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Ambulatory care nurses give power to their patients

Monday June 9, 2014
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Pamela Kostic, RN
Nurses who work in ambulatory care say they want their patients to go home with more than a care plan and prescriptions.

They want them to see the hope in their conditions and feel confident that they have the power to improve their health.

For Pamela Kostic, RN, BA, CCCC, chest pain accreditation coordinator at Stony Brook (N.Y.) University Heart Institute, empowering patients in the outpatient setting means making sure they know risk factors and lifestyle changes that will affect their chances of having a heart attack.

The institute has adopted the Society of Cardiovascular Patient Care’s “Early Heart Attack Care” program, which focuses on recognizing early, subtle signs. She said asking about discomfort in general is important because early symptoms vary.
“The early symptoms may not be chest pain,” she said. “They could be fullness in the abdomen, shortness of breath, back pain.”

Kostic said she had a 49-year-old patient with tooth pain and jaw pain for nearly two years before she sought help in the ED.

“They gave her a sublingual (nitroglycerin therapy for early myocardial infarction) and her pain disappeared,” Kostic said. Two of the patient’s main arteries were 95% blocked.

Kostic wants to educate patients to know the early signs before she sees them in the ED. To do that, she has been compiling the ZIP codes of people who wait more than two hours after symptoms to get help to see if there are particular regions where she needs to target her educational outreach.

She also wants patients she sees to feel they have enough information to help others when they leave her care.

“Now that you know what I know,” she tells patients, “spread the word to family members, loved ones and friends.”


Yesenia Cabral, RN
Patient priorities

Yesenia Cabral, RN, a disease manager with the outpatient diabetes management program at NewYork-Presbyterian Hospital, Manhattan, said she empowers patients’ behaviors related to healthy eating, monitoring and coping.

One of the ways she engages patients is by having them help set their priorities. Talking with patients about their living situation, for instance, may help determine which goals need work first.

“Maybe the patient is having housing issues,” Cabral said. “Obviously, that may not be the best time to talk about their healthy eating, because they don’t even have a place to live.” In that case, the first step may be connecting them with social services.

With diabetes, patients also may be dealing with overwhelming multiple co-morbidities, such as hypertension or obesity. Setting goals is particularly important to celebrate incremental advances when achieving an end result may seem so far away, she said.

Cabral wants patients to know their numbers, what the desired range is and what the numbers mean, such as the targets for good and bad cholesterol and the desired range for A1C (a measure of blood sugar over the past two to three months.)

“I’ve had patients say ‘I’ve had diabetes for 10 years, 20 years, 30 years and no one has ever taken the time to talk with me this way,’” she said.

From April 2012 to June 2013, the percentage of those in the program with A1C below 7 (good glycemic control) went up 7%, she said, while those with A1C levels above 9 (poor control) fell 16%. Those with blood pressures higher than 140/80 went down 7%.


Emina Useinovic, RN
Buying screen time

Helping a younger population stay adherent and engaged requires imaginative strategies.

Emina Useinovic, RN, is an ambulatory care staff nurse with the child and adolescent psychiatry day treatment program at Bellevue Hospital Center, Manhattan. Her program treats children ages 6 to 17 who are referred by schools or parents for disorders such as ADHD, depression and schizophrenia.

“We’re trying to battle some of the street culture that our patients are coming from [such as fighting],” Useinovic said. “Our job is to help them change those behaviors so they can return to the community and be successful and prevent them from ending up on an inpatient unit.”

Patients get points for signing in, taking their medication, avoiding conflict, attending school and doing homework. An average stay in the program is about six months, she said.

Patients can use points to get time to do a chosen activity, such as playing video games, or they can save points to purchase items such as headphones. “They have to save for weeks. It’s not like you can have one good day,” Useinovic said.

The overall success rate, she said, is 60% for patients coming in from a higher level of care, such as inpatient units and residential facilities, and 80% for those coming from outpatient clinics and schools.

Marcia Frellick is a freelance writer.


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Power tools

Nurses from the New York/New Jersey region who work in the ambulatory setting offer the following tips on how to help engage patients:

TIP 1:
Involve patients in setting their goals and priorities.

TIP 2:
Use the word “discomfort” when asking patients about symptoms rather than asking about something too specific, such as, “Do you have chest pain?” Being too specific may cause nurses to miss important information.

TIP 3:
Try to read patients’ level of understanding by asking what they’ve been told or what they know about their condition to tailor your level of diction.

TIP 4:
Use simple examples familiar to the patient to show how body systems work, such as comparing cells that get overloaded with work to people who take on more work after a coworker leaves a job.

TIP 5:
Use positive reinforcement whenever possible to change a patient’s behavior.

TIP 6:
Remind patients when they head home that they have the knowledge now to educate their family members and friends.

Source: Nurse interviews