Postpartum Depression For Dummies, 2nd Edition

Penulis: Chow, Cheryl
Impresum: HOBOKEN: WILEY PUBLISHING; 2007
Kolasi: xii, 276 hlm.
Keyword: Postpartum, Depression
ISBN:    978-0-470-12170-2
Tebal    362 halaman

   It's a great blessing when a new mom with postpartum depression (PPD) is fortunate enough to be diagnosed early by a knowledgeable medical practitioner or therapist. But without guidance, it isn't always clear where the boundary between normal baby blues and PPD lies. As with any other illness, the quicker that PPD is identified and treated, the faster the woman will recover.
   Postpartum Depression For Dummies can help you begin the process of determining what’s going on with you and give you a better idea of where you fall so that you can get yourself into proper treatment right away. The book covers all aspects of PPD, from its history and its origins to its effects on women and their families to the wide variety of treatments available—including conventional Western medicine, psychological therapy, alternative medical treatments, and self-care measures. Postpartum Depression For Dummies reveals:

- Why some doctors may be hush-hush about PPD
- How to distinguish between pregnancy hormone changes, "baby blues," and PPD
- The difficulties of getting a proper diagnosis
- The role and importance of a therapist
- The benefits of medication for depression
- Alternative treatments with  a successful track record
- How to find the right balance of psychological, medical, and alternative treatment
- Ways you can help foster recovery
- The nutrition you need to care for yourself properly
- How to help your partner help you

   Postpartum Depression For Dummies also provides the additional resources you need—web sites, organizations, and further reading—to help avoid the unnecessary suffering caused by undiagnosed and untreated PPD and survive and thrive as a new mom

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Therapy And The Postpartum Woman: Notes On Healing Postpartum Depression For Clinicians And The Women Who Seek Their Help

Penulis:Kleiman, Karen R
Impresum:NEW YORK: TAYLOR & FRANCIS GROUP; 2009
Kolasi:xxi, 334 hlm.
Keyword:Postpartum
ISBN:978-0-415-98996-1;1135856338
Tebal    250 halaman

   This book provides a comprehensive look at effective therapy for postpartum depression. Using a blend of professional objectivity, evidence-based research, and personal, straight-forward suggestions gathered from years of experience, this book brings the reader into the private world of therapy with the postpartum woman. Based on Psychodynamic and Cognitive-Behavioral theories, and on D.W. Winnicott's "good-enough mother" and the "holding environment" in particular, the book is written by a therapist who has specialized in the treatment of postpartum depression for over 20 years. Therapy and the Postpartum woman will serve as a companion tool for clinicians and the women they treat.

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Best Practices: Tube Thoracostomy Insertion

Sarah L. Melendez, MD; Mark A. Silverberg, MD Contributor Information


 Tube thoracostomy is the insertion of a tube (chest tube) into the pleural cavity to drain air, blood, bile, pus, or other fluids. Whether the accumulation is the result of rapid traumatic filling or insidious malignant seepage, placement of a chest tube allows for continuous, large volume drainage until the underlying pathology can be more formally addressed. The list of specific treatable etiologies is extensive, but without intervention, patients are at great risk for major morbidity or mortality.


ndications for chest tube placement (thoracostomy) include the following:
- Pleural effusion (shown)
- Spontaneous or traumatic pneumothorax
- Tension pneumothorax (should be treated first with needle decompression and then with tube thoracostomy)
- Empyema
- Hemothorax
- Chylothorax


Standard instrumentation for tube thoracostomy is shown. To perform a chest tube placement, the following equipment is needed: sterile gloves, preparatory solution (chlorhexidine and/or Betadine), sterile drapes, surgical marker, two 10- to 20-mL syringes, a 25-gauge 5/8" needle, a 23-gauge 1.5” needle or 27-gauge 1.5” needle (for instilling local anesthesia), no. 10 blade on a handle, Vaseline gauze, ten 4×4 inch gauze squares, sterile adhesive tape (4" wide), 0 or 1-0 silk or nylon suture, large and small needle drivers, large and medium Kelly clamps, large curved Mayo scissors, large straight suture scissors, lidocaine, and a drainage device (with suction source and tubing).


Standard instrumentation for tube thoracostomy is shown. To perform a chest tube placement, the following equipment is needed: sterile gloves, preparatory solution (chlorhexidine and/or Betadine), sterile drapes, surgical marker, two 10- to 20-mL syringes, a 25-gauge 5/8" needle, a 23-gauge 1.5” needle or 27-gauge 1.5” needle (for instilling local anesthesia), no. 10 blade on a handle, Vaseline gauze, ten 4×4 inch gauze squares, sterile adhesive tape (4" wide), 0 or 1-0 silk or nylon suture, large and small needle drivers, large and medium Kelly clamps, large curved Mayo scissors, large straight suture scissors, lidocaine, and a drainage device (with suction source and tubing).


To begin the procedure, place the patient in a supine position or at a 45-degree angle, to reduce the risk of diaphragm elevation and improper chest tube placement. Abduct and externally rotate the arm on the patient’s affected side, so that the patient’s palm lies behind his or her head. A chest tube is typically inserted in the triangle of safety, a region delineated by the anterior border of latissimus dorsi, the lateral border of pectoralis major, and a horizontal line lateral at the level of the nipple, or about the 5th intercostal space. The tube insertion area is between the midaxillary and anterior axillary lines at the level of the nipple. Prepare and mark the skin (shown) to demarcate the relevant anatomy


nject a systemic analgesic (shown), unless contraindicated. Using the 25-gauge needle, inject 5 mL of local anesthetic solution into the skin that will overlie the initial incision. Using the 23-gauge or, preferably, 27-gauge needle, infiltrate approximately 5 mL of the anesthetic solution to a wide region of subcutaneous tissue that is superior to the targeted site of initial incision. Redirect the needle along the expected course of the chest tube. Inject approximately 10 mL of anesthetic solution into the periosteum (if bone is encountered), intercostal muscle, and pleura. Look for aspiration of air, blood, or pus into the syringe, to verify that the needle entered the pleural cavity.

With the no. 10 blade, make a 4-cm horizontal skin incision (shown) above the rib that is below the desired intercostal level of entry.


Use a Kelly clamp to bluntly dissect through subcutaneous tissue and fascia (shown), creating a tract by intermittently advancing the closed instrument and opening it.


Use an index finger to palpate the tract (shown) and tunnel upward over the rib that is above the skin incision. Inject additional local anesthetic into the intercostal muscles and pleura.


Using the closed Kelly clamp, apply some force and a twisting motion to pass through the intercostal muscles and parietal pleura and enter into the pleural space (shown). Be careful to perform this motion with a controlled approach, to prevent the clamp from entering too far into the chest and potentially injuring the lung or diaphragm. Listen and feel for a pop (resulting from a rush of air or fluid) to confirm the entry of the Kelly clamp into the pleural space.


Within the pleural space, open the Kelly clamp and then withdraw it so that its jaws enlarge the dissected tract through all layers of the chest wall (shown). This will make it easier to insert the chest tube. When opening and withdrawing the Kelly clamp, the orientation of the clamp should be parallel (as opposed to perpendicular) to the rib space, in order to minimize morbidity associated with damage to the neuromuscular bundle.


Use the index finger to palpate the tract and feel for adhesions (shown). Rotate the finger by 360 degrees, to confirm the tract and try to loosen and break easily disrupted adhesions. Do not try to lyse significant, organized adhesions manually, as doing so may cause significant bleeding. Determine the distance between the incision and the apex of the lung, in order to know how far to advance the chest tube.
 

 Clamp the fenestrated proximal end of the chest tube with a Kelly clamp (shown) and introduce it through the tract. Next, clamp the distal end of the chest tube until it can be connected to a drainage system, in order to prevent blood from pouring out of the tube onto the floor.
 

