paid where a therapy has demonstrated clinical efficacy”.

“Therefore, the Australian Government has decided to remove private health insurance coverage for these services from complying health insurance products that attract the private health insurance rebate,” she added. “It is important that practitioners note that some private health insurers provide access to gym services and other products as incentives under their insurance.” 

'CATASTROPHIC' NURSE SHORTAGE PREDICTED IN NSW NSW New South Wales faces a huge nursing crisis – with official data predicting the State’s 70,000 full-time staff will soon be unable to meet patient demand.

“By 2030, the modelling suggests while 82,000 full-time registered nurses and midwives will be needed, only 74,000 will be available,” according to an ABC News report of modelling that the station obtained through a Freedom of Information application.

“For hospitals and aged-care centres who rely on enrolled nurses – the less-qualified workers who provide vital one-on-one care – the situation looks particularly dire.

This year alone, NSW will need to find 2,000 full-time enrolled nurses to meet demand, and on current trends, the shortage will continue to grow.”

South-west Sydney will “bear the brunt of the modelled shortages” with the risk of an enrolled nurse shortfall “described on a bushfirestyle chart in the documents as ‘catastrophic’”. The ABC said that area will “need about 600 enrolled nurses in 2030, but instead only 150 will be available”.

Health Minister Brad Hazzard’s spokeswoman told the ABC: “Workforce modelling takes a longterm look at possible scenarios so strategies can be developed.

This includes actions such as the employment of more than 2,400 nursing and midwifery graduates in 2018 to ensure NSW has a healthy supply of nurse graduates to meet future demand”. 

DISCOVERY COULD REDUCE DIABETES CASES IN STATINS USERS WA A new mouse study has revealed cholesterol-lowering statin medications can cause changes in the human body’s gut bacteria – which can trigger the development of type 2 diabetes.

The new work offers hope for reducing the incidence of diabetes, because previous studies reported up to 12 percent more type 2 cases among patients taking statins, but “until now the cause has been a mystery”, according to peak diabetes research funding body, Diabetes Research WA. “Our work has demonstrated for the first time profound changes in the microbial composition of the gut following statin treatment, and in our study, mice experienced higher fasting blood glucose levels and weight gain,” said Professor Fergal O’Gara, who led the team of Curtin University researchers who did the study.

“We discovered the changes in gut bacteria were linked to the activity of a key protein receptor called PXR which is known to be involved in lipid and glucose metabolism. Both of these pathways are also altered in type 2 diabetes.”

Professor O’Gara said the Curtin team would use a new $80,000 grant from Diabetes Research WA, to “investigate ways to prevent these negative effects which may ultimately lead to the development of new probiotic-type therapeutics to counteract the negative impact of the statin”. 

BABY BRAIN BREAKTHROUGH VIC Victorian researchers believe they’ve proven “baby brain” does exist.

Analysis of 20 studies that encompassed 709 pregnant and 521 non-pregnant subjects, shows

women do experience “cognitive changes” during pregnancy, according to Deakin University.

Deakin psychologist and neuroscientist Associate Professor Linda Byrne said symptoms of what is “colloquially known as ‘baby brain’” can include poor concentration and absentmindedness, “with memory problems the most commonly reported”.

“The studies we analysed showed general cognitive functioning, memory, and executive functioning performance of pregnant women was significantly lower than in non-pregnant women, both overall and particularly during the third trimester of pregnancy,” Associate Professor Byrne said. “The data also showed that the memory performance of pregnant women appears to decline between the first and second trimesters.”

TEENS IMPROVING ON BOOZING SMOKING AND DRUGS AUS Drinking, drug use and smoking rates are dropping amongst teenagers from WA, Victoria and Queensland.

More than 41,000 teenagers with an average age of 13, were surveyed from 1999 to 2015, by researchers led by Deakin University and Murdoch Children’s Research Institute, reported The West Australian newspaper.

