Western Nurse Magazine March April 2018 by ANF WESTERN NURSE MAGAZINE

March – April 2018

incorporating western midwife

31,000 MEMBERS AND GROWING Unrivalled for services and support

LET’S TAKE THE NEXT STEP SEE PAGE 8

western nurse is the official magazine for ANF members in WA

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Secretary's Report March - April 2018 on the

State Secretary Mark Olson

FEATURED

cover

Anzac Anne Leach

ANF: The Future

14 Mark’s Q & A

LET’S TAKE THE NEXT STEP

FAVOURITES

By now you will have received an email from me that links to our ANF Futures Survey – a questionnaire that in a nutshell asks: What do you want from your ANF over the next five years?

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?

22 Across the Nation

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;

26 Around the Globe

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;

30 Research Roundup

Consumables – percentage based on work usage. i.e printer cartridges, paper, pens etc;

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.

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. 

The survey questions cover topics ranging from the key areas of your working conditions that you want to see improved, to the type of ANF app that you want, and what you need from our coming new computer classes. We continue to use this method of asking our members directly for their opinions on our concepts quite simply because it works.

31 ANF Contact Details

The reason you have the best wages and conditions in Australia is because we’ve always listened to you and focused on member priorities when negotiating agreements.

HOLIDAY ANF 20 ANF Holiday Units – book now!

When I first created your iFolio website back in 2005, members told me they loved it, but they wanted even more. My response was to look around and see what key services could be added. So I created your online CPD, and then further shaped it over the years by listening to your views on how it worked for you.

WIN!

My initial conceptualisation of quality, yet highly affordable, ANF holiday accommodation focused on Margaret River. Then members asked whether we could have a separate site in the north of the State. This led to me starting the ANF Kalbarri Holiday Units.

Mark’s Q & A

I have a list of goals and priorities to take the ANF forward, but it is extremely important to me, as it has always been, that the direction I want to take is one you want to follow. Therefore, I’m using the tried and true ANF method: Do the planning, raise the issues and initiatives, and then ask you, our members, what you think, so the result reflects your wishes.

18 ANF Out ‘N’ About

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.

We are in the process of moving your organisation in new directions that will benefit members for many years to come.

28 Jamie Oliver Recipes

6 Internet Watch Mark’s

This is a key moment for the ANF and, therefore, for you, our members.

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

CLINICAL UPDATES

The comprehensive legal and insurance coverage, and the products that are these days just a normal part of your membership, were all launched from our office, but were fine-tuned by your input to deliver services that are unique to the ANF in WA. But I want to provide even more services and benefits in the next five years, and the views you express through the Futures survey will help me to do that.

We've already started shaking things up a bit with a soon-to-be-launched revamped iFolio home page that features an exciting new stand-alone ANF Member Rewards and Offers section. We’ve given you a sneak preview of 16 Enhancing safety in inpatient care that upgrade in this edition of western nurse.

13 Temperature measurement in critically ill patients CHICKEN BREASTS WITH CRISPY POSH HAM

serves 2

21 Ulipristal 24 Diabetic foot ulcers

KEEPING COOKING SKILLS ALIVE

EQUIPMENT LIST ❏ Knife

This is a great way to prepare chicken breasts. The texture of the crisp cooked prosciutto goes brilliantly with the tender

❏ Spatula chicken. Also, bashing the chicken out thinly before you start cooking means it cooks much faster than a regular chicken breast.

❏ Chopping board ❏ Box grater or microplane grater ❏ Cling film

Jamie Oliver Recipes ❏ Frying pan

INGREDIENTS 2 sprigs of fresh thyme

JAMIE’S TOP TIPS

2 x 120g skinless chicken breasts, preferably higherwelfare

★ It’s a good idea to use a non-stick pan for cooking this recipe; it will make your life so much easier.

freshly ground black pepper

★ Pounding out a chicken breast helps it to cook evenly and makes a little chicken go a long way.

1 lemon

★ If you can’t get hold of prosciutto then any kind of very thin ham, such as pancetta, Parma ham or even smoked streaky bacon will work just as well.

4 slices of prosciutto, the best quality you can afford

For now, I encourage you to log in to your iFolio and complete the Futures survey – to help me to give you the best possible ANF into the future. We now have more than 31,000 members, and responsible management of your membership fees has resulted in the ANF now having about $34 million in cash and assets – giving us the ability to fund your campaigns professionally and effectively, and to provide you the best quality services. I know we can go even further, and this survey is the starting point of the next phase. Let's do this together.

olive oil extra virgin olive oil

K EEP I NG C O O K I NG S K I L L S A L I V E

March–April 2018 western nurse |

END of an ERA As world war veterans continue to dwindle in number, we lost yet another brave soul last year – Anne Leach, a highly respected long-serving WA nurse and community service champion. Our Anzac Day feature this year pays tribute to this stalwart of the dawn services that are key to the fabric of the Australian identity.

Anne (foreground) in a hospital in Gaza, Palestine

Anne Leach with Florence Nightingale Medal

Anzac Day services henceforth will be all the poorer with the absence of Anne Leach. Famous for heading WA Anzac marches in her bright lipstick and World War II nurse’s uniform, Anne died on June 4 last year, just 11 days short of her 103rd birthday. After training at what is now Royal Perth Hospital, and stints at the original Perth Children’s Hospital, and the forerunner to Hollywood Repatriation Hospital, Anne Metzke (her maiden name) embarked from Fremantle for overseas service in February 1941, aged 26. She ended up in the Middle East with the 2/7th Australian General Hospital – serving in Palestine, Syria Anne met Vernon Leach in Gaza, and married him in Perth in 1943

western nurse March–April 2018

Anne outside a war hospital in the Middle East

and Egypt, where extreme heat and cold battered both nurses and their patients, in the tents that served as hospital and home. Anne and her colleagues had no respite from work. Battles including those of El Alamein meant they had to deal with up to 1000 patients at a time. Amongst all the bloodshed and horror, love still managed to bloom – in Gaza she met Captain Vernon Leach of the 2/16th Battalion. On February 18th 1943 Anne returned to Perth and married Capt. Leach, and from then until the end of the war in 1945 she nursed at the 110th Australian General Hospital (now Hollywood Hospital). Anne was Senior Sister in charge of the Orthopaedics Ward, and also Night Superintendent, retiring from military service at the end of the war with the rank of Captain. Eleven years after the war’s end, and four children later, Anne and Vernon – who was by then resident Magistrate of the Gascoyne – were living in Carnarvon when tragedy struck, and Vernon drowned while fishing at the Blowholes on Quobba Station.

Anne (on the left) with other nurses in the Middle East

Anne subsequently returned to their home in Perth and continued her many community service roles, including decades on the Red Cross’s Divisional Council and Divisional Executive. She was also 32 years on the Blood Transfusion Committee – with the Donor Lounge named after her in 1994. A Red Cross Divisional Commandant for 12 years, Anne was also on the Executive Council of the Silver Chain association, and was President of the Royal Flying Doctor Service Ladies Auxiliary, Divisional Commissioner of the Girl Guides, and Returned Sisters Sub-branch President four times.

Anne at the front of an Anzac Day parade in Perth

Anne’s daughter Margaret Burridge told western nurse that even after all those roles her mum still found energy for her original passion. “Over the years she was 'nurse' at Legacy’s children’s Busselton camp, and she was also often Rottnest Island nurse during school holidays,” Margaret said.

The International Committee of the Red Cross awarded Anne the prestigious Florence Nightingale Medal in 1983, and the following year she received an Order of Australia medal. Last year, Anne was featured in western nurse when participating in a service commemorating the 75th anniversary of the Vyner Brooke tragedy, where 41 army nurses, including five from WA, died during events near, and on, the Indonesian island of Bangka in World War II. Anne never missed an Anzac service from the end of World War II till her death in 2017 – merely a month after attending her final Anzac service in Perth. RIP.  Anne, aged 102, with Governor Kerry Sanderson at last year's service for the 75th anniversary of the Vyner Brooke tragedy

March–April 2018 western nurse |

InternetWatch AMAZING APPS + ONLINE NEWS

Cat Alone Who says cats can’t see screens or navigate devices? It’s time for moggy to have a go. The idea is to let your cat attempt to chase and catch various objects on the screen. Of note is the irresistible laser pointer. Or try out the ladybug, butterfly or cockroach. 99 cents or Free with ads

Optus Stadium Unless you’ve been living under a rock you’ll be aware that the new (Perth) Optus Stadium is running at full steam, having already hosted sporting events and concerts. Here you can peruse the food and beverage options, or view maps to help you find your seats and plan your journey. Free

Transperth In addition to using Transperth for your day-to-day public transport needs, how better to organise your visit to Optus Stadium than with this app? Plan your journey and view possible disruptions in real time. Access all your Smartrider information and balance in one spot. Free

Google Arts & Culture Here’s a collaboration between Google and about 1200 international museums. Discover exhibits and collections curated by experts from the most famous museums around the world. Find your favourite artworks, create your own collections and share them with friends. Free

VR Guide: 2018 Tour de France While we’re on the sports theme, there’s a bike race coming up - the Tour de France! This is a GPS and Virtual Reality guide to the cycling events starting in July of 2018. Follow the riders and stages throughout the tour and throughout France. Free

