theNursingPost www.nursingpost.com.au
The Career and Education magazine for Nurses and Health Professionals
Inside this issue:
NURSING MANAGEMENT
28 November 2011 - Issue 23
Visit us online for the latest jobs and articles
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n bea a c h t l little bu Sometimes, hea mpy.
We supply the nurses needed to care.
We supply general nurses and are the largest supplier of mental health nurses in Australia. To find out more visit www.swingshift.com.au or call us on 03 9481 7222.
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Welcome to Issue 23 From the Editor... Hello readers and welcome to our second last issue of the year! My, how time has flown indeed. This issue, we took a look at what Nurse Management involves, and what opportunities are available to you. Turn to page 14 now to start reading! Secondly, a big congratulations goes to Gloria Collins for her brilliant photo submission win for our Front Cover Competition! Here is what Gloria had to say about the photo; “The 2H surgical unit team of nurses got together to raise funds for the Breast Cancer Fund.” What a superb effort to the entire team as they managed to raise $1628.75! Congratulations once again Gloria! And do not forget to keep an eye out for next issue readers, it’s our final edition for the year! We’ll
Inside this Issue Nursing and Management
be bringing you a special feature on the year that was, as well as profile all the latest career and study opportunities for next year. We’re also now on Facebook, so remember to look us up and ‘Like’ us! You can check out all the previous winners for our Front Cover competition, as well as keep up to date with the latest news, stories and jobs available. Happy reading! ABN: 28 105 044 282 | PO BOX 6213, East Perth, WA, 6892 Ph: +(618) 9325 3917 | Fax: +(618) 9325 4037 E: admin@nursingpost.com.au | W: www.nursingpost.com.au Next Publication Details: Issue 24: 12 December 2011 Material Deadline: 5 December 2011 Editor / Artwork: Amrit Bhabra For media-kits, deadlines or advertising queries, please contact Amrit Bhabra. Printed by Westcare Pty Ltd
Next Issue Christmas Special
Merry Christmas! CONTENTS Ausmed (Inside Front Cover) ...................................00 Swingshift Nurses . .................................................01 Mediserve Nursing Agency .....................................03,BC Nursecare Personnel . .............................................04 Pulse International ..................................................05 CQ Nurse.................................................................06 Government of Western Australia.............................07 WA Country Health Service......................................08 Hays Healthcare.......................................................09 Queensland Health...................................................10 NSW Health.............................................................10 Medacs Healthcare..................................................11 RACHS.....................................................................12 RNS Nursing............................................................13 FEATURE: Nurse Management..................................14 Article: Nurse Practitioners Celebrate 1Year Anniversary
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Development in Nursing...........................................15 Article: Nursing Management, Is it in Yout Future?...16,19 Australian Recruiting Group......................................18 UHG.........................................................................20 CCM Recruitment International................................21 Article: Nurses Claim Violence in Hospitals Is Rising...................................................................23 NAHRLS...................................................................24 Quick N Easy Finance..............................................25 Educational Courses,Conferences & Events..............26 Ausmed Article: Identifying Eating Disorders...........28+29 Ausmed Article: A World Without Nurses..................30 The College of Nursing.............................................31 Oceania University of Medecine ..............................33 Healthcare Australia.................................................36 Continental Travelnurse............................................37
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Government of Western Australia Department of Health
Registered Nurse – Oncology/Haematology Child and Adolescent Health Service
Government of Western Australia Department of Health
Registered Nurse Paediatric Intensive Care Unit
Web Search No: 00005396
Child and Adolescent Health Service
Level/Salary: ANF Level 1 $53,222 - $70,036 pa pro rata
Web Search No: 00005370
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Level/Salary: ANF Level 1 $53,222 - $70,036 pa pro rata
