Healthy Skin Volume 11 Issue 3 by Medline Industries

VOLUME 11, ISSUE 3

Improving Quality of Care Based on CMS Guidelines

Volume 11, Issue 3 October 2013

HEALTHY SKIN

SPECIAL ISSUE!

SOCIAL MEDIA IF PRESSURE ULCERS WERE APPLES FREE CE! CREATING A

QUIETER www.medline.com

HOSPITAL STAY

PINK GLOVE DANCE! Make your vote count October 24!

GET THE RAISE YOU’VE EARNED

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JOIN THE TEAM!

Healthy Skin When it comes to hot topics, you’re the experts! You, our readers, are on the front lines of everything that happens in the healthcare industry – and we want to hear from you! Have you ever wished you could write an article that would be published in a large-circulation magazine? Now’s your chance. Healthy Skin is looking

for writers and contributors. Whether you’d like to try your hand at writing or offer suggestions for future articles, we want to hear what you have to say! You never know – the next time you open an issue of Healthy Skin, it might be to read your own article! Contact us at healthyskin@medline.com to learn more!

ON THE COVER. This issue highlights Breast Cancer Awareness Month and social media. If you want to spread the word about breast cancer awareness, turn to pages 42 - 50 and learn how to use Twitter, Facebook and other popular forms of social media.

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C O N T E N T S O CTO B ER 2013

F E AT U R E S Editor Sue MacInnes, RD Clinical Editor Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA Senior Writer Carla Esser Lake Creative Director Michael A. Gotti Clinical Team Clay Collins, BSN, RN, CWOCN, CFCN, CWS, DAPWCA

CE ARTICLE

Apples to Ulcers: Tips for Staging Pressure Ulcers. Learn a simple analogy related to apples to understand the differences between the stages of pressure ulcers.

Patients’ Most Frequent Complaint: Noise. Facing potential ﬁnancial penalties from the Centers for Medicare and Medicaid Services (CMS), hospitals are making changes to lower the noise level for patients.

Tonya Dixon, MSN, MBA, MPH, RN Doreen Gendreau, MSN, MS, RN-BC,

Nutrition Pearls: Gem Quality Information on the Latest Hot Topics in Nutrition. The pneumonic PEARL represents six important concepts where nutrition and wound healing intersect.

Getting Started with Social Media in Health Care. Learn how and why to get connected to Twitter, Facebook and other forms of social media.

CWCN, CNS, DAPWCA Rebecca Huff, MSN, RN Kim Kehoe, BSN, RN, CWOCN, DAPWCA Carrie L. King, MSN, RN, CWOCN Joyce Norman, BSN, RN, CWOCN, DAPWCA Jackie Todd, MBA, BS, RN, CWCN, DAPWCA Patty Turner, BSN, RN, CWOCN, CWS

About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 350,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 1,100 dedicated sales representatives nationwide to support its broad product line and cost management services. ©2013 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

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LETTER FRO M THE E D ITOR

Dear Reader, Welcome to October – my favorite time of the year. Apple-picking season. Falling leaves. Trick-or-treaters. But most of all, everything around us turns pink in honor of National Breast Cancer Awareness Month. I can remember years ago when I was grocery shopping with my kids. For the first time I discovered Yoplait yogurt with the pink label. It was October 1997, and Yoplait was donating 10 cents of each unit sold to breast cancer awareness. I never saw anything like that before, and I felt myself gravitating to the Yoplait brand. I liked that the company was doing something positive in their marketing efforts: “Save Lids to Save Lives.” It was “different”; something that benefited people in need and the community. I started to buy Yoplait yogurt and collected pink foil labels for years and years. Fast forward…my kids are now in their mid- to late 20s, I have two grandchildren…and Medline has also embraced this cause. Pink gloves in the healthcare provider world – where patients rely for help, and hope, in the fight against breast cancer…makes sense, right? It’s a wonderful thing to see the healthcare world join forces with the corporate world, the entertainment world and everyday people wearing their pink like a badge of honor in support of this devastating disease that affects more than 220,000 lives each year. I’m so proud. Not only has Medline made pink gloves for nurses, doctors and hospital administrators to wear in support of their patients, their patients’

families and all people affected by the disease here and abroad, but these gloves also have meaning. They create important discussions among patients and caregivers, and they represent a phenomenal cause and awareness campaign that continues to grow. They have also helped Medline donate more than $1.2 million for free mammograms for people who otherwise couldn’t afford them. This October, visit us at PinkGloveDance.com to see the remarkable impact this campaign is having on the participants and their communities. Join us in the celebration, excitement and passion that is the Pink Glove Dance. See how the Pink Glove Dance is being embraced by the healthcare community, creating an infectious movement that continues to spread and bring joy to everyone who participates and watches, while raising money for prevention.

In closing, I must share with you a special story that was recently brought to my attention. It is the story of a healthcare worker who wanted to indulge in a moment of pure joy and celebration before she died. With the help of her colleagues, Deb, a labor and delivery nurse at Mercy Medical Center in St. Louis, did just that by participating in the Pink Glove Dance. Deb lost her seven-year battle with breast cancer on September 8, 2013. But her memory lives on through a Pink Glove Dance video. Deb once said, “we should all fight until we can’t fight anymore.” Check out her story on YouTube (www.youtube.com/ watch?v=xCmvyVsmtyQ). At Medline, we know everyone has a breast cancer story to tell and a reason to celebrate and dance – whether you’ve been affected directly or know someone who has. These stories are refreshing and fulfilling and we, at Medline, want to tell them all! Let the legacy of those in our memories who have touched us…live on. Take a minute in October to throw on some music and dance! For more on breast cancer awareness and the Pink Glove Dance Video Competition, see pages 58-65. All the best,

Kristin Wald (left) is a nurse practitioner at Women’s Health Partners and Deb Johns is on the right. Kristin worked with Deb in Labor and Delivery and they remained great friends. Kristin is doing the voice over in the video.

Sue MacInnes, RD Editor Follow on Twitter: @smacinne Connect on LinkedIn: LinkedIn.com/in/smacinnes

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Join 420,000 other nurses for FREE CE courses

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CONTENTS OC TOBE R 2013

IN THIS ISSUE 10 Healthcare News 17 Skin & Wound Care Common Skin Issues Associated with Infusion Therapy Patient-Centered Care 20 Ears Wide Open 22 Avoiding Power Struggles: Using Validation to Honor People with Dementia

22 58

52 Caring for Yourself Get the Raise You Have Earned Breast Cancer Awareness 58 Early Detection 62 Medline and the National Breast Cancer Foundation 66 Recipe Cheddar Broccoli Soup Forms & Tools 68 Reducing Pressure Ulcers – for CNAs 72 Ten Absolutes: Simplify Daily Tasks and Create Positive Interactions with People with Dementia – English 74 Ten Absolutes: Simplify Daily Tasks and Create Positive Interactions with People with Dementia – Spanish

Connect with us: /MedlineIndustriesInc Inc /medline /+medline /medlineindustriesinc nc /medline /medlineindustries /medline /medline.com/blog g

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Pressure relief and skin protection all in one. PILLOW-LIKE DESIGN Provides comfort and protection

UNIQUE STRAPS Multiple strapping options based on the patient’s needs

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OPEN HEEL DESIGN For pressure off-loading and easy clinical checks

Heels are the #1 site for facility-acquired pressure ulcers.1 HeelMedix should be your #1 choice for protection.

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Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48.

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CONTR IB UT IN G W R ITER S

Beth Boynton, MS, RN

Beth Boynton is an organizational development consultant specializing in issues that affect nurses and other healthcare professionals. She is a national speaker, coach, facilitator and trainer for topics related to communication, conflict management, team building and leadership development and author of the book, Confident Voices: The Nurses’ Guide to Improving Communication & Creating Positive Workplaces.

Nancy Collins, PhD, RD, LD/N, FAPWCA

Nancy Collins is a registered dietitian based in Las Vegas, and founder and executive director of Nutrition411.com. For the past 23 years, she has served as a consultant to healthcare institutions and as a medicolegal expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com.

Doreen A. Gendreau, MSN, MS, CNS, BS, RN-BC, CWCN, DAPWCA

Doreen Gendreau received her associate’s degree in nursing at Bristol Community College, and then earned a bachelor’s and master’s degree in nursing from Western Governors University, as well as a master’s degree in health. She is board certified in both wound care and nursing education, and she is an active member of the Wound, Ostomy, and Continence Nurses Society and other national nursing organizations. Doreen has held both clinical and leadership roles in critical care, surgery and outpatient wound care. As a Six Sigma Yellow belt, she has developed curriculum for wound and quality care education and initiatives. Chad Plass

Chad Plass is the Social Media Manager at Medline Industries, Inc., and an experienced social strategist with over 12 years experience developing both B2B and B2C digital and social marketing campaigns. He currently manages the social media accounts and presence for Medline, Medline University, Pink Glove Dance, and Medline Careers, actively supporting Medline’s mission and vision through the social media. You can connect with him on LinkedIn: linkedin.com/in/cplass. Dr. Wolf J. Rinke, RDN, CSP

President, Wolf Rinke Associates, Inc. CPE Accredited Provider of pre-approved high quality home study courses since 1990. Receive the FREE eNewsletter: “Read and Grow Rich” for savvy Nutrition Professionals who want to succeed faster. To subscribe go to www.easyCPEcredits.com and click on the newsletter link. 13621 Gilbride Lane, Clarksville, MD 21029, USA, Tel. 800-828-9653, 410-531-9280, fax 410-531-9282. Email:WolfRinke@aol.com; ORDER ON-LINE www.easyCPEcredits.com Patricia Turner, BSN, RN, CWOCN, CWS

Patty Turner received her bachelor of science in nursing from William Paterson College in Wayne, NJ. She is board certified as a CWOCN and a Certified Wound Specialist. She is an active member of the Wound, Ostomy and Continence Nurses Society, Sigma Theta Tau, the American Academy of Wound Management and the Association for the Advancement of Wound Care. She has many years of experience as a wound care nurse and has vast knowledge of outpatient wound care centers.

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Science +Nature

Clinical skin care. Nurturing botanicals.

Phytoplex is a trademark of Medline Industries, Inc., for its line of all natural, plant-based skin cleansers, moisturizers, treatments and protectants.

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HEA LT H CA R E NEW S

New Insights into Fungi3

CMS Recognizes Kennedy Terminal Ulcer in Long-Term Care Hospitals1,2

In a new transmittal from the Centers for Medicare and Medicaid Services (CMS), the Kennedy Terminal Ulcer (KTU) can now be used to avoid reporting a pressure ulcer as a quality measure in long-term care hospitals (LTCHs). Until recently, CMS had not acknowledged the KTU in its regulatory and reimbursement guidelines for hospitals and nursing homes. This step goes a long way in legitimizing the concept that certain medical conditions can lead to unavoidable pressure ulcers that are not indicative of inadequate quality of care. A quality reporting program has already been in effect for Medicare Certified Skilled Nursing Facilities through mandatory documentation in the Minimum Data Set. CMS has recognized that several conditions in hospitals are reasonably preventable, and will not pay for Hospital Acquired Conditions that include Stage III and IV pressure ulcers. The LTCH Quality Reporting Program Manual mandates data collection beginning on January 1, 2014. One major exception is

found in the Coding Tips, where the Kennedy Terminal Ulcer is specifically mentioned: “Skin ulcers that develop in patients who have terminal illness or are at the end of life should be assessed and staged as pressure ulcers until it is determined that the ulcer is part of the dying process (also known as Kennedy ulcers). Kennedy ulcers can develop from 6 weeks to 2 to 3 days before death. These ulcers present as pear-shaped purple areas of skin with irregular borders that are often found in the sacrococcygeal areas. When an ulcer has been determined to be a Kennedy Ulcer, it should not be coded as a pressure ulcer.” These instructions potentially eliminate (based on resident assessment) new pressure ulcers in persons who are expected to die from quality indicator reporting in longterm acute care hospitals (LTACs).