The New York Times Fancy a daily dose of the Big Apple from the NYT? Subscribe here for daily news and award–winning journalism. There are plenty of subscription options; free with limited access, basic, and add–on features such as their famous crossword and the bestseller book list. Various prices

Perth Glory If you’re a Perth Glory fan then this is a must-have app for you! Access the live match centre and all the latest breaking news. Plus find out how to get your Perth Glory membership, tickets and merchandise. Get to know your favourite Perth Glory player and find all the stats you need to know. Free

FIFA Keep up to date with live football scores from across the globe, as well as breaking news, videos and highlights, interviews and features. Get live coverage of every FIFA Tournament, including the World Cup that’s just around the corner. Have the beautiful game with you, any time, any place. Free

western nurse March–April 2018

FIVESuperSites Antiques Roadshow Here’s a great site based on the hit BBC TV show. It’s the one where punters bring in their treasures and have them scrutinised for origin, pedigree and value. Have a look at when a fancy vase is declared a fake! There’s even the script from the first episode of Dr Who. https://www.bbc.co.uk/ programmes/b006mj2y

Cat Bounce So lame it’s fun. There’s nothing fancy about this site. It’s a screen of cats bouncing around. And you can click on them so they move even faster. A genius time waster and quite hypnotic. http://cat-bounce.com/

Koalas to the max Adorable, stylish and inventive. Koalas to the max is an interactive experience. Simply move your cursor over the image to begin. Keep at it, and before you know it a gorgeous koala will emerge. http://www.koalastothemax.com/

Meetup Meetup brings people together in thousands of cities. It brings people together to do, explore, teach and learn the things that interest them. Find people that have similar interests. Or start up your own group! Also a website. Free

musical.ly Create awesome short videos with editing tools and share with the world. With musical.ly, you can use their music and sound library, stickers, filters and more for your videos. It’s a great way for kids to SMS and share music and it can all go through the parent phone – meaning you can keep an eye on the content. Free

MyUV Just because summer has been and gone it doesn’t mean we can disregard ultraviolet radiation, which is known as a major cause of skin cancer. The clever crew at MyUV want to provide us with the knowledge and tools to read the UV Index, allowing us to be ‘SunSmart’. http://www.myuv.com.au/

Rotten Tomatoes Rotten Tomatoes is a highly regarded guide for movies and TV shows. Reviews are aggregated from professional critics in the form of the ‘Tomatometer’ score, which represents the percentage of positive professional reviews. https://www.rottentomatoes.com/

AUDIT. Your CPD is due by MAY 31

Don't risk your registration by failing a CPD audit! Of course, if you’re using your iFolio to knock off your required Continuing Professional Development (CPD) hours, the thought of an AHPRA audit is no issue. But to make life even easier, we have a feature on iFolio that allows you to create a complete CPD audit log. Your iFolio is easy and it's free. Use it to meet your CPD requirements!

March–April 2018 western nurse |

THE FUT

Just two decades ago, the ANF in WA had only 7500 members, did not own any property, and WA nurses had suffered a decade of lost conditions.These days we have 31,000-plus members with the best wages and conditions nationwide. And responsible management of your fees has paid off handsomely for our members. We now have $34 million in cash and assets that will secure the future of your ANF – enabling us to properly fund your campaigns and provide you a list of services unequalled by any other industrial or professional organisation in Australia. And all that with no membership fee increase in 14 years. Now, State Secretary Mark Olson is asking you to be part of the ANF moving into the next phase.

The ANF has continued to grow significantly in membership numbers, assets and services in the past 15 years – while many other industrial organisations are struggling for their very survival.

Topics on the survey include key areas of your working conditions you want improved, through to the type of ANF app you want, and what you need from our coming new computer classes.

But State Secretary Mark Olson is not content to rest on past successes, and has a list of goals and priorities to take the ANF forward, to help keep prosperity and innovation in your organisation into the future.

"I believe this survey is really important, because your feedback in previous years has helped influence how we move forward with the goals and priorities of the ANF,” Mark said.

As part of this planning, Mark has designed the ANF Futures Survey to gauge your priorities amongst those on his list, and he encourages you to log in to your iFolio and be part of the ANF’s move into the next phase.

western nurse March–April 2018

“I designed services such as your iFolio, the online CPD, the ANF Holiday Units, and the legal coverage you have, but without your input I could not have fine-tuned these features as much as I have, to be exactly what you want. “Now, we want to deliver even more in the next five years, and this

In this special feature, western nurse is giving you a sneak preview of some of the first steps of the ANF’s new direction – the soon-to-be-launched revamped iFolio home page.

survey will definitely help us do that." In this special feature, western nurse is giving you a sneak preview of some of the first steps of the ANF’s new direction – the soon-to-belaunched revamped iFolio home page, which includes our brand new comprehensive members’ offers section. “We often hear from members that they want more special deals from retailers,” Mark said. “So we put some months into researching service providers comprehensively before creating our new ANF Member Rewards and Offers section. “We’re pretty excited about the benefits that you will be able to access, including special mortgage and credit card deals, best-price

online appliance shopping, and discounts on groceries, manchester, stationery, giftware, furniture, and optometry services. “There are also offers on car leasing and private insurance, and we’re even currently negotiating with a major utilities supplier to get a better deal for ANF members. And wherever we can, we offer options on similar businesses, so you get even more choice.” Mark said the ANF is also continuing to buy new holiday units and improve our existing ones, as well as constantly finding ways to make your holidays even better. “One example is our brand new ANF Holiday Unit Member Offers at Margaret River. That initiative came about after spending time talking March–April 2018 western nurse |

to local businesses to find out what they could do for you, our members,” he said. “Now when you stay at the ANF Holiday Units in Margaret River, you’ll not only get your usual welcome email from us about the accommodation, but you’re also getting a list of local businesses giving generous discounts to ANF members – with the likes of gourmet food, restaurant meals, wines from a boutique winery, and adventure tours all on offer.” We at western nurse have also been given the word by Mark to look out for even more ways to make life better for members. You may have noticed that many of the ads we’ve been running from private advertisers in recent months have special offers if you belong to the ANF. We’ve also set up more opportunities for members to win prizes, including the ANF Holiday Unit Photo Competition and in the Out ‘N’ About section, on top of the usual prizes in the magazine.

ANF MEMBER OFFERS – Margaret River THE LARDER

Mouth-watering readymade gourmet meals are our specialty – created onsite by owner-chef, and MasterChef top 50 finalist, Siobhan Halse. Vegetarian and gluten-free options are available, and our weekly meal and hamper menu is on our website. 2/99 Bussell Hwy, Margaret River (opp. Margaret River visitor centre) (08) 9758 8990 Larder.biz

KINGFISHER INDIAN RESTAURANT/CAFE

Kingfisher Indian Restaurant/Cafe brings the exotic tastes of India to Margaret River, offering high-quality Indian food in a modern cafe setting with views overlooking a park. With 4 star reviews on Trip Advisor, dine in, BYO and take away options.

ANF MEMBER OFFER:

10%

DISCOUNT

Plus free delivery directly to your ANF Margaret River unit – perfect after a day of touring wineries

ANF MEMBER OFFER:

10%

DISCOUNT

On dine-in or takeaway – free delivery to your ANF Margaret River unit

Shop 15 & 16, Woolworths Centre, Margaret River (08) 9758 8509

ROBERT OATLEY VINEYARDS MARGARET RIVER

The Robert Oatley property is one of the most spectacular cellar doors in the entire region. Featuring over 1000 rose bushes and the legendary ‘chick on a stick’, it is a landmark to locals and tourists alike. With numerous award winning wines and a brilliant new menu, Robert Oatley is a must see destination. Cellar Door, 3518 Caves Road, Wilyabrup WA 6280 (08) 9750 4000 robertoatley.com.au

MARGARET RIVER TOURS

Visit a selection of the following iconic and boutique wineries daily for the chance to taste truly great wines from: Stella Bella, Cape Mentelle, Leeuwin Estate, Voyager Estate, Watershed, McHenry Hohnen, and Vasse Felix. Perfect for wine and food lovers – includes plenty of gourmet samples.

ANF MEMBER OFFER:

20%

DISCOUNT

On our wide range of wines, including many trophy and gold medal winners or, 1 FREE magnum of wine ($60 value), with every 6 bottles of wine purchased

ANF MEMBER OFFER:

10%

DISCOUNT

On any tour

0419 917 166 margaretrivertours.com

COLONIAL BREWERY CO

Colonial Brewing Company is an award winning microbrewery situated in the beautiful Bramley Brook Valley, only 8km NE of Margaret River. Set on 30 hectares, the whole family will love the sublime views, kids’ playground, tasty menu, and of course a fantastic range of locally produced beers – including several award-winners.

ANF MEMBER OFFER:

10%

DISCOUNT

Excludes daily specials

56 Osmington Road, Margaret River (08) 9758 8177 colonialbrewingco.com.au

SURF N DIRT ADVENTURE TOURS

Surf N’ Dirt Adventure tours showcase how incredible the Margaret River Region really is, guiding you through the exciting range of outdoor activities available – whether it’s mountain biking, kayaking, surfing, scenery and wildlife, or enjoying the wineries, breweries and gourmet food producers of the Margaret River Region, we’ve got it all covered.