 

Hold the chest tube in one hand and direct it through the incision (shown), releasing the Kelly clamp proximally and pushing in posteriorly and superiorly using a circular motion.


Use the index finger of the other hand to help guide the chest tube posteriorly and superiorly (shown), using circular motion and making sure all holes are within the thoracic cavity


Make certain that the final hole is inside the thoracic cavity. This hole crosses the white line on the tube (shown) and aids in detecting it on x-rays.


Connect the chest tube’s distal end to a drainage device (shown). To make it easier to connect to the drainage device, some practitioners cut the distal end of the tube. Once the chest tube and drainage device are connected, release the cross clamp that is on the chest tube. To confirm proper intrathoracic placement, look for a respiration-related swing in the fluid level of the drainage device and for respiration-related condensation levels in the tube.


Suture the tube securely to the patient’s chest with 1-0 silk or nylon sutures (shown), using a curved or straight needle.


To secure sutures, use 2 distinct through-and-through, simple, interrupted stitches on each side of the chest tube (shown). Ensure that there are no possible areas for air to leak. Each stitch should be tied tightly to the skin, then wrapped tightly around the chest tube several times to cause slight indentation, and then tied again without breaking suture. Some physicians favor locking sutures to secure a large-bore thoracostomy tube.


Place Xeroform gauze (shown) over the skin incision. Fold the gauze on itself, wrap it around the thoracostomy tube, and then push it down to the skin insertion site to create an additional barrier
 

Make an occlusive dressing to cover the chest tube. Turn regular 4×4 inch gauze squares into Y-shaped fenestrated gauze squares (shown), and secure them to the chest wall with 4-inch adhesive tape.
 

 To create adequate padding, place multiple gauze sponges over the chest tube (shown) as well as between the chest tube and chest wall. To minimize how much tube movement and traction is directly transmitted to the insertion site, many practitioners create a tape “tether.”
 

Place tape over gauze on the chest (shown). Tape the tube along the chest wall in an “umbilicated” fashion to prevent kinking of the tube as it passes through the chest wall. This will also help to reduce wound site pain and discomfort for the patient.
 

Check to make sure that the chest tube is still working. Then, tape the distal end of the tube to the drainage system (shown). Be sure to tape along the long axis, so as not to obstruct your ability to see the tube and its drainage. The most common area for clots to form is at the connecting ends of the tubes


Confirm tube placement with chest x-ray (shown). Notice the final hole (arrow) is in the thoracic cavity and is seen as an interruption in the white line of the chest tube.
 

Complications of chest tube placement include horizontal placement over the diaphragm (acceptable for hemothorax; tube should be repositioned for pneumothorax), placement in subcutaneous tissue outside thoracic cavity (shown; note the subcutaneous emphysema), final hole outside of thoracic cavity, and kinked tube. Once sterility has been broken, it is never appropriate to advance the chest tube; it may only be withdrawn. Sterility is broken when the chest x-ray is performed. It is not permissible to withdraw and readvance the existing tube in a new position. If the tube needs to be repositioned by withdrawing and readvancing, then a new tube must be placed through a new incision.

Assessment of Acute Pain

   Accurate assessment of acute pain is essential for the development of an effective pain management plan. Nurses play a pivotal role in the assessment of pain, owing to the nature of their relationship with patients. Pain assessment can be challenging because of the subjectivity and multidimensionality of the pain experience. The patient's self-report of pain includes the sensory, emotional, psychological, and cultural components of the pain experience, which cannot be captured on the unidimensional tools typically used in practice. A comprehensive pain assessment includes pain location and quality, aggravating and alleviating factors, timing and duration, pain relief and functional goals, and intensity. The effectiveness of any previous pain treatment, as well as the effects of pain on quality of life, should also be determined.

   The comprehensive pain assessment should be performed when patients present with pain to the healthcare setting and at the onset of new acute pain. To determine treatment effectiveness and guide further interventions, subsequent pain assessments should focus on the nature of the pain, pain intensity, and responses to treatment. Pain assessment tools should be valid and reliable for the patient population in which they are used.

Unidimensional pain intensity scales.

   Unidimensional scales are quick and easy to use, provide rapid feedback about the effectiveness of interventions, and are valid and reliable measures of pain intensity. Because the unidimensional scales measure only intensity, they cannot substitute for a comprehensive pain assessment. The unidimensional pain intensity scales used most often in the clinical setting are:

- Numeric Rating Scale (NRS), also known as the Numerical Pain Intensity Scale (NPI);
- Visual Analog Scale (VAS); and
- Verbal Descriptor Scale (VDS).

Numeric Rating Scale.

   The NRS can be used graphically (visually) or verbally. When used graphically, the NRS consists of a vertical or horizontal line that is anchored by the number 0 on the bottom or the left side and the number 10 on the top or the right side. Patients are instructed to rate the intensity of their pain on this scale, with "0" indicating no pain, and "10" indicating the worst pain imaginable.

Visual Analog Scale.

   The VAS is a 10-cm (100-mm) line on which the patient is asked to place a mark that corresponds with his or her current pain intensity. The line is then measured from the beginning to the patient's mark, and this distance is translated into a pain intensity score ranging from 0 to 10. The format of scale, coupled with the need for a marking implement and for the patient to be able to clearly visualize and mark the line, make the VAS impractical to use in the clinical setting.

Verbal Descriptor Scale.

   The VDS uses the verbal descriptors "no pain," "mild pain," "moderate pain," "severe pain," "very severe pain," and "worst pain possible." This scale can be administered verbally or visually, and the patient is instructed to pick the words that best describe his or her current pain intensity.

Pain assessment in older adults.

   Older adults deserve special consideration in a discussion of pain assessment. As the number of older adults in society increases, it is important to understand the effect of pain on this population and determine the appropriate assessment and management techniques. Older adults with mild to moderate cognitive impairment can self-report pain. Many unidimensional pain tools have been tested in older adults, and several of these tools, including the NRS, have been validated for use in this population. In addition to the NRS, the Faces Pain Scale-Revised (FPS-R) and the Iowa Pain Thermometer (IPT) have been validated for use with older adults. When compared with other commonly used pain intensity scales (NRS, VAS, VDS, and FPS-R), the IPT was the scale most preferred by both younger and older adults, supporting findings that older adults prefer scales with verbal descriptors.

Hierarchy of Importance of Pain Measures

   In many situations, particularly in the acute care setting, it is not possible to obtain a patient self-report of pain intensity. Patients who are critically ill, sedated, confused, delirious, or otherwise cognitively impaired may be unable to report pain. The assessment of pain in this population is challenging because no single objective strategy, such as observation of behaviors or vital signs, provides sufficient information to assess pain. Nurses often rely on heart rate, respiratory rate, blood pressure, and other physiologic data to confirm the presence of pain; however, these variables are the least sensitive indicators of pain and may be affected by many other factors.

   In response to this challenge, the ASPMN published a position statement that recommends a comprehensive, hierarchical approach to the assessment of pain in nonverbal patients, which provides the framework for a decision-making process that can be used to manage pain in nonverbal patients. The hierarchical approach has 5 key steps:

1. When possible, obtain self-report.
2. Look for possible pathologies, procedures, or other causes of pain.
3. Observe for behaviors that may indicate the presence of pain.
4. Obtain input from caretakers who know the patient and the patient's usual behaviors and responses
    to pain.
5. Use an analgesic trial and observe for changes in behavior.

Step 1: Patient self-report of pain.

   The hierarchy affirms that the patient's self-report is the most reliable indicator of pain and the sole indicator of pain intensity. Ascertaining the patient's report of pain should always be attempted first. Reliability of the patient's self report may diminish with advancing cognitive impairment, but many valid and reliable tools are available that may be effectively used with cognitively impaired persons. No method has been identified to establish a patient's ability to reliably use a self-report tool; it is therefore helpful to have several tools available in the clinical setting so that the tool that yields the most consistent results for the individual patient may be selected. Once identified, this tool should be used at each assessment.

