Hypoglycemia

<65 - dizziness, confusion, weakness, tremors.

<40 - coma, seizures, irreversible brain damage.

Treat with quickly absorbed glucose - orange juice, soft drinks, glucose tablets (15-20g), cake icing applied to the inside of the mouth.

Hyperglycemia

Blood glucose >130.

Dangerous when symptomatic, but must be identified and treated to avoid complications. Signs and symptoms are as above. If associated with infection, can lead to diabetic ketoacidosis. This results in severe dehydration, acidosis and sepsis. This is a potentially fatal illness; therefore, early recognition and avoidance is important. It is imperative not to skip insulin if the diabetic is unwell and not eating. Maintain adequate hydration. Get urgent medical help if unable to control blood glucose levels or if patient appears unwell.

Hyperosmolar non-ketotic state

In the elderly, Type 2 diabetes is more prevalent. Because there is no absolute lack of insulin, ketoacidosis does not occur. What does occur is a hyperosmolar non-ketotic state which can lead very quickly to coma. Again, prevention is better than cure.

Skin care

Diabetic patients suffer from skin problems for a number of reasons. First, they are more prone to developing infections due to impaired immunity; secondly, they develop peripheral neuropathies which allow easy disturbance of skin integrity; thirdly, they have microvascular disease, which prevents adequate perfusion and immensely compromises the ability to repair. It is imperative to educate patients in thorough cleansing and inspection of extremities. Good podiatry care is very important. Any injuries should be addressed quickly and treated aggressively to avoid chronic ulcers.

Foot ulcers

The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.

There are several key factors in the appropriate treatment of a diabetic foot ulcer:

•  Prevention of infection

•  Taking the pressure off the area, called “off-loading”

•  Removing dead skin and tissue, called “debridement”

•  Applying medication or dressings to the ulcer

•  Managing blood glucose and other health problems

Not all ulcers are infected; however if the podiatric physician diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.

There are several important factors involved in keeping an ulcer from becoming infected:

•  Keep blood glucose levels under tight control

•  Keep the ulcer clean and bandaged

•  Cleanse the wound daily, using a wound dressing or bandage

•  Do not walk barefoot

For optimum healing, ulcers, especially those on the bottom of the foot, must be “off-loaded.” Patients may be asked to wear special footgear, or a brace, or specialized castings, or to use a wheelchair or crutches. These devices will reduce the pressure and irritation to the ulcer area and help to speed the healing process.

The science of wound care has advanced significantly over the past ten years. The old thought of “let the air get at it” is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full strength betadine, peroxide, whirlpools and soaking are not recommended, as this could lead to further complications.

Appropriate wound management includes the use of dressings and topically-applied medications. These range from normal saline to advanced products, such as growth factors, ulcer dressings and skin substitutes, which have been shown to be highly effective in healing foot ulcers.

For a wound to heal there must be adequate circulation to the ulcerated area. The podiatrist can determine circulation levels with noninvasive tests.

Vision and dentation

Diabetics should receive regular follow-up for their vision and dentation. They should also be monitored closely by their primary care physician or diabetology team in order to maintain optimum health and prevent future complications.

Medications commonly used to treat diabetes and their side effects

Sulfonylureas

Sulfonylureas stimulate the beta cells of the pancreas to release more insulin. Sulfonylurea drugs have been in use since the 1950s. Chlorpropamide (brand name Diabinese) is the only first-generation sulfonylurea still in use today. The second-generation sulfonylureas are used in smaller doses than the first-generation drugs. There are three second-generation drugs: glipizide (brand names Glucotrol and Glucotrol XL), glyburide (Micronase, Glynase, and Diabeta), and glimepiride (Amaryl). These drugs are generally taken one to two times a day, before meals. All sulfonylurea drugs have similar effects on blood glucose levels, but they differ in side effects, how often they are taken, and interactions with other drugs.

Meglitinides

Meglitinides are drugs that also stimulate the beta cells to release insulin. Repaglinide (brand name Prandin) and nateglinide (Starlix) are meglitinides. They are taken before each of three meals.

Because sulfonylureas and meglitinides stimulate the release of insulin, it is possible to have hypoglycemia (low blood glucose levels).

It is important to be aware that alcohol and some diabetes pills may not mix. Occasionally, chlorpropamide and other sulfonylureas can interact with alcohol to cause vomiting, flushing, or sickness.

Biguanides

Metformin (brand name Glucophage) is a biguanide. Biguanides lower blood glucose levels, primarily by decreasing the amount of glucose produced by the liver. Metformin also helps to lower blood glucose levels by making muscle tissue more sensitive to insulin so glucose can be absorbed. It is usually taken two times a day. A side effect of metformin may be diarrhea, which can be reduced by taking the drug with food.

Thiazolidinediones

Rosiglitazone (Avandia), troglitazone (Rezulin), and pioglitazone (ACTOS) form a group of drugs called thiazolidinediones. These drugs help insulin work better in the muscle and fat and also reduce glucose production in the liver. Thiazolidinediones are taken once or twice a day with food. Although effective in lowering blood glucose levels, thiazolidinediones can have a rare but serious effect on the liver. For this reason, the physician should perform blood tests regularly to monitor the health of the liver.

Alpha-glucosidase inhibitors

Acarbose (brand name Precose) and meglitol (Glyset) are alpha-glucosidase inhibitors. These drugs help the body to lower blood glucose levels by blocking the breakdown of starches, such as bread, potatoes, and pasta in the intestine. They also slow the breakdown of some sugars, such as table sugar. Their action slows the rise in blood glucose levels after a meal. They should be taken with the first bite of a meal. These drugs may have side effects, including gas and diarrhea.

Oral combination therapy

Because the drugs listed above act in different ways to lower blood glucose levels, they may be used together. For example, a biguanide and a sulfonylurea may be used together. Many combinations can be used. Though taking more than one drug can be more costly and can increase the risk of side effects, combining oral medications can improve blood glucose control when taking only a single pill does not have the desired effect. Switching from one single pill to another is not as effective as adding another type of diabetes medicine.

Insulin therapy

Most insulin in use today is synthetically produced from laboratory cultures. However, a small percentage of people with Type 1 diabetes still use animal-based insulins that are distilled and purified from the pancreases of cows (bovine insulin) and pigs (porcine insulin).

There are six types of synthetic insulin available-rapid-acting, regular, NPH (N), lente (L), ultralente, and long-acting basal. Each has its own unique therapeutic effect. An insulin’s onset of action is how long it takes the hormone to start working at lowering blood glucose levels. The peak is the point at which the dose is at the height of its therapeutic effectiveness, and the duration is how long the insulin’s blood glucose lowering effect lasts from injection to end.

Summary

Diabetes is a multi-systemic disease with grave implications for future health. A multi-disciplinary approach to the care of these patients is important and has proven to improve morbidity and mortality from the disease. Monitoring and maintaining good blood sugar levels is the most important intervention in the care of the diabetic. This involves patient education and a teamwork approach. Long-term complications from diabetes can be delayed and their extent controlled with good evaluation, treatment and management.

go to test.

Barnett, Anthony H., Diabetes - Best Practice & Research Compendium. Saunders 2006. ISBN: 0080446868.

Harmel, Anne Peters and Ruchi Mathur, Davidson’s Diabetes Mellitus , 5th ed. Saunders, 2004. ISBN: 0721695965.

Marso, Steven P. and David M. Stern, Diabetes and Cardiovascular Disease . Lippincott Williams & Wilkins, 2003. ISBN-10: 0-7817-4053-3.

Springhouse , Diabetes Mellitus: A Nurse’s Guide to Patient Care. Lippincott Williams & Wilkins, 2006. ISBN-10: ISBN-10: 1-58255-732-2.

www.cdc.gov/diabetes/statistics/maps/index.htm

www.diabetes.niddk.nih.gov/complications/index.htm

www.diabetes.org/type-2-diabetes/complications.jsp

www.fda.gov/diabetes/related.html

www.ndep.nih.gov/diabetes/WhatIs/WhatIs.htm

I. What is diabetes?

II. Definition of diabetes

III. Signs/symptoms

IV. Prevalence of diabetes

V. Complications of diabetes

A. Heart and blood vessel disease

B. High blood pressure

C. Blindness

D. Kidney disease

E. Foot ulcers

F. Nervous system disease

G. Amputations

H. Dental disease

I. Complications of pregnancy

J. Impotence

K. Other complications

VI.   Management of some common complications

A. Hypoglycemia

B. Hyperglycemia

C. Hyperosmolar non-ketotic state

D. Skin care

E. Foot ulcers

F. Vision and dentation

VII. Medications commonly used to treat diabetes and their side effects

A. Sulfonylureas

B. Meglitinides

C. Biguanides

D. Thiazolidinediones

E. Alpha-glucosidase inhibitors

F. Oral combination therapy

G. Insulin therapy

VIII. Summary

To update health care professionals on the risks, complications and management of diabetes.

