THE LNC NEWSLETTER
Patient Safety: Restraint Standards
March 2004 Maggie Driscoll RN,BSN,CCRN,CLNC
Volume 3, Issue 6 Restraints as Deterrents to Falls and Injury local levels.
The use of physical and chemical restraints All hospitals and healthcare facilities
has long been accepted as standard practice when receiving Medicare and Medicaid reimbursement
Inside this issue: aimed at preventing falls and injuries in hospitalized must comply with specific standards outlined by
patients and long-term care residents. However, the Health Care Financing Administration (HCFA,
recent studies have demonstrated that restraints do now known as Centers for Medicare and Medicaid
Case Managers not necessarily prevent injuries. In fact, physical Services) and The Joint Commission of
as LNCs 3 restraint use has been associated with such adverse Accreditation of Healthcare Organizations
Not Everything outcomes as pressure sores, strangulation deaths, (JCAHO). Restraint care may also be guided by
Green is Irish 4 decreased mobility, increased agitation and state code such as in North Carolina
in March, OR: depression. Often there is no increase in serious Administrative Code, Section 3302R: “The patient
Mold, Friend or injury when physical restraints are replaced with has the right to medical and nursing treatment that
Foe? other less restrictive safety measures based on the avoids unnecessary physical and mental
The Unasked 5 individual's specific needs. A restrained patient who discomfort”.
Question falls is more likely to sustain a more serious injury The Joint Commission of Accreditation of
than one who falls while unrestrained. Healthcare Organizations defines physical
Restraint Standards restraints as “any manual method of physically
Rising concerns over injury, death, loss of restricting the patient’s movement, or normal
dignity and independence among restrained patients access to his/her body, material, or other
in both long-term and acute care facilities prompted equipment, attached or adjacent to the patient’s
regulatory agencies to define the standards of care. body that (s)he cannot easily remove.”
Restraint standards span across national, state and Cont on p. 2
What you always Wanted to Know about Medicare Set Asides but Were Afraid
Pattie Patterson RN, LNCC, Life Care Planner, MSA Allocator
Medicare Set Aside (MSA) actually affects not only compliant with its terms, there is no danger of CMS refusing to pay
worker’s comp injuries but motor vehicle accidents and personal if, for some unforeseen circumstance, the funds are exhausted before
injuries, i.e. injuries involving liability insurance, no-fault the end of the beneficiary’s life.
insurance and uninsured motorist insurance, but in this article I Criteria for Submitting a Claim to CMS
will be speaking only to the worker’s comp injuries, just to not There are two classifications for submitting to CMS
confuse the article, although the others have the same criteria for • Class I - The individual is a Medicare beneficiary at the time of
submission to CMS (Center for Medicare and Medicaid the settlement regardless of the amount of the settlement.
Services). • Class II – The individual is not currently a Medicare beneficiary
In 1980 the Medicare Secondary Payer (MSP) statute at the time of the settlement but:
was created as part of the Omnibus Reconciliation Act (OBRA) o The total amount of the settlement is over $250,000.00
to ensure that Medicare was only secondarily responsible for (including attorney fees and costs) and
payment of medical expenses for persons covered by Medicare o There is a reasonable expectation of Medicare enrollment
who were also covered by another type of private insurance. within 30 months of the settlement date. This can be a
This means if a worker is injured in a work related accident and reasonable expectation if the individual:
this same worker meets certain criteria, then the settlement must Is 62 ½ years of age.
be approved by CMS in order to assure that CMS’s interests are Has applied for SSD (Social Security Disability) benefits.
being served. The individual was denied SSD benefits but anticipates
What Exactly is a MSA? appealing.
MSA is a designated amount of the entire settlement Is in the process of appealing or refilling.
that is set aside to pay for medical services and/or supplies that Has end stage renal disease and is not yet on Medicare.
would normally be paid by Medicare were it not for the For any client who falls within these criteria, a claim must
insurance involvement. These allocated funds are to be used to be filed to CMS for approval before you settle the case, or it could
pay only the items that would normally be paid by Medicare. As back and bite you and/or your client later on down the line.
long as Medicare approves the amount and the beneficiary is Cont on p. 3
Volume 3, Issue 6 Page 2
Patient Safety: Restraint Standards
Continued from page 1
Under JCAHO guidelines, healthcare aggressive and the least restrictive method to physical and chemical restraints.