Big decreases in use of tobacco, alcohol and cannabis, particularly in smoking rates, were found.

But she said “baby brain shouldn’t be cause for concern”, because pregnant women have “more important concerns than minor memory lapses”. And the analysis also showed “as soon as pregnant women were required to focus, they behaved at normal levels of cognitive function”.

The researchers of the study – which was published in the journal Drug and Alcohol Review – said the reductions were “probably linked to more parents frowning on their children drinking and smoking”, and reduced availability because of tighter restrictions on cigarette and alcohol sales.

Lead researcher Sasha Davies said it was important to note the limitations of the data used for the study – which was published in the Medical Journal of Australia in January – such as having little information on the women pre and post-pregnancy. 

Also, since 2007, parents had become less likely to supply alcohol to their underage children, other studies showed.

The researchers also said the results highlighted positive effects of school drug education, and measures to limit the supply of alcohol to teens.

Brewers Association chief executive Brett Heffernan said the findings reflected recent Australian Institute of Health and Welfare data, showing underage drinking and alcohol misuse were declining.

“According to the institute, 82 per cent of 12 to 17-year-olds in Australia do not drink any alcohol at all, up from 56 per cent in 2007,” he said.  January–February 2018 western nurse |

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update: Reviewing the basics: Assessing A to E Read this article and complete the online quiz to earn 1 iFolio hour

A complete head to toe assessment is a useful nursing tool for all patients, including adults and children, in emergency settings and during routine care. The A to E assessment technique offers a systematic approach to determine a patient’s baseline clinical status and signs of deterioration. By focusing on the most life threatening conditions, it helps improve clinical efficacy and communication between practitioners, and reduce time to treatment (see Table 1).

Table 1. Benefits of an A to E assessment

- Offers a systematic approach to managing complex patient conditions - Can be performed by any practitioner - Addresses the greatest threats to life in sequential order - Allows for early assessment and focused treatment

- Identifies the need for assistance and ensures clarity in clinical handover - Encourages continual re-assessment and response as required

Each stage of the A to E assessment involves the look (inspect), listen (auscultate) and feel (palpate) approach. Compliance with each sequential step of the assessment is required to prevent missed opportunities, particularly for the identification and treatment of lifethreatening conditions. For example, the presence of a broken limb is insignificant compared to an airway obstruction. Therefore, airway management is required prior to assessing the rest of the body.

Practitioner safety is paramount in all clinical settings. Personal protective equipment including gown, gloves, goggles and masks should be applied as clinically appropriate prior commencing assessment.

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AIRWAY The easiest way to identify a patent airway is to determine if a patient is speaking. Those who respond in a normal tone have a viable airway. Signs of incomplete obstruction include an abnormal voice, and loud and laboured breathing. Patients with a complete obstruction cannot breathe despite considerable effort. Risk factors for obstruction include a reduced level of consciousness, the presence of a foreign body, inhalation injury or a large haematoma, injury, or burn to the head and neck.

Interventions to effectively manage an airway vary in complexity. The head-tilt chin lift or jaw thrust technique may help improve airway patency. Contents in the mouth such as sputum, blood or vomit may be removed with suctioning. An airway device such as an oropharyngeal or nasopharyngeal airway or a laryngeal mask airway may also be required.

If these measures are ineffective, a definitive airway strategy using endotracheal intubation or a surgical airway will be required (see Table 2 and Illustration 1).

Table 2. Indications for a definitive airway strategy

- Apnoea

- Protection from aspiration - Unconsciousness

- Severe facial fractures

- High risk of obstruction

- Inability to maintain oxygen saturations

BREATHING

Breathing is assessed by visualisation of the rise and fall of the chest, auscultation to determine breath sounds and percussion to identify dullness or resonance. Respiratory rate and pulse oximetry are also essential to determine respiratory compromise. Potential complications include pneumothorax, tension pneumothorax, haemothorax, and bronchospasm (see Table 3).