OBJECTIVES:

Upon completion of this program the learner will be able to:

•  Explain the difference between Type 1 and Type 2 diabetes

•  Name 5 complications of diabetes.

•  Identify the most important intervention in the care of the diabetic.

•  List four medications commonly used in the treatment of diabetes.

What is diabetes?

Diabetes mellitus is a chronic health condition in which the body is unable to produce adequate insulin to properly break down sugar (glucose) in the blood. Symptoms include hunger, thirst, excessive urination, dehydration and weight loss. Over time, diabetes can lead to heart and blood vessel disease, blindness, kidney failure, and foot ulcers, among other conditions.

Diabetes is a disease of the endocrine system, specifically, the pancreas, and of glucose metabolism. Insulin is normally produced in the pancreas in response to high blood glucose levels; for example, after a meal. The Islets of Langerhan are small areas of tissue within the pancreas that contain beta cells, which produce insulin. In Type 1 diabetes, the beta cells are destroyed, leading to an absolute lack of insulin. In Type 2 diabetes, there is resistance peripherally to the inherent insulin. This leads to a relative lack of insulin and therefore hyperglycemia.

Type 1 diabetes occurs at a very early age, caused, as mentioned above, by a destruction of beta cells in the pancreas. People with Type 1 diabetes have little or no ability to produce insulin and are entirely dependent on injections of insulin for survival.

The cause of Type 1 diabetes is unknown, although childhood infections and a genetic tendency are two possibilities. The pancreas undergoes a change, and cells that normally produce insulin are destroyed. This may be a result of the body’s own immune system believing the pancreas to be a foreign organ. Patients with Type 1 diabetes tend to be very slim people.

Type 2 diabetes tends to be of adult onset, although more and more young people are now being diagnosed with this insulin-resistance syndrome.

In Type 2 diabetes , the pancreas retains its ability to produce insulin , but either the quantity is inadequate for the body’s needs, or insulin cannot be used to its full extent by the tissues. Most people who have this condition suffer from being overweight, and require a strict weight-reducing diet and exercise program, as well as possible treatment with drugs, sometimes including insulin.

Definition of diabetes

•  Random plasma glucose of >200mg/dL

•  Fasting plasma glucose =126mg/dL on 2 separate occasions

•  Fasting plasma glucose 110-125mg/dL is considered Impaired Glucose Tolerance

•  Fasting plasma glucose <110mg/dL is considered normal

•  HbA1c <6.5% indicates good glucose control

Signs/symptoms

At onset, the two types of diabetes present with distinction:

Type 1 - weight loss, polyuria, polydypsia

Type 2 - polyuria, polydypsia, recurrent infections

Prevalence of diabetes

It is estimated that 20.8 million people in the United States –7 percent of the population-have diabetes, including 6.2 million who are undiagnosed. Ninety-five percent of people with diabetes have Type 2. Diabetes was the sixth leading cause of death listed on U.S. death certificates in 2002. Diabetes is also likely to be underreported as a cause of death. Overall, the risk of death among people with diabetes is about twice that of people without diabetes of similar age.

Complications of diabetes

Diabetes is a systemic disease which can have devastating effects on the body as a whole. Diabetes has numerous serious complications.

Heart and blood vessel disease

Heart disease is the leading cause of death for people with diabetes. Heart disease and stroke account for about 65 percent of deaths in people with diabetes.

People with diabetes are 2-4 times more likely to have heart disease than persons without diabetes. Even people with Type 2 diabetes who do not have heart disease have an increased risk of having a heart attack. People with diabetes also tend to have other risk factors for heart disease, including obesity, high blood pressure, and hardening of the arteries (atherosclerosis).

High blood pressure

About 73 percent of adults with diabetes have blood pressure greater than or equal to 130/80 mm Hg or use prescription medications for hypertension.

Blindness

Diabetes is the leading cause of new cases of blindness among adults aged 20 to 74 years. Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.

Adults with diabetes should have yearly eye exams to ensure the health of their eyes and to protect their vision.

Over time, high blood sugar levels can damage the blood vessels that feed the retina of the eye. In nonproliferative diabetic retinopathy (NPDR), an early stage of diabetic eye disease, the blood vessels may leak fluid. This may cause the retina to swell and vision to blur, a condition called diabetic macular edema. In advanced or proliferative diabetic retinopathy (PDR), abnormal new blood vessels grow on the surface of the retina. The abnormal blood vessels don’t supply the retina with normal blood flow. In addition, they may eventually pull on the retina and cause it to detach.

Some cases of diabetic retinopathy can be treated with laser surgery. In this procedure, doctors aim a strong beam of light onto the patient’s retina to shrink or seal leaking or abnormal vessels. Laser surgery can’t restore vision already lost, so early detection is important. In some advanced cases of PDR, a surgeon may remove the vitreous portion of the eye and replace it with a clear solution (called a vitrectomy).

Kidney disease

Over time, high blood sugar levels can damage the kidneys. Even when drugs and diet are able to control diabetes, the disease can lead to kidney disease (diabetic nephropathy) and kidney failure.

Healthy kidneys act like filters to clean the blood of waste products and extra fluid. Damaged kidneys do not clean the blood well. Instead, waste products and fluid build up in the blood.

Diabetes is the leading cause of kidney failure. People with kidney failure must either have dialysis treatment (to substitute for some of the filtering functions of the kidneys) or receive a kidney transplant.

Foot ulcers

Adults with diabetes need to take special care of their feet. People with diabetes are at risk for foot injuries due to numbness caused by nerve damage (diabetic neuropathy) and low blood flow to the legs and feet. The most serious injury is a foot ulcer. Diabetic foot ulcers are at very high risk of becoming infected, and sometimes they cannot be healed. Non-healing foot ulcers are a frequent cause of amputation in people with diabetes. Patients with foot ulcers may use wound dressings, skin substitutes, or other treatments to protect and heal their skin.

Wound dressings are medical devices that are used to protect ulcerated skin and assist in its healing. They can range from simple bandages that can be bought in the drug store to complex materials that contain antibacterial and antiviral substances.

Skin substitutes are products that help in closing the wounds of slow healing ulcers in patients with diabetes. They are made from human cells known as fibroblasts that are placed on a dissolvable mesh material. When the mesh material is placed on the ulcer, it is gradually absorbed and the human cells grow and replace the damaged tissue in the ulcer.

Nervous system disease

About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage. The results of such damage include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, and other nerve problems.

Almost 30 percent of people with diabetes aged 40 years or older have impaired sensation in the feet. Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations.

Amputations

More than 60 percent of nontraumatic lower-limb amputations occur among people with diabetes.

Dental disease

Periodontal (gum) disease is more common in people with diabetes. Among young adults, those with diabetes have about twice the risk of those without diabetes. Almost one-third of people with diabetes have severe periodontal diseases with loss of attachment of the gums to the teeth measuring 5 millimeters or more.

Complications of pregnancy

Poorly controlled diabetes before conception and during the first trimester of pregnancy can cause major birth defects in 5 to 10 percent of pregnancies and spontaneous abortions in 15 to 20 percent of pregnancies.

Poorly controlled diabetes during the second and third trimesters of pregnancy can result in excessively large babies, posing a risk to both mother and child.

Impotence

Impotence is a common problem for men and is more common in men with diabetes. The relationship between diabetes and impotence is not clear and the reasons why men with diabetes are more prone to problems with impotence are not fully understood. Some people with diabetes suffer from hardened arteries, which may contribute to impotence by restricting the flow of blood to the penis. Nerve damage, another problem for people with diabetes, may also contribute to impotence. If blood glucose levels are kept in the normal range, it will help reduce the chance of these problems occurring.

Other complications

Uncontrolled diabetes often leads to biochemical imbalances that can cause acute life-threatening events, such as diabetic ketoacidosis and hyperosmolar (nonketotic) coma. People with diabetes are more susceptible to many other illnesses and, once they acquire these illnesses, often have worse prognoses. For example, they are more likely to die with pneumonia or influenza than people who do not have diabetes.

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1. Register for the Online BLS for Healthcare Poviders Renewal Class.
2. Complete the Online Class
3. Print your certificate (please bring it with you to the skills assessment)
4. Call our office (800) 852-4126 and register for the skills assessment
5. Demonstrate CPR skills
6. Receive your AHA Provider card good for two years.

The cost for the Skills Assessment is $25.  If you have registered for Nursing Unlimited’s Online CPR class there is no cost for the skills assessment.  After demonstrating skills, you will be given your provider card.

Register for the Online CPR Class.