A team from the National Institutes of Health (NIH) National Human Genome Research Institute (NHGRI) and National Cancer Institute (NCI) used genomic techniques to gain a better understanding of the fungi that live on human skin. Fungi include molds, mushrooms and yeast. These microbes have been associated with many skin diseases and conditions, including athlete’s foot, eczema, dandruff and toenail infections. Fungal skin infections affect an estimated 29 million people nationwide. But fungi can be slow and difficult to grow in laboratories, making fungal infections hard to identify and treat. As described online in Nature on May 22, 2013, the scientists collected samples at 14 body sites from 10 healthy adults. They focused on a fragment of DNA shared by all fungi—the intervening internal transcribed spacer 1 (ITS1) of ribosomal RNA—that could be used to classify fungi at the genus level with greater than 97% accuracy. By generating more than 5 million ITS1 sequences from the samples, the team was able to identify more than 80 genus-level fungal types living on human skin. In contrast,

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APIC Releases New Guide for Preventing C. diff4 Athlete’s foot fungus

traditional culturing methods could identify only 18 types. Ascomycetes and Basidiomycetes were found at all the skin sites. Fungi of the genus Malassezia were the predominant type on 11 of the 14 sites, including behind the ears, in nostrils, on the back, and on the arms. The team found that heels, which don’t show extensive bacterial diversity, were the most complex site for fungi, with about 80 types represented. Toe webs, with about 60 types, and toenails, with 40, had the next highest levels of fungal diversity. Hands and arms, which harbor a great diversity of bacteria, had relatively few types of fungi. “By gaining a more complete awareness of the fungal and bacterial ecosystems, we can better address associated skin diseases, including fungal infections, which can be related to cancer treatments,” said co-senior author Heidi Kong of NCI.

A new edition of the Association for Professionals in Infection Control and Epidemiology (APIC) Guide to Preventing Clostridium difficile Infections has been revised and expanded by a team of experts in the field of infection prevention and is now available as a free online download. It features up-to-date It features up-to-date research research and guidance and guidance on the prevention on the prevention and and treatment of Clostridium treatment of C. difficile infections and incorporates difﬁcile infections and incorporates current regulations. current regulations. Included are an overview of C. difficile, strategies for prevention, considerations for specific patient populations and evolving practices. Topics include C. difficile in pediatrics and skilled nursing facilities, the pathogenesis and changing epidemiology of C. difficile diagnosis, environmental control and new and emerging technologies. A practical resource for infection preventionists and anyone who cares for patients with C. difficile or in facilities with patients who are being treated for C. difficile, the guide informs and supports implementation efforts with tools and examples to help apply preventive measures. The easy-toread format includes tools for hand hygiene monitoring, environmental cleaning and isolation compliance. To download a copy of the guide, go to http://apic.org/Resource_/EliminationGuideForm/59397fc6-3f90-43d19325-e8be75d86888/File/2013CDiffFinal.pdf. References 1. Ostomy Wound Management website. CMS recognizes Kennedy Terminal Ulcer in Long-Term Care Hospitals. July 12, 2013. Available at: http://www.o-wm.com/news/cms-recognizes-kennedy-terminal-ulcer-long-term-carehospitals. Accessed August 30, 2013. 2. Jeffrey M. Levine, MD website. CMS recognizes the Kennedy Terminal Ulcer in Long-Term Care Hospitals. July 10, 2013. http://www.jeffreymlevinemd.com/unavoidable-kennedy-ulcer-in-long-term-care-hospitals. Accessed August 30, 2013. 3. National Institutes of Health. Fungal Findings. NIH Research Matters. June 2013. Available at: http://www.nih. gov/researchmatters/june2013/06032013fungal.htm. Accessed August 30, 2013. 4. Download New Guide to Preventing Clostridium difficile Infections [news release]. Washington, DC: Association of Professionals in Infection Control; March 8, 2013. http://www.apic.org/For-Media/NewsReleases/Article?id=2122443e-6d22-46ae-aecc-e9512e98e1cb. Accessed August 30, 2013.

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CE ARTICLE P RE SSU RE U LC E RS

APPLES TO ULCERS: Tips for staging pressure ulcers by Patricia Turner, BSN, RN, CWOCN, CWS

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How common is it in your facility or in your experience, that despite numerous references, in-services and reviews, some clinicians still struggle with the pressure ulcer staging system? Are the “fruits” of your labor paying off in the educational plan for yourself or for your staff? As adults, our learning styles and patterns tend to be more visual in nature, and adult learning is often solidified by equating concepts to past experiences or ideas that are familiar to us.1 Malcolm L. Knowles identified six principles of adult learners. Adults learners are internally motivated and self-directed, and they bring life experiences and knowledge to learning. Adult learners are also goal- and relevancy-oriented, as well as practical, and they like to be respected.1 Since adults bring life experiences and prior knowledge to learning, it is helpful when educators can provide an opportunity to use that existing foundation of knowledge and apply it to their new learning experiences. This reflective learning can also assist the adult learner to examine existing biases or habits based on life eperiences and “move them toward a new understanding of information presented.”2 This article presents a simple analogy anyone can use to help themselves, or staff, really understand the differences between the stages of pressure ulcers.

Pressure ulcer staging and CMS Pressure ulcer staging became particularly important with the passing of the Deficit Reduction Act (DRA). Effective October 1, 2008, payment for pressure ulcers and a list of other high-cost, highly

preventable conditions would not be covered if they developed during a patient’s hospital stay, coining the phrase, hospital-acquired conditions (HAC). Policy set by the Centers for Medicare and Medicaid Services (CMS) states that the physician or other licensed provider must complete a skin assessment when the patient is admitted to the hospital. This skin assessment must document whether the patient does or does not have pressure ulcers or other skin problems. This documentation is referred to as “present on admission,” or POA. POA indicates that the problem was present when the patient arrived at the facility. Clinicians also assess the patient on admission to determine the risk for developing pressure ulcers. Some patients are at greater risk of pressure ulcers than others for a variety of reasons. Over the course of the patient’s hospital stay, frequent, often daily, skin inspections should be conducted. Skin inspections should be performed at every shift in critical care areas such as the intensive care unit (ICU). Overall skin assessments should be performed at regular intervals based on the facility’s protocols. The concept of “hospital-acquired” and “present on admission” brought to the forefront the importance of accurate assessment and staging

because of the financial implications when pressure ulcers are not accurately staged and assessed on admission. So how can we, as clinicians, help ourselves and our staff get this right?

Identifying pressure ulcers Let’s begin with the definition of a pressure ulcer according to the National Pressure Ulcer Advisory Panel (NPUAP): “A pressure ulcer is localized injury to the skin and/ or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.”2 Pressure ulcers are described using a staging system. The stages are based on identifying and knowing the levels of skin and tissue involved in each wound. By knowing just how deep each layer goes, we can more easily identify the correct stage. We also need to remember that there are some stages of pressure ulcers where the patient’s skin is still intact. These pressure ulcers have certain discolorations associated with them. Now, let’s equate the concept of “layers” and “colors” to something we come across maybe almost every day … an apple. The old saying is “An apple a day keeps the doctor away.” Well, how about, “An apple a day can help take pressure ulcer staging confusion away.” Let’s compare that apple to the NPUAP pressure ulcer staging descriptions using the apple images on the chart that follows.2

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If Pressure Ulcers Were Apples STAGE l Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk). STAGE lI Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should NOT be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury. STAGE lII Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but it does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue, so Stage III ulcers in these areas can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. STAGE lV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Further description: The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue, so these ulcers can be shallow. Stage IV ulcers can extend into muscle and/ or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Suspected Deep Tissue Injury (sDTI) Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

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Visit www.medlineuniversity.com and login or create an account. Choose your course and take the test to receive 1 FREE CE credit. Course is approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing.

Stage I Stage I pressure ulcers are identified as “non-blanchable erythema of intact skin.” Think of the normal state of a delicious red apple. The red color is something that will not go away. We can’t “touch” a red apple and make the color be less vibrant or make the color go away. Just like a Stage I pressure ulcer, we can’t take away the redness simply by touching it. It will not blanch because there are already signs of capillary compromise within the layers of the skin.

Stage II These pressure ulcers are defined as partial thickness loss of the dermis presenting as a shallow open ulcer. The key here is that there is not a lot of depth to these wounds and that it is right at the layer of the dermis, the inner most layer of skin. Think of apple being peeled. Just the layer of outside “skin” is being removed or impacted when we carefully peel an apple. The same superficial layer has been removed or compromised in a Stage II pressure ulcer. These wounds will not have slough, and they will be superficial in nature.

Stage III Pressure ulcers at this stage are full thickness. They involve the underlying subcutaneous tissue. All layers of skin are missing and the wound has greater depth. Think of what your apple looks like when you take a nice healthy bite out of it... and the skin is gone, you are into the juicy “meat” of the apple. A Stage III pressure ulcer is similar. It’s migrated into the subcutaneous tissue and there is usually depth to these wounds.

Stage IV

Unstageable

These pressure ulcers are also full thickness wounds, but the difference from Stage III is that there is underlying structure involved. If you were to bite too far into your apple, you would get to the core…to the inner structure of that apple. This is what happens in a Stage IV pressure ulcer. You are down to the inner structure under that subcutaneous layer.

Unstageable pressure ulcers are completely covered with eschar or slough, so that the depth of the base of the wound cannot be visualized. Think of a caramel-covered apple. That thick, tannish brown caramel completely coats the apple. Because of that caramel, we don’t really know the state of the apple underneath. Just like an unstageable pressure ulcer, because of the slough or eschar obstructing the base of the wound, we don’t know how deep it is, and therefore, we cannot stage it, and we consider it unstageable.

Suspected Deep Tissue Injury (sDTI) What if your apple had a purple or dark spot on it. You wouldn’t know just how “bad” that apple was underneath that spot. The skin looks intact, but you know that part of that apple is bad and is not good to eat. That’s what happens with a suspected deep tissue injury. Just like an apple with a soft discolored spot, a deep tissue injury presents with skin intact, but with a top layer of maroon or purple localized discoloration, letting you know that there is tissue damage underneath even though the skin is intact.

Although this analogy and comparison is relatively easy, hopefully it will clarify in a simple way, some of the confusion that can be associated with the pressure ulcer stages. You may not ever think of an apple the same way again!

Sources 1. Richardson, V. The diverse learning needs of students. In: Billings DM & Halstead JA (eds.) Teaching in Nursing. 2nd ed. St. Louis, MO: Elsevier; 2005. 2. NPUAP Pressure Ulcer Staging Classiﬁcation 2007. Available at: http://www.npuap.org/resources/educational-andclinical-resources/npuap-pressure-ulcer-stagescategories/. Accessed August 16, 2013.

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I N F US I O N T H E R A P Y S K I N & WOUN D CARE

By Doreen A. Gendreau, MSN, MS, CNS, BS, RN-BC, CWCN, DAPWCA

Infusion therapy has long been held as a standard of care in preventing and treating health-related issues from simple rehydration to more complex and more caustic infusates such as chemotherapy for cancer and intravenous (IV) antibiotics to fight infections. In the process of IV therapy, the skin is breached when attempting to access a vein, creating a full thickness injury, while the solvents, antimicrobials and alcohol used to prepare the access site create the possibility of further skin breakdown. We know it is important to use a dependable securement device once the vein is accessed to avoid rotation and further damage. A further benefit provided by these adhesive dressings is the added protection of the entry site. Although dressing the IV access site is imperative, there are also some common skin damage etiologies associated with this practice: moisture-associated skin damage, contact dermatitis and trauma from adhesive to name a few.