Supplemental oxygen may be indicated. Other useful interventions include assisted ventilation, use of a bag valve mask, inhalation medications and chest x-ray (if available).

Illustration 1. Endotrachial intubation

Laryngoscope

Endotrachial tube advanced through vocal cords to 23 cm (21 cm in women)

Trachea Cuff

Oesophagus

Table 3. Clinical features of common respiratory complications

Complication

Description

Clinical features

Pneumothorax

Air in the pleural space between the lungs and the chest wall.

Asymmetrical expansion Reduced breath sounds Hyperresonance to percussion Increased respiratory rate Reduced oxygen saturations

Tension pneumothorax

Worsening air in the pleural space as a result of lung conditions which allow air to leak into the pleural space but not return (see Illustration 2).

Asymmetrical expansion Reduced breath sounds Hyperresonance to percussion Increased respiratory rate Reduced oxygen saturations Tracheal shift to the opposite side

Haemothorax

Blood in the pleural space.

Increased work of breathing Decreased chest expansion Reduced breath sounds Dullness to percussion Increased respiratory rate Reduced oxygen saturations

Bronchospasm

Excessive contraction of the bronchial smooth muscle.

Increased work of breathing Coughing Shortness of breath Audible wheeze

with the more detailed Glasgow Coma Scale (GCS) (see Table 4). Pupillary reflexes may also be used to assess brain stem function. As a low level of consciousness may be caused by low blood sugar, it is important to check blood glucose as well. A quick look for facial asymmetry and abnormal movements may also be useful to rule out common neurological conditions such as seizures or an acute stroke.

Individuals who score a P or U or have a GCS of eight require airway protection for a decreased level of consciousness.

EXPOSURE

Once airway, breathing and circulation are confirmed and the appropriate life-saving interventions have been initiated, it is essential to look for other potential threats. A detailed examination requires the removal of bed sheets and clothing to observe for signs of trauma, bleeding, swelling, skin reactions or illicit drug use. Body temperature should also be taken. Following exposure, covering the patient is important to maintain warmth and prevent hypothermia. Additional blankets may be required.

REFERENCES CIRCULATION

Inspection and palpation are particularly useful tools for assessing circulation. Skin colour and temperature are important indicators of adequate circulation. Well-perfused areas are warm and pink with a palpable pulse and a capillary refill of less than three seconds.

Poorly perfused areas are cool and dusky with a weak pulse. Heart rate, rhythm and blood pressure are also important measures, which can indicate the presence of shock. If the patient has been involved in a traumatic incident it is important to assess for blood loss.

Major areas of internal bleeding include the chest, abdomen, pelvis and long bones. Initial measures to reverse inadequate circulation include gaining intravenous access and the administration of fluids. Depending on the patient’s cardiac rhythm and vital signs, other life saving medications and blood products may be required.

DISABILITY Disability refers to neurological status. It can be quickly measured using the A-V-P-U scale (alert, responsive to voice, pain or unresponsive) or

1. Jarvis C. Assessing respiratory function: Thorax and lungs. In: Jarvis C, Forbes H, Watt E, editors.

Jarvis’s physical examination and health assessment. Australian and New Zealand Edition.

Chatswood: Elsevier; 2012.

2. Thim T, Krarup NHV, Grove EL, Rohde CV, Lofgren B. Initial assessment and treatment with Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med. 2012;5;117-21.

3. Health Education & Training Institute.

A-G assessment [Internet]. Sydney: NSW Government; n.d. [cited 2016 Oct]. Available from: http://www.heti.nsw.gov.au/ResourcesLibrary/A-G-assessment/.