Don’t Forget About HIV/AIDS Update, Domestic Violence Mandatory Requirement, and Prevention Of Medical Errors Mandatory Requirement

Types of Rhythms Where Pacing Is Indicated
• Bradycardias that are unresponsive to drug therapy or are symptomatic
• 2nd degree heart block type II
• 3rd degree heart block

Clinical Note:
Atropine may be given to 2nd degree type II heart block or a narrow complex 3rd degree heart block as a trial but, when detected, the American Heart Association ACLS guidelines recommend that these dysrhythmias be managed by immediate application of the transcutaneous pacer and close observation of the patient for any signs of hemodynamic instability, e.g., shortness of breath – hypotension – altered level of consciousness – chest pain – pallor – nausea & vomiting – profuse sweating. If unstable and in 2nd degree heart block type II or 3rd degree heart block, then the pacer should be used to correct the rate only until transvenous pacing can be accomplished by a qualified person.

Remember from earlier in the reading that if a patient is bradycardic and hemodynamically unstable, as described in the previous paragraph, then transcutaneous pacing should be considered as a first line treatment.
Setting a transcutaneous pacemaker will be discussed in the electrical therapy station on day 1 of ACLS

Three Basic Rhythms
There are 3 categories of abnormal rhythms: too fast, too slow or none. Patients with any dysrhythmia may be stable, unstable or in cardiac arrest. Recognizing which type of patient you have will decide your treatment choices: medicine, electrical, and/or mechanical (BLS).

Too Fast
The first rhythm is too fast. Our goal is to slow it down. We have two methods to slow down a rhythm: electrical therapy and/or medicine. If the patient is hemodynamically stable, pharmacology should be the first line treatment. If our patient were hemodynamically unstable, synchronized cardioversion should be the first line treatment.

Too Slow
The second rhythm is too slow. Our goal is to speed it up. We have two methods of speeding up a rhythm: electrical therapy and/or medicine. If the patient is hemodynamically stable, pharmacology should be the first line treatment. If our patient were hemodynamically unstable, transcutaneous pacing should be the first line treatment.

None
Ventricular fibrillation, pulseless ventricular tachycardia, pulseless electrical activity and asystole are the dysrhythmias associated with cardiac arrest. As these are lethal dysrhythmias, management must be quick and aggressive.

• FROM THE SOUTH: Take I-95 to the Forest Hill Blvd West exit.  Go West to Congress Ave and turn right (North) to NW Collin Drive.  Make a U-turn on Collin Drive the building will be on your right hand side.
• FROM THE NORTH: Take I-95 to Southern Boulevard . West exit.  Go West to Congress Ave. and turn left. Building will be on the right side past Collin Drive.
• FROM THE TURNPIKE: Take Turnpike to Southern Boulevard . East exit.  Go East to Congress Ave. and turn right. Building will be on the right side past Collin Drive.

Classes offered at this location

• CPR Renewal
• CPR Skills Assessment
• ACLS
• PALS
• AIDS/OSHA/TB - BBP
• Domestic Violence
• Prevention of Medical Errors
• Phlebotomy
• Starting and Maintaining IV Certification
• PICC Line Insertion Class

• FROM ANY DIRECTION: Take I-95 to Palmetto Park Road Exit, and go East and the medical center will be on the left

• FROM ANY DIRECTION: The hospital is located West of 441 (also called State Road 7) between Broward and Sunrise Boulevards. Take any major road to 441 and when you get to Broward Blvd. or Sunrise Blvd., follow the Blue Hospital roadway signs. Parking is in the visitor’s lot.

Plantation General Hospital
Medical Office Building II
4101 NW 3rd Court
Plantation, FL

• FROM THE SOUTH: Take I-95 to the Broward Blvd. West exit.  Go West to 441 (State Road 7) and turn right (North) to NW 3rd Court.  Turn left (West) on NW 3rd Court. The Medical Office Building II is the 1st building on your right.  Parking is available underneath the building.
• FROM THE NORTH: Take I-95 to the Sunrise Blvd. West exit.  Go West to 441 (State Road 7) and turn left (South) to NW 3rd Court. Turn right (West) on NW 3rd Court.  The Medical Office Building II is the 1st building on your right.  Parking is available underneath the building.
• FROM ANY OTHER DIRECTION: Take 441 (State Road 7) to North Hospital Drive (NW 4th Street). Turn left (West) on North Hospital Drive. The Medical Office Building II is the 1st building on your left. Parking in under the building.

• FROM THE EAST: Take I-95 to Commercial Blvd (Exit 32). Go west for approximately one mile.  Turn left at NW 17th Way (Spectrum Way).  Keiser University will be on your left.  Please park on the unpaved lot behind the building.
• FROM THE WEST: Take the Turnpike to Commercial Blvd (Exit 62).  Go east for approximately three miles. Turn right at NW 17th Way (Spectrum Way).  Keiser University will be on your left. Please park on the unpaved lot behind the building.

• FROM ANY DIRECTION: Take the Turnpike to Eureka Drive (SW 184 Street) and go east to
  US-1.  Proceed North to SW 174 Street and Gramercy Park is on the right facing US 1. It is a four story, pastel colored building surrounded by a black iron ornamental fence.  Pull up to the gate on
  US-1 and it will open automatically. The classroom is located on the first floor in the education
  center.

Medical Office Building
11760 SW 40th  Street (Bird Road)
Miami, FL

The successful graduate must achieve a 70% score on all final written exams as well as 70% completion/competency on skills, ranging from basic care procedures to more complex procedures.

Since programs range from two to six weeks in total length, academic progress is noted by final exam or skills checklist only. Please see the failure policy below.

Failure Policy

Nursing Unlimited Health Career Training School policy is that students who do not complete a program, with the exception of Nursing Assistant Review, for any reason other than conduct, will be allowed to retake that program once at no additional cost. They will be admitted into the next class with space for them. Students who fail the written portion of the state CNA exam will be allowed to retake the Nursing Assistant Review class one time at no additional cost. Such students will be admitted into the next available class.

All students must demonstrate competency in reading and writing English by achieving a score of 70% or better on Nursing Unlimited Health Career Training School’s Competency Exam. Students unable to demonstrate this required competency will be encouraged to enroll in a county public school ESOL program. The student may choose to be refunded their complete tuition at that time (see cancellation policy, page 28). Upon completion of the ESOL program, the student may return to enroll in the program of their choice.

Students enrolling must be physically able to perform the required functions for successful completion of the program. This includes sitting, standing, stooping, kneeling and lifting 25 lbs.

Nursing Unlimited Health Career Training School does not grant credit or advanced standing for previous education or training. Previous education must be proved only when registering for the Nursing Assistant Review course. This proof shall consist of certificates or diplomas from approved schools in the field of healthcare.

Reasons for denying admission to any prospective student shall be documented and kept on file for at least one year.

Our Purpose

The purpose of Nursing Unlimited Health Career Training School is to enable our students to acquire both the knowledge and the practical skills necessary to obtain gainful employment and to achieve their career goals within the healthcare industry.

Our Mission

Nursing Unlimited Health Career Training School continuously strives to provide an effective learning environment and opportunities for students interested in vocational training in the health care industry.

Our mission is to ensure continuous quality improvement in all areas in order to meet and exceed the needs of our students and the community at large.

Home Health Aide 35 Course Textbook
Sherron Newberry, RN
Nursing Unlimited, 2001

Nursing Assistant Review Course Textbook
Paula E. Glass, RN, BSN
Nursing Unlimited, 2002

Phlebotomy Essentials, 3rd ed., 2003, Lippincott Williams and Wilkins
Ruth E. McCall and Cathee M. Tankersley

Career Development for Health Professionals, 2nd ed., 2006, Elsevier
Lee Haroun

EKG Workout: Exercises in Arrhythmia Interpretation, 5th ed., 2006,
Lippincott Williams & Wilkins
Jane Huff

Nursing Unlimited Health Career Training School has approximately 6800 square feet, 50% of it devoted to actual classroom space. Formal instruction is provided in a modern, comfortable classroom setting designed especially for nursing skill education. The laboratory portion of classes takes place in classrooms that are similar to a working environment, complete with hospital bed, wheelchairs, walkers and other equipment utilized in a healthcare facility. It is here that students learn everything from bed making to taking blood pressure. All of the skills that are needed are practiced before the student is permitted to care for patients, and competency is graded, utilizing a skills competency checklist.

Nursing Unlimited’s media center measures approximately 256 square feet, and contains 6 computers and over 80 medical/nursing reference books and manuals. Additionally, we subscribe to numerous professional journals. Books, journals, a/v materials and laboratory equipment are regularly reviewed and updated as needed. Students have access to the media center at specified times, posted in the lobby. All faculty members have access to the media center to support the students’ education.