ANF MEMBER OFFER:

10%

DISCOUNT

focusing our efforts on other workplace issues you've told us really matter to you, including ensuring those bullying performance appraisals meetings you hate so much stay out of public hospitals. Mark said life at the ANF hasn’t always been so rosy. "We've come a long way since my early days as State Secretary, when the ANF had just 7500 members, we owned nothing, and we had so few savings that I was checking the bank balance weekly, trying to figure out if we'd have enough money to pay our staff their wages," he said. “Back then we just started pushing forward – trying to improve from month to month, step by step, always keeping our members as our sole focus.

“We fought relentlessly for better pay and conditions, and created new services that had never been seen at the ANF, or, for that matter, in other unions before. And WA’s nurses and midwives really got behind us.”

For bookings call Paul on 0458 191 469 or visit: surfndirtadventuretours.com.au

Of course, all this has been happening behind the scenes while the ANF has been continuing our industrial role of fighting pay battles for our 31,000 members – which has seen them get the best wages and conditions nationwide in their professions. We've also never ceased

Mark said this joint effort meant by 2003 the ANF in WA was attracting thousands of new members on top of the 7500 he started out with.

PERFECT FOR SHIFT WORKERS

We're there when you need us, at short notice, seven days a week and overnight – not just normal daycare hours.

DAYCARE to the

MAX

Providing personalised care for children from 6 weeks old.

0407 890 590

daycaretothemax@amnet.net.au Easy access to major hospitals in the metro area from our location near the corner of Reid Highway and Wanneroo Road. Registered with Nature Alliance.

10 |

western nurse March–April 2018

State Secretary Mark Olson has a list of goals and priorities to take the ANF forward into the future. He has designed the ANF Futures Survey to gauge your views for the next phase. "Now, we find ourselves in 2018 with more than 31,000 members, and $34 million in cash and assets that is there to fund your campaigns, provide inexpensive holidays at our units, and to get you the services you deserve," he said. “And that's without having raised our fees since 2004, which is something we're really proud of. “It’s time now to push forward again, to do what we’ve done so well in the past together – assess what best suits ANF members, and go out and do exactly that.” 

AUTUMN WINTER COLLECTION O U T N OW

ANF MEMBERS RECEIVE

OFF

When you spend over $100

ANF20 Present this voucher instore or enter promo code ANF20 at online checkout to redeem this offer

One time use only. Valid until 30/06/2018 Excludes rewards club discount

We s p e c i a l i s e i n c o m f o r t a b l e a n d s t y l i s h s h o e s for hard working feet.

paulcarroll.com.au

March–April 2018 western nurse |

JUST SAY NO

The Minister has abolished appraisals. Don't let anyone bully you into doing them no matter what they call them. If you feel you are being bullied or harassed into doing an appraisal call the ANF right away.

12 |

western nurse Marchâ&#x20AC;&#x201C;April 2018

Temperature measurement in critically ill patients Box 1. Who are critically ill patients? Frenulum of tongue Sublingual pocket

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

Temperature is one of the vital signs routinely measured to assess physiological function and monitor response to treatment. Specifically, it is used to determine hyper and hypothermia. Critically ill patients commonly experience altered thermoregulation and accurate temperature measurement in this patient population may be difficult. Specific measurement techniques are required to guide appropriate therapeutic interventions.

THERMOREGULATION Core temperature encompasses the range of temperatures that occur deep within the structures of the body (see Table 1).1 It is maintained through a negative feedback loop controlled by the hypothalamus, which stimulates vasodilation in response to elevated temperatures, and shivering following hypothermia.1 It is also influenced by a range of other factors including diurnal variation, cellular metabolism, exercise, ambient (room) temperature, and age.1 A normal body temperature is essential to optimise physiological functions such as enzymatic activity and chemical reactions.1 Extreme hyper and hypothermia are both medical emergencies that require intensive care interventions to prevent end organ failure. Table 1. Core body temperature ranges.1 Temperature range

Condition

>41.5

Extreme hyperpyrexia

40-41

Hyperpyrexia

38.4 – 39.9

Hyperthermia

37.5-38.3

Fever

36.5-37.5

Normal body temperature

34-35.9

Mild hypothermia

32-33.9

Moderate hypothermia

<31.9

Moderate – deep hypothermia

NON-INVASIVE TEMPERATURE MEASUREMENT There are many ways to measure temperature in critically ill, stable patients (see Box 1). Non-

Illustration 1. Correct placement of oral temperature probe

invasive temperatures are obtained from the tympanic, temporal artery, axillary, and oral routes. Despite the prevalence of measurement devices in many clinical settings, tympanic and temporal artery temperature measurements are not accurate and are not recommended for any patient population where accurate body temperature will influence clinical decision making.1,4 Axillary and oral temperatures are preferred as a systematic review of available evidence has demonstrated that their results are variable but clinically acceptable.2 Axillary temperatures are measured by placing a temperature probe under the arm pit with the arm adducted to the chest wall. For an oral measurement, the probe must be placed in the posterior sublingual pocket (see Image 1). Non-invasive measurements may be influenced by ambient temperature, blood flow, sweat, placement of the probe, mouth breathing, and the length of time the probe is left in situ.1

INVASIVE TEMPERATURE MONITORING Continuous invasive temperature monitoring is indicated for all critically ill, unstable patients and should be recorded every hour.1 Invasive techniques include rectal, oesophageal, urinary catheter, pulmonary artery, or brain probes.1 If used, rectal probes need to be positioned at least 4cm inside the rectum. However, rectal thermometry has been demonstrated not to correlate well with core body temperature.1 More invasive techniques such as urinary bladder or oesophageal temperatures may be an alternative.1 These methods are equivalent to intra-vascular and brain thermometry.1 Unfortunately, they are more difficult to insert than a rectal probe and require greater time and expertise. They may also be affected by external factors such as fluids passing through the oesophagus or bladder.1 The most invasive measures, pulmonary artery and brain thermometry, are highly accurate but associated with a significant risk of complications. They are only used when clinically indicated and must be removed as soon as no longer required.1

Critically ill, unstable patients are those with a significant threat to life. They may have haemodynamic, respiratory, thermoregulatory, or neurological complications. This includes patients with multi-organ dysfunction, traumatic injuries, sepsis, and burns. Hourly invasive temperature monitoring is recommended.1 Stable patients are those who may be unwell but are not experiencing any immediate threat to life. They do not require intensive monitoring. For these patients, non-invasive temperature monitoring is recommended every four hours.1

ADDITIONAL CONSIDERATIONS Most thermometers are multi-patient use and must be cleaned between patients (based on local infection control procedures). The presence of hyper or hypothermia may indicate the need for further assessment and interventions, such as screening for sepsis and the commencement of antibiotics. Further, evidence suggests that the use of nonsteroidal anti-inflammatories and paracetamol are independently associated with 28-day mortality in adults with sepsis.3 Therefore, antipyretic medications for fever management should only be administered following consultation with an appropriately trained medical professional.1

REFERENCES 1. Rolls K, Wrightson D, Schacht S, Keating L, Irwin S & Walker S (2013) Temperature Measurement for Critically Ill Adults: a clinical practice guideline; Agency for Clinical Innovation Version 1; Chatswood, NSW, Australia. ISBN: 978-1-74187976-6. 2. Jefferies S, Weatherall M, Young P, Beasley R. A systematic review of the accuracy of peripheral thermometry in estimating core temperatures among febrile critically ill patients. Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine. 2011;13(3):194. 3. Lee BH, Inui D, Suh GY, Kim JY, Kwon JY, et al. Association of body temperature and antipyretic treatments with mortality of critically ill patients with and without sepsis: multi-centered prospective observational study. Crit Care. 2012;16(1):R33. 4. Niven DJ, Gaudet JE, Laupland KB, Mrklas KJ, Roberts DJ, Stelfox HT. Accuracy of peripheral thermometers for estimating temperature: a systematic review and meta-analysis. Ann Intern Med. 2015 Nov 17;163(10):768-77. doi: 10.7326/ M15-1150.

March–April 2018 western nurse |

Mark’s

Your Continuing Professional Development (CPD) hours are due to be completed by the end of May. You can lose your registration if you’re audited by the Australian Health Practitioner Regulation Agency and haven’t fulfilled your CPD requirements. Below are some tips to help you meet your obligations. For more detail, the ANF will be visiting Perth suburbs in April and May to provide free 30-minute Audit Without Tears talks. Q: When are my CPD hours due each year? A: May 31. Q: Where can I find and complete CPD modules easily? A: Your ANF iFolio has hundreds of quickly accessible Clinical Updates (CUs) across a range of topics that fulfil your AHPRA obligations. Your western nurse magazine also contains CUs. Q: How much does it cost to do ANF CPD units? A: You don’t pay anything! CPD units are included as part of your local ANF membership in WA. Q: Is there an easily accessible evidence record of my CPD I can show AHPRA if need be? A: Your iFolio has a convenient downloadable evidence record that lists everything AHPRA asks for on CPD. This includes your identified learning need, activity undertaken and reflection on the activity. The ANF evidence record also details other relevant CPD activities on it, not just iFolio modules. If you attend ANF seminars, education sessions or legal talks, these are automatically updated on your ANF iFolio, so you receive CPD credit you can show AHPRA, all in one location.