Step 2: Assumption of pain.

   If a reliable self-report of pain cannot be elicited, the next step in the hierarchy is to consider whether the patient has a condition that is typically associated with pain or is undergoing procedures that are generally considered painful. In such cases, the nurse should "assume that pain is present" (abbreviated "APP" for documentation when approved by facility policy and procedure) and provide the appropriate treatment. It is never appropriate to assume that a patient who is unresponsive, nonverbal, confused, demented, or delirious cannot feel or is not feeling pain. Similarly, pain must be assumed to be present and treated if the patient who is receiving paralytics or sedatives has an underlying painful condition or is undergoing painful procedures.

Step 3: Behavioral indicators of pain.

   The third step in the hierarchy requires the nurse to observe the patient for possible indicators of pain, such as grimacing or other indicative facial expressions, bracing, rocking, or changes in activity. Recognizing that certain behaviors may indicate pain, researchers have developed behavioral pain assessment tools for use in patients who cannot self-report. Many of these tools yield a behavioral score that can help determine the presence of pain, and when changes are noted, can be used to evaluate the effectiveness of interventions; however, a behavioral score is not a pain intensity score. If the patient cannot report the intensity of his or her pain, then the intensity is unknown.

Tools for pain assessment include:

1.  The Critical Care Pain Observation Tool (CPOT) was designed to assess pain in critically ill adults.

     It uses facial expression, body movement, muscle tension, and ventilator compliance or

     vocalization as pain indicators.

2. The Payen Behavioral Pain Scale, which uses facial expression, upper extremity movement, and

     ventilator compliance as pain indicators, may also be used for critically ill adults who are intubated.

3. The Pain Assessment in Advanced Dementia (PAINAD) is used to assess pain in patients who have

    dementia or Alzheimer's disease and are nonverbal. It uses breathing, negative vocalization, facial

    expression, body language, and consolability as pain measures.

   City of Hope Research (Visit&Contact: cityofhope.org) provides a brief summary and critique of many of the tools that have been developed for the assessment of pain in nonverbal patients. Validity and reliability have not yet been fully established for some of these tools. As with pain intensity scales, behavioral tools should be used only in the patient populations for which they were intended and in patients who are able to respond with the requisite behaviors for each tool. Although many tools have been developed to aid in the assessment of pain, the patient's self-report of pain intensity remains the most dependable method of pain assessment.

Step 4: Solicit information from caregivers and family members.

   A surrogate who knows the patient's usual behavioral responses can provide input about pain behaviors, which can be valuable in identifying the patient's unique responses to pain.

Step 5: Analgesic trial.

   The last step of the hierarchy of measures is an analgesic trial, which involves observing the patient's behavior before and after administration of a low dose of analgesic medication. An improvement in behaviors after the analgesic dose helps confirm the presence of pain and serves as the basis for a pain treatment plan. If the patient does not respond to the trial, an increase of the analgesic dose or trial of a different analgesic should be attempted. If the behaviors do not improve despite optimal titration of the analgesic regimen, causes of the behaviors other than pain should be considered

Feeling Your Patient's Pain

   For most of us, medical students and physicians alike, treating patients in pain can be, well, a pain. Aside from having to know which medicines to use and how to use them, there's the issue of not being able to objectively measure what we're treating, as well as the unfortunate reality that some patients abuse narcotics. Patients in pain can really put our bedside manners to the test.

   The following are some pearls, from the perspective of a general internist who works with medical students and who was a medical student himself not all that long ago, on how you can interact with people who are hurting. By "pain" I'm referring to the physical kind, although the same principles may apply for emotional pain.

1. Address pain before you address anything else.

   As a medical student, you may be the first person on your team to sit down with a patient to interview and examine him. If you are pressed for time, you may be tempted to proceed with this even if the patient is in pain. It's easy to justify; after all, the sooner you get information from the patient, the sooner you can help him, right?

   While there are certain situations where pain has to be put on the back burner, these are very rare. Imagine how distressing it must be for the patient to be asked questions about family history or to get a full neurological exam when writhing from abdominal pain. (Believe me, I've seen it happen.) Show the patient that you care by getting your resident or attending physician and making sure that the person's pain is addressed first and foremost.
2. When a patient says he's in pain, even if he has a history of substance abuse, believe him.
If you haven't seen a situation like this yet, you will:

"A patient comes in to the hospital after a fall and complains of excruciating leg pain – "15 out of 10," he says. He looks uncomfortable but not that uncomfortable. The leg is visibly bruised but, according to the x-ray, not broken. The patient is a "frequent flyer" with a history of substance abuse. Your resident's or attending physician's assessment? He's exaggerating, probably playing the system for pain meds."

   In general, if a patient has reason for pain and says that he's in pain, I believe him. I call this the "innocent until proven guilty" principle. Nothing is potentially more toxic to the therapeutic relationship than questioning the veracity of what a patient is telling us from the very beginning.

   Pain is, by its very nature, subjective. There is no way for us to definitively know if another person is in pain. That said, just because we can't objectively quantify pain doesn't mean we should dismiss it.

   Don't get me wrong; I'm always on the look-out for narcotic abuse. If a patient says he is in pain but he seems completely comfortable, or if I know the patient is getting narcotics from multiple providers, I'll respectfully question the claim of pain. Otherwise, I'm going to take his word for how he feels. Keep in mind that even people with a history of substance abuse can experience excruciating pain. Between the 2 evils of undertreating pain or inadvertently indulging addiction, I'd much rather err on the side of the latter.

3. Empathize, but realize that you don't really know how the patient feels.

   When faced with someone who is suffering, many medical students want to share their own struggles as a way of trying to empathize with that person. For instance, if you have a patient who broke her arm and is in pain, and you once broke your arm, it's only natural to want to talk about your experience.

   Tread carefully here. This goes back to the point that pain is an intensely personal experience. While some patients might find it comforting to hear someone who isn't in pain say that he's been through something similar, others might find it isolating or condescending.

   I encourage my medical students to let the patient take the lead. Share a personal experience only if the patient gives you an opening, and only if you are comfortable sharing it. Otherwise, keep the focus on the patient. Show her you care by giving her space to talk. One of the most meaningful things that we as healthcare providers can do for someone in pain is just be there, and listen.

   In summary, treating a patient in pain can be challenging. But, like with most obstacles, the flipside is that it presents an opportunity to make a difference. As a medical student and later on as a doctor, if you give patients the benefit of the doubt, realize that you don't know exactly how they feel, and address their pain first, you'll go a long way toward establishing a strong relationship.

Menilai Nyeri pada Pasien tidak Sadar (Absence of Self-report Patient)

   Nyeri benar-benar subjektif, dan Gold standar penilaian nyeri adalah laporan dari pasien. Beberapa alat penilaian dapat memfasilitasi penentuan penilaian intensitas nyeri pasien, dan rumah sakit nasional telah menerapkan kebijakan dan  prosedur menguraikan penggunaan instrumen ini.

   Alat yang paling umum digunakan pada pasien yang mampu mengukur rasa sakit mereka adalah skala nyeri Wong-Baker FACES  rating atau Skala Nyeri dari Ekspresi Wajah yang dinumerikkan dengan angka 1-10; banyak pasien yang bisa melaporkan nyerinya tetapi tidak dapat mengukurnya. Alat ini membantu dengan memilih ekspresi wajah yang paling mencirikan diri mereka pada saat nyeri. Namun, tidak semua pasien dapat melaporkan nyeri dengan menggunakan alat penilaian tersebut, dan ini merupakan tantangan yang signifikan bagi tim kesehatan yang harus memastikan sakit yang diderita guna pengobatan tepat.