Inventory of Equipment

Laboratory equipment includes:

• Hospital beds
• Toothbrush/toothpaste
• Sink/ scale with height Over-the-bed tables
• Dentures/denture cup & personal care items Chux (bed protection pads)
• Bed linens Restraints
• Wheelchairs Walkers
• Gait / transfer belts Teaching (dual) & regular stethoscopes
• Emesis basins Lotion
• Bedside commodes Crutches
• Combs Full patient simulator mannequin
• Gloves Blood pressure cuffs & stethoscopes Canes Thermometers
• Orange stick/emery board Indwelling urinary catheters and collection bags

Administration

Steven W. Pollack
President

Reinaldo Rementeria
General Business Manager

Galen Heneghan
Director of Instructor Relations & Curriculum Development

Jean Wainwright
Administrative Officer

Administrative Hours

Monday - Friday
8:00am - 5:00pm

Steven W. Pollack
President, Secretary and Treasurer

Reinaldo Rementeria,
Vice President

Headquarters

Nursing Unlimited
18405 NW 2nd Avenue
Miami Gardens, FL 33169

9:00 am - 5:00 pm (Day 1)
9:00 am - 5:45 pm (Day 2)

February 13 - 14 (Wednesday & Thursday)
May 31 - June 1 (Saturday & Sunday)(MOB II, Room 758)
August 13 - 14 (Wednesday & Thursday)
November 12 - 13 (Wednesday & Thursday)

Thursday & Friday
9:00 am - 5:00 pm (Day 1)
9:00 am - 5:45 pm (Day 2)

March 27 - 28
May 29 - 30
July 31 - August 1
September 25 - 26
November 20 - 21

Register now for the 2-day Class

Register now for the 1-day renewal Class

Commission for Independent Education

American Heart Association

Oncology Nursing Society

If you are looking for other types of training, check out the training-classes.com directory of telecommunications career training

Miami Dade County Business List

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MEDS CLINICAL UPDATES

IV THERAPY SKILLS DEVELOPMENT

CRITICAL CARE SERIES

Telemetry for Nurses and Technicians
40 Contact Hours - $300

12 and 15 Lead ECG
8 Contact Hours - $90

Introduction to Critical Care Nursing
64 Contact Hours - $450

Don’t see the program that you need? Call our office at (800) 852-4126 or contact us via email.  We can design a program to meet your needs or bring one of our contract only programs such as LPN Supervision and Conscious / Moderate Sedation to you.

Nursing Unlimited is delighted to announce the addition of the Neonatal Resuscitation Program to our list of offerings. Neonatal resuscitation skills are essential for all healthcare providers who may be called upon to resuscitate infants at birth or at any time during their initial hospital admission.

The new, extensively updated Neonatal Resuscitation Program (NRP) is based on the 2005 American Academy of Pediatrics (AAP)/American Heart Association (AHA) “Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Neonatal Resuscitation Guidelines.” All program components reflect the AAP/AHA guidelines’ increased emphasis on evidence-based treatment recommendations, as well as the new International Liaison Committee on Resuscitation (ILCOR) evidence-based consensus on science.

The 5th edition of the NRP textbook features new lessons on resuscitating pre-term babies and dealing with ethical issues, as well as case scenarios for each major resuscitation technique. You will enter into a highly interactive, scenario-based learning experience, seamlessly integrating the course material into your life as a healthcare provider dealing with newborns.

The course fee is $150 for 8 Contact Hours or $100 for the 4 Contact Hour renewal and includes the course textbook from Nursing Unlimited’s library.

NRP - Neonatal Resuscitation Classes in Ft Lauderdale, Plantation and Broward County.

Don’t see the dates you want? Call our office at (800) 852-4126 to schedule a private class around your schedule.

West Broward
Plantation General Hospital
401 N.W. 42nd Avenue
3rd Floor, Classroom 3
Plantation, FL
(Directions)

Renewal Class
Monday
9:00 am - 1:00 pm

February 2
April 6
June 8
August 3
October 26
December 14

8-hour class
Tuesday
9:00 am - 5:00 pm

February 3
April 7
June 9
August 4
October 27
December 15

]]> http://www.nursingunlimited.com/nrp-neonatal-resuscitation-program/ PURPOSE:
To educate healthcare professionals about the risks, symptoms, complications and treatment of aspiration pneumonia.

OBJECTIVES:
Upon completion of this program the learner will be able to:

• Distinguish between aspiration pneumonitis and aspiration pneumonia
• List 2 causative organisms of community-acquired aspiration pneumonia
• List 5 risk factors for aspiration pneumonia
• List 4 symptoms of aspiration pneumonia
• Identify 6 tests used to diagnose aspiration pneumonia
• List 3 complications of aspiration pneumonia
• Discuss 3 methods of prevention of this disease

OUTLINE:

I.          Definition
II.         Aspiration Pneumonitis
III.        Aspiration Pneumonia
IV.        Causative Organisms
V.         Risk Factors
VI.        Frequency
VII.       Mortality/Morbidity
VIII.      Symptoms
IX.        Diagnosis
X.         Physical Examination
XI.        Signs and Tests
XII.       Lab Studies
XIII.      Imaging Studies
XIV.     Treatment
XV.      Prehospital Care
XVI.     Emergency Department Care
XVII.    Consultations
XVIII.   Complications
XIX.     Prognosis
XX.      Prevention
XXI.     Summary
XXII.    References

TARGET AUDIENCE:
Healthcare professionals wishing to know more about aspiration pneumonia.

CONTACT HOURS: 1

Definition
Pneumonia remains the seventh leading cause of death in the United States. As the US population ages, healthcare providers may encounter an increasing number of cases of aspiration pneumonia, both community-acquired and nosocomial infections. Awareness of this disease is important, because diagnosis is usually based on clinical findings and initial therapy is primarily empirical.

Aspiration pneumonia is caused by inhaling foreign material (usually food, liquids, vomit, or secretions from the mouth) into the lungs. This may lead to an inflammatory reaction, a lung infection (pneumonia), or a collection of pus in the lungs (lung abscess). Aspiration pneumonia is also known as anaerobic pneumonia; aspiration of vomitus; necrotizing pneumonia; aspiration pneumonitis or chemical pneumonitis.

Aspiration Pneumonitis
Aspiration pneumonitis represents chemical damage to the tracheobronchial tree. Such materials as mineral oil, hydrocarbons, and gastric acid may cause different patterns of injury. The most common clinical scenario is aspiration of gastric contents. Aspiration of low pH gastric secretions is associated with immediate injury to the tracheobronchial tree and lung parenchyma best likened to a “flash burn”.  Bronchoscopy in such cases shows diffuse bronchial erythema. The severity of lung injury is directly related to the pH of the aspirated material and is greatest when the pH is less than 2.5.

Because of the relative sterility of normal gastric contents, bacteria do not play an important role in the early stages of this disease. However, this does not hold true in patients with gastroparesis or small-bowel obstruction, or in those using antacids (PPI, H₂-receptor antagonists). Regardless of the bacterial load of the inoculum, bacterial superinfection may occur after the initial chemical injury.

Aspiration Pneumonia
Aspiration pneumonia results from chronic, usually unwitnessed, inhalation of small amounts of oropharyngeal contents, leading to an infectious process. Aspiration pneumonia is defined as the development of an infiltrate in a patient at increased risk of oropharyngeal aspiration. It occurs when a patient inhales material from the oropharynx that is colonized by upper airway flora.

Causative Organisms
Initial bacteriologic studies into the causative organisms of community-acquired aspiration pneumonia indicated the anaerobic species as the predominant pathogens. However, subsequent studies revealed that Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Enterobacteriaceae are the most common organisms implicated in community-acquired aspiration pneumonia. Hospital-acquired aspiration pneumonia, on the other hand, is often caused by gram-negative organisms, including Pseudomonas aeruginosa, particularly in intubated patients.

Risk Factors
Aspiration pneumonia most commonly occurs in individuals with chronically impaired airway defense mechanisms. Thus, any condition that reduces a patient’s gag reflex and/or ability to maintain an airway increases the risk of aspiration pneumonia or pneumonitis.

Risk factors for this disease include:

• Decreased level of consciousness (acute and chronic alcohol abuse; drug overdose; stroke; seizure; head trauma; anesthesia, including conscious sedation for upper gastrointestinal endoscopy)
• Isolated alteration of the swallowing reflex associated with pharyngeal disease
• Dysphagia (esophageal cancer, achalasia, tracheobronchial fistula, neurologic disorders)
• Gastroesophageal reflux
• Neurologic disease (stroke, amyotrophic lateral sclerosis, myasthenia gravis, multiple sclerosis, Parkinson’s disease)
• Mechanical and device-related impairment of upper aerodigestive tract (nasogastric and percutaneous feeding tubes, endotracheal tubes, tracheostomy)
• Vomiting
• Bronchial obstruction due to neoplasm or foreign body
• Bronchiectasis
• Pulmonary infarction

Other risk factors include poor dentition and poor oral care, both of which increase the bacterial burden of oropharyngeal secretions. Some studies indicate that aspiration pneumonia is more common in males than in females, and that it is also more prevalent in extremely young or old patients.

Frequency
The true incidence of aspiration pneumonia is unknown, because many cases of community-acquired and nosocomial pneumonia may be due to unrecognized aspiration. Also, few studies have been designed that distinguish between aspiration pneumonia and aspiration pneumonitis. However, several studies suggest that 5-15% of the estimated 4.5 million cases of community-acquired pneumonia in the United States per year result from aspiration pneumonia.