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Q: I’ve been charged by the federal office for CPD units. Why is that? A: You signed up to the wrong provider! Save your cash – do your CPD with us, it’s free in WA with your local ANF membership. Q: What other types of activities are valid as CPD apart from ANF iFolio modules and activities? A: Tertiary courses and other accredited study, conferences, short courses and workshops, as long as they are recognised to relate to your work, can count towards CPD and be recorded on your iFolio. Q: How many CPD hours am I required to complete annually? A: You need to do a minimum of 20 CPD hours yearly, even if you work part-time or are on maternity leave. If you are also a midwife you need to do a further 20 hours, although some CPD hours can count towards both nurse and midwife registrations. Q: I’m a nurse or midwife practitioner. How many CPD hours do I need? A: You need an additional 10 hours on top of the CPD hours needed for your normal registration. Q: I have scheduled medicines endorsement. How many CPD hours do I need? A: You need an additional 10 hours on top of the CPD hours needed for your normal registration. Q: I’m on maternity leave, long service leave or other leave. Do I still need CPD? A: To retain your registration, yes, you need to complete normal CPD hours.

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.

AUDIT WITHOUT Book on TEARS iFolio Why?

• The registration year is almost over (ends May 31) • Nurses & midwives are now randomly audited throughout the year • Know your responsibilities under National Registration • ANF iFolio–a big help with your annual CPD requirements • Don't risk your registration with AHPRA!

Where?

How?

Joondalup, Rockingham, Gosnells, Melville, Midland and also hospital visits - we'll notify you when we're coming. There’s also an online Video Tutorial in case you can’t get to a session!

Log on to iFolio and click 'Courses' to see locations and times that suit you. Choose a venue, make a booking! Heaps of venues makes it easy for everyone to come along and learn (and earn some CPD time).

ANF LEGAL TALKS 30-minute legal talk

Questions? email: legaltalks@anfiuwp.org.au phone: 6218 9444

Legal talks are free, informative and you'll earn CPD time too.

March–April 2018 western nurse |

Enhancing safety in inpatient care: alternatives to the use of restraints Read this article and complete the online quiz to earn 1 iFolio hour

The use of restraints in inpatient environments has concerned healthcare professionals for several decades.1 In settings such as mental health, the Emergency Department (ED), and acute aged care, many advocates argue that restraints have the potential to cause harm and injury. General recommendations suggest that restraints should be used only as a last resort, and that additional documentation is required prior to and during use in all settings.2 Nurses face many challenges when caring for individuals who are at high risk for behaviour that may result in harm to themselves or others. Despite the controversy, restraints are often deployed as a strategy of last resort.3 In order to embrace a restraint-alternative method of care, preparation and de-escalation in crisis situations is required.4 By establishing effective therapeutic relationships and practicing a patient-centred approach to care, nurses can minimise the use of restraints throughout inpatient care settings.

HOW TO PROVIDE RESTRAINTALTERNATIVE CARE IN AN INPATIENT ENVIRONMENT It is a nursing priority to understand the personal and medical history of each patient and establish a therapeutic relationship. The goal is to identify risk factors that may lead to the potential use of restraints, and to create individualised care plans for ongoing assessment and management. Multidimensional strategies may be required to de-escalate crisis scenarios, ensuring patient safety and mitigating the risk of harm for everyone involved. Step 1: Establish a therapeutic relationship Establishing a therapeutic relationship between patients and staff has been demonstrated to contribute to a reduction in disturbed or aggressive behaviour in healthcare facilities.4 Encouraging the foundation for trust and positive communication between the patient and their caregiver is important, and a nurse’s ability to explore emotions, thought content, and behaviour in the development of a plan of care is critical.4 When there is trust between

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patients and caregivers, calming techniques, de-escalation, and crisis management strategies are more likely to be effective.4 Step 2: Assess the risk, and assess the individual Nurses are well placed to use their knowledge of a patient’s diagnosis and history to identify risk factors that may lead to the use of restraints.4 These factors can be classified as predisposing or precipitating risk factors. Predisposing risk factors are pre-existing behaviours or individual characteristics that may increase the likelihood of harm to oneself or others, such as advancing age, cognitive changes, or challenges in communication. Precipitating risk factors are environmental or situational changes, which threaten an individual’s ability to cope. They include a new admission to a health care setting, falls, or the influence of medications (see Table 1).4 Early identification of ‘patients at risk’ of adverse behaviour helps to ensure that practitioners can anticipate crisis events and select appropriate restraint-free management strategies before they are required.4 Step 3: Create and maintain an individualised plan of care Individualised care plans are designed to meet the unique needs of each client. It is important that nurses, multidisciplinary care teams, individuals, and families all participate in the

development of new plans. The client’s level of orientation, and their physical and functional ability must be considered to create strategies that will resolve potential issues through the use of distraction and diversion, explanation and reminders, or comfort and positioning, rather than restraint.4 These care plans require continuous monitoring and re-evaluation, so that symptoms requiring further investigation can be identified, and prevention and management interventions be altered.4 A structured or standardised approach to this review is helpful, as tools or protocols will help to guide the team to a multi-factorial review. It is this process that will alert nurses to any immediate needs for an alternative strategy that prevents or de-escalates a crisis situation.4 Step 4: Implementing multi-component strategies for preventing the use of restraints There are several types of strategies that may be deployed to prevent the need for restraints in inpatient settings. These include explanation and reminders, distraction and diversion, camouflage, and comfort and positioning (see Table 2).4 Often, a multifaceted approach is required to keep at-risk patients away from crisis situations and ensure safety for all individuals involved in the care.4

Table 1: Risk factors that can lead to the potential use of restraints4 Predisposing risk factors 1. Advanced chronological age 2. Cognitive changes (e.g. trauma, moderate-severe dementia) 3. Decreased/inability to communicate (e.g. aphasia) 4. Incontinence 5. A history or fear of falling 6. Increasing dependence 7. Psychiatric conditions 8. Responsive behaviours (e.g. aggression, history of violence, anxiety, restlessness or wandering, risk of injury to self or others) 9. Sensory impairments (e.g. deafness, blindness)

Precipitating risk factors 1. Cognitive changes (e.g. delirium, dementia, an inability to remember instructions) 2. Decreased mobility 3. Environmental factors (e.g. music, noise, temperature) 4. Falls 5. Medication influences (e.g. alcohol abuse, polypharmacy, benzodiazepines, new medications, psychoactive agents, unanticipated side effects) 6. Multiple admissions 7. Surgery or procedural interruptions 8. Unmet needs (e.g. anxiety, fear, hunger, thirst, toileting)

Table 2: Non-restraint strategies to prevent treatment interference in adults4 Strategy

Examples and prompts

Explanation and Reminders

• Frequently and repetitively explain what is happening • Visualise, with guidance, the devices in the environment • Share written reminder

Distraction and Diversion

• • • • • • • •

Camouflage

Comfort and Positioning

Utilise activity aprons Perform and utilise occupational therapy consultations Utilise and share writing tools Utilise and share reading materials Utilise and share gadgets Utilise and share photo albums Utilise and share music, television, and other media Utilise and share empty tubing/packaging

• Provide long sleeved gowns • Ensure the availability of generous tape, ace wrap, and/or dressings • Provide commercial device-protective, cushioned sleeves or IV site guards • Provide abdominal binding • Keep tubing out of the visual field • Regularly maintain positioning and the availability of specialty mattresses • Deploy tube stabilisation • Employ augmentative communication • Employ analgesia and sedation (as indicated following complete patient assessment) • Introduce aromatherapy and massage and touch therapies

CONCLUSION Reports of injury and death from the practice of restraint continue to emerge.4 By focusing on assessment, prevention, restraint-alternative de-escalation, and crisis management, their use can be minimised or eliminated entirely.4

REFERENCES 1. Brophy et al. (2016). Consumers and their supporters’ perspectives on poor practice and the use of seclusion and restraint in mental health settings: results from Australian focus groups. International Journal of Mental Health Systems 10:6. DOI: 10.1186/s13033-016-0038-x. 2. Chapman, R., Ogle, K. R., Martin, C., Rahman, A., McKenna, B. and Barnfield, J. (2016), Australian nurses’ perceptions of the use of manual restraint in the Emergency Department: a qualitative perspective. J Clin Nurs, 25: 1273– 1281. doi:10.1111/jocn.13159 3. Muir-Cochrane, E. C., Baird, J. and McCann, T. V. (2015), Nurses’ experiences of restraint and seclusion use in short-stay acute old age psychiatry inpatient units: a qualitative study. J Psychiatr Ment Health Nurs, 22: 109–115. doi:10.1111/jpm.12189 4. Registered Nurses’ Association of Ontario (2012). Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, ON: Registered Nurses’ Association of Ontario.

March–April 2018 western nurse |

ANF Out ‘N’ About

King Edward Memorial Hospital Kristen Rowe and Breda Calderwood

Fiona Stanley Hospital Soumya Saly Jose, Tresa Verghese, Daphne Kirsten and Kelly How

Hello to all our Out ‘N’ About readers – looks like this section is getting popular because we’ve been getting calls from nurses and midwives wondering when we’re going to get to their workplace so they can get into western nurse! Don’t worry, we’ll be doing loads of visits this year. As we said last edition, we selected 75 lucky members as prize winners from last year’s photos, so those who scooped up a prize should be receiving their terrific ANF rewards soon, if not already. And for those who haven’t yet won, make sure you have some of our brilliant ANF products around when our ANF officers are snapping you, because the 2018 competition is now in full swing. Remember we also give you loads more chances to win prizes throughout the year, with the ANF Holiday Unit Photo Competition. That’s the comp where we award 10 prizes each month for the best snaps at one of the ANF Holiday Units, either in Margaret River or Kalbarri, and at the end of the year we have additional major prizes such as laptops, iPads and holidays. See your iFolio for more details. Royal Perth Hospital Agnes Malek and Antonia Hart

Fiona Stanley Hospital Stephanie Burgess and Alison Devenish

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See you soon at our ANF visits!