Permanent Full Time/Part Time and Fixed Term/Full Time
Vacancy Reference No: 911789
(up to 12 months) positions currently available
Permanent Full Time/Part Time & Fixed Term Full Time/Part Time (up to 12 months) vacancies available
Position Profile: We are actively seeking dedicated nurses who will provide exceptional clinical care to patients and their families in the area of Oncology/Haematology. This is an opportunity to travel and experience the lifestyle of Western Australia. Successful applicants will be eligible for flight reimbursement including immediate family members (conditions apply). Area Profile: Princess Margaret Hospital is a 220 bed, internationally recognised paediatric facility that’s treats children and adolescents from around the state with approximately 250,000 patient visits (inpatient and outpatient) each year. In addition to providing hospital based care, the Child and Adolescent Health Service is committed to population health and ambulatory care programs aimed at providing services for children and promoting life-long health. This includes preventing health problems through promoting wellbeing, early detection of diseases and intervention and provision of services in the community rather than the hospital setting. New Children’s Hospital: Construction of a $1.2billion new children’s hospital is scheduled to start in early 2012 and finish at the end of 2015. The tertiary hospital will have capacity for 274 beds and will house the State’s only paediatric trauma centre. You can visit the New Children’s Hospital Project at: http://newchildrenshospitalproject.health.wa.gov.au/Home.aspx WA Health welcomes the diversity of experience new applicants bring to our health service. To Access Detailed Information: jobs.wa.gov.au and key in the Web Search No. to access detailed information or Ph: 9480 9307 to be mailed an information pack. For Specific Inquiries: Please contact Ronald Laurie,
Position Profile: We are actively seeking dedicated nurses who will provide exceptional clinical care to patients and their families in the area of Paediatric Intensive Care. This is an opportunity to travel and experience the lifestyle of Western Australia. Successful applicants will be eligible for flight reimbursement including immediate family members (conditions apply). Area Profile: Princess Margaret Hospital is a 220 bed, internationally recognised paediatric facility that’s treats children and adolescents from around the state with approximately 250,000 patient visits (inpatient and outpatient) each year. In addition to providing hospital based care, the Child and Adolescent Health Service is committed to population health and ambulatory care programs aimed at providing services for children and promoting life-long health. This includes preventing health problems through promoting wellbeing, early detection of diseases and intervention and provision of services in the community rather than the hospital setting. New Children’s Hospital: Construction of a $1.2billion new children’s hospital is scheduled to start in early 2012 and finish at the end of 2015. The tertiary hospital will have capacity for 274 beds and will house the State’s only paediatric trauma centre. You can visit the New Children’s Hospital Project at http://newchildrenshospitalproject.health.wa.gov.au/Home.aspx WA Health welcomes the diversity of experience new applicants bring to our health service. To Access Detailed Information: jobs.wa.gov.au and key in the Web Search No. or Ph: 08 9480 9307 to be mailed an information pack.
Nurse Manager Recruitment on (08) 9340 8689.
For Specific Inquiries: Please contact Katherine Griffiths on 08 9340 8163.
Location: Princess Margaret Hospital for Children, Subiaco.
Location: Princess Margaret Hospital for Children, Subiaco.
Closing Date: Monday, 19 December 2011 at 4.00pm.
Closing Date: Monday, 19 December 2011 at 4.00pm.
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WA Country Health Service Nursing Opportunities of a Lifetime Are you looking for a chance to travel, experience adventure and work in rural and remote Western Australia? A WA Country Health Service rotational nursing/midwifery program could be for you. There are three programs catering for varying levels of nursing and midwifery, ranging from Registered Nurse 1.2 and Registered Nurse or Midwife 1.3–1.9. Our rotational programs offer the opportunity to travel, experience rural and remote Western Australia and broaden your professional skills in: aged care emergency high dependency medical mental health
operating theatre paediatrics palliative care remote health surgical.
Travel, costs and accommodation are arranged for all rotational programs. WA Country Health Service provides: an attractive salary package with superannuation, subsidised accommodation and excellent professional and leave entitlements.