   Untuk pasien yang tidak dapat melaporkan rasa sakit melalui metode diatas, direkomendasikan pendekatan alternatif berdasarkan Hierarchy of Pain Measures (Tabel). Komponen utama dari hirarki adalah sebagai berikut:

- Mencoba UntukMemperoleh Laporan Nyeri dari Pasien;
- Pertimbangkan mendasari patologi atau kondisi dan prosedur yang mungkin menyakitkan;
- Amati perilaku;
- Evaluasi indikator fisiologis, dan
- Melakukan percobaan analgesik.

Tabel. Hierarchy of Pain Measures

   1.Mencoba UntukMemperoleh Laporan Nyeri dari Pasien, merupakan indikator yang paling dapat diandalkan untuk nyeri. Jangan berasumsi bahwa pasien tidak dapat melaporkan nyeri, pasien dengan gangguan kognitif banyak yang mampu menggunakan self-report tool, seperti Wong-Baker FACES Skala/ Skala Wajah Sakit Descriptor Skala-Revisi, atau verbal.

   2. Pertimbangkan kondisi pasien atau paparan prosedur yang dianggap menyakitkan. Jika sesuai, anggap nyeri itu ada (APP).

   3. Amati tanda-tanda perilaku (misalnya, ekspresi wajah, menangis, gelisah, dan perubahan dalam aktivitas). Banyak alat penilaian perilaku nyeri akan menghasilkan skor perilaku rasa sakit dan dapat membantu untuk menentukan keberadaan nyeri. Namun, skor perilaku tidak sama dengan skor intensitas nyeri. Intensitas nyeri tidak diketahui jika pasien tidak mampu menyampaikannya. Seorang yang tahu keadaan pasien dengan baik (misalnya, orangtua, pasangan, atau pengasuh) mungkin dapat memberikan informasi yang dapat menjelaskan nyerinya.

   4. Evaluasi indikator fisiologis dengan pemahaman bahwa mereka adalah indikator paling sensitif untuk nyeri dan mungkin menandakan keberadaan kondisi selain nyeri (misalnya, hipovolemia, kehilangan darah). Pasien mungkin memiliki tanda-tanda vital yang normal atau abnormal pada saat nyeri. Tekanan darah tinggi atau denyut jantung tidak berarti tidak adanya nyeri.

   5. Melakukan percobaan analgesik untuk mengkonfirmasi adanya nyeri dan untuk mengembangkan rencana perawatan dasar jika nyeri diyakini ada. Sebuah percobaan analgesik melibatkan pemberian dosis rendah analgesik nonopioid atau opioid dan mengobservasi respon pasien. Dosis rendah mungkin tidak cukup untuk memperoleh perubahan perilaku dan harus ditingkatkan jika dosis sebelumnya ditoleransi, atau analgesik lain dapat ditambahkan. Jika tidak ada perubahan perilaku hingga dosis analgesik yang optimal, kemungkinan harus diselidiki penyebab lain. Pada pasien yang benar-benar tidak responsif, tidak ada perubahan dalam perilaku akan jelas dan dosis analgesik dioptimalkan harus dilanjutkan.

Pilihan Penilaian Nyeri pada Pasien tidak Sadar

   Evidence-based guidelines tidak merekomendasikan penilaian intensitas nyeri oleh siapapun selain orang yang mengalaminya. Pentingnya mengandalkan laporan diri telah ditegaskan oleh penelitian selama bertahun-tahun, yang telah menunjukkan adanya hubungan antara persepsi pasien dari rasa sakit dan perawat serta anggota dari tim kesehatan lain. Selain itu, perbedaan terbesar sering terjadi di tingkat nyeri tertinggi.

   Berbagai penjelasan untuk perbedaan tersebut telah diusulkan, termasuk pengalaman penyedia layanan, jenis kelamin pasien, hambatan bahasa, dan kemampuan untuk membedakan perilaku nyeri dari perilaku lainnya. Prinsip manajemen nyeri menyebutkan bahwa pasien adalah otoritas pada intensitas nyeri, dan jika dia tidak dapat melaporkan intensitas, maka hal itu tidak diketahui.

Estimasi nyeri oleh orang lain.

   Penelitian telah menunjukkan bahwa orang yang tahu keadaan pasien dengan baik (misalnya, orang tua, pengasuh) sering melebih-lebihkan atau meremehkan rasa nyeri pasien. Perbedaan yang dipengaruhi oleh berbagai faktor, termasuk keberadaan dan tingkat penurunan kognitif pasien, jenis kelamin caregiver, beban yang dirasakan dari pengasuh, anggapan tentang nyeri yang dirasakan, dan ketakutan efek samping analgesik. Kekhawatiran menampakkan bahwa nyeri menjadi lebih parah. Meskipun orang yang tahu keadaan pasien tidak harus ditanya untuk intensitas tingkat nyeri, mereka dapat memfasilitasi penilaian dengan menyediakan tim kesehatan dengan informasi tentang patologi mendasar nyeri atau perilaku yang dapat menunjukkan adanya nyeri.

Paparan prosedur yang menyakitkan.

   Ketika laporan secara langsung tidak dapat diperoleh, Hierarchy of Pain Measures dapat digunakan sebagai pertimbangan kondisi yang berpotensi nyeri atau prosedur yang pasien mungkin alami. Dalam kasus pasien yang tak sadarkan diri, pasien mengalami luka traumatis yang menyakitkan. Dia juga mengalami gangguan intubasi endotrakeal, ventilasi mekanis, dan suctioning, yang semuanya telah teridentifikasikan sebagai prosedur yang dapat menghadirkan nyeri. Namun, ia tidak dapat melaporkan nyeri dan tidak dapat menunjukkan perilaku nyeri.

   Menurut Hierarchy of Pain Measures, nyeri harus diasumsikan hadir pada pasien tersebut dan pengobatan harus dimulai dengan rekomendasikan dosis analgesik awal yang tepat. Dosis subanesthetic propofol yang digunakan dengan tujuan sedasi menghasilkan analgesia yang toleran. Ini menggarisbawahi pentingnya pemberian analgesik yang sesuai, seperti nonopioids dan opioid. Menilai kembali pengobatan analgesik dapat menjurus tidak adanya perubahan dalam perilaku pada pasien yang tidak responsif, sehingga dosis analgesik optimal harus dilanjutkan.

   Kemampuan pasien untuk menyampaikan atau kelayakan menggunakan alat penilaian perilaku nyeri harus dievaluasi secara berkala (misalnya, setiap shift). Keputusan untuk peralihan asesmen didasarkan pada asumsi patologi nyeri untuk penggunaan alat penilaian perilaku nyeri atau laporan nyeri pasien selalu tergantung pada kemampuan pasien untuk menunjukkan perilaku nyeri.

Perilaku/Kebiasaan Pasien.

   Perilaku pasien sering memberikan petunjuk tentang apakah pasien memiliki rasa nyeri. Misalnya, ekspresi wajah, gelisah, dan perubahan dalam aktivitas telah terbukti menjadi indikator rasa nyeri. Alat penilaian perilaku nyeri memfasilitasi penilaian nyeri. Salah satu alat yang paling umum digunakan di ICU adalah Critical-Care Pain Observation Tool (CPOT), yang telah terbukti dapat diandalkan dan valid dalam berbagai populasi pasien sakit kritis. Alat ini memerlukan evaluasi dari 4 kategori berikut:

   - Ekspresi wajah;
   - Gerakan tubuh;
   - Ketegangan otot, dan
   - Kepatuhan dengan ventilator (pasien diintubasi) atau vokalisasi (pasien diekstubasi).