Joondalup Hospital Georgia Rowbottam, Jenny Koteka and Kiri Huxford

Fiona Stanley Hospital Diana Player, Amanda Bath and Maree Benson-Lidholm

Rockingham General Hospital Cassandra Robertson, Melissa Williams and Justine Tinsley

Royal Perth Hospital Rebecca Montgomery and Karen Payne

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

March–April 2018 western nurse |

KALBARRI PERFECT RIGHT NOW SPECIAL FAMILY EVENT: Kalbarri Canoe and Cray Carnival Friday June 1, 2018 - Sunday June 3, 2018

From less than $ 50 per night.*

BOOKINGS AND INFORMATION ON YOUR IFOLIO

ifolio.anfiuwp.org.au

* Rates are higher for Easter, the two weeks prior to school holidays and during school holidays. Please see terms and conditions for full pricing list.

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Ulipristal Table 1. Drugs interactions with ulipristal.3 Drugs which interact Examples with ulipristal

Clinical implications

Progestogens

· Levonorgestrel · Norethisterone

Delay commencing progestogen-containing hormonal contraception until five days after administration of ulipristal.

Drugs that induce CYP3A4 response

· · · · · · · · · · · ·

Consider alternative form of emergency contraception such as insertion of a copper intrauterine device (IUD).

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

Generic name: Ulipristal acetate Brand name: EllaOne (indication: emergency contraception), Esmya (indication: fibroids) Drug class: Drugs for contraception

INDICATIONS Ulipristal is a new contraceptive agent available in Australia. It is used for emergency contraception, to prevent pregnancy following unprotected sexual intercourse.1 It has also been approved for the management of fibroids.2

MECHANISM OF ACTION Ulipristal is a progesterone receptor modulator. It binds to progesterone receptors as an antagonist and partial agonist to limit the release of luteinising hormone and prevent or delay ovaluation.1,3 By inhibiting progesterone, ulipristal also prevents the growth of uterine fibroids and may reduce their size over time.2

PRECAUTIONS As it is a newly approved product, there is limited available evidence regarding safety, efficacy, and adverse effects.1 To date there have been limited cases of women who have continued through to childbirth after ulipristal has failed to prevent pregnancy. Of two documented cases, one resulted in a normal live birth. The second child born had significant complications.1 Therefore, use in pregnancy is suspected to increase the risk of birth defects.1,3 Use of ulipristal while breastfeeding will result in excretion into the breast milk.1,3 Drug manufacturers recommend avoiding breastfeeding for seven days following administration.3 Caution is required when using ulipristal with other medications including progestogens and drugs that induce cytochrome enzymes such as CYP3A4, as they may reduce the effectiveness of the contraception (see Table 1).3

ADVERSE EFFECTS Common adverse effects of ulipristal include nausea, abdominal pain, dysmenorrhoea, breast tenderness, headache, and dizziness.

Aprepitant, asunaprevir Bosentan Carbamazepine, corticosteroids Dabrafenib Efavirent, enzalutamide, etravirine Lumacaftor Nevirapine Phenobarbitone, phenytoin Rifabutin, rifampicin, ritonavir St. John’s wort Tipranavir Vemurafenib

Menorrhagia, vomiting, and spotting may also occur.3 Use of the medication may also result in the next period arriving earlier or later than expected.1,3 Box 1. Comparing new and old emergency contraceptives.3,4 Ulipristal is similar to levonorgestrel, another emergency contraceptive available in Australia. A double-blind study has compared the efficacy of the two agents based on how long contraception was taken after unprotected sex. Within the first 24 hours of unprotected sex, the use of ulipristal resulted in pregnancy in 0.9% of cases, while levonorgestral resulted in pregnancy in 2.5% of cases. Within 120 hours (5 days) of unprotected sex, pregnancy occurred in 1.3% of cases with ulipristal and 2.2% of cases with levonorgestral. Ulipristal and levonorgestrel should not be taken together as they may result in reduced effectiveness.

form of hormonal contraception. Abstinence or barrier methods, such as condoms are recommended for up to two weeks to prevent pregnancy (including approximately seven days after the re-introduction of hormonal contraception).3 If menstruation has not begun seven days after it was expected, a pregnancy test should be performed. A daily dose of 10mg has also been used in clinical trials.4 Treatment is introduced during the first week of menstruation. The dose is sufficient to cause amenorrhoea, which is beneficial to women who suffer from severe, heavy bleeding often associated with fibroids.4 Women should be aware that despite the prevention of ovulation, pregnancy is still possible while taking ulipristal. Alternative forms of contraception (such as barrier devices) are recommended. It should be noted that the long term effect of repeated courses of ulipristal on fertility is not yet known.4

REFERENCES

Ultimately, evidence suggests that ulipristal is a non-inferior alternative to levonorgestral.

1. Australian Medicines Handbook 2017 [online]. Adelaide: Australian Medicines Handbook Pty Ltd; 2017 Jan. Available from: https://amhonline. amh.net.au/auth

DOSAGE AND ADMINISTRATION

2. NPS MedicineWise. Ulipristal acetate for emergency contraception. Aust Prescr. 2016;39:228-9.

When used for emergency contraception, ulipristal is administered as a single, 30mg tablet. It is recommended as soon as possible following unprotected sexual intercourse or contraception failure.3 It may be taken up to 120 hours later with slight reductions in efficacy over time.1,3 Following use, it is important to wait at least five days before re-commencing any

3. NPS MedicineWise. Ulipristal acetate for fibroids. Aust Prescr. 2016;39:230-1. 4. Glasier AF, Cameron ST, Fine PM, Logan SJ, Casale W, Van Horn J, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and metaanalysis. Lancet. 2010;375:555-62.

March–April 2018 western nurse |

AcrosstheNation NEWS, VIEWS AND GOSSIP FROM ALL OVER AUSTRALIA Nurses Day on May 12. Winners, including WA Nurse or Midwife of the Year, will be announced at a gala dinner at the Perth Convention and Exhibition Centre on Saturday, May 12. 

SPICY DEPRESSION TREATMENT WA Relief from depressive and anxiety symptoms in adolescents could be sitting in your spice rack, local research has found.

Last year's WA Nursing and Midwifery Excellence Awards

WA NURSING AND MIDWIFERY EXCELLENCE AWARDS FINALISTS WA Among WA’s thousands

of dedicated nurses and midwives, 28 have been selected as finalists in this year’s WA Nursing and Midwifery Excellence Awards. Chosen from public, private, education and community workplaces across the State, they were nominated by their colleagues and patients for making a significant contribution to their professions, organisations, and to the health of West Australians. In the Excellence in Registered Nursing category, finalists are Linda Campbell of Sir Charles Gairdner Hospital, Barbara O’Callaghan of Fiona Stanley Hospital, and Robyn Ellis of Geraldton Hospital. The Excellence in Midwifery award has Jennifer Pitcher of Osborne Park Hospital, and Alison Jennings of King Edward Memorial Hospital as finalists. Dr Caroline Nilson of Murdoch University, and Helen McLean of the Training Centre in Subacute Care WA, are the Excellence in Aboriginal Health finalists. For the Excellence in Rural and Remote Health award, the finalists are Brett Hayes of the WA Country Health Service – Wheatbelt, and Megan McDermott of the WA Country Health Service – South West. Finalists in the Excellence in Enrolled Nursing award are Rebecca Godin of Hollywood Private Hospital, Leisha

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Oliveri of the WA Country Health Service – Geraldton Hospital, and Amanda Major of the Rockingham Peel Group – Mental Health. Graduate of the Year is being contested by Samantha Johnson of Hollywood Private Hospital, Amber Murphy of Joondalup Health Campus, and Christian Wright of the Women and Newborn Health Service. Lesley Abraham of Sir Charles Gairdner Hospital, Simon Hulatt of St John of God Hospital, and Natalie Gray of Pilbarra Population Health are the Consumer Appreciation award finalists. In the Excellence in Education and Research section, Nicholas May of Royal Perth Hospital – Bentley Group, Dr Lucy Lewis of Curtin University and King Edward Memorial Hospital, and Emma Arnold of Hollywood Private Hospital are the finalists. Anne Capes of Silver Chain, Kym Heine of the Neurological Council of WA and Susan Pettigrew of Amana Living are finalists in the Excellence in Primary Public and Community Care award. In the Excellence in Leadership division, Janet Fountaine of North Metropolitan Area Health Service – Mental Health, Trulie Pinnegar of the Child and Adolescent Health Service, Amber Warnes of Peel Health Campus, and Suki Loe of South Metropolitan Health Service are the finalists. The awards are hosted annually to coincide with International Day of the Midwife on May 5, and International

“Saffron has been shown to be an effective natural antidepressant in adults, but we were interested in its potential to alleviate depressive and anxiety symptoms in teenagers,” said Murdoch University researcher Dr Adrian Lopresti. He and Murdoch’s Professor Peter Drummond recently finished studying nearly 70 Australian adolescents suffering from moodiness or mild anxiety, aged 12 to 16 years, who participated in an eight-week trial using the spice, with “very promising results”. Participants ingested 14mg of a saffron supplement or placebo twice daily. The teens who took saffron improved their mood by 33 per cent, compared with 17 per cent in the placebo users, according to the study published in the Journal of Affective Disorders. Dr Lopresti said: “This study has shown that saffron has the potential to be an effective treatment with very few side effects for anxiety and depression in adolescents. “Saffron was particularly effective in reducing symptoms associated with separation anxiety, depression and social phobia, and participants reported a reduction in headaches over the eight weeks as well.” The two academics are now investigating whether using saffron and a pharmaceutical antidepressant works better than antidepressants alone for depressed adults. 