To find out more about the opportunities available call 08 9222 6497 or 0429 419 360, or visit www.wacountry.health.wa.gov.au
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THEATRE NURSE Apply yoUR SpECIAlIST SkIllS IN SCRUB pRoCEDURES Joining a leading provider of innovative care in East London, your skills will be recognised and rewarded. You will directly contribute to the day-to-day running of the operating theatre suite, ensuring the provision of outstanding care and services. You will take responsibility for the nursing team and clinical decisions, proactively adapting care plans in response to the patient’s condition. As a Registered Nurse you have knowledge and understanding of scrub procedures/responsibilities including: • Assisting with leading and monitoring the performance of the nursing team • Peri-operative care appropriate to individual surgical needs of patient • Accurate accounting of all disposable and non-disposable instrumentation before, during and following a clinical procedure • Safe positioning and transfer of patients within the department in accordance with trust and theatre policy and procedures • Ensuring availability and readiness of all equipment and instrumentation before anaesthesia commences In return you will receive a leading jobs benefits package including competitive salary reflecting your experience, 25 days leave, life assurance, private healthcare and career development opportunities. This position is currently vacant and as such will suit someone who is quick to travel, has a UK/EU passport or is eligible for a suitable working visa and holds NMC registration. Not travelling until 2012 or 2013? We offer comprehensive advice on all aspects of relocating and can source a role to suit your career objectives and travel plans. For further information about this vacancy or working abroad, please contact your local consultant: QlD/NT/NSW/WA Rose Holden T: 07 3243 3023 E: rose.holden@hays.com.au VIC/SA/TAS/NZ kerrie Smith T: 03 8562 4288 or 0800 001 718 (Free Call NZ) E: kerrie.smith@hays.com.au
hays.com.au 9
More than just a job If you are an experienced nurse or midwife looking to make the move to a rural and remote community – Queensland Health can offer competitive incentives, leading rates of pay, options to grow your career, supportive and lifestyle-friendly workplaces plus the relaxed Queensland way of life.
Queensland Health Search for vacancies or send an online Expression of Interest today at www.health.qld.gov.au/nursing
NURSING Orange Clinical Midwife Educator (After Hours) PFT (Jobshare considered), Salary: $80,448– $83,063 pa, Recruitment No: 45983, Enquiries: Jenny Soar, (02) 6369 2222 or Jenny.Soar@gwahs.health.nsw.gov.au Close: 23/12/11. For an Application Kit or to apply online please go to http://nswhealth.erecruit.com.au We are committed to Equal Employment Opportunity Ethical Practices, the principles of Cultural Diversity and promote a smoke-free environment. Appropriate criminal record and child protection checks conducted for all positions. All employees (except casuals) are eligible to Salary Package.
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NM101111
“Working in remote Queensland has been one of the toughest things I have ever done in my life, but also the most rewarding! And the Remote Area Nursing Incentive Package supports your professional development and helps maintain your clinical currency.” Beverley Hamerton, District Director of Nursing, Torres Strait and Northern Peninsula Health Service District
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Thank you to all our RAHC health professionals for being a part of the effort to improve Indigenous health.
Season’s Greetings and Best Wishes for 2012.
Imagine a great Australia... for everyone Funded by the Australian Government
NURSE
Management
INSIDE THIS FEATURE: - Nurse Practitioners Celebrate 1 Year Anniversary This field of nursing may be new to the scene, but it sure is leaving a good impression on our health system. Page 15
- Is Nurse Management in YOUR Future?
You’re a registered nurse, been working long enough, now what’s the next step? See what opportunities nursing lies for you. Page 16,19
NURSE PRACTITIONERS Celebrate 1Year Anniversary It was only a year ago that nurse practitioners and eligible midwives were finally given authority to offer clients rebates on services provided under the Medicare Benefits Schedule (MBS) and to write prescriptions that qualify for Pharmaceutical Benefits Scheme (PBS) subsidies.
extensive experience needed to see and treat clients in an advanced clinical role, with their scope of practice extending beyond that of a registered nurse.”
The Australian Nursing Federation (ANF) is now celebrating this important achievement as a symbol of important work that nurses and midwives are providing to Australians.
November the 1st of 2010 was the date that the employment of the new reforms was initiated, which allowed nurse practitioners to successfully register under Medicare.
The ANF Federal Secretary Lee Thomas said that this achievement for nurse practitioners and midwives has been one of the biggest and potentially important health reforms in Australia.
Now, approximately 29,000 nurse practitioner services and 5,200 midwifery services have since been subsidised by Medicare, with 11,000 prescriptions also being successfully provided by nurse practitioners through the PBS.
“For the ANF and our growing membership, this has been a long-overdue acknowledgement of the important role the nursing and midwifery workforce plays in Australia’s primary healthcare system.”
Ms Thomas stated that because of these authorized changes,
“Nurse practitioners are registered nurses with the high-level education and the
“they [nurse practitioners] are being called upon to provide frontline services to people who otherwise would need to see their local GP.”
NURSING MANAGEMENT: Is it in your future?