Table 4. Glasgow Coma Scale

Glasgow Coma Scale

Score

Description

Motor

1

No response

2

Abnormal extension

3

Abnormal flexion

4

Flexion withdrawal from pain

5

Localises to pain

6

Obeys commands

1

No response (T if intubated)

2

Incomprehensible sounds

3

Inappropriate words

4

Confused

5

Oriented to person, place and time

1

No response

2

To pain

3

To speech

4

Spontaneous

Verbal

Eye opening

Illustration 2: Tension pneumothorax Right Lung

Left Lung

Compression of opposite lung

Air

Mediastinal shift Pleural membrane

January–February 2018 western nurse |

25

AroundtheGlobe WORLD NEWS

SNOOZE AND LOSE – WEIGHT Sleeping more can reduce cravings for sugary food, according to a leading research university.

Researchers from King’s College London examined the impact of increasing sleep hours on nutrient intake, and found “extending sleep patterns resulted in a 10-gram reduction in reported intake of free sugars compared to baseline levels”.

They also saw “trends for reduced intake of total carbohydrates reported by the sleep extension group”, the college said.

“The fact that extending sleep led to a reduction in intake of free sugars, by which we mean the sugars that are added

SUPER-SIZED CHOCOLATE BAN IN HOSPITALS

English hospitals are restricting sale of super-sized chocolate bars and high calorie bags of sugary snacks from all their outlets this year.

As the UK’s war on obesity continues, National Health Service England chief executive Simon Stevens announced the ban, by imposing a 250 calorie limit on confectionery sold in hospital canteens, stores, vending machines and other outlets.

ANIMALS THERAPEUTIC FOR SCHIZOPHRENIA AND BIPOLAR DISORDER Dogs, rabbits and even rats are helping in the treatment of patients with schizophrenia and bipolar disorder at a UK hospital.

The “animal-assisted therapy” – run as a seven-week course at North Manchester General Hospital – sees animals visiting men with longterm and severe mental health conditions.

Former mental health nurse Sharon Hall, 54, runs the program. She found buying a puppy helped her cope with the loss of her own parents, reported The Huffington Post UK website.

These days that dog, named Moose, a two-year-old King Charles Cavalier Spaniel, is in the program, along with Maggie the Jack Russell, rats, rabbits, guinea pigs and a mouse.

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western nurse January–February 2018

to foods by manufacturers or in cooking at home as well as sugars in honey, syrups and fruit juice, suggests that a simple change in lifestyle may really help people to consume healthier diets,” said principal investigator, Dr Wendy Hall, from the Department of Nutritional Sciences.

This potential weight-loss finding is a more specific extension of the view that not sleeping enough can alter levels of hormones that control appetite.

The sugar-specific observations came from a pilot investigation that ran alongside a randomised controlled trial published in the American Journal of Clinical Nutrition, examining the feasibility of increasing sleep time in adults who slept less than the recommended minimum of seven hours. 

The NHS has detailed the plan, saying “hospital chiefs will have to ensure that four out of five items purchased on their premises do not bust the limit, which is an eighth of a woman’s and a tenth of a man’s recommended daily intake, or lose out on funding ring-fenced for improving the health of staff, patients and their visitors”.

“Unhealthy sandwiches and drinks are also being targeted as the NHS, Europe’s largest employer, takes a lead in tackling the availability of unhealthy food and drinks that are fuelling an obesity crisis,” the NHS statement added.

Mr Stevens said: “The NHS is now stepping up action to combat the ‘super-size’ snack culture which is causing an epidemic of obesity, preventable diabetes, tooth decay, heart disease and cancer. In place of calorie-laden, sugary snacks we want to make healthier food an easy option for hospital staff, patients and visitors.” 

“Occupational therapists have told us that some of the men we have on the course never attend any group activities – yet they have come to, and really enjoyed these sessions,” Hall said.

“The animals can be a real comfort – and the simple physical connection of holding or cuddling an animal can bring profound relaxation even at a time of major mental or emotional anguish. It can be that small ray of light that gives hope for enjoying other things in life too …that connection builds a bridge to helping start conversations with people. It’s a common bond that breaks down barriers.”