SOFT DRINK CANCER RISK VIC Regular consumers of sugary soft drinks “no matter their size” are more at risk of developing several types of cancer than those who don’t drink them. These are the findings of new research by the University of Melbourne and the Cancer Council Victoria, where more than 35,000 Australians who developed 3283 cases of obesity-related cancers were studied.

RICH SYDNEYSIDERS VACCINATING LESS NSW Some of Sydney’s

wealthier areas are vaccinating children less than the rest of the State. The full immunisation rate among infants aged 24 months in the Northern Sydney Local Health District (LHD) – which includes Manly, Mosman, Killara and Palm Beach – was 88.3 per cent in 2016, compared with NSW’s average of 90.5 per cent. This is despite an overall increase in children in that State being “fully immunised for all key milestone ages – 12 months, 24 months and five years – in 2016”, the ABC reported last month, citing the latest NSW Annual Immunisation Coverage Report. The rates of full immunisation for the “milestone ages of 12 months and five years old” in the Northern Sydney LHD were also below the rest of the state and nation. NSW Minister for Health and Medical Research Brad Hazzard said the overall results were promising, but some areas in Sydney and Northern NSW were behind the rest of the state. “It is very concerning that there are some pockets of NSW that aren’t keeping up with the overall increase of vaccination rates, we think that may be effects from anti-vaxxers’ message but I think also particularly in one of the Sydney areas it may well be that parents are just extremely busy,” he said. 

“These particular cancers are commonly associated with obesity, however, our research found this risk existed for all participants, no matter their size,” said Associate Professor Allison Hodge, a Senior Research Fellow at Cancer Council Victoria and the University of Melbourne. The researchers examined obesityrelated cancers such as kidney, colorectum, oesophagus, postmenopausal breast, pancreas, endometrium, and gastric cardia varieties, as well as liver, aggressive prostate, ovary and gallbladder types. “We were surprised to find this increased cancer risk is not driven completely by obesity,” Associate Prof Hodge said. “Even people who are not overweight have an increased cancer risk if they regularly drink sugary soft drinks. “But this is not the case with those who drink diet soft drinks, suggesting sugar is a key contributor.” However, regular diet drink drinkers are just as likely to be obese as those regularly drinking sugary drinks, which also carries health risks, but cancer risks are only higher among sugary drink consumers. 

RICE-SIZED PACEMAKER VIC A wirelessly powered

cardiac pacing device the size of a grain of rice has been implanted in an Australian patient for the first time. The operation is part of an international clinical trial of the cutting -edge equipment in 350 heart failure patients who don’t respond to, or can’t receive, conventional pacemakers. It will involve 45 sites in the U.S.A, Europe and Australia. “This new wireless device known as WiSE™ (Wireless Stimulation Endocardially) is designed to improve the heart’s pumping ability and help overcome symptoms of heart failure,” said Dr Jeffrey Alison who performed the procedure in March at Monash Medical Centre. Dr Alison, a cardiologist at non-profit cardiological service MonashHeart, who also leads the Cardiac Rhythm Management research team at Victoria’s Monash University, said cardiac resynchronisation therapy (CRT) treats heart failure by electrically stimulating the heart, but up to 30 per cent of heart failure patients do not respond to that treatment. But the new wireless device “paces the heart via a tiny wireless electrode, implanted directly in the heart’s left ventricle”, as opposed to “pacing leads – decades-‐old technology with well‐ documented problems. Dr Alison added: “This approach provides the cardiologist greater choice of pacing locations, enabling patientspecific customisation of pacing site. “It also eliminates the need for a pacing wire on the outside of the heart’s left ventricle that can have associated problems.” 

March–April 2018 western nurse |

Diabetic foot ulcers

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

Diabetic ulcers are complex, chronic wounds that have a major long-term impact on the health and wellbeing of patients.1,2 About 15% of people with diabetes develop foot ulcers.3,4 While the majority heal, 10 to 15% remain active, and 5 to 24% lead to amputation.3 Ulcers also have a negative impact on quality of life, causing physical and emotional distress, and create a substantial financial burden for those affected.1,2

RISK FACTORS All individuals with diabetes are at risk of a diabetic ulcer. Other risk factors include peripheral neuropathy, peripheral arterial disease, previous foot ulcers or amputations and foot deformities. Generally, ulcers develop as a result of trauma or injury to those at risk.1,3,4 Wounds may start small and progress to become deep ulcers with bone or joint involvement. Frequent assessment of the feet is required to prevent significant complications.

MULTIDISCIPLINARY CARE FOR DIABETIC ULCERS Diabetic ulcers are best managed with holistic patient centred care, provided by a multidisciplinary foot care team.1-6 Not all members of the team are required to provide direct patient care. Rather, they may work in a virtual capacity using digital imaging and telemedicine to provide specialist input as required.2,4 Members of the active team will vary based on the complexity of the wound. Relevant practitioners include general practitioners, podiatrists, nurses, allied health professionals, and specialists from a tertiary care centre such as a wound care specialist or vascular surgeon.1,4,5

CLASSIFICATION OF DIABETIC ULCERS There are three main types of diabetic ulcers: neuropathic, ischaemic and neuroischaemic ulcers. They are differentiated based on characteristics including neurovascular observations of the affected limb, the presence of a callus or necrosis, the state of the wound bed, and the location of the wound.1

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Neuropathic ulcers. Neuropathic ulcers make up approximately 35% of diabetic ulcers. They arise in patients who have normal colour, temperature and pulses but absent sensation to the affected limb. These ulcers are generally found in weight bearing areas, such as the metatarsal heads or the heel of the foot. Their wound bed is pink and granulating and tends to be covered by a thick callus.1 Ischaemic ulcers. Ischaemic ulcers are the least common diabetic ulcers (approximately 15%). They occur in patients with diminished neurovascular observations, such as a cool limb with weak pulses. The ulcers tend to arise on the toes or around the nail edges and are painful, necrotic and slow to heal.1 Neuroischaemic ulcers. Neuroischaemic ulcers account for approximately 50% of all diabetic ulcers. They are associated with a degree of neurovascular compromise including reduced sensation and peripheral circulation. Wounds affect the margins of the foot and toes, with poor granulation in the wound bed and a high risk of infection.1

ULCER MANAGEMENT Cleaning and debridement is required for all types of ulcers. Clean water and normal saline help to remove devitalised tissue and bacteria, reduce exudate and facilitate healing. Topical antiseptics are not recommended as they have the potential to damage granulation tissue and prevent healthy growth.1,5,6

If foot pulses are present, debridement may be performed to further stimulate wound healing. In individuals with known or suspected peripheral artery disease, a vascular examination is required prior to removing non-viable tissue, as there is a risk of trauma to compromised tissues.1,6 A referral to the multidisciplinary team and/or vascular surgeon is required prior to initiating treatment.6

Benefits of debridement include: • Removing necrotic tissue, slough or foreign material • Removing surrounding callus and reducing pressure • Allowing full inspection and collection of culture samples • Helping drainage of secretions or pus • Stimulating healing by removing bacteria and aiding tissue formation.1-3,5

The gold standard for debridement is sharp debridement using a scalpel, scissors or tissue snips.1,2,4,6 Other methods include biological or larval therapy, mechanical or hydrosurgical debridement or autolytic or enzymatic debridement.1,3 Sharp debridement is an invasive procedure and can be extensive.1 Informed consent is always required. All devitalised tissue, callus and foreign bodies are removed from the wound margins and base, down to the viable bleeding tissue.1

Illustration 1

Illustration 2

Illustration 3

Bleeding is likely and wounds may appear larger after the procedure.2 The need for further debridement is determined at each dressing change.1 Sharp debridement is generally required every one to two weeks.6 Frequent re-assessment of the wound, including accurate measurements of length and width are essential to monitor progression (see Illustrations 1-3). Photographs may be helpful for documenting this process.2,6

INFECTION More than half of all diabetic foot ulcers become infected.1,6 Individuals at risk of infection include those with a positive probeto-bone test, as well as those with a history of ulcers, chronic ulcer, traumatic wounds to the feet (or participation in high risk behaviours such as walking barefoot), peripheral artery disease, previous amputation, neurovascular compromise or kidney disease.1,2 If an infection is suspected, tissue samples or deep tissue swabs are recommended after wound cleaning and debridement.2,4,6 Systemic antibiotic therapy is only required for patients with an infected ulcer. Prophylactic agents are not recommended.1,2,5,6 Duration of treatment depends on the severity of infection and response to treatment. One to three weeks of oral therapy is usually sufficient for mild to moderate infections, while severe infections may require prolonged use of parenteral antibiotics.1,5