Aspiration pneumonia occurs most commonly in hospitalized and chronically institutionalized adults, particularly those with preexisting stroke, seizures, or other conditions that predispose to aspiration. In light of an increasing elderly population with many comorbid conditions predisposing to aspiration, the incidence of aspiration pneumonia among patients admitted to US hospitals is likely to rise. In addition, approximately 10% of patients who are hospitalized after drug overdoses will have an aspiration pneumonitis.  Internationally, aspiration pneumonia is considered a common disease, but no statistics are available.

Mortality/Morbidity
The mortality associated with aspiration pneumonia mimics that of community-acquired pneumonia: approximately 1% in the outpatient setting and up to 25% in those requiring hospitalization. This mortality range depends on complications of the disease.

The mortality rate for severe chemical pneumonitis (Mendelson syndrome) can be up to 70%.

Without treatment, aspiration pneumonia is associated with a high incidence of cavitation and abscess formation, in comparison to community-acquired pneumonia. Other complications of both aspiration pneumonia and pneumonitis include empyema, acute respiratory distress syndrome, and respiratory failure. Aspiration pneumonitis can rapidly progress to respiratory failure.

Symptoms
Symptoms of aspiration pneumonia include: Fever, fatigue, cough (with greenish or foul-smelling sputum or sputum containing pus or blood), chest pain, shortness of breath, bluish discoloration of the skin caused by lack of oxygen, rapid pulse (heart rate) and wheezing. Additional symptoms that may be associated with this disease include excessive sweating, difficulty swallowing and breath odor.

Diagnosis
The clinical presentation in both aspiration pneumonitis and pneumonia ranges from mildly ill and ambulating to critically ill with signs and symptoms of septic shock and/or respiratory failure. There are no specific diagnostic tests for aspiration pneumonia. Clinicians must surmise this diagnosis when a patient presents with risk factors and radiographic evidence of an infiltrate suggestive of aspiration pneumonia. The location of the infiltrate on chest radiograph depends on the position of the patient when the aspiration occurred.

The diagnosis is usually based on new findings of hypoxemia, pulmonary infiltrates in gravity-dependent lung regions, fever, and leukocytosis after an observed or suspected episode of vomiting or regurgitation in a patient at risk for aspiration. Most affected patients are febrile and tachypneic. Rales are present in about two thirds of patients, and cough, wheezing, or cyanosis is seen in one third.

Most patients with aspiration pneumonia are treated in the absence of a specific microbiologic diagnosis. The main barriers to establishing such a diagnosis are the difficulty in obtaining specimens of deep respiratory tract secretions without contamination by oral flora and the limited laboratory capacity for isolation of anaerobic organisms. Expectorated sputum is not a valid specimen for anaerobic culture because it is invariably contaminated with oral flora. However, sputum should be examined by Gram stain and culture for aerobic pathogens.

Physical Examination
Physical examination findings vary, depending on the severity of the disease, the presence of complications and host factors. Patients with aspiration pneumonitis secondary to seizure, head trauma, or drug overdose should be inspected for signs related to these processes. Both aspiration pneumonia and pneumonitis can present with the following:

• Fever or hypothermia
• Tachypnea
• Tachycardia
• Decreased breath sounds
• Dullness to percussion over areas of consolidation
• Rales
• Egophony and pectoriloquy
• Decreased breath sounds
• Pleural friction rub
• Altered mental status
• Hypoxemia
• Hypotension (in septic shock)

In addition, patients may exhibit signs associated with the underlying disease that led to their aspiration.

Signs and Tests
Physical examination may reveal crackling sounds in the lungs. Tests which can help diagnose this condition include:

• Chest X-ray
• Sputum culture
• CBC
• Blood culture
• Bronchoscopy
• Swallowing studies
• CT scan of the chest

Lab Studies
The lab studies obtained should be guided by the clinical presentation. Patients with signs or symptoms of sepsis or septic shock require further lab testing than those with uncomplicated aspiration syndromes. The following lab tests are useful in both aspiration pneumonia and pneumonitis.

• Complete blood count with differential
• Determine white count as marker of possible infection.
• Determine band count; a left shift further supports the diagnosis of bacterial pneumonia.
• Determine baseline hemoglobin/hematocrit and platelets for further management.
• Basic metabolic panel
• Serum electrolytes, BUN, and creatinine can be used to assess fluid status and the need for intravenous hydration. This is especially important in patients presenting with fever, vomiting, or diarrhea that may have significant fluid loss.
• Serum BUN and creatinine can also be used to assess renal function in order to appropriately dose antibiotics. In addition, these values can be used to assess end-organ damage in patients who present with sepsis or septic shock.
• Arterial blood gas
  • Arterial blood gas is used to assess oxygenation and adds information to guiding oxygen supplementation.
  • Assess the patient’s pH status.
  • Lactate (often included with blood gases) can be used as an early marker of severe sepsis or septic shock.
• Mixed venous gas
  • This should be obtained in any patient in whom septic shock is suspected.
  • Decreased mixed venous oxygen saturation is a marker for septic shock.
• Blood cultures
  • Baseline screening for bacteremia
  • In uncomplicated pneumonia (no signs of sepsis or septic shock), blood cultures have a low yield and are not necessary for initial management and treatment.
• Sputum culture and Gram stain - Generally not helpful in initial diagnosis or treatment

Imaging Studies

A chest radiograph - PA and lateral – is used to locate any infiltrate. The right middle and lower lung lobes are the most common sites of infiltrate formation, due to the larger caliber and more vertical orientation of the right main stem bronchus.

Patients who aspirate while standing can have bilateral lower lung lobe infiltrates.

Patients lying in the left lateral decubitus position are more likely to have left-sided infiltrates. The right upper lobe is a common area of consolidation in alcoholics who aspirate in the prone position.

The presence of pleural effusion may indicate the need to perform thoracentesis to rule out empyema. A chest CT is not usually necessary on an emergent basis, although in the presence of pleural effusion or empyema, it may aid in further characterization of the infiltrate.

Treatment
Treatment varies, depending on the severity of the pneumonia. Some patients may require hospitalization. Antibiotics may be administered, with patients receiving special antibiotics that specifically treat organisms that live in the mouth. The types of organisms present depend on the patient’s health and location (private residence or chronic nursing facility, for instance). The antibiotics of choice should be tailored to the setting in which the aspiration occurred (community vs. nosocomial); however, antibiotic agents with activity against gram-negative organisms as well as gram-positive organisms is usually required.

Patients may need to have their swallowing function assessed. If they have trouble swallowing, patients may need to use other feeding methods.

Prehospital Care
Prehospital care should focus on stabilizing the patient’s airway, breathing, and circulation.

• In patients found with signs of gastric aspiration (i.e., vomitus) suctioning of the upper airway may remove a significant amount of aspirate or potential aspirate.
• Intubation should be considered in any patient who is unable to protect his or her airway. The ability of paramedics to provide this intervention depends on their level of training. In addition, EMTs trained in intubation may choose to intubate patients with poor gag reflex prior to aspiration.
• Oxygen supplementation.
• Cardiac monitoring and pulse oximetry.
• Intravenous catheter placement and intravenous fluids as indicated.

Emergency Department Care
Emergency department care should start with stabilizing the patient’s airway, breathing, and circulation.

• Oropharyngeal/tracheal suctioning may be indicated to further remove aspirate.
• Reassess the need for intubation on a frequent basis, depending on oxygenation, patient’s mental status, signs of increased work of breathing, or impending respiratory failure.
• Continue supplemental oxygenation as needed.
• Continue cardiac monitoring and pulse oximetry.
• Provide continued supportive care with intravenous fluids and electrolyte replacement.
• Antibiotic therapy:
  • Aspiration pneumonia: Always indicated
  • Aspiration pneumonitis:
    • Prophylactic antibiotics are not recommended in most cases.
    • In addition, those patients with recent aspiration, fever, and leukocytosis should not be treated, even in the presence of a pulmonary infiltrate, due to the risk of development of resistant organisms.
    • When to use antibiotics: (1) Pneumonitis fails to resolve within 48 hours. (2) Patients with small bowel obstruction – lower bacteria may colonize gastric contents. (3) Antibiotics should be considered for patients on antacids due to the potential for gastric colonization.
  • Corticosteroids
    • Historically, corticosteroids have been used in the treatment of aspiration pneumonitis, but randomized control studies have been unable to demonstrate a benefit to using high-dose corticosteroids.
    • Patients with septic shock requiring vasoactive substances to maintain blood pressure should receive stress-dose steroids.

Consultations
A pulmonary/critical care specialist may be consulted in severe cases of respiratory failure requiring ventilatory support. An infectious disease specialist may advise regarding proper antibiotic therapy.