   Skor 0-2 untuk setiap kategori, tergantung pada tingkat respon pasien. Total skor maksimum adalah 8. Keterbatasan dari banyak alat penilaian perilaku nyeri (seperti CPOT) adalah perlunya perhatian khusus pada setiap gerakan, sehingga penting bagi perawat untuk hati-hati mengevaluasi setiap kemampuan pasien untuk menunjukkan perilaku yang diperlukan dalam penilaian. Pada pasien seperti yang tidak sadarkan diri, perilaku nyeri tidak akan dijumpai, penggunaan alat penilaian perilaku nyeri menjadi tidak efektif.

   Meskipun kemampuan untuk mengandalkan indikator fisiologis, seperti detak jantung dan tekanan darah, tanda-tanda vital telah terbukti menjadi indikator paling sensitif pada nyeri, perlu diketahui peruahannya dipengaruhi oleh berbagai faktor lain selain nyeri (misalnya, hipovolemia, kehilangan darah, hipotermia, dan anestesi dan agen analgesik).

Hasil dari penilaian Sakit

  Tim kesehatan yang merawat pasien tak sadarkan diri menggunakan Hierarchy of Pain Measures sebagai kerangka kerja untuk penilaian nyeri. Pasien yang tidak responsif, tidak dapat menyampaikan nyerinya, dan tidak menunjukkan perilaku nyeri. Sebagaimana diarahkan oleh Hierarchy of Pain Measures, nyeri diasumsikan atas dasar patologi yang mendasari nya merasakan nyeri (misalnya, trauma kepala dan patah ulnaris) dan prosedur yang invasifnya (misalnya, intubasi endotrakeal, ventilasi mekanis, dan suctioning). IV morfin secara kontinyu sebesar 2,5 mg / jam dimulai. Dosis 1 mg morfin bolus. IV diberikan sebelum prosedur yang invasifnya. Selain itu, dosis dijadwalkan IV acetaminophen dan IVibuprofen diberikan asekitar se-jam.

Original Text

Assessing Pain When the Patient Cannot Self-report

   Pain is completely subjective, and the gold standard of pain assessment is self-report by the patient. Several assessment tools can facilitate determining the patient's assessment of pain intensity, and hospitals nationwide have implemented policies and procedures outlining the use of these instruments.

   The most commonly used self-report tools in patients who are able to quantify their pain are the 0-10 numerical pain rating scale and the 0-10 Wong-Baker FACES pain rating scale or the Faces Pain Scale-Revised; many patients who can self-report pain but are unable to quantify it may be able to select the face that best characterizes their pain on a faces pain rating scale. However, not all patients are able to report pain using customary assessment tools, and this presents a significant challenge for the healthcare team who must ensure that pain is recognized and treated appropriately.

   For patients unable to report pain through traditional methods, an alternative approach based on the Hierarchy of Pain Measures is recommended (Table). The key components of the hierarchy are as follows:

- Attempt to obtain self-report;
- Consider underlying pathology or conditions and procedures that might be painful;
- Observe behaviors;
- Evaluate physiologic indicators; and
- Conduct an analgesic trial.

Table. Hierarchy of Pain Measures

   1. Attempt to obtain the patient's self-report, the single most reliable indicator of pain. Do not assume that a patient cannot report pain; many cognitively impaired patients are able to use a self-report tool, such as the Wong-Baker FACES Scale, Faces Pain Scale-Revised, or Verbal Descriptor Scale.

   2. Consider the patient's condition or exposure to a procedure that is assumed to be painful. If appropriate, assume pain is present (APP) and document APP when approved by institution policy and procedure.

   3. Observe behavioral signs (eg, facial expressions, crying, restlessness, and changes in activity). Many available behavioral pain assessment tools will yield a pain behavior score and may help to determine whether pain is present. However, a behavioral score is not the same as a pain intensity score. Pain intensity is unknown if the patient is unable to provide it. A surrogate who knows the patient well (eg, parent, spouse, or caregiver) may be able to provide information about underlying painful pathology or behaviors that may indicate pain.

   4. Evaluate physiologic indicators with the understanding that they are the least sensitive indicators of pain and may signal the existence of conditions other than pain or a lack of it (eg, hypovolemia, blood loss). Patients may have normal or abnormal vital signs in the presence of severe pain. The absence of elevated blood pressure or heart rate does not mean the absence of pain.

   5. Conduct an analgesic trial to confirm the presence of pain and to establish a basis for developing a treatment plan if pain is believed to be present. An analgesic trial involves administration of a low dose of nonopioid or opioid and observing patient response. The initial low dose may not be enough to elicit a change in behavior and should be increased if the previous dose was tolerated, or another analgesic may be added. If behaviors continue despite optimal analgesic doses, other possible causes should be investigated. In patients who are completely unresponsive, no change in behavior will be evident and the optimized analgesic dose should be continued.

Pain Assessment Options in the Absence of Self-report

   Evidence-based guidelines recommend against the rating of pain intensity by anyone other than the person who is experiencing the pain. The importance of relying on self-report has been underscored by research over the years, which has shown a lack of correlation between the patient's perception of pain and that of nurses and other members of the healthcare team. Furthermore, the greatest discrepancies often occur at the highest pain levels.

   Various explanations for such discrepancies have been proposed, including care provider experience, patient gender, language barriers, and ability to distinguish pain behaviors from other behaviors. A principle of pain management is that the patient is the authority on pain intensity, and if he or she cannot report the intensity, then it is unknown.

   Estimation of pain by others. Research has shown that individuals who know the patient well (eg, parents, caregivers) often overestimate or underestimate the patient's pain. Discrepancies are influenced by a various factors, including the presence and level of cognitive impairment in the patient, caregiver gender, perceived burden of caregiving, preconceived ideas of acceptable pain relief, and fear of analgesic side effects. A concern has been raised that discrepancies occur when pain is more severe. Although individuals who know the patient should not be asked to rate pain intensity, they can facilitate assessment by providing the healthcare team with information about underlying painful pathology or behaviors that may indicate the presence of pain.

Exposure to painful procedures.

   When self-report cannot be obtained, the Hierarchy of Pain Measures calls for consideration of any potentially painful underlying conditions or procedures that the patient might be experiencing (Table). In this case, the patient has sustained painful traumatic injuries. He is also being subjected to endotracheal intubation, mechanical ventilation, and suctioning, all of which have been identified as painful procedures. However, he cannot report pain and is unable to demonstrate pain behaviors.

   According to the Hierarchy of Pain Measures, pain should be assumed to be present in such patients and treatment should be initiated with recommended starting doses of appropriate analgesics. The subanesthetic doses of propofol that are used for goal-directed sedation produce negligible analgesia. This underscores the importance of co-administering appropriate analgesics, such as nonopioids and opioids. Reassessing analgesic treatment may yield no change in behavior in unresponsive patients; therefore, the optimized analgesic dose should be continued.

   The patient's ability to self-report or the appropriateness of using a behavioral pain assessment tool should be evaluated regularly (eg, every shift). The decision to switch from assessment based on assumption of painful pathology to the use of behavioral tools or the patient's report of pain always depends on the patient's ability to demonstrate pain behaviors or report pain.

Patient behaviors.

   Patient behaviors often provide clues about whether a patient has pain. For example, facial expressions, restlessness, bracing, and changes in activity have been shown to be indicators of pain. Behavioral pain assessment tools facilitate pain assessment. One of the most commonly used tools in the ICU setting is the Critical-Care Pain Observation Tool (CPOT), which has been shown to be reliable and valid in a variety of critically ill patient populations. The tool requires evaluation of the following 4 categories:

   - Facial expression;
   - Body movements;
   - Muscle tension; and
   - Compliance with ventilator (intubated patients) or vocalization (extubated patients).

   A score of 0-2 is assigned to each category, depending on the degree of the patient's response. The maximum total score is 8. A limitation of many of the behavioral tools, such as the CPOT, is that they designate specific behaviors that must be observed, making it essential for nurses to carefully evaluate each patient for the patient's ability to demonstrate the requisite behaviors in the tool. In patients such as the one described above, behaviors are absent, rendering behavioral tools ineffective.