facilities are required to determine their to assure patient safety and/or the safety Alternatives may include the
own systematic approach for restraint use. of others is a restraint. A registered nurse following interventions:
Because restraints are considered a form may initiate the restraint, but a physician environmental modification, limiting
of medical treatment, they can only be must make a face-to-face assessment physical accessibility to lines and
used under the direction of a physician. In within one-hour of the initiation of the tubes, pain relief, reality orientation,
ordering the use of restraints, the restraint. Chemical restraints are also anticipation of toileting and hydration
physician must specify the medical reason considered restraints for the purposes of needs, distraction, and physiological
for using the device (i.e., confusion, behavioral management. A drug is used assessment of factors contributing to
prevention of removal of tubes and lines), as a restraint when it is used to control confusion.
the type restraint (i.e., wrist mittens, vest, violent or aggressive behavior or to When reviewing medical
side rails) and the length of time over restrict the patient’s freedom of records of a restraint-injured client, it
which it can be used. Restraint use must movement and is not considered standard is imperative to analyze both the
be carefully monitored and documented, treatment for the patient’s medical or medical and nursing processes that
and its effectiveness must be continuously psychiatric condition. Restraint lead to the use of the restraint.
evaluated. An effort must always be made assessment and monitoring frequencies Physiologic imbalances that lead to
to use the least restrictive available are also determined by patient age. The confusion, such as hypoxia (low
method of restraint, and to restore each younger the patient, the more frequent the oxygen levels), electrolyte
individual to his or her maximum possible assessment should be. abnormalities and uremia require
level of independence. Side Rails as Restraints prompt medical treatment.
In acute care facilities, restraints In 1995 the Food and Drug Medication regimens that may lead to
are either for acute medical-surgical care Administration (FDA) issued a safety confusion or toxicity should be
or for behavioral management. Each alert, citing concerns of entrapment, carefully examined upon admission.
category has its own specific restraint care injury and strangulation death resulting Medications that are usually
guidelines for physician prescription, from the use of side rails. Between 1985 therapeutic for the elderly patient can
restraint selection, assessment, and and 1999, the FDA received 371 reports quickly become toxic in the face of an
ongoing monitoring. An example of of patients caught trapped, entangled or acute illness. The need for restraints
restraints used for acute medical-surgical strangled in hospital beds. Of these should be assessed according to
care may be immobilizing the hip and arm mostly frail, elderly or confused patients, institutional and regulatory
to prevent a confused patient from getting 228 died as a result. requirements. Restraint
out of bed unassisted and removing an IV To date, no research study has documentation should include: the
line after a hip replacement. A registered demonstrated that the use of side rails patient’s behavior requiring restraint
nurse may initiate a physical restraint prevents injury as a result of a fall. In intervention, immediate physician
based on professional nursing judgment. fact, a patient who falls from a greater notification if this is a change in
A verbal or written order from the height while climbing over a side rail is patient condition, the appropriate
physician must be obtained within 12 more likely to be seriously injured than physician order, response to restraint
hours of the initiation of the restraints. one who falls from the bed mattress. alternatives, the appropriate nursing
According to JCAHO standards the HCFA (CMS) defines restraints observation, assessment and
physician must be notified immediately if to include side rails as well: any device intervention of the restrained patient,
the initiation of the restraint is a result of a that restricts a patient’s voluntary the type of restraint, time of
change in patient condition. Patients in movement or access to his body and that application and patient response to the
restraints must be monitored at least every can’t easily be removed by the patient. restraint. Negative outcomes
2 hours. If the ongoing patient assessment Most healthcare facilities now use beds (pressure ulcers, contractures and loss
indicates a clinically justifiable need for that have 4 side rails. A half or quarter- of ability to ambulate) associated with
continued restraint use in acute medical- length upper side rail is not considered a restraint use should also be carefully
surgical care patients, then the order for restraint if the patient uses it to assist assessed.
restraints must be renewed each calendar himself into or out of bed. Additionally, 4 Litigation surrounding falls
day. While JCAHO has set minimum half-length side rails are not considered a and restraint-injury claims continues
standards for restraint care, hospital policy restraint if the patient requests them and to rise. Just as the key to ensuring
may actually mandate a higher frequency the patient can lower them before entering patient safety is to formulate the plan
of assessment and monitoring of or exiting the bed. of care based on the patient’s
restrained patients. Alternatives to Restraints individualized needs, careful analysis
The behavioral restraint In an effort to use the least of the medical facts will assist
management standard applies in restrictive method of restraint available to attorneys in determining the merits of
emergency situations where the patient’s ensure patient safety and dignity, each individual case.