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SK IN & WO UND C A R E IN FU SION TH E R A P Y Skin is dry by nature, but it has the ability to emit moisture in a process called transepidermal water loss or TEWL. This process is increased when the skin is occluded, or when poorly breathable adhesive products such as transparent film are applied, leaving moisture on the epidermis. Three changes in the skin have been identified when the skin is exposed to excessive moisture: an increase in the permeability of the subcutaneous tissue, which compromises the integrity of the barrier, a change in the skin pH toward an alkaline environment, which is also potentially destructive), and the triggering of an inflammatory process. If the skin remains in this overly moist state for a length of time, the texture becomes soft, soggy, pale grey or white, and if extended, will result in skin damage referred to as maceration. The current terminology for this phenomenon is moisture-associated skin damage. There are two types of contact dermatitis described in dermatologic literature; Irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). Both of these conditions present with erythema and may have additional signs and symptoms such as edema and vesicular formation. ICD is a nonallergic response to an exposure to an irritating substance, whereas ACD is an immune-mediated response that runs through both the sensitization and inflammatory phases. It is nearly impossible to discern the difference between ICD and ACD with just a visual assessment. The rates and frequency of this type of reaction occur less frequently than reported. Although many patients report â&#x20AC;&#x153;allergicâ&#x20AC;?

responses to tape and other adhesives, their skin damage is more likely to be mechanical in nature rather than the result of ICD or ACD.

Although there are few published studies focusing on the repeated removal of adhesives, the orthopedic community has focused on their surgical population and two areas: skin stripping and tension blisters from strapping (resulting from stretching dressings too tightly). Skin stripping is usually described as delamination of the layers of epidermis and/or total epidermal removal. Traumatic or harsh removal of these adhesive dressings over the IV site can frequently result in skin damage. Moisture that builds up beneath the dressing also may contribute to Candida and folliculitis. The clinician must familiarize herself with appropriate assessment, correct dermatologic terms, as well as accurate clinical presentation. It is important to use appropriate descriptors to present a clear picture of the situation. Although common, terms

like excoriation are frequently used erroneously to describe skin damage due to erosion, the true meaning of the term is a linear break in the skin. Clinicians are responsible for advocating for their patients and are accountable for their actions in caring for them. As moisture-associated skin damage increases in prevalence, itâ&#x20AC;&#x2122;s important for nurses to be aware that the intravenous site is just one area of risk. Diligent assessment and caution with site preparation and dressing choices will diminish the damage caused by increased moisture and adhesive use. Proper securement devices are necessary to eliminate and prevent biological contamination, but are to be used with caution, taking care not to apply the dressing too tightly to avoid epidermal stripping. Upon removal, deftly remove these dressings to avoid delamination of the epidermis. Prudent skin site preparation and assessment of the IV site for any moisture or fluids beneath the dressing that may compromise the integrity of the host is not only appropriate, but expected for quality of care. With proper identification, application and assessment, skin damage associated with intravenous therapy may be avoided, and patient satisfaction and outcomes will improve.

Recommended reading 1. Infusion Nurses Society. Vascular access device stabilization .Infusion nursing standards of practice. J Infusion Nursing, 2011;34(1 suppl):S46. 2. Misery L, Sibaud V, Merial-Kieny, Taieb C. Sensitive skin in the American population: prevalence, clinical data and the role of the dermatologist. Int J Dermatology. 2011;50(8):961-967. 3. Corrigan A. Infusion nursing as a specialty. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidenced Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier. 2010:1-9.

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PATIENT-CEN TER ED C A R E E ARS W I D E O P E N

Most people do not listen with the

by Kelsey Bongiovanni

The most important lesson Vashti Livingston, MS, CNS, CWOCN, has learned over her 20 years of nursing is to really listen to the patient. No experience drove home the idea more than her interaction with an 86-yearold bladder cancer patient with a new ostomy. When the patient told her eight months after surgery that he was finally back on track, she naturally thought he was referring to his adjustment to living with an ostomy. In actuality, he had been going to the Sexual Medicine clinic and was sharing his delight that his sexual function had returned. “By his standards, he was now finally doing well,” Vashti says. “Changing the ostomy pouch

was not as relevant to his feeling of recovery. When I thought about it, I recalled that at his preoperative visit and stoma site marking, he had mentioned he was very concerned about the return of sexual function, not to mention his 52-year-old girlfriend. So, I now listen. What may be of the utmost concern to the patient is not what we clinicians always think.”

Vashti’s initial plan wasn’t always to be a nurse, let alone a wound, ostomy, and continence nurse. She studied biology at the City University of New York (New York, NY) before becoming a high school science teacher. After a couple of years in the classroom, she decided to turn the tables and once again become the student. She headed back to City University, where she earned her nursing degree in 1989 and began working for the Visiting Nurse Service of New York (VNSNY). During this time, Vashti was introduced to wound care; she developed so much interest she sought wound certification in 1997. Later, she went to Emory University and obtained certification as a CWOCN. While still working in home care, Vashti decided to return to school to obtain a master’s degree in Adult Health Nursing, opening up the possibility for her to work as a clinical nurse specialist (CNS). More than a decade after taking her first nursing job at VNSNY, Vashti left home care to work as an outpatient CWOCN CNS in Urology at Memorial Sloan-Kettering Cancer Center (MSKCC). Leaving home care to work in a hospital clinic was a major change in Vashti’s career, but like all great nurses, she was able to adapt to her new environment and eventually shape her position into what she thought it should be. “My role in the urology clinics really evolved over the past seven-plus years,” Vashti says. “I believe in the beginning the staff— doctors and nurses—just thought I was a pouch changer. All visits were

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intent to understand; they listen with the intent to reply. — Stephen R. Covey, author

scheduled for only 15 minutes, and they could not understand why I spent so much time with my clients and why the CWOCN visit was important.” It didn’t take long before the physicians at MSKCC realized the value of a CWOCN. “I worked mainly with four attending doctors in the bladder group,” Vashti says. “They slowly began to realize that not only do I manage ostomies, but that I also know current wound care management (so now I get all those consults), and that I also could do an incontinence consult (so the incontinence clinic uses me as needed). The prostate attending doctors acknowledged I knew about catheters, skin care, containment products, teaching pelvic floor exercises, leaky tubes, and so on, so they referred clients to me if needed.

Patients aren’t the only ones benefitting from Vashti’s teaching. “I now work with a team of seven CWOCNs, and as a group we do ostomy education programs, policies and procedures, and collaborative communication between the inpatient and ambulatory divisions,” she says. “We provide educational programs for the staff nurses, the fellows, and the physician’s assistants as needed, especially to keep them aware of new products and how to use them correctly. Many of my new surgeons still love wet-to-dry dressings, or wet-to-nowhere, as one of my peers is known to comment. So after my instruction, it is interesting to hear, ‘Where is the Aquacel or Medihoney?’ Now, that’s progress! And you know

you have made a difference when an attending tells me he knows where to find my wound care supplies.” Providing excellent wound care, product information, and clinical direction to her patients and colleagues is vital to her responsibilities, but most of all, Vashti has proven that listening is the most valuable tool in any scope of practice.

Word spread to Oncology Medicine, and when they have a client with wound or skin issues that could impair the type of chemotherapy used, I may be consulted.” As the CWOCN for the Urology Ambulatory Clinic, Vashti enjoys working one-on-one with her patients and helping them come to terms with their new lifestyle. “I love seeing how my patients progress from being scared and anxious when I first meet them in the preoperative setting to learning to care for their ostomies,” she says. “I jokingly call it ‘graduation day’ when they come in for their regular postcancer screening and they say to me, ‘Vashti, I do not need you today, I’ve got this’.”

This article originally appeared in Ostomy Wound Management, June 2013. Reprinted with permission.

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PATIENT-CENT ER ED C A R E D E ME N T I A

Avoiding

POWER STRUGGLES Using validation to honor people with DEMENTIA

by Beth Boynton, MS, RN

As rational judgment and situational awareness deteriorate with progressive forms of dementia, individuals may want to do things that arenâ&#x20AC;&#x2122;t realistic or safe, such as driving a car or leaving a secure unit in a long-term care facility. Each individual has different limitations in the ability to process and express verbal and nonverbal language. Awareness and responsiveness may shift over the course of the day and disease process. Also remember that each person is a unique individual despite having dementia.

Validation is a principle of listening that demonstrates understanding what the other person is saying, feeling or thinking. It is a communication step that is easy to skip,

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PATIENT-CENTE R ED C A R E D E ME N TI A

but extremely important in building relationships and minimizing conflict —two things that are important in providing care for people with dementia. Here’s an example of a nurse validating a resident who wants to “go home” or is “exit-seeking.” This is a common experience, especially in the late afternoon to early evening when “sundowning” (increased confusion, frustration and combativeness) tends to occur among people with dementia.

Resident: I want to go home. Nurse: You want to go home? Resident: Yeah, how do I get out of here? Nurse: It sounds like you don’t want to be here one bit! Resident: I hate it here. Nurse: I’m sorry it is so hard to be here.

At this point the conversation could go in several different directions, and I can’t guarantee that validating will eliminate escalating frustration or even a physically threatening situation, but I promise it is better for everyone to try.

Consider how it might be more difficult for you if you had this conversation instead: Resident: I want to go home. Nurse: You can’t go home. Resident: I want to go home. Nurse: This is your home. Resident: I want to go home. Nurse: I’ll get you some ice cream.

Notice how validating someone helps you join with the person in the situation rather than contribute to a power struggle. Validation is so important, I sometimes think we are showing love, compassion and even acknowledgment of another person’s very existence. We don’t have to fix, change or even believe the circumstances in order to validate someone’s experience. It is part of the listening process in which the listener is active, but it has little, if anything to do with the listener. Offering ice-cream, engaging in an activity or walking with the resident to their room, or “home,” all may be very effective also, but only after validating!

taste very good. This is a great opportunity to spend a moment, seek eye contact and/or a simple light touch on an arm and say, “I’m sorry. That tasted gross didn’t it? I’ll get you some juice.” Whether or not there is a conscious exchange of information, people with dementia feel safer and more trusting when you validate. Remember, somewhere between 80 and 90 percent of our communication is nonverbal! Building the “soft skills” such as listening, speaking up, empathizing and cooperating contribute to positive patient experiences as well as safe, quality and cost-effective care.

Validation is also effective even when someone can’t speak. For example, sometimes when I give someone medication mixed in applesauce, she makes a face. I can tell by her expression, and the fact that I have mixed in a pill or two, that it doesn’t

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FEATURE NU TRITION PE ARLS

Nutrition Pearls: Gem Quality Information on the Latest Hot Topics in Nutrition by Nancy Collins, PhD, RD, LD/N, FAPWCA

Nutrition pearls are small nuggets of information that convey some of the most important and newest information related to wound healing. The pneumonic PEARLS is easily remembered because it represents six important concepts where nutrition and wound healing intersect. PEARLS stands for: P: Protein E: Energy A: Amino acids R: RDAs/RDIs L: Laboratory data S: Sarcopenia

Protein ein in n Protein is important because it is the only nutrient containing nitrogen. It is responsible for the synthesis of enzymes involved in wound healing as well as collagen synthesis. Protein is needed at every step of the wound healing process. When a patient does not consume an adequate supply of protein and calories over time, the result is protein-energy malnutrition (PEM). Often this manifests itself as unintended weight loss (UWL), which is one of the reasons it is so important to monitor each patientâ&#x20AC;&#x2122;s body weight on a regular basis.