Complications
Complications of aspiration pneumonia include:

• Spread of infection to the bloodstream (bacteremia)
• Spread of infection to other areas of the body
• Low blood pressure
• Shock
• Acute respiratory distress syndrome
• Pneumonia with lung abscess

Prognosis
The outcome depends on the severity of the pneumonia, the type of organism and the extent of lung involvement. If acute respiratory failure develops, the patient may have a prolonged illness or die.

Prevention
Aspiration pneumonia is a potentially preventable illness, requiring attention to the small details of patient care. Elevation of the head of the bed, using gravity to prevent reflux and aspiration of gastric contents, is an important safety measure. High-risk patients should be fed in the sitting position and not placed supine until 1 to 2 hours after meals. Dental prophylaxis and good oral hygiene are also important. Nonrestorable teeth are a nidus for pathogenic bacilli and should be extracted.

Feeding tubes should be managed properly. The position of oral feeding tubes should be monitored, because they can easily become displaced over time. The position of small-bore nasogastric tubes should be confirmed by radiography after reinsertion or repositioning. The residual volume of tube feedings in the stomach should be monitored, and tube feedings should be held if the residual volume exceeds 50 mL. There is no evidence that prophylactic antibiotic therapy after a recognized episode of aspiration prevents the subsequent development of bacterial pneumonia; rather, it may select for resistant organisms.

Summary
Gross aspiration of liquid or particulate matter into the lung can result in severe hypoxemia, pulmonary infiltrates in dependent lung regions, fever, and leukocytosis. The initial lung injury is primarily due to inflammatory mediators rather than infection. The responsible bacterial pathogens differ between community-acquired and nosocomial aspiration pneumonia.Many aspiration pneumonias are mixed aerobic-anaerobic infections. Enteric gram-negative bacilli and S aureus are more common in nosocomial aspiration pneumonia.

Current treatment guidelines support initial empirical antibiotic therapy in patients with severe aspiration pneumonia pending culture results. Appropriate initial treatment improves outcome. Antimicrobial therapy for aspiration pneumonia is often empirical, and should be based on patient characteristics, the setting in which aspiration occurred, the severity of the pneumonia, and available information regarding local pathogens and resistance patterns.

REFERENCES

Akritidis, N., Gousis, C., Dimos, G: Fever, cough, and bilateral lung infiltrates. Achalasia associated with aspiration pneumonia. Chest 2003 Feb; 123(2): 608-12.

Bartlett, J.G. Pneumonia: Management of respiratory tract infections, 2^nd ed. (1999) Lippincott Williams & Wilkins, Philadelphia, PA.

Campbell, G.D., Niederman, M.S., Broughton, W.A., et al. Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventive strategies. A consensus statement. American Thoracic Society, November 1995. Am J Respir Crit Care Med 1996;153(5):1711-25.

Drakulovic, M.B., Torres, A., Bauer, T.T., et al: Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999 Nov 27; 354(9193): 1851-8.

Ferri, F.F. Ferri’s Clinical Advisor (2007), 1^st ed. Mosby, Philadelphia, PA..

Goldman, L., Ausiello, D. Cecil Textbook of Medicine, 22^nd ed. (2003). Saunders, Philadelphia, PA.

Marik, P.E., Careau, P: The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study. Chest 1999 Jan; 115(1): 178-83.

Marik, P.E. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001;344(9):665-71.

Marom, E.M., McAdams, H.P., Erasmus, J.J: The many faces of pulmonary aspiration. AJR Am J Roentgenol 1999 Jan; 172(1): 121-8.

Marx, J.S., Hockberger, R.S., Walls, R.M., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5^th ed. (2002). Mosby, St. Louis, MO.

Russell, S.L., Boylan, R.J., Kaslick, R.S., et al. Respiratory pathogen colonization of the dental plaque of institutionalized elders. Spec Care Dentist 1999;19(3):128-34.

Sasaki, H., Sekizawa, K., Yanai, M: New strategies for aspiration pneumonia. Intern Med 1997 Dec; 36(12): 851-5.

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Modes of Transmission of HIV

Research has revealed a great deal of valuable medical, scientific, and public health information about the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). The ways in which HIV can be transmitted have been clearly identified. Unfortunately, false information or statements that are not supported by scientific findings continue to be shared widely through the Internet and the popular press. Therefore, the Centers for Disease Control and Prevention (CDC) has prepared a fact sheet to correct a few misperceptions about HIV.

How HIV Is Transmitted

HIV is spread by sexual contact with an infected person, by sharing needles and/or syringes (primarily for drug injection) with someone who is infected, or, less commonly (and now very rarely in countries where blood is screened for HIV antibodies), through transfusions of infected blood or blood clotting factors. Babies born to HIV-infected women may become infected before or during birth or through breastfeeding after birth.

How Does Mother-to-Child HIV Transmission Occur?

Mother-to-child transmission (MTCT) of HIV, also called perinatal or vertical transmission, occurs when HIV is spread from an HIV+ woman to her baby during pregnancy, labor and delivery or breastfeeding. For an HIV+ woman not being treated for HIV, the chance of passing the virus to her child is about 25% during pregnancy, labor and delivery. Breastfeeding increases the risk of transmission by an additional 12%.

In 2005, around 700,000 children under 15 became infected with HIV, mainly through mother to child transmission. About 90% of these MTCT infections occurred in Africa, where AIDS is beginning to reverse decades of steady progress in child survival. In high-income countries, MTCT has been virtually eliminated, thanks to effective voluntary testing and counseling, access to antiretroviral therapy, safe delivery practices, and the widespread availability and safe use of breast-milk substitutes. If these interventions were used worldwide, they could save the lives of thousands of children each year.

Can MTCT be reduced?

Yes. Advances in treatment and new classes of drugs have provided the opportunity to greatly reduce rates of MTCT worldwide. However, these advances have not made their way to developing countries to the extent that is needed, and we have still not addressed the root cause of MTCT, mainly heterosexual HIV transmission. The best way to prevent MTCT is to prevent HIV transmission in the mother and father.

In order to reduce MTCT, all pregnant women should have access to free or low-cost prenatal care and voluntary HIV testing and counseling. If a pregnant woman is HIV+, she should have access to antiretroviral treatment, both to treat HIV and improve her own health, and to decrease the chances of HIV infection in her infant. Treatment options for preventing MTCT include giving antiretroviral drugs to the mother after the first trimester of pregnancy and during labor, and to her infant for the first six weeks of life. In the US, these drug regimens have dramatically reduced the chance of transmission, from about 25% to 4-10% for women who did not breastfeed.

MTCT can be further reduced to less than 2% if a woman is on antiretroviral drugs, has a low viral load, follows the recommended MTCT treatment regimen and does not breastfeed. However, little is known about the long-term impact of these drugs on the child. Taking greater care during labor and delivery can also help reduce MTCT; for example, by not artificially rupturing membranes or doing routine episiotomies, and by providing cesarean delivery when indicated.

HIV Transmission in the Healthcare Setting

In the health care setting, workers have been infected with HIV after being stuck with needles containing HIV-infected blood or, less frequently, after infected blood gets into a worker’s open cut or a mucous membrane (for example, the eyes or inside of the nose). There has been only one instance of patients being infected by a health care worker in the United States; this involved HIV transmission from one infected dentist to six patients. Investigations completed the review of more than 22,000 patients of 63 HIV-infected physicians, surgeons, and dentists, and no other cases of this type of transmission have been identified in the United States.

Some people fear that HIV might be transmitted in other ways; however, no scientific evidence to support any of these fears has been found. If HIV were being transmitted through other routes (such as through air, water, or insects), the pattern of reported AIDS cases would be much different from what has been observed. For example, if mosquitoes could transmit HIV infection, many more young children and preadolescents would have been diagnosed with AIDS.

All reported cases suggesting new or potentially unknown routes of transmission are thoroughly investigated by state and local health departments with the assistance, guidance, and laboratory support from CDC. No additional routes of transmission have been recorded, despite a national sentinel system designed to detect just such an occurrence. The following paragraphs specifically address some of the common misperceptions about HIV transmission.

HIV in the Environment

Scientists and medical authorities agree that HIV does not survive well in the environment, making the possibility of environmental transmission remote. HIV is found in varying concentrations in blood, semen, vaginal fluid, breast milk, saliva, and tears. To obtain data on the survival of HIV, laboratory studies have required the use of artificially high concentrations of laboratory-grown virus. Although these unnatural concentrations of HIV can be kept alive for days or even weeks under precisely controlled and limited laboratory conditions, CDC studies have shown that drying of even these high concentrations of HIV reduces the amount of infectious virus by 90 to 99 percent within several hours. Since the HIV concentrations used in laboratory studies are much higher than those actually found in blood or other specimens, drying of HIV-infected human blood or other body fluids reduces the theoretical risk of environmental transmission to that which has been observed–essentially zero.