   Although it is tempting to rely on physiologic indicators, such as heart rate and blood pressure, vital signs have been shown to be the least sensitive indicators of pain and are known to be influenced by a variety of factors other than pain (eg, hypovolemia, blood loss, hypothermia, and anesthetic and analgesic agents).

Outcomes of Pain Assessment

   The healthcare team caring for this patient used the Hierarchy of Pain Measures as a framework for pain assessment. The patient was unresponsive, unable to self-report pain, and did not demonstrate any pain behaviors. As directed by the Hierarchy, those caring for him assumed that he had pain on the basis of his underlying painful pathology (eg, head trauma and ulnar fracture) and painful procedures (eg, endotracheal intubation, mechanical ventilation, and suctioning). A continuous IV morphine infusion at 2.5 mg/hour was initiated. Bolus doses of 1 mg IV morphine were administered before painful procedures. In addition, scheduled doses of IV acetaminophen and IV ibuprofen were administered around-the-clock.

Universal HIV Screening Recommended by USPSTF

   The US Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen all people aged 15 to 65 years for HIV infection, according to a draft recommendation statement posted online November 20. The statement also recommends HIV screening for all pregnant women, including those who present at the time of labor, and for younger adolescents and older adults who are at increased risk.

   "The draft recommendation reflects new evidence that demonstrates the benefits of both screening for and earlier treatment of HIV," task force member Douglas K. Owens, MD, said in a USPSTF news release. "Because HIV infection usually does not cause symptoms in the early stages, people need to be screened to learn if they are infected. People who are feeling well and learn they are infected with HIV can begin treatment earlier, reduce their chances of developing AIDS and live longer and healthier lives."

   Although US prevalence of HIV infection is nearly 1.2 million and annual incidence is about 50,000, nearly one quarter of those infected are unaware that they are HIV-positive. Since the first reports of AIDS in 1981, more than 1.1 million people have been diagnosed with AIDS and nearly 595,000 have died from it.

   Combined antiretroviral therapy (ART) has been shown to reduce the likelihood of HIV transmission, and earlier initiation of treatment lowers the risk for AIDS-related complications.

In issuing this recommendation, the task force hopes to improve and maintain the health of persons who are already infected with HIV, to delay the onset of AIDS, and to lower the risk for HIV transmission. The USPSTF is offering the public an opportunity to comment on this draft recommendation until December 17 and will consider all public comments when writing its final recommendation.

   Clinicians should screen adolescents and adults aged 15 to 65 years for HIV infection, as well as younger adolescents and older adults who are at increased risk (grade A recommendation).

Although evidence is insufficient to define optimal time intervals for HIV screening, the statement suggests that a reasonable strategy would be 1-time screening of adolescent and adult patients to identify those who are already HIV-positive and repeat screening of those known to be at risk for HIV infection, those who are actively engaged in high-risk behaviors, or those living in a high-prevalence setting.

   Clinicians should screen all pregnant women for HIV, including those of unknown HIV status who present in labor (grade A recommendation).

Evidence and Rationale

   The USPSTF updated their 2005 review on the benefits and harms of HIV screening in adolescents and adults by searching MEDLINE (2004 - June 2012) and the Cochrane Library (through the second quarter of 2012). Inclusion criteria were English-language randomized trials and observational studies comparing HIV screening approaches and reporting clinical outcomes, assessing the effect of initiating ART at different CD4 cell count thresholds and long-term harms, or reporting the effect of interventions on transmission risk.

   "Previous studies have shown that HIV screening is accurate, targeted screening misses a substantial proportion of cases, and treatments are effective in patients with advanced immunodeficiency," the USPSTF task force writes in its systematic review. "New evidence indicates that ART reduces risk for AIDS-defining events and death in persons with less advanced immunodeficiency and reduces sexual transmission of HIV."

   Evidence was convincing that standard and rapid HIV antibody tests are both highly accurate in diagnosing HIV infection.

   Evidence also was convincing that identifying and treating HIV infection in individuals with immunologically advanced disease (CD4 count <200 cells/mm 3) is associated with a substantially lower risk for progression to AIDS, AIDS-related events, and death.

   Evidence was adequate that starting ART earlier (at CD4 counts of 200 - 500 cells/mm 3) is associated with a lower risk for AIDS-related events or death.

   Finally, evidence was convincing that ART is associated with a markedly lower risk for transmission from HIV-positive persons to uninfected heterosexual partners and that identifying and treating HIV-positive pregnant women substantially lowers rates of mother-to-child transmission. Therefore, there are significant overall benefits of screening for HIV infection in adolescents, adults, and pregnant women.

   Although evidence is convincing that individual antiretroviral drugs, drug classes, and combinations are all associated with short-term adverse events, many are transient or self-limited, and there are often effective alternatives. Long-term use of certain antiretroviral drugs is linked to a small increase in risk for cardiovascular and other adverse events.

   "The overall harms of screening for and treatment of HIV infection in adolescents, adults, and pregnant women are small," the task force writes in its draft guidelines.

   "The USPSTF concludes that there is high certainty that the net benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial."

Ethical Dilemma Case

The Case of Anne R.

1st Situation
Your longtime patient, Anne R., is a relatively frail, 85-year-old woman who has lived more or less successfully at home since her retirement 20 years ago. Paul, her husband of 47 years, died 10 years ago. In many respects, she is still mourning his loss. Her life is generally solitary, inactive, and boring.
Anne has 2 daughters who live with their families in Houston and Toronto, both 3-hour plane rides away. They try to visit for holidays, and each daughter attempts to arrange to have her visit at least once a year. They seem to be a dedicated and loving family, albeit separated by nontrivial distance. However, Anne is increasingly reluctant to travel.
Anne has several maladies that you have been managing: atrial fibrillation; an arteriovenous malformation that causes occasional, and sometimes severe, gastrointestinal bleeding; chronic obstructive pulmonary disease; and osteoporosis. She has fallen twice but suffered only minor bruises.
Nine years ago, you partly convinced Anne of the importance of advance directives, although she winced and turned away when you raised the issue. In a designation of surrogate, she named both her daughters to make decisions for her if she became unable to do so, but she also declined to complete a living will. "I can't think about that right now," she said.
One night at 11:50, you receive a call from a hospitalist at General Medical Center, where you have privileges. Anne apparently had begun to feel very poorly and called 911. A workup in the emergency department showed atrial fibrillation. She is currently stable but uncomfortable. Her daughters do not yet know of this episode. You need to decide what to do.

What Should You Do?
Decision Point: Should You Go to the Hospital to See Anne?
Pro: You know Anne better than the doctors at the hospital do, and she is frightened and alone, with several comorbidities. You know it would be supportive and helpful to go, and you might be able to provide some information or help in some way.
Con: It is late and you're tired. You tell yourself that your presence would add very little. Anne could be transferred to the floor or admitted to the critical care unit, in the capable hands of others, until tomorrow.

*) Would you go to the hospital?

*) Would you wait until the next morning?



2nd Situation
Anne should probably be cardioverted, but this presents a small risk for stroke. You recommend the cardioversion and mention the stroke risk. Anne asks you to do whatever you think is best, so you order the procedure.
Normally, you would start prophylaxis against stroke with an anticoagulant, but Anne's arteriovenous malformation puts her at higher-than-normal risk for blood loss. You therefore decide against use of warfarin (or anything similar). You do not mention this to her, reasoning that she has already placed herself in your hands.
The cardioversion is successful, and at an office visit 1 week after Anne is discharged from the hospital, you broach the topic of implanting a pacemaker/defibrillator. She is very anxious and reluctant to undergo the procedure. You explain how the device works and how it is implanted. She is worried about the risks of the procedure; you are worried about the risks of not doing it.
There is a long-standing debate about whether physicians should discuss statistics with patients. Some prefer to make recommendations in the context of a trusting relationship. Others might cite the literature and ask the patient to make a decision. It is significant that every option poses risks, and these risks often need to be weighed against each other, not against a baseline or gold standard. Moreover, risks vary from patient to patient and -- perhaps most important -- can be very difficult to measure or determine.