The question of how much protein is required each day is one that permeates the literature with both pro-protein and anti-protein camps. The Recommended Dietary Allowance (RDA) of protein according to U.S. government standards is 0.8 grams per kilogram (2.2 pounds) of ideal body weight for the adult. Those who believe the RDA is sufficient point out that too much protein may lead to various ailments such as osteoporosis, cancer, kidney disease, and cardiovascular issues from the high saturated fat content of certain high protein meats. Those who feel the RDA is woefully

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inadequate believe that while the RDA may be sufficient for the average sedentary adult, it is certainly not enough for optimal health and wellbeing in many populations. They point to athletes, elderly persons and those with sickness and infirmities as just three groups who may require much greater amounts. Patients with chronic and nonhealing wounds are routinely given additional protein in order to promote a positive nitrogen balance. Most clinicians recommend between 1.2 and 1.5 grams per kg. For a 140pound patient, this means consuming between 11 and 14 ounces of protein each day. In order to reach this level,

most patients require supplementation. A modular protein supplement is an easy solution. Table 1 lists factors to consider when selecting a protein supplement. Energy Energy is another word for calories. If a patient consumes an inadequate amount of energy over a period of time, the result is UWL. The problem with UWL is that often, the lost weight is not fat but metabolically active lean body mass. UWL in the wound population is frequently driven by a stress response

to the wound. When the body is under stress, whether physical or psychological, its fight-orflight mechanism is amplified. The initial insult leads to local and generalized inflammation and an increase in the level of stress hormones, particularly catecholamines and cortisol. At the same time, the body experiences a decrease in the level of anabolic hormones (human growth hormone and testosterone). This hormonal imbalance leads to a catabolic state, in which the body breaks down lean body mass to release

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FEATURE NU TRITION PE ARLS

energy to meet increased demands. Working harder and faster than usual to fight off the stressor and regain homeostasis causes both body temperature and metabolic rate to increase, or the hypermetabolic state. This leads to an increased demand for glucose, which may be met by gluconeogenesis or rapidly breaking down lean body mass as a means of obtaining more energy. For these reasons it is important for a patient to meet his or her energy needs each day. There are a multitude of interventions that may be used, including provision of favorite and culturally appropriate foods, recipe modification to provide more nutrientdense foods, socialization at mealtime, proper positioning and assistance, use of oral nutrition supplements (ONS), use of appetite stimulants, and patient education emphasizing the importance of proper nutrition in wound healing. Amino Acids A polypeptide chain is comprised of three categories of amino acids. Indispensable amino acids (IAA), also known as essential amino acids, are not synthesized by humans and must come from the diet. Dispensable amino acids (DAA), also known as nonessential amino acids, are produced by the body in sufficient amounts under normal, healthy conditions. Conditionally indispensable amino acids (CIAA) are

produced in sufficient amounts by healthy individuals. However, in the presence of certain disease states or underlying physiological stress such as nonhealing wounds, supplementation often is required to achieve an adequate supply of CIAAs. Two CIAAs that are often supplemented are arginine and glutamine. Some of the latest information about amino acids explores the relationship between arginine, glutamine and leucine and a cellular protein called target of rapamycin (TOR), which is involved in the cell signaling for protein synthesis and wound healing.

TOR is protein kinase that functions as a central element in signaling pathways involved in cell growth and proliferation, as well as in pathways of protein breakdown. mTOR stands for mammalian target of rapamycin. mTOR was discovered when rapamycin was tested as a cell growth inhibitor and a potential anti-cancer agent. Amino acids are involved because arginine, glutamine and leucine all activate mTOR signaling. This is consistent with what is known about the roles of these amino acids in promoting anabolic

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FEATURE NU TRITION PE ARLS

processes, such as in wound healing. Evidence is accumulating to show that when the mTOR pathway is somehow disrupted, wound healing is altered. An unplanned medical experiment first demonstrated a link between the mTOR pathway and wound healing. A study by Buhaescu and associates1 showed that when transplant patients were given an anti-rejection medication, it had an unexpected adverse side effectâ&#x20AC;&#x201D;impaired wound healing. The drug was found to inhibit mTOR. Normal mTOR function is vital for normal wound healing. Excessive mTOR activity leads to excessive scarring, such as keloids. Inhibition or underexpression of mTOR is associated with poor wound healing. The amino acids arginine, glutamine and leucine each can activate mTOR.

RDA/RDI The topic of vitamin and mineral supplements for patients with wounds elicits many opinions and questions because there are only vague guidelines and little grade A evidence. The recommendation offered

by most clinical practice guidelines is to provide vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected. The issue is further complicated when one considers that deficiencies run the gamut from subclinical to severe. A nutritionfocused clinical exam can be utilized by a trained professional to identify symptoms of many deficiencies. This type of thorough physical assessment combined with clinical judgment and a complete diet history can shed light on the supplementation issue. Vitamin C and zinc are perhaps the two most common individual micronutrients associated with wound healing. Vitamin C is water soluble, meaning the body does not store it so it must be supplied each day. Vitamin C is needed for the hydroxylation of proline and lysine during collagen synthesis. It is also needed for carnitine production for fatty acid metabolism and to give tensile strength to newly built collagen. Symptoms of vitamin C deficiency may develop rapidly but reverse quickly with treatment. Some of the consequences of a vitamin C deficiency include lack of secretion of procollagen chains, wrong amino acid sequences and increased blood cell fragility. Zinc is needed for all enzymatic reactions and in a deficiency state, there may be a low rate of epithelialization as well as decreased

wound healing and collagen strength. Urinary losses of zinc increase with stress and weight loss. Body stores may be depleted in patients with malnutrition, chronic diarrhea and chronic corticosteroid use. Before supplementing, consider that (above 40 mg day, excess zinc may interfere with wound healing via affecting lysyl oxidase, an enzyme involved in collagen synthesis. Excessive zinc also interferes with copper and iron absorption and metabolism. It is important to remember that there is no magic combination of supplements that will make up for generalized poor nutrition and inadequate oral intake. Laboratory Data When evaluating laboratory or biochemical data, it is important to note the date on which the labs were drawn. If the labs are several months old, they may not reflect the patientâ&#x20AC;&#x2122;s current situation. However, the reverse is also true. Daily labs may be too frequent to detect any true changes in nutritional status; small daily changes are often the result of hemoconcentration fluctuations. It is also important to note if the patient had a recent blood transfusion in which case some labs may be more reflective of the donor rather than the patient.

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N UTRITIO N PE ARLS

Historically, serum proteins— albumin, prealbumin, transferrin and retinol-binding protein—were used to measure malnutrition. C-reactive protein (CRP), total lymphocyte count and serum total cholesterol are not serum proteins but sometimes are used as indicators of malnutrition. Normal ranges for these lab tests are listed in Table 2. Despite the standard use of lab tests to help diagnose malnutrition, experts have no consensus about which, if any, biochemical markers identify malnutrition, especially in the frail, elderly population. Current thinking suggests that hepatic proteins are not indicators of nutritional status but rather indicators of morbidity and mortality and recovery from acute and chronic disease. Changes in albumin, prealbumin or transferrin should not be used to suggest changes in protein status in individuals with acute or chronic inflammatory states.2

Although laboratory values taken singly or together may provide some clues to nutritional status, they probably do not provide sufficient information to identify malnutrition or evaluate the success of nutrition interventions. The good news is that there is an effort underway to identify and document malnutrition. In 2012 the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) released a joint consensus statement titled “Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition).”3 This groundbreaking article will likely change the world of adult malnutrition as we know it. The authors propose the three-pronged etiology-based definition of malnutrition that was adopted by the international consensus committee: starvation-

Nearly 3.6 million people in the United States have sarcopenia, putting them at increased risk for physical disability and frailty.4

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Table 1 Considerations when selecting a modular protein supplement • Form – Liquid or powder • Final volume • Nutrient density • Palatability • Ease of administration • Use in tube feedings

• Digestibility and tolerance • Source of protein – Whey – Casein – Soy – Collagen • Cost

Table 2 Normal laboratory values of selected nutrition indicators Lab test Normal range Albumin 3.5–5.0 g/dL Prealbumin 16–36 mg/dL Retinol-binding protein 2.6–7.6 mg/dL C-reactive protein <0.8 mg/dL Cholesterol <200 mg/dL Transferrin 212–360 mg/dL Total lymphocyte count ≥1,800 cubic millimeter (mm3) Sources: Litchford ML. The Advanced Practitioner’s Guide to Nutrition and Wounds. Greensboro, NC: Case Software and Books; 2006. Pronsky ZM. Food Medication Interactions, 15th ed. Birchrunville, PA; 2008.

Table 3 Proposed Etiology-Based Deﬁnitions of Malnutrition 1. Malnutrition in the Context of Social or Environmental Circumstances (starvation-related malnutrition). This may be pure starvation due to financial or social reasons, or could be caused by anorexia nervosa. 2. Malnutrition in the Context of Acute Illness or Injury. Examples include organ failure, pancreatic cancer, rheumatoid arthritis or sarcopenic obesity. 3. Malnutrition in the Context of Chronic Illness. Examples include major infections, burns, trauma or closed head injury. References: 1. Buhaescu I, Izzedine H, Covic A. Sirolimus—challenging current perspectives. Ther. Drug Monit. 2006;28:577-584. 2. Fuhrman MP, Charney P, Mueller CM. Hepatic proteins and nutrition assessment. J Am Diet Assoc, 2004;104:1258-1264. 3. White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Acad Nutr Diet. 2012;112:730-738. 4. Morley JE. Abbott Nutrition Health Institute. The 110th Abbott Nutrition Research Conference: Selected Summaries. Columbus, OH. June 23– 25, 2009. 5. Vella C, Kravitz L. Sarcopenia: The Mystery of Muscle Loss. Available at: www.unm.edu/~lkravitz/Article%20folder/sarcopenia.html. Accessed March 28, 2010.

related, chronic disease-related, and acute disease or injuryrelated. Table 3 outlines and defines the proposed categories. Sarcopenia Sarcopenia often is defined as an age-related shift in body composition, specifically the loss of muscle mass. The word sarcopenia has Greek origins and literally means “poverty of flesh.” As we age, we naturally lose muscle mass and replace it with fat—anyone over the age of 45 can tell you how the body changes. Nearly 3.6 million people in the United States have sarcopenia, putting them at increased risk for physical disability and frailty.4 People who are obese also can suffer this loss of muscle loss. In this case, we term it sarcopenic obesity. Although sarcopenia

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N UTRITIO N PE ARLS is seen mostly in physically inactive individuals, it is also evident in individuals who remain physically active throughout their lives. This finding suggests that physical inactivity is not the only contributing factor to sarcopenia. Current research is finding that the development of sarcopenia is a multifactorial process generally attributed to three factors: motor unit restructuring, protein deficiency, and changes in hormone concentrations.5 Stemming sarcopenia is important because patients with wounds are often also affected by a cytokinedriven stress response, which causes additional losses of lean

body mass. In combination, there may be a critical loss of lean body mass and in turn, delayed healing or chronic wounds. Interventions focus on progressive resistance exercise to turn on the body’s own anabolic drive, provision of adequate protein at each meal, and amino acid supplements. Several other therapies are currently being explored.

there is no magic vitamin supplement or laboratory test. Sarcopenia doesn’t have to be inevitable. Keep patients moving!

This article is adapted and updated from Dr. Collins’ lecture presented at the Symposium on Advanced Wound Care and printed in Ostomy Wound Management, April 2010.

Putting It All Together You are now in possession of six nutrition pearls. Make sure your patients consume adequate protein, energy and amino acids each day. Meet the RDAs/RDIs and monitor labs, but remember,

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Use under medical supervision as part of a complete, balanced diet. References: 1. Williams JZ, et al: Ann Surg 2002;236:369-375. 2. Wilson GJ, Wilson JM, Nutr Metab (Lond) 2008;5:1. 3. Stechmiller JK et al. Nut Clin Pract 2005;20:5261. 4. Bellon G, et al: Biochem Biophys Acta 1995; 1268:311-323. 5. Karma E, et al: Comp Biochem Phisiol B Biochem Mol Biol 2001; 130:23-32. ©2013 Abbott Laboratories 88931/July 2013

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N O IS E FEATURE

HOSPITALS WORK ON PATIENTS’ MOST-FREQUENT COMPLAINT:

NOISE By Laura Landro The Wall Street Journal June 10, 2013

First it’s the beeping of a heart monitor. A nurse comes in to take a patient’s temperature. There’s conversation during the shift change, overhead pagers, a visitor’s cellphone conversation and the din of a TV talk show. An aide pushes a cart of rattling dishes. An alarm goes off when IV medication is finished. All these sounds make up the steady assault of beeps and bustle during a typical night in a hospital bed. More hospitals are getting creative about lowering the noise level, masking intrusive sound and distracting patients from the cacophony. Facing potential financial penalties from Medicare, more hospitals are changing decades-old practices that contribute to the din. Some are replacing overhead staff paging systems with wireless headsets, and allowing patients to shut room doors and post a Do Not Disturb sign. Designated sleep hours in some units mean there are no routine checks of vital signs unless necessary. Some hospitals are installing ambient white-noise machines and soundabsorbing ceiling tiles and carpets in rooms and corridors. They are offering televisions with closed-circuit “relaxation programming” of soothing music and nature imagery. “Quiet Kits” with sleep masks, earplugs and crossword puzzles help patients tune out intrusive sound. Hospital noise is more than an annoyance. It disturbs patient sleep, prompts spikes in blood pressure and interferes with wound healing and pain management, studies show. Some hospitals have installed a device like a traffic light that heightens awareness of the need for quiet by monitoring the noise level and turning from yellow to red as it rises.