A second project targets female patients struggling with depression, bereavement and psychosis. 

STOP CIGGIES ON SCREEN – SAY GERMAN DRUG AUTHORITIES Too many German films show people smoking cigarettes – which encourages young people to start the lethal habit.

That’s the view of German Federal Drugs Commissioner Marlene Mortler, referencing a recent study, which revealed smoking was present in 33 of 39 films nominated for the German Film Prize in 2016 and 2017, or nearly 85 per cent. About 64 percent of films nominated for an Oscar during the same period also showed smoking.

Mediengruppe, translated by German international broadcaster Deutsche Welle (DW).

The commissioner also said she hoped to make the film industry “more aware of their role in influencing the health of their viewing public.”

Despite declining numbers of people smoking in Germany, especially among those aged 18 to 25, the commissioner said smoking is still presented in a positive light in films and on television, for which the industry could take greater responsibility.

“The idea that audiences have this kind of media literacy is reckless and short-sighted,” she said. 

“The more frequently that young people see others smoking in films and on television, the greater the likelihood is that they will pick up a cigarette,” the commissioner told German publisher Funke

RODENTS WRONGLY TOOK THE RAP OVER BLACK DEATH Flea and lice-ridden humans not rats likely caused European outbreaks of the plague – including the infamous 14th century “Black Death”.

Up to 200 million people died in Europe and the Middle East during plague outbreaks, and traditionally, it is thought rats spread the culpable bacterium Yersinia pestis.

But modelling by scientists from Norway’s University of Oslo and Italy’s University of Ferrara, “supports human ectoparasite transmission of plague during the Second Pandemic”, which included the Black Death.

EATING SUSHI LEADS TO 168CM TAPEWORM A 168 cm tapeworm that “wiggled” out of a California man is believed to be the result of eating lots of sushi.

Emergency department doctor Kenny Banh, from Fresno’s Community Regional Medical Center in California, told the Guardian newspaper’s US website that a man walked into his hospital, asking for treatment for a worm.

“We have shown that, in seven out of nine (outbreak) localities, the human ectoparasite model was the preferred model to explain the pattern of plague mortality during an outbreak, rather than models of pneumonic and rat–flea plague transmission,” they said in their study, recently published in Proceedings of the National Academy of Sciences of the USA. Using recent experimental data on human fleas and body lice as “plague vectors”, the scientists developed a “compartmental model that captures the dynamics of human ectoparasite transmission” for the pandemic.

“Overall, our results suggest that plague transmission in European epidemics occurred predominantly through human ectoparasites, rather than commensal rat or pneumonic transmission,” they said. 

When the worm was unravelled at the medical centre, it was 5ft 6in (167.64cm) long. Dr Banh said the patient “was given a deworming pill … no different from the kind generally given to pets”.

Last year, the U.S. Centers for Disease Control and Prevention warned of an elevated risk of parasitic larvae that can grow into tapeworms, found in Pacific Ocean salmon.

Cooking kills the larvae, and sushi is supposed to be flash-frozen to kill parasites, but they can survive in poorly prepared raw salmon, and live in a human digestive tract.

Worms often die and are passed out, or they can also slip out alive. 

But when the patient opened a plastic bag, a “giant parasite was inside, wrapped around a toilet roll”.

Dr Banh said the patient, who reportedly ate sushi daily, told him that during a bout of bloody diarrhoea he had looked down and “thought a piece of his intestine was hanging from his behind”. The man pulled on it and realised it was moving, and must be a worm.

January–February 2018 western nurse |

27

A CRACKING BURGER

6 S E V R E S

Everyone loves quick and easy ways to prepare tasty dishes, so your western nurse is introducing a brand new recipe section – courtesy of working families’ favourite celebrity chef, Jamie Oliver!