Decision Point: How Do You Continue the Informed Consent Process?
Pro: Informed consent is not a courtesy, nicety, or risk-management stratagem. A foundation of medical ethics, the valid consent process requires that patients be given adequate information and have the capacity to understand and appreciate the information and make a voluntary decision. There is evidence to support the practice of robust communication: It leads to improved trust and better adherence to treatment regimens, for instance.
Con: The patient has already asked you to use your judgment. You believe you know what is best for her. There is no point in standing on ceremony, especially when it seems she simply does not want to hear at least some of what you might have to say. In any case, she is not incompetent, and no one is forcing her to accept the pacemaker/defibrillator.

*) Would you strongly recommend the defibrillator and mention but deemphasize the risks?

*) Would you be completely neutral, make no recommendation, and strongly encourage Anne to seek her daughters' advice?

*) Would you lay out the pros and cons equally and leave the decision to her, and if she doesn't make a decision, remind her in 2 months?



3rd Situation
Anne's living arrangements also pose some challenges. Because she lives alone, you're concerned about her getting help if she needs it. You ask her whether she has considered moving to an assisted living facility ("There is no way you're putting me in a nursing home with all those old people!") or moving in with one of her daughters ("I couldn't bear to be such a burden at my age"). You have now spent 20 minutes with her and are running far behind schedule.
Frustrated and a little annoyed, you ask her to call you in 2 weeks and recommend that she get an emergency medical alert bracelet. You also instruct one of your staff members to phone her in 1 week. At that time, she is fine and very grateful for the call; she keeps your aide on the phone for 10 minutes, chatting about the events of her day.
Three days later, at about 5 PM, you receive a call from a hospitalist at General Medical Center. Anne has had a severe myocardial infarction. She was found on her doorstep, apparently while picking up the daily newspaper. An untrained neighbor attempted cardiopulmonary resuscitation, and another summoned emergency medical services. She was resuscitated after 10-12 minutes of hypoxia/anoxia.
You arrive at the hospital a few hours later. Anne is in the intensive care unit (ICU). She is on a ventilator and receiving a variety of medications. She broke her hip during the fall and is also receiving opiate analgesia. A neurology consultation has been requested.
A social worker had seen that Anne's daughters are named as surrogates; they were contacted, and both arrive the next morning. You meet them in an ICU conference room. The consultant had determined that Anne's neurologic prognosis is bleak and that she is at best in a minimally conscious state. Her daughters are distraught. Both recall little about any conversations with her about end-of-life care, but one shared memory included Anne saying that she would not want to "live on tubes."
One daughter wants her to continue to receive full support. The other says she is ready for all nonpalliative treatment to cease and for her mother to die.

Decision Point: Do You Continue to Monitor the Patient and Work With the Family?

Pro: Of course. She is no less your patient now than before her myocardial infarction, and she will be your patient until she dies. Indeed, until a decision is made to terminate treatment, someone is needed to manage her treatments. Communication with family members continues to be an obligation of the professional physician.
Con: There is nothing more of substance for you to contribute medically. The daughters' disagreement puts you in a tight spot, and until they sort it out, there is nothing for you to offer. What is wanted now is some sort of end-of-life counseling, not competent medical treatment. Someone else needs to take over.

*) Would you accede to one daughter's wish to continue full support?

*) Would you oppose life support and strongly recommend, if not insist on, hospice?

*) Would you urge the daughters to reach an agreement?

*) Would you call the hospital lawyer or ethics committee?

Dilema Etik

Dilema etika adalah situasi yang dihadapi seseorang dimana keputusan mengenai perilaku yang layak harus di buat. (Arens dan Loebbecke, 1991: 77). Untuk itu diperlukan pengambilan keputusan untuk menghadapi dilema etika tersebut. Enam pendekatan dapat dilakukan orang yang sedang menghadapi dilema tersebut, yaitu:

1. Mendapatkan fakta-fakta yang relevan

2. Menentukan isu-isu etika dari fakta-fakta

3. Menentukan siap dan bagaimana orang atau kelompok yang dipengaruhi dilemma

4. Menentukan alternatif yang tersedia dalam memecahkan dilema

5. Menentukan konsekwensi yang mungkin dari setiap alternative

6. Menetapkan tindakan yang tepat.

Dengan menerapkan enam pendekatan tersebut maka dapat meminimalisasi atau menghindari rasionalisasi perilaku etis yang meliputi: (1) semua orang melakukannya, (2) jika legal maka disana terdapat keetisan dan (3) kemungkinan ketahuan dan konsekwensinya.

Pada dilema etik ini sukar untuk menentukan yang benar atau salah dan dapat menimbulkan stress pada perawat karena dia tahu apa yang harus dilakukan, tetapi banyak rintangan untuk melakukannya. Dilema etik biasa timbul akibat nilai-nilai perawat, klien atau lingkungan tidak lagi menjadi kohesif sehingga timbul pertentangan dalam mengambil keputusan. Menurut Thompson & Thompson (1981 ) dilema etik merupakan suatu masalah yang sulit dimana tidak ada alternatif yang memuaskan atau situasi dimana alternatif yang memuaskan atau tidak memuaskan sebanding. Kerangka pemecahan dilema etik banyak diutarakan oleh para ahli dan pada dasarnya menggunakan kerangka proses keperawatan / Pemecahan masalah secara ilmiah, antara lain:

1. Model Pemecahan masalah ( Megan, 1989 )

    Ada lima langkah-langkah dalam pemecahan masalah dalam dilema etik.

    a.Mengkaji situasi

    b.Mendiagnosa masalah etik moral

    c. Membuat tujuan dan rencana pemecahan

    d. Melaksanakan rencana

    e.Mengevaluasi hasil

2. Kerangka pemecahan dilema etik (kozier & erb, 2004 )

    a. Mengembangkan data dasar.

        Untuk melakukannya, perawat memerukan pengumpulan informasi sebanyak mungkin meliputi :

        1) Siapa yang terlibat dalam situasi tersebut dan bagaimana keterlibatannya

        2) Apa tindakan yang diusulkan

        3) Apa maksud dari tindakan yang diusulkan

        4) Apa konsekuensi-konsekuensi yang mungkin timbul dari tindakan yang diusulkan.

    b. Mengidentifikasi konflik yang terjadi berdasarkan situasi tersebut

    c. Membuat tindakan alternatif tentang rangkaian tindakan yang direncanakan dan

        mempertimbangkan hasil akhir atau konsekuensi tindakan tersebut

    d. Menentukan siapa yang terlibat dalam masalah tersebut dan siapa pengambil keputusan yang tepat

    e. Mengidentifikasi kewajiban perawat

    f. Membuat keputusan

3. Model Murphy dan Murphy

    a. Mengidentifikasi masalah kesehatan

    b. Mengidentifikasi masalah etik

    c. Siapa yang terlibat dalam pengambilan keputusan

    d. Mengidentifikasi peran perawat

    e.  Mempertimbangkan berbagai alternatif-alternatif yang mungkin dilaksanakan

    f. Mempertimbangkan besar kecilnya konsekuensi untuk setiap alternatif keputusan

    g. Memberi keputusan

    h. Mempertimbangkan bagaimanan keputusan tersebut hingga sesuai dengan falsafah umum untuk

        perawatan klien

    i. Analisa situasi hingga hasil aktual dari keputusan telah tampak dan menggunakan informasi tersebut

       untuk membantu membuat keputusan berikutnya.