Noise-reduction efforts really gained momentum last year, when Medicare began basing a portion of hospital reimbursement on quality measurements including patient ratings of the quality of care. Noise consistently gets the worst marks on patient surveys. The latest data from the federal program for the year ended in June 2012 shows that only 60% of patients said the area outside their room was quiet at night, representing the lowest satisfaction score among 27 questions about the hospital experience. In a 2013 State of Patient Experience report released in April by the Beryl Institute, a nonprofit that helps hospitals improve patient satisfaction, hospital administrators ranked noise reduction as their top priority for the second time since the last report in 2011. They cited changing behavior and culture as the biggest challenge. “There is a constant tension in hospitals between the need to create

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FEATURE NOISE

“Hospitals are asking staffers to use ‘library’ voices because quiet murmurs can be more comforting than normal speaking tones.” a place where patients can rest and heal and the realities of an active and almost chaotic work environment,” says Jason Wolf, Beryl president. Noise can never be completely eradicated, he adds, but “we can counteract it.” Many hospitals now have only private rooms, but noise remains hard to control in shared rooms. A complicating factor is hospitals’ increasing openness, including more liberal visiting hours and policies that permit cell phones and other devices. “It’s also the responsibility of patients and family members to remember this is a hospital,” Mr. Wolf says. “You aren’t hanging out at your friend’s apartment.” Dignity Health, based in San Francisco, is forming quiet teams at its 39 hospitals to identify ways to reduce noise. Some are reducing the frequency and intensity of medical alarms, dimming lights in the evening and replacing nurses’ pagers and walkie-talkies with mobile headsets. Patients are getting Quiet Kits, whitenoise machines and headsets for TVs and iPads, says Tracy Sklar, senior vice president of quality, adding patient satisfaction scores on noise levels have improved.

Margaret Burleson-Turner, 80, was admitted to Dignity Health’s St. John’s Regional Medical Center in Oxnard, Calif., after a heart attack in April. She says she was kept awake by the constant “ding ding ding” of bells, alarms and phones on the telemetry floor where she was monitored. She was transferred to a rehabilitation unit with a noise-reduction program and noted how sounds were muted and voices hushed. She used a sleep mask and Do Not Disturb sign for naps, and worked on the crossword puzzle to tune out her surroundings. Overall, she says the experience was like “being wrapped in a warm little blanket.” Some hospitals hire consultants offering “soundscaping” solutions, including architectural changes and the use of ambient sound. Gary Madaras, director of Making Hospitals Quiet, a consulting service, says a $10,000-to-$50,000 investment over two years can raise patient satisfaction scores enough to bring in $100,000 to $150,000 over three years in additional Medicare payments.

“We encourage clients to stop chasing silence and increase the ratio of good sounds to bad noises,” Mr. Madaras says. Complete silence can actually be worrisome and isolating. The sickest patients “want to get quality sleep but want to feel connected to their caregivers and know that they are not far away” in case of an emergency, he adds. Hospitals are asking staffers to use “library” voices because quiet murmurs can be more comforting than normal speaking tones. They are adding white-noise machines in patient rooms and hallways because studies show sleep and relaxation are aided by an unvarying but unobtrusive sound. A recent study at Baylor Health Care System’s Heart Hospital in Plano, Texas, found white-noise machines made no difference in patient perception of noise in rooms. But construction during the study period may have elevated noise levels,

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according to Linda Tjiong, a study investigator and director of education and research at Baylor Medical Center at McKinney. That facility, which opened last summer, is installing white-noise machines in some halls and common areas to mask noise. Terri Nuss, vice president of patient centeredness at Dallasbased Baylor, says there may be other factors to weigh against noise mitigation. Smooth, hard surfaces enhance noise but they are easy to clean and help fight infection. Alarms alert staff to potential emergencies. “We are trying to figure out what is an acceptable sound level,” she says.

The Roar of the Hospital Some common sources of hospital noise and creative solutions: • Loudspeaker paging system: More staffers have wireless

headsets and vibrating pagers. The CARE Channel—it stands for “continuous ambient relaxation environment”—offers a 24/7 television menu of original instrumental music and nature imagery, including a starry night sky. Susan Mazer, chief executive producer of Healing HealthCare Systems Inc., says foreground music can mask other sounds and has been shown to induce relaxation and improve the quality of sleep.

• Televisions: Patients use headsets, and some hospitals offer

closed-circuit programming of music and nature imagery. • Talking visitors: Where appropriate, patients can close room

doors and post Do Not Disturb signs. • Medical equipment: White-noise machines can mask the sound;

in some cases, lower-decibel alarms can be used. • Squeaky carts, clattering trays: Sound-absorbing ceiling tiles

and carpets help reduce the din. • Caregiver conversation: Designated “sleep hours” mean there

are no routine checks of vital signs unless medically necessary. Lights are dimmed in evenings to encourage quiet. • Patient noise: “Quiet Kits” with earplugs, sleep masks and puzzles help tune out staff and equipment noise or a chatty roommate with a cell phone.

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CarePacs

™

Setting a new standard in patient care

It’s never been more important for health care systems to provide the best experience for patients, their families and their care team. Medline offers simple, customizable CarePacs to improve the patient care experience and strengthen brand equity.

Custom-designed QuietPac™ Restful sleep is one of the most important elements of healing. Offer patients amenities that will help them feel calm and well-rested.

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Restful sleep is one of the most important elements of healing. Offer patients amenities that will help them feel calm and well-rested.

Custom-designed ComfortPacâ&#x201E;˘

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Create an experience that is both refreshing and relaxing. Contain clutter in a travel bag with removable pockets that patients will appreciate both during their hospital stay and when they return home.

Contact your Medline representative or call 1-800-MEDLINE to learn more about developing customized patient Care Pacs for your healthcare system.

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FEATURE SOC IAL ME D IA

by Chad Plass

todayâ&#x20AC;&#x2122;s digital world, social media is having a profound effect on the way information is being conveyed and shared within the healthcare industry. More and more breaking news, clinical studies and new industry reports are being shared and tweeted through social media. Clinical nursing professionals are signing up, creating accounts, sharing information and increasing their presence across social sites. If you havenâ&#x20AC;&#x2122;t already joined in the movement, now is the time for you to get involved. Check the next page for some simple tips on how to get started with social media and become a part of the social conversation.

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FEATURE SOC IAL ME D IA

1 Create Your Social Persona If you’re not already using social media, get started by joining some of the more prominently used social sites such as Facebook, Twitter, Instagram, Google+ and LinkedIn. Signing up for these sites is quick, free and requires minimal information. One rule of thumb to remember when creating your account and building your profile is that honesty is the best and most respectable policy. The more real you are with your profile information, bio, etc., the more likely people, brands and organizations will want to follow you.

2 To Follow or Not to Follow After you have created your profile, you’ll want to decide who to follow. Think about your interests, websites you enjoy, writers you respect, thought leaders you admire, and seek out their social media accounts and profiles. Once you find those accounts, you can then follow and/or subscribe to their social media profile to receive their latest updates, tweets and posts. As you begin to follow more accounts, people and brands, you will eventually find more accounts of interest and slowly build up the number of sites adding information to your social feed.

3 Search and Research Each day, every minute, and every second, there are millions of messages

being sent out from various social media accounts. Those messages can range from breaking news from @CDC regarding the latest information on influenza, to new blog posts from healthcare bloggers like @MarkGraban. You can search and research relevant information related to your interests by using hashtags. Hashtags are keywords that have the hash sign (#) in front of them.

Most original authors love when you share their content and may even show appreciation for your efforts by thanking you via social media in a tweet or message. Also, through sharing and retweeting, those who follow you will appreciate your sharing relevant and useful content they may find interesting as well.

5 Join the Conversation

For example, if you wanted to see what’s happening in healthcare news, you would search #Healthcare. This can be done across almost all social media sites, including Twitter, Facebook and Google+, just to name a few. You can also get more detailed results by using a more specific hashtag such as #InfectionPrevention, which will pull up all specific posts, articles and messages related to infection prevention. Social search is a wonderful tool that can help you find people, businesses, and organizations that fall into your specific interest group.

4 Share and Retweet One of the best ways to become more involved with social media is through sharing, retweeting and forwarding information. On Twitter, when you want to share a tweet that you found interesting, you retweet it, meaning you re-send that very same message. If you share a message on Facebook or on LinkedIn, you are sharing that post and update with all of those individuals that you are connected to.

It’s important with social media not only to get active, but to be vocal. Consistency is the key to staying engaged. Check your social sites often to engage with other users, comment on interesting posts and share your thoughts on the latest news, updates or findings. The more engaged you are as a social media user, the more likely you are to attract and grow your following and increase your social influence. When attending healthcare-related events or tradeshows, find out the hashtag for the event and send out tweets, posts or photos using that hashtag. You’ll be amazed by the connections you will make! These five tips are just a starting point. Don’t be afraid to ask questions, do your own research and read other people’s posts before diving into the deep end of social media. Everything takes time, and social media is constantly changing with new updates, sites and rollouts every day. Start slow, build up momentum and confidence and find what interests you most. The social world is out there just waiting to hear what you have to say.

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Connect with Medline!

Twitter

Facebook

Instagram

Twitter is a social network made up of 140-character messages called tweets. It’s a fast and easy way to discover the latest news related to topics you find interesting.

Facebook is the largest social network in the world made up of more than one billion people. It’s a place to share stories, receive news and catch the latest from the friends, brands and businesses you care about most.

Instagram is the world’s largest social photo sharing site. Right now there are over 45 million photos being shared daily.

To get started, go to twitter.com/ signup and enter your name, email address, secure password, and choose a username. Your name is your personal identifier (a business name or real name) displayed on your profile page. It will be used to identify you to friends, brands, and business partners. Your username, also called your handle, will appear in your profile URL and will be unique to you. Add an interesting bio about yourself describing your interests, professional background, etc. Now you’re set to tell people to start following you on Twitter using your “@” symbol and your username, such as @Medline. Happy tweeting!

Follow Medline on Twitter: @Medline or twitter.com/Medline

If you don’t have a Facebook account, signing up for one is easy and only takes a few short steps. First enter your name, birthday, gender and email address into the form on www.facebook.com. Then pick a password. After you’ve completed the sign up process, fill out your About section with information that you’d like to share about yourself. Finally, take the time to create a custom Username which will allow you to easily promote your presence on Facebook with a short URL. This username can be used in your marketing communications, company website and business cards. Example: Facebook.com/ MedlineU.

In order to sign up for an Instagram account, you’ll need to use their app on your iOS (e.g., iPhone) or Android device. Below are some quick steps on how to get started. Download the Instagram app in the App Store for your iPhone/ iPad, or in Google Play for an Android device. Once the app is installed, tap the Instagram icon to open it, and tap Register. Here you can create a username and password and fill out your profile information. Share your username with friends, family and business associates, letting them know to start following you on Instagram using your “@” symbol and your username.

Follow Medline on Instagram: Instagram.com/ Medlineindustriesinc or @Medlineindustriesinc

Join and “Like” Medline on Facebook: facebook.com/ MedlineIndustriesInc

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Change your CULTURE. Change your BRIEF. A culture change is sweeping through long term care. It honors individuals. It’s where “the way we’ve always done it” is replaced by “How would you like us to do it?” The importance of personal choices and care is a central theme of the culture change movement. Asking a resident to fit into your routines is the old way; adapting to fit individual needs is the new way. Medline is proud to provide you videos, tools and educational resources to help you identify and nurture changes that keep your facility moving forward. In continence care, fostering a culture of change means using a brief that is designed with each individual’s needs in mind. It must deliver dignity and comfort. And the idea of “one size fits all” is replaced by choosing one that will FitRight.

medline.com/pages/ﬁtright

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Make the change to

FitRight. Skin-Safe Closures Provide secure, safe, and repeated refastenability.