behavior has become violent or healthcare researchers have studied and
recommended varying alternatives to
Medical-Legal Interface Page 3
Case Managers as LNC’s
Robert Morrison, RN BSN
The case that has occupied much accident. However, the results were will form the basis of the attorney’s
of my time the past week illustrates the declared invalid even by the evaluator. It courtroom presentation. What the LNC
need for plaintiff attorneys to keep nurse was too early in the course of treatment to does best is provide a legally astute
case managers close at hand. This case do this. He was still regaining his abilities assistant with a medical background. When
started for us almost two years ago and at this point. Even if they had been able to you’re deciding what nursing backgrounds
has been very complicated throughout. measure exact limits, they would have to have available, don’t forget the case
We are preparing for court this spring and changed as soon as John progressed to the manager. Their occupational brief is to
hoping to bring the patient closure at last. next stage of therapy. bring order to chaos and keep all of the
John (not his real name) is a 48 To make sure all of the different pieces together in a single,
year-old man who was involved in an individual providers and managers had, in sensible picture.
automobile accident in 1998 injuring fact, brought John to his maximum state
himself and his wife. The other driver was of recovery an Independent Medical Medicare Set Asides
found at fault and ticketed. However, her Evaluation (IME) was done. This looked Continued from page 1
insurance coverage had not anticipated at all of the information starting with the
multiple injuries. The medical treatment accident through the current date. Detailed How the Process Works
was handled through two different medical records were provided to the IME The MSA Allocator, a person
insurers during the next four years. Each physician which showed all of the activity trained in drafting and submitting MSAs to
insurer provided its own nurse case from the various providers. After CMS, will collect all pertinent medical
manager, each steering the injured reviewing all of the information at-hand, information, and establish, from the life
patients through a combination of family this physician agreed that further care plan how much of the monies need to
practice, neurosurgery, therapy and rehab. treatment was unlikely to improve John’s be allocated to the MSA. Then the
His wife’s case eventually reached situation, and that he did appear to have Allocater will, with the beneficiary, decide
maximum medical improvement (MMI) reached a state of maximum how the funds will be held in trust and who
and was settled by the insurer. John, improvement. He also provided a will administer the funds. This can be done
however, was seemingly stuck in the calculated impairment rating to help by structured settlement annuity, placed in
middle. quantify John’s losses as a result of this the bank with an executor or both. The
Our first order of business was to accident. Allocator then prepares all of the necessary
clearly establish John’s current medical Since John had not been able to documents for the proposed settlement and
status and needs. This was important, as return to his previous occupation as a submits these same said documents to CMS
you cannot establish permanent truck driver it needed to be established for approval. Once CMS approves the
functionality (and thus damages) while what his occupational situation was. A settlement it will then need to be finalized.
the patient remains in active treatment. Loss of Earning Capacity evaluation was Any negotiations related to the claim must
The goal of treatment is to change and done at this point by a certified vocational be done prior to the submission of the final
improve the patient’s ability and function. counselor. This evaluation involved a proposal, as once CMS approves it, it must
You need to make sure that the medical detailed work and educational history stand as is.
providers have done all they can to from John covering his entire life. This Why Should you Submit a MSA to
advance the patient’s condition before you allowed the counselor to establish what CMS?
stop. By working directly with all of the occupations John would be qualified for. The statue allows CMS to expect
doctors involved we were finally able to Then, by eliminating those whose reimbursement for any and all conditional
document a state of MMI in December of physical requirements were beyond the payments, payments they make while
2002. An experienced case management limits set in the FCE, the counselor was awaiting the settlement. Also, if Medicare
approach was used to bring all three able to show what possibilities were left. has to pay any future medicals on anyone
doctors and the patient together to a single The earning potential of these occupations who has received a settlement because
understanding. was compared to that of his prior field of Medicare’s interest was not protected by
Next came the need to quantify driving a truck. The difference between submitting a MSA allocation for approval
the patient’s damages. You always prefer these figures represented part of the double damage plus interest may be
that they return to their pre-accident state. damages suffered by John as a result of assessed against all parties responsible.