Nurse managers are experienced clinicians, who specialise in human resource and information management, business planning, budget and personnel management, plus they are also responsible for recruitment and developing appropriate strategies and services to better their organization, whilst meeting the changing needs of their health facility. There are a variety of different nurse management roles available in Australia, from managing particular sector of nursing within a health facility, to operational management and even directing an entire nursing staff. Whatever role it is, nurse management usually involves information and project management as part of the job description. To become a nurse manager, you do need to be an experienced registered nurse who has pursued further education. The role normally requires a nurse with a Master’s Degree. This enables them to work closely
with doctors in a wide range of health facilities and specialities. Some of these include paediatrics, mental health, women’s health and cardiac care to name a few. Some common management roles available in the healthcare workforce include nurse unit manager, director of nursing, nurse educator and nurse practitioners.
NURSE UNIT MANAGER : A NUM is a registered nurse who is responsible for overseeing and directing a ward or unit of a hospital or medical facility. This includes directing the nursing staff
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and overseeing the care that patients are receiving within their ward. NUMS also have to work with other managers to ensure that an overall high level of care is being delivered throughout the hospital or health service. NUMS can also hire, train, schedule and mentor nurses within their unit.
NURSING CLINICAL DIRECTOR Director of Nursing : A DON is required to plan, organise, direct, control and coordinate medical programs and clinical services in a hospital or other health service facility, whilst maintaining appropriate standards of medical care. They also have to provide leadership to ensure an appropriately skilled medical workforce, and contributes to health service planning. A DON is a member of the nursing executive team who oversees several nurse managers and reports to the chief nursing officer of the organization. They are key players in health care reform. A DON is required to have regular meetings and discussions with the organization’s clinicians and hospital leaders as part of a combined effort to further the values and mission of the health facility.
NURSE PRACTITIONERS : Nurse practitioners require the highest level of education and experience out of all management roles available in nursing. A NP is qualified to work in local or regional areas were a doctor may not be readily available. If need be, NPs can refer patients to physicians if a health issue is out of their expertise. Family nurse practitioners are qualified to run their own practices from clinics. These clinics assist with family planning, important to many in both small and large communities, as well as providing daily medical needs to families. The pay isn’t too bad either, with nurse practitioner jobs paying extremely well internationally. Travelling nurse practitioners is a lucrative and relatively new role, but this allows you to experience travel and social work. This type of management role usually pays the highest, so if you are interested; it is worth finding out more about it.
FOR MORE INFORMATION : If you are interested in finding out more information on management roles, the best people to talk to is NUMS, DONS and Nurse Practitioners, or you can visit: www. nurseinfo.com.au/becoming/management
Independent Contract Nurses Required!
creating freedom and choice ...the innovative way
UHG is a leading provider of customised healthcare solutions for insurers, employers and individuals across Australia. We are offering unique opportunities for Registered and Enrolled Nurses to undertake sub-contract work with our innovative mobile health service division. • • • •
National Opportunities Different work locations & environments Discover new challenges Take control of your work-life balance!
The following are minimum requirements for these roles: • Competent phlebotomy skills - Min 2yrs experience • Current CPR Certification • Own Vehicle and Drivers License • PC & Printer, Internet Access, Email, Fax/Scanner • Australian Police Check • Public Liability & Professional Indemnity Insurance • ABN Experience in small business, insurance assessments, pre-employment medicals and vaccination programs would be well regarded, but not essential.
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Prefer a more laid back lifestyle? How about Guernsey? Ideally located between the UK & France. Lined with quaint cobblestone streets, restaurants & cafes. You’ll pay a lower tax than the main land & be provided with subsidized accommodation! Vacancies also exist in the UK! Enquire now for more info...