Soft Anti-Leak Guards Reduce leakage and improve containment. Restore patient conﬁdence, impact facility utilization.

4D Core with Odor Protection Wicks ﬂuid away quickly to promote dryness and help maintain skin integrity.

Ultra-Soft Cloth-Like Backsheet Provides a discreet, garment-like, natural feel.

The all-new FitRight brief helps accelerate your culture of patient-centered care. • Designed with individual in mind • More high-tech features for high performance • Discreet, comfortable, garment-like ﬁt and feel • 4D core with odor protection for dryness and dignity

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1-800-MEDLINE I www.medline.com Ask your Medline rep for a free sample and more about the #FitRight story.

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MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

Each package is a 2-Minute Course in Advanced Wound Care ™

Medline’s Educational Packaging offers all the information you need, step by step, short and sweet. In a study involving 139 nurses at eight different facilities, 88% who used a wound care product with an education guide attached were able to apply the dressing correctly. None of the nurses who received traditional dressing packaging were able to apply the dressing correctly.1

medline.com/ep

Reference 1. Kent DJ. Effects of a just-in-time education intervention placed on wound dressing packages. Journal of Wound, Ostomy and Continence Nursing. 2010; 37(6):609-614. ©2013 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

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S O C I A L MEDIA FEATURE

Get Social with Your Favorite Organizations American Health Care Association (AHCA) American Hospital Association (AHA) American Nurses Association (ANA) American Nurses Credentialing Center (ANCC) Association of Nurse Executives (AONE) Association for Professionals in Infection Control and Epidemiology (APIC) Centers for Disease Control and Prevention (CDC) The Joint Commission Medline Industries, Inc. National Association of Health Care Assistants (NAHCA) National Association of Long Term Care Administrator Boards (NAB) Wound, Ostomy and Continence Nurses Society (WOCN)

✔ ✔ ✔ ✔ ✔ ✔

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SO C IA L MED IA F EATU R E

Are you a social media pro? Take this quiz to ﬁnd out! (Tip: Questions can have multiple answers.)

1. What’s the maximum number of characters you can use on Twitter?

4. Which of the following organizations has the most “likes” on their Facebook page?

a. 140 b. 18 c. 55 d. 125

a. The Joint Commission b. Wound, Ostomy and Continence Nurses Society (WOCN) c. Medline d. National Association of Health Care Assistants (NAHCA)

2. On which social media site did Medline’s ﬁrst Pink Glove Dance video make its debut?

a. Facebook b. Twitter c. YouTube d. Instagram

5. Which of the following electronic devices can you use to participate on Instagram?

3. What symbol appears when something

a. digital camera b. smart phone c. tablet with camera d. all of the above

goes wrong with Twitter?

a. sad face b. pig c. whale d. peace sign

What your score says about you Number of questions you answered correctly: 5 – You are a social media guru. Share your knowledge with your friends and colleagues! 4 – Great! You have arrived in the social media world. 3 – You have considerable knowledge about social media. Stay curious and keep learning! 2 – You are getting there! Ask for tips from a social media savvy friend. 1 – When was the last time you were on the Internet? 0 – Have you been hiding under a rock?

Answers: 1 a, 2 c, 3 c, 4 a, 5 b & c

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Gentle on patients. Tough on exudate. Optiva™ Gentle takes the dread out of dressing changes. There’s so much that makes Optiva Gentle so gentle... Gently adheres – Silitac™ holds fast, but repositions easily Gently protects – two layers of soft foam plus an absorbent core Gently absorbs – with the superabsorbant Liquitrap™ polymer core Gently retains – exudate is converted to a gel within the dressing Gently adjusts – keeping the wound environment optimally moist

For samples of the Optiva family of dressings, visit medline.com, contact your Medline representative, or call 1-800-MEDLINE.

Optiva™ Gentle

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C ARING FO R Y O U R S ELF GE T THAT R A I S E

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GET THE

RAISE YOU HAVE EARNED by Wolf J. Rinke, PhD, RDN, CSP

When it comes to employment news, there is good news and bad news. The bad news: although improving, unemployment is still high. The good news: Unemployment is going down and wages are rising. So maybe this is a good time to ask for a raise, especially if… • You are improving the “bottom line” The most important criterion that will help determine whether your boss is going to be receptive to a salary increase is the question: “What have you done for our organization lately?”

So if your accomplishments have improved the bottom line by either helping your organization make more money or decrease expenses, you are ready to schedule an appointment with your boss. • You are solving lots of problems Directly related to the item above, if you’ve been actively looking for problems, especially ones that impact negatively on the bottom line, and have assembled crossfunctional teams to solve those problems, it’s time to let others know (especially the powersthat-be) what a great job you and your team have done and how much your team has improved the profitability or productivity of your organization. By the way, keeping your boss in the loop of your accomplishments is not bragging. It’s a smart thing to do.

• You have assumed new and/or more important roles and responsibilities Let’s say that during the recession your organization has radically downsized and asked you to assume some of the responsibilities of positions that have been eliminated. Or you have been asked to assume the role of supervisor or manager. Or you have been transferred to another job that requires additional skills or competencies. These are all great reasons to go after that raise. • New hires are being paid more than you If the marketplace has changed significantly, and your newly hired colleagues are getting paid more than you, it’s time to do a little research and find out what comparable positions are getting paid. Start by talking to your human resources department to find out the current salary range for your position. If you are on the low end of

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CA RING FO R Y O U R S ELF GE T THAT R A I S E

that range, dig deeper by going to www. Salary.com or www.Payscale.com to find salary levels for comparable jobs at other organizations. • You have continued to invest in yourself Are you continuing to do all you can to become the best you can be by reading, studying and engaging in continuing education, training and development? Face it—the people who are the best in their profession are typically the most valued team members and tend to be compensated accordingly.

“

No matter what happens, remember your attitude is always your choice. So choose to always exhibit a

”

positive attitude.

• You are doing more of the things your boss does not like to do To make yourself indispensable to your boss, figure out what she does not like to do, and do more of it. Consistently executing this strategy may get you a pay raise or promotion without even asking for it.

• You make it a habit to always go beyond the expected People who consistently deliver more than expected typically are the first to get recognized, promoted and compensated accordingly. • You exhibit a consistently positive attitude No matter what happens, remember your attitude is always your choice. So choose to always—yes, I do mean always—exhibit a positive attitude. Because if you do it consistently, your subconscious will internalize it, and cause you to behave accordingly. Psycho (the mind), over the long run, will control how soma (the body) feels. If you would like help with this, read or listen to my Make It a Winning Life book available at http:// wolfrinke.com/miwlbook.html; or if you need CPE credits,read “Develop a Positive Attitude: Live a Healthier and More Productive Life” available at http://www.wolfrinke.com/CEFILES/ C230CPEcourse.html. • You say good things about others or say nothing at all Even though just about everyone seems to complain about something or someone—don’t be like everyone.

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Be the exception. Don’t gossip, whine, complain or say anything bad about anyone, especially not your boss! And right along with that, avoid office politics like the plague. And by all means, distance yourself from people who engage in any of these counterproductive behaviors. • Your organization is growing and doing well ﬁnancially Even if all of these apply to you, but your organization is struggling financially, imposing pay cuts, laying people off or cancelling bonuses and/ or dividends, it may not be a good time to ask for a raise. If on the other hand, your organization’s financial health is in good shape, and you can answer most of the above in the affirmative, you may want to go for it. Here are 10 tips to help you get the raise you have earned:

1. Get very clear about how much you enjoy working for this organization. It will determine how aggressively you should negotiate. If you love everything about your organization except the compensation package, you might want to wait. If, on the other hand, pay is just the tip of the iceberg, it’s time to go for it with gusto. (Of course, if you hate everything about this organization, it’s time to start shopping for a new job now.)

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Relax, it’s easy Your path to quality enlightenment is now a whole lot simpler. The INTERACT curriculum and tools are now online exclusively through Medline University.

“The goal of the INTERACT eCurriculum is to make INTERACT easier to use through state-of-the-art online education and training available on Medline University so that nursing home staff can improve care and safely reduce unnecessary hospitalizations.” -Joseph G. Ouslander, MD

Want to get started right away? Try the free INTERACT introductory training module at medlineuniversity.com.

Online eCurriculum

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CARING FO R Y O U R S ELF GE T THAT R A I S E

2. Put it in writing. Prepare a written proposal that clearly delineates in one or two pages how much money you have made or saved the organization, how many groundbreaking ideas you have generated and implemented, how many people you have developed, how many patients you have taken care of or any other bottom line results relevant to your area of responsibility. Also be sure to include data that identify how much it would cost to replace you. Then ask for a proportionate raise. Be as specific as you possibly can.

by verbally using information from your written proposal. Leave the proposal, and ask when it would be reasonable to expect a decision.

how long it typically takes to get a raise in your organization, then add one month before you start following up with your boss.

6. Keep it cordial and congenial.

9. Be prepared to compromise.

Never threaten, give ultimatums or mention that you are shopping around, unless you are prepared to walk. Even then, remember that regardless what industry you are in, it is a very small place. And the last thing you want to do is leave an employer on a negative note.

If the raise does not meet your expectation, offer a compromise. Many people would rather get additional free time than more money. So offer a counter proposal that will work for both of you. For example, instead of a 4% raise, suggest a 2% raise plus one extra week off per year. Or offer no raise and a disproportionate amount in bonuses or stock options instead. Whatever you do, be creative in generating lots of win-win options.

7. Leave your ego at the door. 3. Reverse the risk. The best way to get anything you want is to assume the risk. So identify specific and measurable future results in your proposal and offer to revert back to your previous compensation if you do not achieve those results by a specified time.

4. Create a win-win proposal. One way to do this is to give your boss a range. Knowing full well that she is going to pick from the low end of the range, adjust your request accordingly. The goal is to have you come across as reasonable and flexible. Also know in your own mind several compromise positions, but do not reveal them at this point.

More salary negotiations get shipwrecked because people attach their self-worth to their compensation. Remember you are not what you earn! So be sure never to leave in anger. You always want to operate from a position of strength, and getting angry is operating with a severe handicap. No matter how indispensable you think you are . . . you are not! When you attempt to get even, you will only hurt yourself.

8. Be patient. Raises take time. Plus the larger the organization, the longer it takes. Find out

5. Time it right. Set up an appointment with your boss. If at all possible engineer it so that it’s a time when she is most receptive. (I’m assuming that you know your boss well enough to know when that is. If not, it’s high time to get to know her better!) Brief your boss

10. If all else fails, start shopping … carefully. If things don’t work out to your satisfaction, keep your current job and start floating your resume. (In this tough economy you don’t want to leave your job until you have a better one.) Heads up: No matter what you decide, be sure to keep your performance at very high levels, if possible even higher than before. Source: Excerpted from W. J. Rinke, Win-Win Negotiation: Fail-Safe Strategies to Help You Get More of What You Want, (20 CPEUs), Wolf Rinke Associates, Clarksville, MD, http://www.wolfrinke. com/CEFILES/C184CPEcourse.htm. © 2013 Wolf J. Rinke

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unique

Medline is a registered trademark of Medline Industries, Inc.

A Continence Management Program as your residents thatâ&#x20AC;&#x2122;s as

Continence care from Medline is all about the individual. From the widest variety of form, ďŹ t and function in our products to a full Continence Management Program to educate every member of your staff.

Continence Management Program

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#ContinenceManagement http://goo.gl/Q7xN18

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early

detection could save your...

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E A R LY D E T E C T I O N B R E A S T C A N C ER AWAREN ESS

Life. Your breasts. Your sanity. Every person should know the symptoms and signs of breast cancer, and any time an abnormality is discovered, it should be investigated by a healthcare professional. Most people who have breast cancer symptoms and signs will initially notice only one or two, and the presence of these symptoms and signs do not automatically mean that you have breast cancer. By performing monthly breast self-exams, you will be able to more easily identify any changes in your breast. Be sure to talk to your healthcare professional if you notice anything unusual.