In this case it wasn’t possible, though he the accident. So, the next time you have a case
did come further than he anticipated in the Now, John’s attorney had all of where the client meets the criteria for a
beginning. An FCE (Functional Capacity the medical information about his possible MSA, do yourself and your client
Evaluation) was performed to establish damages. During this time the attorney a favor and have a MSA Allocator glean
his exact level of ability and function. A had been gathering all of John’s financial over the records to assure you that you’re
long and intense two-day evaluation, its records and pension information. When meeting the burden of protecting
basic purpose is to state clearly what the this had been calculated as a single, Medicare’s interest. You’ll be glad you
patient can and cannot do, and where their supportable figure it was added to the did. For more information of other aspects
limits are. One of the insurance case medical damages to make a single of MSA, please don’t hesitate to contact
managers had this done a year post- settlement package. It is this package that me.
Volume 3, Issue 6 Page 4
Not Everything Green is Irish in March, OR: Mold, Friend or Foe?
Sarah McLain RN, CLNC, CLCP
Molds are common life forms. Almost everyone suffers from some microscopic spores (seeds), which enter the air and
They can be found in areas where everything kind of mold related problem. Many times, cause various kinds of problems. If you breathe
freezes as well as in the tropics where however, the effects are mistaken for something them in, they can cause problems inside your nose.
everything is burning hot. They are found in else, such as a headache. Is it a stress headache The chemicals can irritate soft mucous membranes
homes and schools and office buildings. They or did walking into a moldy home give you the inside the nose leading to sneezing and runny nose.
are destructive to many different materials. headache? If you believe you have a cold, you can treat it
They can eat away the leather in your shoes. Many people are taken off mood incorrectly. What works on a cold or a bacterial
They can eat away wood and wood products. altering drugs after their homes are cleared of infection, won't do a thing to mold infections. If
They can invade your body and cause mold. Some have actually avoided time in mental mold spores enter your nose, you can also start
diseases, including allergic reactions, institutions by cleaning up their environments. having allergic reactions. Again you get the
dizziness, sleeplessness and irritability. There was one case where the wife was three sneezing, runny nose and parts of your body begin
To sustain itself, mold releases days away from being committed in a mental to turn red and swell up. Sinusitis and infections
chemicals into the surrounding moisture, institution for severe depression. Her house was can occur when these materials work their way into
which break down the food source into cleaned and the mold was removed and her your sinuses. Millions of dollars are spent each
smaller particles. The food particles mix with depression vanished. There are plenty of year on over the counter medications to incorrectly
the water/juice mixture so the mold can suck scientific studies which document the mood treat sinus problems that are caused by mold. If
it up. One example of how all these things swings in people exposed to chronic mold. mold products get into your lungs, they can lead to
come together for the mold creature is in a Even in two paycheck families, pneumonitis. The tender linings of the lungs have a
forest. Mold grown on dead trees lying in the children suffer more because they spend so much hard time fighting off mold. The insides of the
dark, damp forest. The tree used the sun to time in daycare and schools. Because neither of lungs are warm, moist and have a rich supply of
create food and then stored that food. When these places tend to be well ventilated, both are easy to digest material. All the things mold needs
the mold grows on the dead tree it uses the notoriously high in mold contamination. Add this to set up housekeeping.
natural moisture of the forest. It burrows into to the molds that children bring into the common Mold can cause dermatitis. Some
the tree and secretes its juices. These juices area from their homes and you can have a killer soldiers who fought in the South Pacific area in
eat away the stored food in the tree. Then the combination. Most schools and daycares have World War II have mold-induced dermatitis to this
mold absorbs this food for its own use. The carpets. The food and glue that kids drop on the every day. Ringworm is another skin problem.
mold is actually doing us a favor. If it didn't carpet feed mold growth. In Sweden, school Ringworm can be very destructive if occurring in
eat away the dead creatures around us (trees, officials are removing carpets from schools places like hair regions. It will actually cut a ring
leaves and bugs), we would be drowned in because of the health problems they cause. of hair away leaving something that looks like a
debris. Mold is nature's little garbage The air handlers in many schools are ring shaped scar. Otitis is a common problem
disposal. never turned on. Air filters are seldom changed. among children. Molds such as Penicillium can
Mold causes billions of dollars So mold spores (seeds) float around looking for wreak havoc with a child's ear. This is both a
worth of damage to our food supply each children's lungs and noses. Adding to the mold costly and painful problem. Gastrointestinal
year. How many times have you opened your problem in schools is the toxic chemical problem. distress is a common problem when mold is
refrigerator and found green spots on your When carpets are cleaned in schools, outbreaks of swallowed. Why would we swallow mold? Simple,
cheese? Did you throw that cheese away? Or respiratory disease occurs among school children. it gets in our food in the kitchen. Have you ever
did you cut away the green part and eat what The same thing happens in homes. Many carpet found green spots on your cheese? Some people
was left? Did you get sick? If not, luck may cleaners contain formaldehyde, which damages cut this bad part of the cheese off and eat what is
have been with you. The large immigration tender lungs. left. While this keeps the antacid companies happy,
of Irish potato farmers in the last century was Almost daily someone is doing a story this type of problem costs Americans millions of
caused by mold attacking the potatoes in in the news about a contaminated school and dollars each year.