Results from laboratory studies should not be used to assess specific personal risk of infection because (1) the amount of virus studied is not found in human specimens or elsewhere in nature, and (2) no one has been identified as infected with HIV due to contact with an environmental surface. Additionally, HIV is unable to reproduce outside its living host (unlike many bacteria or fungi, which may do so under suitable conditions), except under laboratory conditions; therefore, it does not spread or maintain infectiousness outside its host.

Households

Although HIV has been transmitted between family members in a household setting, this type of transmission is very rare. These transmissions are believed to have resulted from contact between skin or mucous membranes and infected blood. To prevent even such rare occurrences, precautions, as described in previously published guidelines, should be taken in all settings, including the home, to prevent exposures to the blood of persons who are HIV-infected, at risk for HIV infection, or whose infection and risk status are unknown. For example,

Businesses and Other Settings

There is no known risk of HIV transmission to co-workers, clients, or consumers from contact in industries such as food-service establishments (see information on survival of HIV in the environment). Food-service workers known to be infected with HIV need not be restricted from work unless they have other infections or illnesses (such as diarrhea or hepatitis A) for which any food-service worker, regardless of HIV infection status, should be restricted. The CDC recommends that all food-service workers follow recommended standards and practices of good personal hygiene and food sanitation.

In 1985, the CDC issued routine precautions that all personal-service workers (such as hairdressers, barbers, cosmetologists, and massage therapists) should follow, even though there is no evidence of transmission from a personal-service worker to a client or vice versa. Instruments that are intended to penetrate the skin (such as tattooing and acupuncture needles, ear piercing devices) should be used once and disposed of or thoroughly cleaned and sterilized. Instruments not intended to penetrate the skin but which may become contaminated with blood (for example, razors) should be used for only one client and disposed of or thoroughly cleaned and disinfected after each use. Personal-service workers can use the same cleaning procedures that are recommended for health care institutions.

The CDC knows of no instances of HIV transmission through tattooing or body piercing, although the hepatitis B virus has been transmitted during some of these practices. One case of HIV transmission from acupuncture has been documented. Body piercing (other than ear piercing) is relatively new in the United States, and the medical complications for body piercing appear to be greater than for tattoos. Healing of piercings generally takes weeks, and sometimes even months, and the pierced tissue could conceivably be abraded (torn or cut) or inflamed even after healing. Therefore, a theoretical HIV transmission risk does exist if the unhealed or abraded tissues come into contact with an infected person’s blood or other infectious body fluid. Additionally, HIV could be transmitted if instruments contaminated with blood are not sterilized or disinfected between clients.

Kissing
Casual contact through closed-mouth or “social” kissing is not a risk for transmission of HIV. Because of the potential for contact with blood during “French” or open-mouth kissing, the CDC recommends against engaging in this activity with a person known to be infected. However, the risk of acquiring HIV during open-mouth kissing is believed to be very low. CDC has investigated only one case of HIV infection that may be attributed to contact with blood during open-mouth kissing.

Biting
In 1997, the CDC published findings from a state health department investigation of an incident that suggested blood-to-blood transmission of HIV by a human bite. There have been other reports in the medical literature in which HIV appeared to have been transmitted by a bite. Severe trauma with extensive tissue tearing and damage and presence of blood were reported in each of these instances. Biting is not a common way of transmitting HIV. In fact, there are numerous reports of bites that did not result in HIV infection.

Saliva, Tears, and Sweat
HIV has been found in saliva and tears in very low quantities from some AIDS patients. It is important to understand that finding a small amount of HIV in a body fluid does not necessarily mean that HIV can be transmitted by that body fluid. HIV has not been recovered from the sweat of HIV-infected persons. Contact with saliva, tears, or sweat has never been shown to result in transmission of HIV.

Insects
From the onset of the HIV epidemic, there has been concern about transmission of the virus by biting and bloodsucking insects. However, studies conducted by researchers at CDC and elsewhere have shown no evidence of HIV transmission through insects–even in areas where there are many cases of AIDS and large populations of insects such as mosquitoes. Lack of such outbreaks, despite intense efforts to detect them, supports the conclusion that HIV is not transmitted by insects.

The results of experiments and observations of insect biting behavior indicate that when an insect bites a person, it does not inject its own or a previously bitten person’s or animal’s blood into the next person bitten. Rather, it injects saliva, which acts as a lubricant or anticoagulant so the insect can feed efficiently. Such diseases as yellow fever and malaria are transmitted through the saliva of specific species of mosquitoes. However, HIV lives for only a short time inside an insect and, unlike organisms that are transmitted via insect bites, HIV does not reproduce (and does not survive) in insects. Thus, even if the virus enters a mosquito or another sucking or biting insect, the insect does not become infected and cannot transmit HIV to the next human it feeds on or bites. HIV is not found in insect feces.

There is also no reason to fear that a biting or bloodsucking insect, such as a mosquito, could transmit HIV from one person to another through HIV-infected blood left on its mouthparts. Two factors serve to explain why this is so–first, infected people do not have constant, high levels of HIV in their bloodstreams, and, second, insect mouth parts do not retain large amounts of blood on their surfaces. Further, scientists who study insects have determined that biting insects normally do not travel from one person to the next immediately after ingesting blood. Rather, they fly to a resting place to digest this blood meal.

Infection Control
All healthcare workers and those at risk for occupational exposure should practice standard Universal Precautions. Hand washing, an integral part of infection control, is recommended before and after any possible exposure to blood or other body fluids. The CDC recommends 10 - 15 seconds of vigorous scrubbing with a bactericidal agent. After proper hand washing, personal protective equipment should be worn to prevent contact with any body fluids. Finally, any personal protective equipment or infectious waste should be disposed of in proper biohazardous warning label bags

Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents

The availability of an increasing number of antiretroviral agents and the rapid evolution of new information has introduced substantial complexity into treatment regimens for persons infected with human immunodeficiency virus (HIV). In 1996, the Department of Health and Human Services and the Henry J. Kaiser Family Foundation convened the Panel on Clinical Practices for the Treatment of HIV to develop guidelines for clinical management of HIV-infected adults and adolescents (CDC Report of the NIH Panel To Define Principles of Therapy of HIV Infection and Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. MMWR 1998;47[RR-5]:1-41). The following issues were discussed:

•  Using testing for Plasma HIV ribonucleic acid levels (i.e., viral load) and CD4 + T cell count;

•  Using testing for antiretroviral drug resistance;

•  Considerations for when to initiate therapy;

•  Adherence to antiretroviral therapy;

•  Considerations for therapy in antiretroviral naïve patients;

•  Therapy-related adverse events;

•  Interruption of therapy;

•  Considerations for changing therapy and available therapeutic options;

•  Treatment for acute HIV infection;

•  Considerations for antiretroviral therapy among adolescents;

•  Considerations for antiretroviral therapy among pregnant women; and

•  Concerns related to transmission of HIV to others.

Antiretroviral regimens are complex, have serious side effects, pose difficulty with adherence, and carry serious potential consequences, such as the development of viral resistance because of non-adherence to the drug regimen of antiretroviral agents. Patient education and involvement in therapeutic decisions is critical. Treatment should usually be offered to all patients with symptoms ascribed to HIV infection. Recommendations for offering antiretroviral therapy among asymptomatic patients require analysis of real and potential risks and benefits. Treatment should be offered to persons who have < 350 CD4 + T cells/mm 3 or Plasma HIV ribonucleic acid (RNA) levels of > 55,000 copies/mL (by b-deoxyribonucleic acid [bDNA] or reverse transcriptase-polymerase chain reaction [RT-PCR] assays). The recommendation to treat asymptomatic patients should be based on the willingness and readiness of the person to begin therapy; the degree of existing immunodeficiency as determined by the CD4 + T cell count; the risk for disease progression as determined by the CD4 + T cell count and level of Plasma HIV RNA; the potential benefits and risks of initiating therapy in an asymptomatic person; and the likelihood, after counseling and education, of adherence to the prescribed treatment regimen.

Treatment goals should be maximal and durable suppression of viral load, restoration and preservation of immunologic function, improvement of quality of life, and reduction of HIV-related morbidity and mortality. Results of therapy are evaluated through plasma HIV RNA levels, which are expected to indicate a 1.0 log10 decrease at 2-8 weeks and no detectable virus (< 50 copies/mL) at 4-6 months after treatment initiation. Failure of therapy at 4-6 months might be ascribed to non-adherence, inadequate potency of drugs or sub-optimal levels of antiretroviral agents, viral resistance, and other factors that are poorly understood. Patients whose therapy fails in spite of a high level of adherence to the regimen should have their regimen changed; this change should be guided by a thorough drug treatment history and the results of drug-resistance testing. Because of limitations in the available alternative antiretroviral regimens that have documented efficacy, optimal changes in therapy might be difficult to achieve for patients in whom the preferred regimen has failed. These decisions are further confounded by problems with adherence, toxicity, and resistance. For certain patients, participating in a clinical trial with or without access to new drugs or using a regimen that might not achieve complete suppression of viral replication might be preferable.