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BREAST CANC ER AWA R ENES S E ARLY D E T E C T I O N

A Change in How the Breast or Nipple Feels • Nipple tenderness or a lump or thickening in or near the breast or underarm area. • A change in the skin texture or an enlargement of pores in the skin of the breast (some describe this as similar to an orange peel’s texture). • A lump in the breast. (It’s important to remember that all lumps should be investigated by a healthcare professional, but not all lumps are cancerous.)

A Change in the Breast or Nipple Appearance • Any unexplained change in the size or shape of the breast. • Dimpling anywhere on the breast. • Unexplained swelling of the breast (especially if on one side only). • Unexplained shrinkage of the breast (especially if on one side only). • Recent asymmetry of the breasts. (Although it is common for women to have one breast that is slightly larger than the other, if the onset of asymmetry is recent, it should be checked.) • Nipple that is turned slightly inward or inverted. • Skin of the breast, areola or nipple that becomes scaly, red or swollen or may have ridges or pitting resembling the skin of an orange.

Any Nipple Discharge— Particularly Clear Discharge or Bloody Discharge It is also important to note that a milky discharge that is present when a woman is not breastfeeding should be checked by her doctor, although it is not linked with breast cancer.

If I have some symptoms, is it likely to be cancer? Most often, these symptoms are not due to cancer, but any breast cancer symptom you notice should be investigated as soon as it is discovered. If you have any of these symptoms, you should tell your healthcare provider so that the problem can be diagnosed and treated.

If I have no symptoms, should I assume I do not have cancer? Although there’s no need to worry, regular screenings are always important. Your doctor can check for breast cancer before you have any noticeable symptoms. During your office visit, your doctor will ask about your personal and family medical history and perform a physical examination. In addition, your doctor may order one or more imaging tests, such as a mammogram.

Source: National Breast Cancer Foundation, http://www.nationalbreastcancer.org/breast-cancer-symptoms-and-signs

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Yes, They’re Genuine. Y O Only Generation Pink Pearl® gloves combine aloe, nitrile and breast cancer awareness. a

For more information on Medline’s Breast Cancer Awareness campaign, visit pinkglovedance.com

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A World Without Breast Cancer Is Within Our Reach In 2005, Medline launched a breast cancer awareness campaign with a single vision: A World Without Breast Cancer Is Within Our Reach. Nearly a decade later, Medline’s campaign has helped make signiﬁcant strides to improve the lives of everyone affected by the disease – patients, survivors, families of those who lost their battle, healthcare workers, to name a few.

We are proud to partner with the National Breast Cancer Foundation (NBCF) because we share in their mission to save lives through early detection and to provide free mammograms to those in need. Medline implements a variety of activities throughout the year that support our breast cancer education, awareness and fundraising goals. Here are some highlights:

Pink Product Line Medline donates a portion of the proceeds from the sale of Medline brand PINK products including our signature pink gloves, scrubs, physician gowns, masks and caps, to the NBCF. scrubs123.com and click Shop PINK!

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ME DLINE & NB C F BREA S T CA NCER AWAREN ESS

Education In addition to our breast cancer awareness page on medline.com, we also host Beyond the Shock®, the NBCF’s education portal on Medline University. Beyond The Shock is a free, comprehensive guide to understanding breast cancer, early detection and treatment options. medlineuniversity.com and click Patient Education

Pink Glove Dance Competition Medline celebrates the millions of people affected by breast cancer through our Pink Glove Dance competition. It provides our customers a unique opportunity to build morale in their facility and engage their community in a common cause. pinkglovedance.com

Annual Breast Cancer Awareness Breakfast Since 2006, Medline has hosted its Annual Breast Cancer Awareness Breakfast at the Association of periOperative Registered Nurses (AORN) Annual Congress. It has become a “must-attend” event, attracting more than 1,000 guests. medline.com/special/aorn-2013/ index.html

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2012 Pink Glove Dance First Place Winner Lexington Medical Center West Columbia, South Carolina

pinkglovedance.com

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ar with us Pink Glove Dance voting begins October 25. Dozens of awards Thousands in prizes Unlimited hope

Visit PinkGloveDance.com Winners Announced November 15.

@PinkGloveDance

/PinkGloveDance

@PinkGloveDance Use Hashtag: #PinkGloveDance and #2013PGD in tweets, photos, pins, and other social media posts

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R ECIPE B R OC C OLI C HE D DAR SO UP

Nutrition Information: Servings: 6 Fat: 21.1 g Fiber: 2 g Calories: 258 Sodium: 178 mg

Broccoli Cheddar Soup The creative goodness behind this recipe comes from Kristen Greiner, a freight claims coordinator who has been working five years for Medline at the corporate headquarters Mundelein. “Soups are pretty popular at my house, especially in the cooler months,” she said. “My boyfriend was born in Poland, and over the years I have been trying to pick up some of his inherited culinary prowess.” Kristen’s goal with this soup was to replicate Panera Bread’s cheddar broccoli soup, or as she calls it, one of her favorite guilty pleasures. After a few attempts experimenting with and tweaking recipes from the Food Network, Kristen said, “I think we finally nailed it.” In addition to cooking, Kristen also enjoys do-it-yourself projects, offbeat crafts, camping, kayaking and any outdoor activity. Ingredients: 6 tablespoons unsalted butter 1 small onion, chopped ¼ cup all-purpose ﬂour 2 cups half-and-half 3 cups low sodium chicken broth 2 bay leaves ¼ teaspoon freshly grated nutmeg Kosher salt and freshly ground pepper, to taste

4 (7-inch) sourdough bread boules (round loaves) 4 cups broccoli ﬂorets 1 large carrot, diced 2-1/2 cups (about 8 oz.) sharp white and yellow cheddar cheese, grated Additional grated cheese for garnish

Directions

Melt the butter in a large Dutch oven or other pot over medium heat. Add the onion and cook until tender, about 5 minutes. Whisk in the flour and cook until golden, 3 to 4 minutes; gradually whisk in the half-andhalf until smooth. Add the chicken broth, bay leaves and nutmeg, then season with salt and pepper and bring to a simmer. Reduce heat to medium-low and cook, uncovered, until thickened, about 20 minutes. Meanwhile, prepare the bread bowls: Using a sharp knife, cut a circle into the top of each loaf, leaving a 1-inch border all around. Remove the bread top and hollow out the middle with a fork or your fingers, leaving a thick bread shell. Add the broccoli and carrot to the broth mixture and simmer until vegetables are tender, about 20 minutes. Discard the bay leaves. Puree the soup in batches in a blender until smooth; you’ll still have flecks of carrot and broccoli. Return soup to the pot. (Or puree the soup in the pot with and immersion blender.) Add the cheese to the soup and whisk over medium heat until melted. Add up to ¾ cup of water if the soup is too thick. Ladle soup into the bread bowls and garnish with cheese.

The Medline employee cookbook is $10. To purchase your own copy, please e-mail Judy at jdesalvo@medline.com.

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F ORM S & TOOLS

The following pages contain practical tools for implementing patient-focused care practices at your facility.

Pressure Ulcers Reducing Pressure Ulcers (for CNAs).……………………………………...…68 Dementia Care Ten Absolutes: Simplify Daily Tasks and Create Positive Interactions English………………………………………………………………………...…72 Spanish……………………………………..………………………………...…74

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FO RM S & TO O LS RE D U C IN G PRE S S UR E UL C E R S - C N A s

Reducing Pressure Ulcers Why is reducing pressure ulcers important? A pressure ulcer or bed sore is an injury to the skin caused by constant pressure over a bony area which reduces the blood supply to the area. Nursing home residents who cannot easily reposition themselves are often susceptible to this condition and need special care. Pressure ulcers can be dangerous and painful for a resident, in part because broken skin can allow infection into the body. If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to heal or may not heal at all. Sometimes, pressure ulcers can lead to death. The presence of pressure ulcers limits the quality of life for a resident as evidenced by: • Decrease in bowel and bladder function • More incontinence • Decrease in ability to move without help • Decrease in mental capacity • Increase in pain • Increased risk for infection • Less participation in activities Proven techniques can reduce and almost eliminate this uncomfortable and potentially dangerous condition. Advancing Excellence believes that “Nursing home residents receive appropriate care to prevent and minimize pressure ulcers.”

How can nursing assistants help reduce pressure ulcers? • • • • • • • • • • • • •

Read residents’ care plans to learn who is at risk of developing pressure ulcers. Change the position of residents who are immobilized when in bed or when up in a chair. Provide frequent incontinence care. Remove urine and/or feces from the skin as soon as possible. Provide water to the resident frequently because well-hydrated skin will not break down easily. Check the resident’s skin each time you provide care. Note and report redness -- especially over a bony area -- that does not disappear or a new open skin area. If the resident’s care plan requires a dressing, make sure it is there. Note the resident’s eating habits. Make sure they have nutritious meals. If residents aren’t eating, notify the charge nurse. Look for opportunities to increase residents’ mobility through activities and/or socialization. Observe residents for pain, and notify the charge nurse if a resident complains of pain or if you observe the signs of pain in non-communicative residents. Follow your nursing home’s facility’s protocols for pressure ulcer prevention and treatment. Participate in in-services related to pain. Talk to the charge nurse if you have a suggestion that you think might work better for a resident. Share what you learn and know with other staff.

Advancing Excellence in America’s Nursing Homes is a national campaign to improve the quality of care and life for the country’s 1.5 million people receiving care in nursing homes. Find out if your nursing home is part of the Advancing Excellence Campaign. To sign up or get more information, go to www.nhqualitycampaign.org.

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One pressure ulcer can snap your referrals, your reputation, your record of quality care.

YOUR PATH TO ZERO PRESSURE ULCERS STARTS WITH PUPP.

1,024 facilities in North America are using the PUPP program* 71.5% reduction in facility-acquired pressure ulcers for PUPP users* $215,190

annual average savings for implementing PUPP*

FitRight Continence products and Medline Remedy skin care are part of the PUPP program. For more on PUPP, visit medline.com/programs/ pressure-ulcer-prevention-program.

PUPP PUB_Healthy Skin_V11 I03.indd 69

The Pressure Ulcer Prevention Program Education â&#x20AC;˘ Products â&#x20AC;˘ Clinical Management

*Results on file, data represents averages reported. FitRight, FitRig ht Re Resto store re and Me Medli dline ne Rem Remedy edy ar are e rregi egiste stered red tradem tra demark arkss of of Medl Medline ine In Indus dustri tries, es In Inc. c Oli Olivam vamine ine is a registered trademark of McCord Research, Inc.

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FO RM S & TO O LS RE D U C IN G PRE S S UR E UL C E R S - C N A s

Pressure Ulcer Resources Campaign Resources: •

Webinar: Reducing Pressure Ulcers in Nursing Homes: An Interdisciplinary Process Framework http://www.nhqualitycampaign.org

•

Video: Pressure Ulcers: Best Practices http://www.nhqualitycampaign.org

•

Implementing Change in Long-Term Care http://www.nhqualitycampaign.org

•

Campaign Goals and Objectives http://www.nhqualitycampaign.org

•

Top 10 Ideas to Involve All Staff in Advancing Excellence http://www.nhqualitycampaign.org

Best Practice Resources: •

Preventing Pressure Ulcers: Evidence-based clinical practice guidelines that offer the latest in the management of pressure ulcers emphasize an interdisciplinary team approach http://www.ahcancal.org/News/publication/Provider/CaregivingAug2008.pdf

•

Pressure Ulcer Plan Is Working http://www.ahcancal.org/News/publication/Provider/CaregivingMay2008.pdf

Lessons Learned Resources: •

Getting A Jump On Wound Care: A wound care education program that empowers nurses and CNAs is able to control pressure ulcers at a Colorado state veterans facility http://www.providermagazine.com/pdf/2007/caregiving-01-2007.pdf

Links to Relevant Organizations: •

National Association of Health Care Assistants http://www.nahcacares.org

•

National Network of Career Nursing Assistants http://www.cna-network.org

•

Nursing Assistant Resources On The Web http://nursingassistants.net

•

American Association for Homes and Services for the Aged http://www.aahsa.org/

•

American Health Care Association http://www.ahcancal.org/

•

National Long Term Care Ombudsman Resource Center http://www.ltcombudsman.org/ www.nhqualitycampaign.org

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Opticell and Forzagel are trademarks and Medline is a registered trademark of Medline Industries, Inc.