JAMIE SAYS: “There’s serves 6 nothing better than a homemade burger. Everyone loves them, they’re

Each edition we’ll provide great new ways to put some zing into family meals – Jamie-style – with an emphasis on fast and easy recipes. That way, our busy members can enjoy the food without spending hours in the kitchen.

easy to make and, if made with quality, fresh ingredients (and not overladen with greasy stuff), they certainly don’t have to be unhealthy, EQUIPMENT LIST especially if served with a salad. Once you’ve mastered this tasty basic recipe, you can make ❏ Tea towel ❏ Plates it your own with different herbs, spices and toppings.

The sky’s ❏ Rolling pin the limit!” ❏ Cling film

❏ Bowl ❏ Sharp knife ❏ Chopping board ❏ Teaspoon

This time round, we bring you Jamie’s spin on a sandwich that’s been reinvented so much in recent years that it now has gourmet status – the no-longerhumble hamburger!

❏ Grill pan or frying pan ❏ Spatula ❏ Kitchen paper

INGREDIENTS 12 Sao crackers 8 sprigs of fresh flat-leaf

JAMIE’S TOP TIPS

Come and learnparsley Jamie Oliver’s hints, tips and shortcuts to cooking delicious 2 heaped teaspoons and affordableDijon meals from scratch! mustard

★ I’d still make this quantity even if it was just for 4 people – wrap the extra 2 burgers in cling film andEdith put them into the freezer for another day.

500g good-quality lean Cowan University – minced beef Joondalup Campus

1 large egg, preferably freerangefrom or organic ★ If you prefer to know exactly what sort of meat CarisPark 14 (Access Deakin Road going into your mince, choose a piece of meat and via Lakeside Drive) sea salt and freshly ground black pepper ask your butcher to make you a fresh batch right Courses run at Joondalup from then and there. When you’re shopping for mince, olive oil March 2, 2018 – June 13, 2018 it’s worth remembering you get what you pay for.

1 cos or round lettuce

For more information and to book: 3 tomatoes jamiesministryoffood.com.au 1 red onion

3 or 4 gherkins 6 wholemeal burger buns 28 |

western nurse January–February 2018

optional: 6 slices of Cheddar cheese

EQUIPMENT LIST Tea towel  Rolling pin 

Plates  Cling film 

Bowl  Sharp knife 

Grill pan or frying pan  Spatula 

Chopping board  Kitchen paper  Teaspoon 

INGREDIENTS 12 Sao crackers 8 sprigs of fresh flat-leaf parsley 2 heaped teaspoons Dijon mustard 500g good-quality lean minced beef 1 large egg, preferably free-range or organic sea salt and freshly ground black pepper olive oil 1 cos or round lettuce 3 tomatoes 1 red onion 3 or 4 gherkins 6 wholemeal burger buns optional: 6 slices of Cheddar cheese

To make your burger: 1 Wrap the crackers in a tea towel and smash up until fine, breaking up any big bits with your hands, and put them into a large bowl.

2 Finely chop the parsley, including the stalks. Add the parsley, mustard and beef to the bowl.

Crack in the egg and add a small pinch of salt and pepper.

3 With clean hands, scrunch and mix everything up well. Divide into 6 and pat and mould each piece into a roundish shape about 2cm thick. Drizzle the burgers with oil, put on a plate, cover and place in the fridge until needed (this helps them to firm up).

To cook your burger: 4 Preheat a large grill pan or frying pan for about 4 minutes on a high heat. Turn the heat down to medium.

5 Place the burgers in the pan and use a spatula to lightly press down on them, making sure the burger is in full contact. Cook them to

your liking for 3 or 4 minutes on each side – you may need to cook them in two batches.

To serve your burger: 6 Wash and dry a few small lettuce leaves, tearing up the larger ones.

Slice the tomatoes. Peel and finely slice the red onion. Slice the gherkins lengthways as finely as you can. Place all this on a platter and put in the middle of the table with plates, cutlery, ketchup and drinks.