Ireland. The Irish people were devastated disease epidemics. The classic study on the mold Bone infections result if mold gets into
when their main food source disappeared. subject is the one in Morbidity & Mortality the blood and travels to the bone. Usually this
Starvation was everywhere. Weekly Report Jan 17, 1997. This case even occurs when someone has a depressed immune
The place mold has in history is not limited appeared on TV. Nine kids in Cleveland, Ohio system. But remember, mold can cause a depressed
to just the Irish potato famine. Mold is died from a mold (Stachybotrys chartarum), immune system. Mold can cause endocarditis, an
possibly the cause of the mummy's curse in which was growing in their homes following infection in the heart, through a surface wound. For
Egypt (the people who went into the tombs water problems (leaky pipes, water heaters, etc.) example, after getting a tooth pulled, anything
got sick and died mysteriously). The The children died from lung damage caused by growing in the fluids of the mouth goes through
symptoms of the people who suffered from mold spores destroying the tender lining of their the hole in the jaw into the blood stream. Toenail
the "curse" were similar to those caused by lungs. medications are selling in the millions of dollars
Aspergillus mold. And this mold has been Many childhood illnesses from each year. Toenail fungus causes thick, ugly
found in the Egyptian tombs. It seems that Attention Deficit Disorder (ADD) to asthma have misshapen toenails, which are almost impossible to
when the Egyptians buried their dead, they been reduced or eliminated by getting homes clear up. Some molds produce mycotoxins, which
left food so the dead could continue to eat. properly cleaned. A few years back very few can even cause cancer. The most powerful
The mold grew on this ready food source. children had asthma. Today, many children have naturally occurring carcinogen is aflatoxin, which
Mold may have played a part in the Salem it. Some teachers tell us that up to 50% of the is produced by mold.
Witch Trials. Mold growing on their bread children in their classes have asthma. One teacher The fact is that homes are built differently today.
may have caused hallucinations in the stated that there were more emergency inhalers in And are molds ever glad. To save energy, homes
children who accused people of being her classroom then pencils. have been built tighter. Indoor air takes 5 times
witches. Since the people of that day didn't The biggest health problems occur from what longer to exchange itself with the air outdoors than
understand hallucinogenic chemicals, they mold "gives off". There are chemicals called it did 50 years ago. So toxins and mold products
figured that it had to be satanic influence. VOC's (Volatile Organic Compounds) and are trapped and Cont on p 5
Medical-Legal Interface Page 5
Mold, Friend or Foe?
Continued from page 4
concentrated in the home. Add to that the
chemicals we spray into our homes that
Some Molds and the Diseases They Cause
causes all kinds of diseases. We have
created a pollution problem in our homes Absidia - Skin eruptions.
that rivals the most polluted cities in the Acremonium - Skin infections as well as meningitis, arthritis and hard palate lesions.
USA. Alternaria - Skin, ear, nasal and pulmonary infections.
If you read the EPA's Aspergillus - Pulmonary infections and blood vessel diseases. Possible cause of King Tut's curse.
"Introduction to Indoor air Quality" manual, Aureobadidium - Foot and leg infections.
they tell you to use bleach on "non-porous" Candida - Erosive skin infections, yeast infections.
surfaces. They tell you to dispose of porous Chrysosporium - General infections.
materials contaminated by mold. Cleaning Cladosporium - Skin infections, tinea.
the surface of a mold colony doesn't affect Coccidoides - Flu like infections and possible brain infections.
the insides of the colony. Like an iceberg, Curvularia - Mycetoma, endocarditis, pulmonary and nasal infections.
most of the mold's colony is unseen, below
Drechslera - Meningitis, skin and nasal infections, peritonitis, and abscesses.
the surface. In our case, below the surface
means, "hidden inside the wall, floor or Fusarium - Skin, bone, ear infections and skin ulcers.
ceiling". And remember, the unseen part of Microsporum - Tinea, mycetoma. Mucor - Ear infections.