4. Langkah-langkah menurut Purtilo dan Cassel ( 1981)

    Purtilo dan cassel menyarankan 4 langkah dalam membuat keputusan etik

    a. Mengumpulkan data yang relevan

    b. Mengidentifikasi dilema

    c. Memutuskan apa yang harus dilakukan

    d. Melengkapi tindakan

5. Langkah-langkah menurut Thompson & Thompson ( 1981)

    a. Meninjau situasi untuk menentukan masalah kesehatan, keputusan yang diperlukan, komponen etis

       dan petunjuk individual.

    b. Mengumpulkan informasi tambahan untuk mengklasifikasi situasi

    c. Mengidentifikasi Issue etik

    d. Menentukan posisi moral pribadi dan professional

    e. Mengidentifikasi posisi moral dari petunjuk individual yang terkait.

    f.  Mengidentifikasi konflik nilai yang ada

Lung Screening May Encourage Smoking Cessation CME

News Author: Damian McNamara

CME Author: Charles P. Vega, MD, FAAFP Faculty and Disclosures

CME Released: 11/08/2012; Valid for credit through 11/08/2013

CLINICAL CONTEXT
There are more than 200,000 new cases of lung cancer diagnosed annually in the United States. However, effective screening strategies for lung cancer have remained elusive. Two major studies have recently evaluated the efficacy of lung cancer screening programs, and Barry and colleagues provide a review of this research. The Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) trial did not find a difference in the rate of lung cancer mortality in comparing a screening group receiving annual chest X-rays with a control group. However, the National Lung Screening Trial demonstrated that individuals receiving lung cancer screening with computed tomography experienced a 20% reduction in the risk for mortality compared with adults screened with chest X-ray alone.

Smoking is the most important risk factor for lung cancer, and previous research suggests that false-positive screening tests for lung cancer are associated with a higher rate of cessation from smoking. The authors of the current study examined variables associated with smoking outcomes in the PLCO study.

STUDY SYNOPSIS AND PERSPECTIVE
Former smokers are more likely to relapse if they are young; black or Hispanic; less educated; unmarried; have a lower income, lower body mass index, and no family history of lung cancer; or have smoked light or ultralight cigarettes, according to a secondary analysis of participants in the PLCO Screening Trial.

Of the 31,694 self-reported former smokers at baseline in the PLCO, 3.3% relapsed and reported on follow-up that they currently smoked, report Samantha A. Barry, BA, from the Prostate Cancer Decision Making and Quality of Life Research Department at Georgetown University Medical Center, Washington, DC, and colleagues in an article published online October 26 in the Journal of the National Cancer Institute.

In addition, long-term smokers and recent quitters were statistically significantly more likely to relapse (both P < .001), according to this secondary analysis of PLCO trial data.

"This relapse prediction model may be useful for identifying former smokers who may benefit most from relapse prevention interventions," the authors note.

Of the 6807 people who reported smoking at baseline, 65.2% said they still smoked on their subsequent questionnaire a median of 8.5 years later (range, 4 - 14 years). Those who were younger, black or Hispanic, or had a lower income or a lower body mass index were more likely to have continued smoking.

"Continued smoking was also more likely among heavier smokers, smokers of light or ultralight cigarettes, and those with greater secondhand smoke exposure," the authors write. "However, current smokers with higher body mass index or new tobacco-related diseases and smokers of unfiltered cigarettes were less likely to continue smoking. These characteristics may be useful in identifying smokers who are most in need of a smoking cessation intervention."

In terms of trial variables, only participation in the PLCO trial for a shorter time was associated with continuation of smoking (odds ratio, 0.85; 95% confidence interval, 0.82 - 0.88). The trial group randomization (screening vs control), screening center, and screening result were not significant factors.

Participants were approximately 60 years old, 50% were men, 90% were white, and about 50% had 2 or more comorbidities. They started smoking at an average age of 18 or 19 years. In addition, 10% reported receiving at least a single false-positive screening result, defined as a positive chest X-ray at 1 or more of the 4 annual assessments that was not followed by a lung cancer diagnosis within 3 years.

Receipt of a false-positive screen was not significantly associated with lower likelihood of smoking relapse or greater likelihood of smoking cessation, however, "suggesting that screening results may have only a short-term effect on smoking behavior," the authors note. "However, we found that being diagnosed with a new noncancer, tobacco-related disease was inversely associated with continued smoking, suggesting another possible teachable moment for altering smoking behaviors: Upon receiving a new diagnosis, smokers may be motivated to quit smoking and become more amenable to formal cessation programs."

Smoking and Risk on Women’s Mortality Rates

News Author: Lara C. Pullen, PhD

CME Author: Charles P. Vega, MD, FAAFP Faculty and Disclosures

CME/CE Released: 11/09/2012; Valid for credit through 11/09/2013

CLINICAL CONTEXT
Smoking is widely recognized as the most important modifiable risk factor in preventing adult mortality in Western countries, but there has been little attention paid overall to sex-based differences in health outcomes of smokers. Huxley and Woodward addressed this issue in a systematic review comparing cardiovascular outcomes associated with smoking among women and men. Their results, which were published in the October 8, 2011, issue of the Lancet, demonstrate that the risk for cardiovascular events associated with current smoking was more profound among women compared with men. There was no sex-based difference in the cardiovascular risk of former smokers.

Long-term data analysis on the health risks of smoking among very large groups of women has only recently been possible. The current study reports on mortality outcomes based on cigarette use in the Million Women Study.

STUDY SYNOPSIS AND PERSPECTIVE
Women who smoke lose at least 10 years from their lifespan. In particular, women who continue smoking past the age of 40 years have 10 times the hazards of those who quit smoking before that age.

Kirstin Pirie, MSc, from the Cancer Epidemiology Unit at the University of Oxford in the United Kingdom, and colleagues presented results from the Million Women Study in an article published online October 27 in the Lancet. Women were recruited for the study between the ages of 50 and 65 years and were followed up for between 9 and 15 years. The women in the study had a relatively low absolute death rate, possibly because various previous illnesses were excluded and possibly because the study included relatively healthy volunteers.

The study examined women in the United Kingdom and found that smoking accounted for two thirds of all deaths of smokers in their 50s, 60s, and 70s. Women smoking at baseline had a 12-year mortality rate of 2.76 (95% confidence interval, 2.71 - 2.81) when compared with never-smokers. For smokers younger than 70 years, the probability of death was 24% compared with 9% for never-smokers of the same age (absolute difference, 15%).

Women who stopped smoking by age 30 years avoided more than 97% of the lifetime hazard from smoking. Women who smoked until age 40 years and stopped had substantial hazards but were able to avoid more than 90% of the excess mortality caused by continuing to smoke. Women who stopped smoking at age 50 years avoided approximately two thirds the excess mortality seen in women who continue smoking at a later age. Women who quit smoking at the age of 40 years still have a mortality rate 1 to 2 times that of the never-smokers, however, and this increased mortality rate lasts for the next few decades of life.

Smokers typically experienced excess mortality from lung cancer, chronic lung disease, heart disease, and stroke, as well as other neoplastic, respiratory, or vascular conditions. For many of these diseases, the study identified a proportional excess risk in smokers that was even higher than that identified in previous studies.

The UK population was useful for studying because it includes a generation of women who smoked through adult life and reached old age. The authors seek to use the data from this study to predict the effect of smoking on female mortality outside the United Kingdom.

In a linked comment, Rachel Huxley, DPhil, from the University of Minnesota in Minneapolis and Mark Woodward, PhD, from Johns Hopkins University in Baltimore, Maryland, write, "The substantial hazards of smoking and the remarkable benefits of stopping now being seen among women in the UK emphasise the need for effective sex-specific and culturally-specific tobacco control policies that encourage adults who already smoke to quit and discourage children and young adults from starting to smoke."