7 Remove your burgers to another plate and carefully wipe your pan clean with kitchen paper.

8 Halve your burger buns and lightly toast them in the pan.

Also great with a chopped salad.

ALLERGY INFO wheat, gluten, dairy, eggs, mustard High in fat, sat fat, salt

Per 245g serving energy

fat

saturates

sugars

sodium

1971Kj 471kcal

22g

7.8g

5.1g

787mg

21%

31%

39%

6%

33%

% of an adult’s reference intake.

Typical values per 100g: Energy 805Kj/192kca

January–February 2018 western nurse |

29

ResearchRoundup LATEST AND GREATEST FROM SCIENCE So, they examined rectal swabs given to 300 people, half of whom regularly surf UK waters.

Bacteria resistant to cefotaxime – a commonly used and clinically important antibiotic – were found in 13 of 143 of surfers, or 9 per cent of them.

This compared with four of 130 non-surfers, or 3 per cent, having the super bugs.

Regular surfers were also four times more likely to harbour bacteria containing mobile genes that create antibiotic resistance.

The researchers said this is “significant because the genes can be passed between bacteria – potentially spreading the ability to resist antibiotic treatment between bacteria”.

Professor Kourosh Kalantar Zadeh. Photo: Peter Clarke/RMIT University

‘GAS-SENSING’ PILL DETECTS GUT DISEASE Invasive procedures such as colonoscopies could soon be unnecessary because of a “gas-sensing” ingestible capsule that reveals and measures gut gases.

Such gases can indicate foreign bodies which can be related to diseases and disorders, according to researchers at Royal Melbourne Institute of Technology.

The vitamin pill-sized object, which has been tested on humans, indicates the presence of hydrogen, carbon dioxide, and oxygen, and the information can be sent to a mobile phone.

Professor Kourosh Kalantar Zadeh, study leader and capsule co-inventor, said the trials showed the human stomach uses an oxidiser to fight foreign bodies in the gut.

“We found that the stomach releases oxidising chemicals to break down and beat foreign compounds that are staying in the stomach for longer than usual,” Prof Kalantar Zadeh said.

“This could represent a gastric protection system against foreign bodies. Such an immune mechanism has never been reported before.”

He said another discovery of the research – the findings of which were recently published in the journal Nature Electronics – was that the colon may contain oxygen.

“Trials showed the presence of high concentrations of oxygen in the colon under an extremely high-fibre diet,” Prof Kalantar Zadeh said.

“This contradicts the old belief that the colon is always oxygen free.

“This new information could help us better understand how debilitating diseases like colon cancer occur.” 

SUPER BUGS LOVE SURFERS’ GUTS If you surf or bodyboard regularly you’re three times more likely to have antibiotic resistant E. coli in your guts than non-surfers, according to groundbreaking research.

University of Exeter scientists were aware surfers swallow 10 times more sea water than swimmers and wanted to determine if that meant more colonisation by such super bugs.

30 |

western nurse January–February 2018

Dr Anne Leonard, of Exeter’s Medical School, who led the research – which was recently published in the journal Environment International, and purports to be the first to identify an association between surfing and gut colonisation by antibiotic resistant bacteria – said: “Antimicrobial resistance has been globally recognised as one of the greatest health challenges of our time. We urgently need to know more about how humans are exposed to these bacteria and how they colonise our guts.” 

HYPNOTISING KIDS AGAINST SURGERY STRESS Hypnosis can be used before and after children’s surgery for pain management and reducing nausea and anxiety.

This is the view of the Australian and New Zealand College of Anaesthetists’ biannual publication Australasian Anaesthesia – a peer-reviewed reference for the College’s 6400 anaesthetists and 1500 trainee anaesthetists.

Hypnosis in paediatric care – targeting the likes of children being scared of needles and other hospital procedures – is examined in the publication by University of Adelaide clinical senior lecturer in anaesthesia, Dr Rob Laing, and University of Sydney clinical associate professor, Dr Allan Cyna.