DRESSING SELECTION There is insufficient evidence to demonstrate that one wound dressing is better than another in the management of diabetic ulcers.1,4,6 Rather, dressing choice is tailored to the clinical appearance and site of the wound, and to patient preferences.1,2,4 Many dressings

can be difficult to apply to the toes or the bottom of the foot.1

Factors influencing dressing choice include: • Location, size and depth of the wound • Amount and type of exudate • Predominant tissue type on the wound surface • Condition of the skin around the wound • Compatibility with other therapies (e.g. offloading device) • Risk or presence of infection • Comfort and cost.1,5 In non-ischaemic ulcers, dressing selection is based on the principles of ‘moist wound healing.’6 Dressings need to provide a warm and moist environment while managing excess exudate.4-6 When there is inadequate blood supply for wound healing, a nonadherent, non-occlusive dressing is used to keep the wound dry until a vascular referral can be arranged.4,6 Where wounds contain mixed tissue types, the predominant factors that affect healing, such as the presence of necrosis or heavy exudate, need to be addressed.1

OFFLOADING Offloading is the process of reducing pressure in and around an ulcer. It helps to prevent further trauma and enhance wound healing.1,2,4 Choice of offloading device is based on wound location, presence of peripheral artery disease or infection, and patient characteristics.2,4 Total contact casts (TCC) are considered gold standard.1,2 TTCs are applied over the foot and lower leg and cannot be removed.1,2 However, casting can cause ulcers or muscle wasting,

increase the risk of falls, and prevent viewing of the wound.2,6 Contraindications include severe peripheral artery disease, deep abscess, spreading infection, osteomyelitis, and poor skin quality.3,6 Removable ambulatory walkers are equally effective for offloading pressure but tend to have poor patient compliance.1,6 Therapeutic shoes, custom insoles, and felted foam may also be used for wounds on the forefoot.3 Trainers or sports shoes may also be an option where custom-built footwear is unavailable or not culturally appropriate.1

REFERENCES 1. International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds International, 2013. Available from: www. woundsinternational.com 2. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases. 2012; 54(12):132–173. 3. Alexiadou K, Doupis J. Management of Diabetic Foot Ulcers. Diabetes Therapy. 2012; 3(4):1-15. Evidence-Based Guideline on 4. National Prevention, Identification and Management of Foot Complications in Diabetes (Part of the Guidelines on Management of Type 2 Diabetes). Melbourne, Australia: 2011. 5. International Working Group on the Diabetic Foot. Guidance on the management and prevention of foot problems in diabetes. 2015. Available from: http://iwgdf.org/guidelines 6. Bergin SM, Gurr JM, Allard BP, Holland EL, Horsley MW, et al. Australian Diabetes Foot Network: management of diabetes-related foot ulceration — a clinical update. Medical Journal of Australia. 2012; 197(4): 226–229.

March–April 2018 western nurse |

AroundtheGlobe WORLD NEWS

HOW SAFE IS YOUR RUBBER DUCK? Children and others who play with bath toys could be at risk of eye, ear and gastrointestinal infections.

NG I N R A W

This is the view of researchers from EAWAG – the Swiss Federal Institute of Aquatic Science and Technology in ETH Zurich university – and the University of Illinois, who have been studying “microbial growth and the types of microorganisms” in new and used bath toys, in clean and dirty bath water. “Between 5 million and 75 million cells per square centimetre were observed on the inner surfaces (and) fungal species were detected in almost 60 per cent of the real bath toys and in all the dirty-water control toys,” said an EAWAG communique last month.

3D PRINTED STETHOSCOPE A 3D printed stethoscope has been developed that can be assembled quickly and cheaply from recycled plastic in places with scarce access to medical supplies. “As far as we know this is the first open-source medical device that has been clinically validated and is widely available,” said the designer, Dr. Tarek Loubani, an associate professor at Western University in Ontario, Canada.

“Potentially pathogenic bacteria were identified in 80 per cent of all the toys studied, including Legionella and Pseudomonas aeruginosa, the rod-shaped bacterium often implicated in hospital-acquired infections.” The scientists found the toys, rather than typically low-nutrient tap water, promote microbial growth, because “the plastic materials – often low-quality polymers – release substantial amounts of organic carbon compounds”. EAWAG Department of Environmental Microbiology Group Leader Dr Frederik Hammes said “mouldy bath toys … have received little scientific attention to date”, despite being “the junction between potable water, plastic materials, external contamination and vulnerable end-users”. Dr Hammes said when children squirt water from bath toys into their faces “this could strengthen the immune system … but it can also result in eye, ear, or even gastrointestinal infections”. Rather than banning such toys, he proposed tighter regulations on polymeric materials used in their manufacture. 

Dr Loubani, an emergency room physician who worked in hospitals in Gaza in the Palestinian territories during war, said: “We wanted physicians and allied health care professionals to be able to have something that was high quality. This study found that the acoustic quality was the same in our stethoscope as in a premium brand stethoscope.” Western University said the stethoscope, which has created hope for more 3D medical devices, can be made in under three hours and costs less than $3 to produce. “Anyone with a 3D printer and access to ABS – a plastic used to make garden chairs and Lego – can create the device,” the university said. Free open source software was used to keep costs low and allow others to easily access the code. The device is being used in Gaza, and is also being trialled clinically at the London Health Sciences Centre in Ontario. The results of the study were published last month in the journal PLOS ONE.

BEDSIDE CHART EASES PAIN OF CANCER PATIENTS

But, “importantly”, using the chart was not linked to higher drug doses.

Cancer patients find their pain is managed better with a simple pen and paper chart next to their bed, Scottish research shows.

But they cautioned more studies are needed to understand how the system could work longer term. The study was published in the Journal of Clinical Oncology. 

During a study of 1921 patients, medical staff used such a chart to “regularly record pain levels in a simple traffic light system”, under the Edinburgh Pain Assessment and management Tool (EPAT). If amber or red pain levels were recorded – indicating moderate or severe pain – this prompted doctors “to review medications and side effects, and monitor pain more closely”, said University of Edinburgh researchers, who developed the EPAT with doctors. The researchers said last month that “patients whose care included use of the chart reported less pain during this time, compared with patients with standard care, who did not show an improvement”.

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The study authors said the system works by encouraging doctors to ask the correct questions so they can act “before patients reach a crisis point”.

STARBUCKS ORDERED TO HAVE CANCER WARNING ON COFFEE After we just finished telling you coffee is great for health, beverage giant Starbucks and other retailers have been ordered to put a cancer warning on coffee sold in California. The ruling last month by a Los Angeles judge comes after a law suit claiming sellers were violating a Californian law requiring companies to warn consumers about cancer-causing chemicals in their products, such as acrylamide. Acrylamide, a byproduct of roasting coffee beans, can also form when starchy foods are cooked or processed. According to Food Standards Australia New Zealand: “While there’s no direct evidence

OPIOIDS ALTERNATIVE IN BRAIN’S NATURAL PAINKILLING SYSTEM The scourge of opioid addiction may have met its match with the discovery of an area of the brain key to “endogenous analgesia – the brain’s intrinsic pain relief system”. The work by a team of UK and Japanese researchers could lead to development of treatments that activate the natural painkilling system, by stimulating this area of the brain, but without the heavily addictive drugs that have devastated America.

THE TERMINATOR IS ‘BACK’ AFTER REPLACING HEART VALVE Arnold Schwarzenegger, the actor best known for portraying the Terminator and Conan the barbarian, has had heart surgery to replace a pulmonic valve that was fitted inside him 21 years ago. And the 70-year-old Austrian-American former Governor of California awoke after the operation with the words “I’m back” – a play on his famous line “I’ll be back” from the film The Terminator. “Yesterday, Governor Schwarzenegger underwent a planned procedure at Cedars-

that acrylamide can cause cancer in humans, there is evidence it can cause cancer in laboratory animals”. Not-for-profit group the Council for Education and Research on Toxics (CERT) sued about 90 coffee retailers, including Starbucks, said news agency Reuters. Los Angeles Superior Court Judge Elihu Berle said in his decision the sellers failed to show there was no significant risk from a carcinogen produced during coffee roasting. The National Coffee Association USA said: “The industry is currently considering all of its options, including potential appeals and further legal actions. “Cancer warning labels on coffee would be misleading. The US government’s own Dietary Guidelines state that coffee can be part of a healthy lifestyle.” 

“We’re trying to understand exactly what the endogenous analgesia system is – why we have it, how it works and where it is controlled in the brain,” said Dr Ben Seymour, of the University of Cambridge’s Department of Engineering, who led the research. “If we can figure this out, it could lead to treatments that are much more selective in terms of how they treat pain.” The researchers said opioid drugs including oxycodone, hydrocodone and fentanyl “hijack the endogenous analgesia system”, which is why they are so effective. But they are also highly addictive, which has led to the U.S. opioid crisis, “where drug overdose is now the leading cause of death for those under 50, with opioid overdoses representing two-thirds of those deaths”. 

Sinai (hospital) to replace a pulmonic valve that was originally replaced due to a congenital heart defect in 1997,” his spokesman Daniel Ketchell said in a statement on social media site Twitter on March 30. “That 1997 replacement valve was never meant to be permanent, and has outlived its life expectancy, so he chose to replace it yesterday with a less-invasive catheter valve replacement.” In another tweet he said: “@Schwarzenegger is awake and his first words were actually ‘I’m back’, so he is in good spirits”. A seven-time winner of the prestigious Mr Olympia bodybuilding competition, who once had 56cm arms, Schwarzenegger is credited more than any other physique athlete for bringing that sport into the mainstream. After retiring from bodybuilding in 1980, he became an actor, and later went into politics. He was elected governor of California in 2003 and 2006 for the Republican Party. 