the iceberg sank the Titanic. Most Nigrosporum - Skin infections.
commercial bleaches also leave a phosphate Paecilomyces - Endocarditis, skin lesions, pulmonary infections.
residue, which is like "mold fertilizer". Use Penicillium - Skin and ear infections.
of bleach can also lead to the formation of Rhizopus - Ear infections. Scopulariopsis - Skin, lung and ear infections and skin ulcers.
chloroamines, which can cause cancer. In Sporothrix - Black, hard ulcers of the skin.
addition, there are studies that show that Stachybotrys - Lung disease, especially in children.
chlorine bleach is toxic to humans, Trichosporon - Beard and mustache infections.
especially to children. "Technology Review,
Jan, 1995 v98 n1 p54(7)".
The Unasked Question
By Gail Hendrickson RN, CEN, LNC
A 58 year old male arrives via ambulance to increase his IV rate, and still no improvement. too embarrassed to tell anyone. He doesn’t
the emergency room. Upon the EMT’s arrival His blood pressure is even lower now. He is take it every day, only occasionally. He was
at his home, he is complaining of substernal, barely responsive at this time. His girlfriend asked what medications he takes on a daily
crushing chest pain, radiating to the left arm arrives, and frantically comes into the room. basis. The EMT didn’t ask before
and jaw. He is sweaty, and complains of The first thing she says when she comes into administration of his first nitroglycerin. The
feeling sick to his stomach. His initial vital the room is “Honey, did you tell them you took emergency nurse and doctor didn’t ask either.
signs were 180/104, pulse 79, respirations 24, Viagra last night?” It can be a very embarrassing question to ask.
and Oxygen Saturation 98%. Everyone in the room feels sick to their In our emergency department we now have
When the patient arrives in the stomach. No he didn’t tell us, but we didn’t little signs above the patients head that say
emergency room, the EMT gives his report. ask either. We all know that medication used “ASK AWAY” as a reminder to us to ask this
He states that he has been in good health. His for erectile dysfunction such as Viagra, Levitra question.
pain began suddenly, and woke him up. He and Cialis can cause life threatening What are the legal implications of
initially rated his pain a 10 on a 0-10 pain hypotension when combined with nitroglycerin this case? If you are reviewing a case in
scale. He has no allergies, and his only daily if. These mediations cause the muscles that which a patient has had a bad outcome after
medication is Pepcid for acid reflux. They control the size of blood vessels to relax. receiving Nitroglycerin, look back to see if he
have administered oxygen at 3 liters via nasal When these muscles relax, the vessels enlarge has ever been prescribed a medication for
canula, 4 baby aspirin, and one nitroglycerin. in diameter, and as a result, the blood pressure erectile dysfunction. Check to see if his
He has an intravenous with normal saline drops. When Viagra and nitrates are taken prescribing doctor did proper teaching. Did
running at 100 cc per hour. His pain is now 6. together, the effects are greater than when he explain the reasons he needs to tell a
As you begin your assessment, you either one is used alone. There may be a health care professional that he was taking
find his blood pressure is now 130/80, pulse marked relaxation of the muscles that control Viagra, if he is goes to the hospital with chest
80, respiration 24, and oxygen saturation is the vessels with a great drop in blood pressure. pain? Where did he get this medication
100%. His EKG shows ST changes, which are A drastic drop in blood pressure is detrimental filled? Are there warnings on the bottle and
indicative of ischemia. He is still complaining to patients who have angina, a condition in on the patient information sheet? Was this
of chest pain, so the emergency room which a higher blood pressure is necessary to question asked before administering
physician asks you to administer another supply the heart with blood. Lowering the nitroglycerin? It is not safe to give
sublingual nitroglycerin. Two minutes after blood pressure decreases the flow of blood to nitroglycerin if a male has taken Viagra,
you have administered the nitroglycerin, he the heart and can precipitate a heart attack. Levitra or Cialis within the past 24 – 48
tells you that he feels very lightheaded, and is Why did this happen? The patient hours. Any health professional who has been
more diaphoretic. When you recheck his may not have realized that he needed to tell involved in a case like this, will never forget
blood pressure it is now 90/40. someone he was taking it. He may have been it. So before you give nitroglycerin, ASK
You quickly put his head down, AWAY.
Pattie Patterson RN, LNCC
Legal Nurse Consultant-Certified
Life Care Planner
Medicare Set Aside Allocator
6501 Galaxie Road
Richmond, Va. 23228
“We get to the heart of your