“Children who are anxious or in pain frequently experience hypnosis or trance-like states spontaneously making them highly responsive to suggestion…that can alter perceptions, mood and/or behaviour,” wrote Dr Laing and Dr Cyna, who are senior consultant anaesthetists at the Women’s and Children’s Hospital in Adelaide.

“Hypnosis can enhance analgesia, reduce peri-operative adverse effects such as nausea and allow patients to envisage recovery, healing and return to normal function.”

The college said hypnosis can be used for “suggesting numbness or presence of local anaesthesia, or loss of sensation … (and) suggestions include replacing pain with comfort, laughter, relaxation, strength or confidence”.

Suggesting pleasant smells, hunger and comfort, so a “young patient thinks of strawberries or chocolate or another favourite food when inhaling anaesthetic gases”, is one of several hypnosis methods used.

ANF HOLIDAY UNIT PHOTO COMPETITION Talk to us...

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Editor Mark Olson Phone 08 6218 9444 Freecall 1800 199 145 Fax 08 9218 9455 Email anf@anfiuwp.org.au Web www.anfiuwp.org.au Australian Nursing Federation 260 Pier Street Perth WA 6000 Use the QR code reader on your smartphone to quickly save all of the ANF’s contact details.

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WIN – just for taking snaps at the ANF Holiday Units when you stay with us.

Terrific prizes all through the year.

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We come out to your workplace and you can WIN for turning up to our sessions and getting your photo taken by our staff! 

WIN A HIGH-DEFINITION BLU-RAY COLLECTION FEATURING SOME OF THE BEST MOVIES OF THE 00S Despite much trepidation, the world didn’t end with the advent of the millennium. But Hollywood did become obsessed with zombies and end of the world movies. This collection of films – up for grabs for ANF members only – includes arguably the funniest cinematic offering of the walking undead ever – Shaun Of The Dead (2004). Directionless electronics salesman Shaun (Simon Pegg) and his equally clueless buddy (Nick Frost) are faced with saving their friends and family from becoming a meal for supernatural flesh eaters, after a zombie apocalypse engulfs London. Winner of a number of awards, including the 2004 British Independent Film Awards best screenplay, Shaun is a clever, humorous twist on the genre.

The year 2000 was when Russell Crowe cemented himself as a Hollywood heavyweight with

Gladiator, despite having been nominated for an Academy Award the same year for his 1999 film The Insider. Gladiator – one of the other films in this special collection – won Crow best actor at the Oscars in 2001 for his role as Maximus Decimus Meridius, a Roman general forced into slavery by the corrupt, incestuous heir to the throne, Commodus (Joaquin Phoenix).

Maximus becomes a gladiator, and his prowess in the arena eventually leads him to Rome, the Colosseum and a showdown with Commodus, who has since become the new emperor.

Our collection also features a strong performance from rapper Eminem in the film 8 Mile (2002), which is set in 1995 in the bleak, urban battle zone of Detroit. The story follows the struggles of a young factory

worker who is desperate to make a better life for himself – Jimmy Smith, Jr. (Eminem), better known as Rabbit. Living in a cramped trailer with his deadbeat mom (Kim Basinger), Rabbit’s only outlet is hip-hop, which seems the only way out of the scrap heap.

Academy Award winner Meryl Streep leads the cast of Mamma Mia! (2008), the screen version of the worldwide stage musical phenomenon featuring the songs of ABBA, which rounds off the 00s special Blu-ray collection. Streep stars as Donna Sheridan, the mother to 20-year-old bride-to-be Sophie Sheridan (Amanda Seyfried), who’s on a quest to discover the identity of her father on the eve of her wedding. Three men from Donna’s past return to the Greek island paradise they last visited 20 years ago, resulting in a trip down the aisle no one will ever forget.

To enter the movie competition or the ANF Holiday Unit Photo Competition, just log on to your iFolio.

January–February 2018 western nurse |

31

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