Benefits on Offer in Guernsey: • £300 towards the flight over • Subsidized accommodation • Additional BONUS: Applies to 1&2 year contracts: £1,000 on completion of 12 months & £3,500 on completion of the second 12 months. Applies to the following specialties only: Adult disability, ICU, Theatres, Mental Health • ANOTHER BONUS! A lump sum retention payment every February of £697, pro rata to your service to that date. • Tax Benefits*: The first £6,000 of your salary is tax free, the remainder is taxed at 20% *Conditions Apply
AUS Free Phone: 1800 818 844 NZ Free Phone: 0800 700 839 dawn@ccmrecruitment.com.au raquel@ccmrecruitment.com.au
www.ccmrecruitment.com CcmAustralasia
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Nurses Claim Violence in Hospitals is Rising The Australian Nursing Federation has stated that violent incidents are increasing at Tasmania’s hospitals, and now wants metal detectors installed in the state’s hospitals as a means of attempting to reduce the violent attacks. Reports indicate that there were 300 serious attacks at the Royal Hobart Hospital alone between the beginning of this year to the end of September. Neroli Ellis, a member from the federation, stated that safety suggestions will be discussed at the next meeting with the health department. “We are concerned with this increasing trend and we did negotiate a policy and strategy that should have been implemented by December, but the department are very tardy.” “In fact they cancelled today’s meeting.” A spokesman from the health department stated that they are currently satisfied with the current level of security within the three main hospitals, and rejects claims that it had cancelled the nurses’ safety meeting. It simply got postponed and will be rescheduled. Jeremy Rockliff, the Opposition health spokesman stated that the current budget cuts will simply make the problem worse.
“Our frontline staff resources are already massively stretched. Now when the Government continues with their madness of cutting resources to frontline services and staff, this is just going to compound what is an increasing problem in our hospitals. It is grossly unacceptable” he said. The Royal Hobart Hospital management has denied the claims that the increase of violence within the hospital is because of the result of budget cuts, as made by the Opposition. Southern Tasmania Area Health Service’s Jane Holden believes the rise is due to the increasing number of patients coming through the doors, as well as stricter recording of incidents. “What the long term strategy is - continue to report everything, because then we get a sense of where situations can arise, increase the confidence of our staff in dealing with de-escalating issues so give them some more experience in that regard, make sure our Code Black responses are really well coordinated,” she said. Ms Holden continued to state that the hospital will change its current methodologies in regards to the current procedures they execute for Code Blacks, mental health and how general medical staff should lead response teams.
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Educational Courses, Conferences & Events
Educational Courses,Conferences & Events
CONTENTS Ausmed Online: Article - Identifying Eating Disorders...................28+29 Feature Article: A World Without Nursing...................................... 30 The College of Nursing.................................................................. 31 Inaugural Commonwealth Nurses Conference 2012.....................32 Australian Wound Management Association Conference 2012.... 33 Oceania University of Medicine.....................................................33
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Decem ber 8th Annual Cardiac Seminar
7th Annual Conference
Experienced nurses working in both metropolitan and rural areas with patients that have cardiovascular conditions.
Health Services & Policy Research
Educational Courses, Conferences & Events
Australian College of Critical Care Nurses (ACCCN) and the Victorian Cardiac Nurses Association (VCNA) 2 December 2011, Melbourne www.acccn.com.au
Health Services Research Association of Australia and New Zealand (HSRAANZ) 5-7 December 2011, Adelaide www.healthservicesconference.com.au
2012 The Early Years Conference 2012 The Development of Children’s Mental Health: How Do We Become Who We Are? The University of British Columbia 2-4 February 2012, Sydney http://interprofessional.ubc.ca/Early_Years.htm
Commonwealth Nurses Federation Inaugural Nurses Conference Our health: our common wealth Commonwealth Nurses Federation 10-11 March 2012, London, UK. www.commonwealthnurses.org
Australian College of Operating Room Nurses 15th National Conference Territorial boundaries: Dare to be diverse Australian College of Operating Room Nurses 22-26 May 2012, Darwin, NT www.acorn.org.au
International Nursing Conference Nursing: Caring to Know, Knowing to Care Nursing Division of Hadassah University Medical Centre 4-7 June 2012, Jerusalem, Israel www.israel.rnao.ca
Australian Wound Management Association Conference Harbouring wound care The AWMA 18-22 March 2012, Sydney www.awma2012.com
2nd National Indigenous Drug and Alcohol Conference Beyond 2012: Leading the Way to Action 6-8 June 2012, Fremantle, WA www.nidacconference.com.au
4th Congress of the Wound Union of Wound Healing Societies Better care - Better life Wound Union of Wound Healing Societies 2-6 September 2012, Yokohama, Japan www.wuwhs2012.com
National Association of Childbirth Educators’ Biennial Conference Generation Now - the fears, the fantasy and finding the balance National Association of Childbirth Educators 16-18 October 2012, Luna Park, Sydney www.nace.org.au
11th Global Conference on Ageing
16th South Pacific Nurses Forum 2012
Ageing Connects
South Pacific Nurses Forum 19-22 November 2012, Melbourne, Leonda by the Yarra. www.spnf.org.au
IFA-FIV 28 May-1 June 2012, Prague Czech Republic www.ifa-fiv.org
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Educational Courses, Conferences & Events
Identifying Eating Disorders With the media so focused on diets and body size there can be little surprise that eating disorders are becoming more common and are affecting a wider variety of people. The Nurse Practitioner has recently published an article focusing on strategies the practising nurse can use to identify and manage individuals with eating disorders.