There are 3 primary classifications of medications used as antiretrovirals to suppress the replication of HIV. The following lists the name of each approved drug including the potential adverse effects of the medication.

Nucleoside Analogs (Antiretroviral medications):

These drugs incorporate themselves into the enzyme that helps the virus to copy itself, thereby stopping the building process. HIV rapidly develops resistance to more drugs when used individually, so current standards require that they be used in combination with one another.

•  Zidovudine (AZT): FDA approval in 1987. Side effects include headaches, fever, chills, muscle soreness, fatigue, anemia, nausea, and fingernail discoloration.

•  Didanosine (ddI): FDA approval in 1991. Side effects include tingling, burning, numbness/pain in hands or feet, visual impairment, headaches, insomnia, diarrhea, and pancreatitis.

•  Zalcitabine (ddC): FDA approval in 1992. Side effects include chest pain, nausea, fever, rash, mouth sores, and headaches.

•  Stavudine (d4T): FDA approval 1994. Side effects include headaches, nausea, and peripheral neuropathy. This drug is tolerated the best.

•  Lamivudine (3TC): FDA approval in 1995. Side effects include headache, nausea, malaise, fatigue, runny nose, diarrhea, and anemia.

•  Abacavir: FDA approval in 1998. Side effects include headache, nausea, vomiting, malaise, and diarrhea. Clinical note: There have also been severe allergic reactions caused by abacavir. If an allergic reaction is noted, the drug should never be given again, as this may lead to anaphylactic shock and possible death.

•  Combivir: Combination of 3TC and AZT.

Protease Inhibitors:

First introduced in 1995, these drugs work at the last stage of the virus replication cycle by preventing HIV from being successfully assembled and released from the infected T cell.

•  Invirase (Saquinavir Mesylate): Used in combination with Norvir. Side effects include diarrhea, mouth sores, and abdominal discomfort.

•  Norvir (Ritonavir): Side effects include diarrhea, nausea, fatigue, and peripheral and circumoral numbness.

•  Crixivan (Indinavir): Used in combination with Combivir, 80% of patients are maintaining undetectable viral loads for two years or more. Side effects include kidney stones, chapped lips, headaches, and nausea.

•  Viracept (Nelfinavir): Relatively new, early studies show success similar to Crixivan. The main side effect is diarrhea and it is well tolerated by patients.

•  Agenerase (Amprenavir): Approved by the FDA in 1999, this drug can cause life-threatening skin reactions, including blisters. Other side effects include nausea, vomiting, and diarrhea.

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI):

First approved by the FDA in 1996, these drugs prevent the conversion of RNA into DNA inside the infected T cell, thus helping to prevent the virus from multiplying.

•  Viramune (Nevirapine or NVP): Side effects include headaches, nausea, and rash.

•  Rescriptor (Delavirdine): Side effects include headaches, nausea, diarrhea, rash, and fatigue.

•  Sustiva (Efavirenz): Side effects are mild and include rash and mood changes.

Entry-inhibitors (Fuzeon): A new class of drug approved only for compassionate use. Fuzeon binds to a protein on HIV’s surface called gp41. Once it does this, HIV cannot successfully bind with the surface of T-cells, thus preventing the virus from infecting healthy cells. Fuzeon will most likely need to be used in combination with other anti-HIV drugs. Because of its fragile structure (it is a peptide), Fuzeon cannot be taken by mouth. It is currently given in an injectable form and requires two shots a day: one in the morning and one 12 hours later at night. Each shot contains 90mg of Fuzeon. Small hypodermic needles, similar to those used by diabetics to inject insulin, are used.

Fuzeon holds promise for HIV-positive patients who have taken (and failed) numerous anti-HIV drugs in the past. Because Fuzeon targets HIV differently than currently available drugs, chances are that most people living with the virus, regardless of the medications they have taken in the past, will likely benefit from using Fuzeon. Two large clinical trials have determined that Fuzeon, when combined with other drugs, is effective for patients who have failed other anti-HIV drugs in the past. However, Fuzeon worked best when it was combined with at least two other drugs that the virus was sensitive to (patients who used Fuzeon in combination with drugs that their virus was highly resistant to did not experience decreases in their viral load for very long). In this way, it is best to use drug-resistance testing to determine which drugs your virus is sensitive to and to use the results of testing to figure out which are the best anti-HIV drugs to combine with Fuzeon.

Skin irritation (e.g., itchiness and swelling) at the site where Fuzeon is injected has been the most common side effect reported in studies. Less than 5% of patients taking Fuzeon have stopped injections of this drug because of this skin irritation. Other side effects may also occur, including fatigue, insomnia, and peripheral neuropathy.

Prevention of HIV

Sexual Behaviors:

If a person does not engage in any sexual activities, then that person has no risk of sexual transmission of HIV. However, for those people who are sexually active, the following options are available. “Safer sex” includes mutual monogamy, latex condoms, female condoms (also made of latex) and polyurethane condoms, which, because of their composition, are much stronger and thinner, thus aiding in compliance. Latex square (dental dam) is recommended for oral-genital contact male to female or female to female.

Illicit Drug Use:

Non-injecting drug use, while not a direct risk factor for HIV transmission, may lead to risky behaviors that might not be committed if the person was not using recreational drugs. Alcohol can have a similar effect. Judgment is impaired and inhibitions are reduced, potentially leading to unprotected sex or increases in the number of sexual partners.

The use of intravenous drugs and the behavior of sharing needles is another mode of transmission of HIV. The best method to prevent HIV transmission among I.V. drug users is to get them off the drugs and into a substance abuse program. The second best method is to get them to not share needles. Studies have show that needle-exchange programs reduce the incidence of HIV, while not encouraging the use of illegal drugs. The DOH supports the use of these programs, but they are currently illegal in the state of Florida. The third best method to prevent HIV transmission among I.V. drug users is to get them to clean their needles and syringes with bleach. It is important to rinse them with water once the bleach is used, because injecting bleach into the veins can be more deadly than HIV.

The Florida AIDS Law:

Statute 381 addresses most of Florida’s AIDS law with most of the accompanying rules in Chapter 64D-2 of the Florida Administrative Code.

Highlights of the Law Include:

Confidentiality : As with any personal medical record information, results of HIV testing and treatment are confidential (384.29, F.S.). Healthcare providers have a “need to know” as defined in Rule 64D-2.003(2)(d)3.

Discrimination : It is against the law to discriminate against persons on the basis of HIV or AIDS status (381.004, F.S.)

Informed Consent : Written consent must be obtained before an HIV test can be performed. Exceptions to this include convicted prostitutes and their solicitors, after sexual battery where a blood sample has been taken from the defendant, persons desiring to immigrate to the U.S., persons desiring to enlist in the military, and medical personnel who receive a significant exposure to blood or OPIM on the job.

Partner Notification : Florida Statute 456.061 provides that a medical practitioner, acting reasonably and in good faith, shall not be civilly or criminally liable for advising the sex or needle-sharing partner of an HIV-infected patient of a positive test, when done in accordance with the following protocol:

•  Without being asked, the patient discloses the identity of such partners.

•  The practitioner recommends the patient avoid any sexual or needle-sharing activities.

•  The patient refuses to inform the sex or needle-sharing partner of a positive test result and the practitioner informs the patient of his/her intent to inform the partners. Ideally, such notifications shall be done face-to-face and the practitioner may choose not to disclose the name of the infected patient.

•  The practitioner shall not disclose the identity of the partner to anyone else.

Insurance Companies : May not discriminate due to sexual orientation in underwriting policies. They cannot cancel or refuse to renew a policy due to HIV/AIDS.

Noncompliant Carriers : It is against the law for HIV-infected individuals to have sex or share drug needles with others without first informing them of their HIV status. (384.24, F.S.) This law also includes the following sexually transmitted diseases:

•  Chancroid

•  Gonorrhea

•  Granuloma inguinale

•  Lymphogranuloma venereum

•  Genital herpes simplex

•  Chlamydia

•  Nongonococcal urethritis

•  Pelvic inflammatory disease

•  Acute salpingitis

•  Syphilis

Minors’ Consent : Parental consent for the examination and treatment of HIV infected minors is not required (384.30, F.S.).

Pregnant Women : Testing for HIV infection shall be offered to each pregnant woman. If she objects to HIV testing, an attempt must be made to obtain a written statement of objection, signed by the patient and placed in the medical record (384.31, F.S.).

State and Federally Funded Programs for People with HIV/AIDS

Ryan White Comprehensive AIDS Resources Emergency Act of 1990:

•  Project AIDS Care: This provides eligible individuals with outpatient services, such as home delivery of meals and adaptive equipment and home health care.

•  AIDS Drug Assistance Program: Assistance for AIDS-related pharmaceuticals is provided through Florida’s county health departments.