March–April 2018 western nurse |

CHICKEN S 2 SERVE BREASTS WITH CRISPY POSH HAM

serves 2

KEEPING COOKING SKILLS ALIVE

JAMIE’S TOP TIPS

This is a great way to prepare chicken breasts. The texture of the crisp cooked prosciutto goes brilliantly with the tender chicken. Also, EQUIPMENT bashing the chicken out LIST thinly before you start cooking means it cooks much faster than a ❏ Knife ❏ Spatula regular chicken breast. ❏ Chopping board

It’s a good idea to use a non-stick pan for cooking this recipe; it will make your life so much easier. Pounding out a chicken breast helps it to cook evenly and makes a little chicken go a long way. If you can’t get hold of prosciutto then any kind of very thin ham, such as pancetta, Parma ham or even smoked streaky bacon will work just as well.

❏ Box grater or microplane grater ❏ Cling film ❏ Frying pan

INGREDIENTS 2 sprigs of fresh thyme

x 120gOliver’s skinless chicken Come and learn 2Jamie hints, breasts, preferably higherJAMIE’S TOP TIPS tips and shortcuts to cooking delicious welfare and affordable meals from scratch! ★ It’s a good idea to use a non-stick pan for cooking this recipe; it will make your life so much easier. ★ Pounding out a chicken breast helps it to cook evenly and makes a little chicken go a long way.

freshly ground black pepper Cowan University –

Edith 1 lemon Joondalup Campus

4 slices of prosciutto, the

Car Park 14 (Access from Deakin Road best quality you can afford via Lakeside Drive) ★ If you can’t get hold of prosciutto then any kind olive oil of very thin ham, such as pancetta, Parma ham or Courses run at Joondalup from extra virgin olive oil even smoked streaky bacon will work just as well. March 2, 2018 – June 13, 2018

For more information and to book: jamiesministryoffood.com.au

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western nurse March–April 2018

EQUIPMENT LIST Knife  Chopping board  Box grater or microplane grater  Cling film  Frying pan  Spatula 

INGREDIENTS 2 sprigs of fresh thyme 2 x 120g skinless chicken breasts, preferably higher welfare

To prepare your chicken: 1 Pick the thyme leaves off the stalks. Carefully score the underside of the chicken breasts in a criss-cross fashion with a small knife. Season with a little pepper (you don’t need salt as the prosciutto is quite salty). 2 Lay your breasts next to each other and sprinkle over most of the thyme leaves. Grate a little lemon zest over them. Lay 3 prosciutto slices on each chicken breast, overlapping them slightly. Drizzle with a little olive oil and sprinkle with the remaining thyme leaves.

best quality you can afford

3 Put a square of cling film over each breast and give them a few really good bashes with the bottom of a pan until they’re about 1cm thick.

olive oil

To cook your chicken:

extra virgin olive oil

4 Put a frying pan over a medium heat.

freshly ground black pepper 1 lemon 4 slices of prosciutto, the

5 Remove the cling film and carefully transfer the chicken breasts, prosciutto side down, into the pan. Drizzle over some olive oil. 6 Cook for 3 minutes on each side, turning halfway through, giving the prosciutto side an extra 30 seconds to crisp up. To serve your chicken: 7 Either serve the chicken breasts whole or cut them into thick slices and pile them on a plate. Serve with some lemon wedges for squeezing over, and a good drizzle of extra virgin olive oil. Lovely with mash and green veg or a crunchy salad! Per 146g serving energy

fat

saturates

sugars

salt

1703Kj 407kcal

25.1g

3.8g

0.2g

79mg

20%

36%

19%

% of an adult’s reference intake. Typical values per 100g: Energy 1703Kj/407kcal High in fat

March–April 2018 western nurse |

ResearchRoundup LATEST AND GREATEST FROM SCIENCE Venter’s company was recently reported by U.S. TV channel CNBC as having “found serious detections of disease in roughly 40 percent of patients, and many of the discoveries are found much earlier than they would have been found previously via traditional testing”. “They are finding cancerous tumors that are in phase 0 and 1 in patients who are experiencing no pain, whereas most people are often diagnosed in phase 4, where pain is prevalent and the disease is more difficult to beat,” CNBC said.

OVER-THE-COUNTER GLAUCOMA TREATMENT

The 71-year-old biotechnologist, biochemist, geneticist and businessman told CNBC: “Only a small fraction of people live into their 90s. We hope to get people in the 90 to 100 range. I’m hoping to make it into triple digits. (I’m) doing as much as I can preventive-wise.” 

Vitamin B3 is being examined as a treatment for glaucoma in a world-first human trial. Researchers from Melbourne’s Centre for Eye Research Australia hope to prove that therapeutic use of high-dosage vitamin B3 (nicotinamide) could support existing therapies for the devastating optic nerve disease that affects 60 million people worldwide. Dr Flora Hui, the Research Fellow conducting the six-month clinical trial, said: “Imagine your car’s engine is running a bit rough and as a result, the car doesn’t drive smoothly. “If you top up the engine with oil, the car runs better, even though you haven’t fixed the underlying problem. “Our study hopes to confirm that vitamin B3 can protect nerve cells from dying, in a similar way that adding oil to a faulty car engine can still allow it to run more smoothly.” The study’s lead investigator, Professor Jonathan Crowston, said though glaucoma currently has no cure and vision loss is thought to be irreversible, “we have recently discovered that in the early stages after an injury, visual function can in fact recover”. He added: “Our premise is that if you can improve optic nerve recovery after an injury that we can reduce the risk of glaucoma progressing.” 

LIVING TO 100 – FOR A PRICE The American scientist who mapped the first human genome reckons he can help you live longer – by revealing any deadly diseases you might have but can’t yet feel. Genetic tests costing from $4,950 to $25,000 are being used by Craig Venter’s company Human Longevity to detect cancer, cardiac disease, metabolic disease, and neurodegenerative and neurovascular diseases.

PLATYPUS MILK BECOMING SUPER BUG MEDICINE A discovery about why platypus milk is so potent against super bugs has brought it closer to being used to save human lives. “By taking a closer look at their milk, we’ve characterised a new protein that has unique antibacterial properties with the potential to save lives,” said CSIRO scientist Dr Janet Newman, lead author on research on the milk, published earlier this year in Structural Biology Communications. Dr Julie Sharp, of Deakin University, who collaborated on the work, said the protein had unusual and protective antibacterial characteristics, likely because platypuses do not have teats, and thus expressed milk onto their belly for the young to suckle, which exposed the milk to the environment, and left babies susceptible to bacteria. “We were interested to examine the protein’s structure and characteristics to find out exactly what part of the protein was doing what,” Dr Sharp said. CSIRO said: “Employing the marvels of molecular biology, the Synchrotron, and CSIRO’s state of the art Collaborative Crystallisation Centre (C3), the team successfully made the protein, then deciphered its structure to get a better look at it. “What they found was a unique, never-before-seen 3D fold. Due to its ringlet-like formation, the researchers have dubbed the newly discovered protein fold the ‘Shirley Temple’, in tribute to the former child-actor’s distinctive curly hair.” 

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Genomics pioneer Craig Venter

ANF HOLIDAY UNIT PHOTO COMPETITION Talk to us...

It’s your magazine. We want your feedback and story ideas! 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. Get QR code readers on iTunes or Google Play

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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. See your iFolio for details right now!

U O B A N’

O T O PHRIZES P

OUT

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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! 

GOD OF THUNDER comes WIN one of 30 Kitchen to your place – courtesy Warehouse vouchers of the ANF This other-worldly blockbuster continues the knockout humour and effects of recent Marvel Comics offerings – with Thor, the Norse god of thunder (Chris Hemsworth), imprisoned on the other side of the universe without his mighty hammer Mjölnir. The blonde beefcake deity finds himself in a race against time to get back to Asgard, the domain of the Norse gods, to stop Ragnarok, which is a huge battle that would bring about the destruction of his home at the hands of an all-powerful new threat, the ruthless Hela (Cate Blanchett), who’s actually Thor’s sister. But first he must survive a deadly gladiatorial contest that pits him against his former ally and fellow Avenger – the Incredible Hulk (Mark Ruffalo). We have 30 Blu-ray discs to give away, so enter now! 

Our new Jamie Oliver’s recipe section is proving a hit with our readers, and so is the special offer for ANF members by Kitchen Warehouse on those pages. So, western nurse has decided to ensure our members have even more chances to get hold of the great gear at Kitchen Warehouse with a special competition – you can win one of 30 gift vouchers valued at $25 to spend on the wonderful products in their various stores! Kitchen Warehouse pride themselves on offering top brands, such as Anolon, Chasseur, Circulon, Cuisinart, Essteele, Jamie Oliver by Tefal, Le Creuset, Maxwell & Williams, Scanpan and Swiss Diamond, to name a few. Their range includes cookware, appliances, bakeware, knives, drinkware, kitchenware, and tableware, as well as indoor and outdoor products and accessories, and DIY products. And watch this space, because this year all sorts of quality goods and services will be up for grabs exclusively for ANF members! 

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

March–April 2018 western nurse |

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