Eating Disorders Most people have heard of anorexia (nervosa) and bulimia (nervosa), both of which are complex psychiatric conditions believed to be on a disease continuum, where symptom overlap is common. Along with eating disorder not otherwise specified (EDNOS), these conditions result in altered body image and abnormal eating habits (starving, binging/purging) with the affected individual preoccupied with weight and body shape. Anorexia nervosa (AN) has one of the highest death rates of all psychiatric disorders, however early diagnosis is often uncommon. Historically eating disorders were considered to be diseases that affected white females with high socioeconomic status, but worldwide evidence suggests that the epidemiology has changed. Incidence is increasing in males, youths and people of colour, with 5-15% of all cases of adult eating 28
disorders being diagnosed in males. Additionally the decade between 1996 and 2006 saw a 119% increase in hospitalisation for children under 12 for eating disorders. Risk factors for eating disorders may include: • Individuals with perfectionistic personalities • Having an emotionally distant father • Coming from families with high expectations • Participating in sports that emphasise certain body weight (such as wrestling), or type (such as gymnastics) • Having a disease that includes strict dietary management (such as diabetes mellitus) • Being a male homosexual • Being influenced by environmental factors such as perceived pressure to be thin or a personal belief that thinness is ideal • Stressful life events such as divorce or empty nest syndrome
Clinical Presentation Early diagnosis along with prompt and efficient treatment is paramount for achieving positive outcomes in patients with eating disorders. An accurate clinical diagnosis requires a high degree of suspicion, as well as a thorough patient history and physical exam. Most people with eating disorders
feel hunger normally, but do not eat normally. They may have only subtle physical findings and present with nonspecific complaints such as dizziness, fatigue and weakness, or infertility secondary to amenorrhea. A patient’s weight may hold little indication of the disease, with those suffering from EDNOS and bulimia nervosa likely to be a normal weight or overweight (while anorexics may be markedly underweight). When performing a clinical assessment, try to include the following:
Management of this disease is complex and requires a multidisciplinary team that includes primary and speciality care, social workers and mental health professionals. While the majority of patients respond to prompt treatment, recurrence occurs in approximately 25% of cases. Nurse practitioners need to be on the lookout for signs and symptoms of eating disorders and appropriately refer patients when necessary.
Physical symptoms are usually the result of nutritional deficiencies and electrolyte imbalances caused by food restriction and binging/purging behaviours. Almost every body system may be affected by eating disorders so a physical assessment needs to include:
Comment on this clinical article at: www.ausmedonline.com/nursing-blog.html
Ausmed has recently added over 10 hours of medicines education to AusmedOnline, this content is available exclusively to our members. Visit www.AusmedOnline.com today to learn more about membership. Source: Garzon, D. L. & Figgemeier, M. E. (2011) Dying to be thing: Identifying and managing eating disorders. The Nurse Practitioner, 36, (10)
• Vital signs • Cardiovascular and peripheral vascular status • Dermatologic abnormalities (such as calluses on dorsal surface of hand or fingers due to trauma from induced vomiting) • Neurological status Red flags for eating disorders include the following: • Fasting or regularly skipping meals • Refusing to eat with family or friends • Two skipped periods along with weight loss • Purging including laxative use for reasons other than constipation • Excessive exercise, including giving up other activities to exercise • Extreme calorie counting and portion control It should be noted that there are a number of other medical conditions that mimic eating disorders, so care needs to be taken when making a clinical assessment. 29
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• Eating and exercise patterns • Menstrual history and patterns if applicable • Identification of food restriction and/or binging behaviour • Medication and nutritional supplement use (laxative use is common) • Perception of body size • Thorough mental health evaluation – suicide is a leading cause of death in individuals with eating disorders so suicidal ideation/plans/ attempts may need to be explored
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