Precision moisture management. Enhanced comfort.

Opticell™ gelling ﬁber provides an optimal healing environment, keeping intimate contact with the wound bed as it manages drainage. Forzagel™ technology allows Opticell dressings to retain their shape and size in the wound while absorbing drainage vertically to minimize the risk of periwound maceration. For easy application and pain-free removal in a wide variety of wounds, ask your Medline rep for a trial sample.

Opticell™ Wound Dressings

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#Optic cel ell http://goo.gl/wKGR GRTD

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FO RM S & TO O LS POSITIVE IN TE R A C T I O N S

Ten Absolutes: Simplify Daily Tasks and Create Positive Interactions with People with Dementia

Absolutely Never!

Do This Instead!

1. Argue “You know your mother has been dead for years. You cannot wait for her to eat dinner” “You have lived in this house for 25 years, you are home”

Agree “I haven’t seen your mother today. If I see her, I will tell her you are looking for her. While we are waiting, let’s have a bite to eat. I want to go home, too. While we are waiting, let’s have a bite to eat.”

2. Reason “You did not take a bath today, and you need to take a bath because we have an appointment with the doctor. Then we are going to go to lunch with Jane, and then we are going to get you a new pair of shoes, and why are you walking off when I am talking to you? We have to go in here and get your bath and we have to hurry.”

Divert “Please come in here with me. Oh, I know you aren’t going to take a bath. Let me help with that shoe. Oh, I know you aren’t going to take a bath. Just slide this off over your arm. Oh, I know you aren’t going to take a bath. How does this water feel? It seems warm enough. Oh, I know you aren’t going to take a bath. Just step right in here.”

3. Shame “How can you accuse John of stealing after all he has done for us?”

Distract “John is here to help us ﬁnd your wallet. Let’s have a cup of coffee and get started.”

4. Lecture “You have got to go back to bed and get some sleep. You have been up half the night and why on earth did you empty these drawers? Who is supposed to clean up this mess? I suppose tomorrow you will want to sleep all day and we won’t be able to go to Carol’s house and help with the children. I am just too tired to deal with this, so you have to get in bed and go to sleep right now. We can’t continue like this. No one can live this way. We both have got to get some sleep.”

Reassure “I can’t sleep either. Let’s go to the bathroom. I need something to drink.” (Offer a drink.) “Try to lie down again.” (Pat the bed.) “No? How about some cookies and milk?” “Try to lie down again.” (Sit beside bed and pat the bed.) “Doesn’t that feel good?” (Stay until settled or asleep. Rub their hand, forehead or arm.)

5. Say “Remember” “Do you remember who this is?” “What did you have for lunch today?” “Did Mary visit today?” “When did Jeanne come to visit?”

Reminisce “Hi, Tom. This is Sarah. She is visiting me from Elmhurst Elementary PTA. I had the nicest lunch today. Mary is such a pleasant person and she visits often. I hoped I would get here before Jeanne’s visit.”

6. Say “I told you” “I just told you that we are not going to the bank today. It is Sunday, and the bank is closed. How many times do I have to tell you we are not going to the bank. It is Sunday.”

Repeat/Regroup “Wouldn’t you know it is too late for church, and we have to go to the bank tomorrow. Since it is Sunday, let’s have fried chicken. Yes, we will go to the bank when it opens tomorrow.”

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P O S I T I V E I N T E R A C T I O N S FORM S & TOOLS

Absolutely Never!

Do This Instead!

7. Say “You can’t” “You can’t wear two shirts. You can’t pick that up with your hands. You can’t eat that like that. You can’t put your sweater on your legs. You can’t put your shoe on your shoe. You can’t go outside; it’s raining. You can’t keep putting things in the wrong place. You can’t go home; you are home.”

Do What They Can “Try this one. It looks nice. See how this spoon works. Isn’t this fun?” Try this one. Try it over here. We need to ﬁnd the umbrella. This looks nice here. I want to go home, too.”

8. Command/Demand “You have got to change your clothes. Sit down right here and stop walking around. This doesn’t belong to you. Now give it back. Why would you take those when we didn’t pay for them? You have to leave your clothes on; we’re in a public restroom. We are in a hurry. You need to do this right now.

Ask/Model “This is pretty. Do you want to try it on? Sit with me a minute.” (Pat the chair.) “This is nice. May I see it? Do you want to buy those? See if you will be warmer with this. How about going here?”

9. Condescend “Did you have any problem with him today? Be sure he takes his medicine; he spit it out this morning. I hope you don’t have trouble today. It took me 20 minutes just to get him into the car. He has been looking for his mother all morning.”

Encourage/Praise “I’m sure you were your sweet, wonderful self today. Dad will help you with his medication today; it has been hard to swallow. We are having a challenging day today, and Dad will help you a lot. He is especially interested in his mother today.”

10. Force “Now you are going to take a bath because you haven’t had one for two weeks. These nice people are here to help us. Give that to me right now; it’s not yours. If you don’t give it back, we will have to take it from you. You may not go into this room. You must come out of this room right now.”

Reinforce “I know you already took a bath. Come right in here. I know you don’t want a bath. Let’s take off this shoe. I know you don’t want to take a bath. This lady is helping out, and it is OK. That is really pretty. May I see it? Do you like this? Would you like to have it? Isn’t this a nice room; would you like to have a cup of coffee?”

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FO RMS & TOO LS IN TE RAC C ION E S P O S I T I VA S

Diez Absolutos: Simplifique las Tareas Diarias y Cree Interacciones Positivas Absolutamente Nunca

¡Haga Esto!

1. Discuta "Tú sabes que tu madre ha estado muerta por años. No puedes esperarla para cenar" "Has vivido en esta casa 25 años, estás en casa"

Esté de acuerdo "No he visto a tu madre hoy. Si la veo , le diré que la estás buscando. Mientras esperamos, comamos algo. Yo también quiero ir a casa. Mientras esperamos, comamos algo."

2. Razone "No te bañaste hoy, y necesitas bañarte porque tenemos una cita con el doctor. Luego vamos a almorzar con Jane, y luego vamos a comprarte un nuevo par de zapatos, y ¿por qué te alejas cuando te estoy hablando? Tenemos que entrar y bañarte, y tenemos que darnos prisa."

Desvíe "Por favor entra aquí conmigo. Oh, Sé que no te vas a bañar. Déjame ayudarte con ese zapato. Oh, sé que no te vas a bañar. Desliza esto por tu brazo. Oh, sé que no te vas a bañar. ¿Cómo se siente esta agua? Parece lo suﬁcientemente tibia. Oh, sé que no te vas a bañar. Pisa justo aquí."

3. Avergüence "¿Cómo puedes acusar a John de robar después de todo lo que ha hecho por nosotros?"

Distraiga "John está aquí para ayudarnos a encontrar tu billetera. Tomemos un café y empecemos."

4. Sermonee "Tienes que volver a la cama y dormir un poco. Has estado despierto la mitad de la noche y ¿por qué vaciaste estos cajones? ¿Quién crees que va a limpiar este lío? Supongo que mañana querrás dormir todo el día y no podremos ir a la casa de Carol y ayudar con los niños. Simplemente estoy demasiado cansada para ocuparme de esto, así que tienes que ir a la cama y dormirte ahora. No podemos seguir así. Nadie puede vivir así. Ambos tenemos que dormir un poco."

Tranquilice "Yo tampoco puedo dormir. Vamos al baño. Necesito algo de beber." (Ofrezca algo de beber.) "Trata de recostarte de nuevo." (Palmadas en la cama.) "¿No? ¿Qué te parece unas galletas y leche?" "Trata de recostarte otra vez." (Siéntese al lado de la cama y dé palmaditas en ésta) "¿No se siente rico?" (Quédese hasta que esté tranquilo o dormido. Frote su mano, frente o brazo.)

5. Diga "Recuerdas" "¿Recuerdas quién es esta persona?" ¿Qué almorzaste hoy?" "¿Te visitó Mary hoy?" "¿Cuándo vino Jeanne de visita?"

Rememore "Hola, Tom. Esta es Sarah. Ella me está visitando de la Asociación de Padres de Familia de Elmhurst. Tuvimos un almuerzo muy agradable hoy. Mary es una persona muy agradable y nos visita con frecuencia. Yo esperaba llegar aquí antes de la visita de Jeanne."

6. Diga “Te lo dije” "Te acabo de decir que no vamos a ir al banco hoy. Es domingo, y el banco está cerrado. ¿Cuántas veces tengo que decirte que no vamos a ir al banco? Hoy es domingo."

Repita/Reagrupe "No sabes que es demasiado tarde para ir a la iglesia, y tenemos que ir al banco mañana. Dado que es domingo, comamos pollo frito. Sí, iremos al banco cuando abra mañana."

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I N T E R A C C I O N E S P O S I T I VA S FORM S & TOOLS

Absolutely Never!

Do This Instead!

7. Diga "No Puedes" "No puedes usar dos camisas. No puedes recoger eso con tus manos. No puedes comer así. No puedes poner tu abrigo en tus piernas. No puedes poner tu zapato en tu zapato. No puedes salir, está lloviendo. No puedes seguir poniendo cosas en el lugar equivocado. No te puedes ir a casa, estás en casa".

Haga lo que Puedan "Pruébate esto. Se ve bien. Ve cómo funciona esta cuchara. No es divertido?" Prueba ésta. Pruébalo aquí Necesitamos encontrar el paraguas. Esto se ve bien aquí. Yo también quiero ir a casa."

8. Ordene/Demande "Tienes que cambiarte de ropa. Siéntate aquí y deja de dar vueltas. Esto no te pertenece. Ahora devuélvelo. ¿Por qué tomaste esto cuando no lo pagamos? Tienes que dejarte la ropa puesta, estamos en un baño público. Estamos apura dos. Necesitas hacer esto de inmediato.

Pregunte/Modele "Esto es bonito. ¿Te lo quieres probar? Siéntate conmigo un minuto." (Toque la silla.) "Esto está bien. ¿Puedo verlo? ¿Quieres comprarlos? Ve si estás más abrigado con esto. ¿Qué tal si vamos aquí?"

9. Sea condescendiente "¿Tuviste algún problema con él hoy? Asegúrate que tome su medicina; la escupió esta mañana. Espero que no tengas problemas hoy. Me tomó 20 minutos simplemente meterlo en el auto. Ha estado buscando a su madre toda la mañana".

Estimule/Alabe "Estoy seguro que fuiste muy dulce y maravilloso hoy. Papá te ayudará con su medicina hoy, ha sido difícil de tragar. Estamos teniendo un día difícil hoy, y Papá te ayudará un montón. Está especialmente interesado en su madre hoy".

10. Fuerce "Ahora vas a bañarte porque no te has bañado en dos semanas. Esta buena gente está aquí para ayudarnos. Dame eso de inmediato, no es tuyo. Si no lo devuelves, te lo tendré que quitar. No puedes entrar en esta habitación. Debes salir de esta habitación de inmediato".

Refuerce "Sé que ya te bañaste. Ven aquí. Sé que no quieres bañarte. Quitemos este zapato. Sé que no quieres bañarte- Esta dama está ayudando, y está bien. Esto es muy bonito. ¿Puedo verlo? ¿Te gusta esto? ¿Te gustaría tenerlo? Qué habitación tan bonita. ¿Te gustaría una taza de café?" © Huey 1996 De: Enfermedad de Alzheimer: Esperanza y Ayuda, por Jo Huey. Reimpreso con permiso.

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From nature’s master architects

Made by bees. Perfected by Medline. Autolytic Debridement | Beneﬁcial Moisture | pH Balanced | Odor Reduction

TheraHoney Gel and Sheet

#Therahoney medline.com/pages/therahoney MKT1329286 / LIT611R / 25M / JBK 5

Medline and TheraHoney are registered trademarks of Medline Industries, Inc.

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