Nurse Assigned in Rural Service (NARS) or Warriors of Wellness

NARS is a Training cum Deployment Project, jointly implemented by the Department of Labor and Employment (DOLE), the Department of Health (DOH) and the Professional Regulation Commission, Board of Nursing(PRC-BON), designed to mobilize unemployed registered nurses to the 1,000 poorest municipalities of the country to improve the delivery of health care services.

Project NARS is built within the frameworks of the Economic Resiliency Plan of the Arroyo Administration and the Department of Health’s “Fourmula One for Health”. The Project aims to mitigate the impact of the global financial crisis, to save and create as many jobs as possible and expand social protection and help achieve better health service and care for the people, especially those in the poorest municipalities of the country.

Project NARS was launched by President Gloria Macapagal-Arroyo on 9 February 2009 during the Multi-Sectoral Summit on “Joining Hands Against the Global Crisis” in Malacañan, Palace, Manila. Nurses will be mobilized in their hometowns as warriors for wellness to do the three I’s:

1. Initiate primary health, school nutrition, maternal health programs, first line diagnosis;

2. Inform about community water sanitation, practices and also do health surveillance;

3. Immunize children and mothers. They shall likewise serve as roving nurses for rural schools.


General Objectives
- Project NARS aims to improve delivery of health care services to our population and create a pool of registered nurses with enhanced clinical and preventive health management competencies for national public and private sector employment.


Specific Objectives

1. Provide registered nurses with necessary competencies that encompass both community health practice as well as clinical skills;

2. Address the shortage of skilled and experienced nurses, both domestic and overseas, through structured competency development program;

3. Provide deployment opportunities for nurses in rural areas and underserved communities;

4. Augment the nursing workforce of hospitals and rural health units in identified poor municipalities of needed clinical and public health nurses.



Delivery Mechanism

Nurses will be deployed at an average of 5 per town in the 1,000 poorest municipalities, for a six-months tour of duty. Another batch will be deployed for the second half of the year. These nurses will undergo training and development for competency enhancement in accordance with the training program designed by the PRC-BON in collaboration with DOH.

The training program will cover both the clinical and public health functions. Nurses trainees will rotate in their assigned hospital or rural unit for a period of three (3) months. At the end of the third month, nurses who have completed their rotation in the hospital will be re-assigned to a rural unit and vice-versa.

A Certificate of Completion/Competency shall be issued jointly by the DOLE, DOH and PRC after an assessment of the gained competencies of nurse trainees.

While on training, nurses will be given a stipend/allowance of P8,000.00 per month. This translates to about P366.00 per day for forty (40) hours training/workweek. As these nurses are already in their hometowns, transportation expenses will no longer be a problem.

The stipend of P8,000 may be increased if the host LGUs will offer a counterpart of say P2,000. LGUs may provide Philhealth coverage to nurse-trainees. Corporations may chip in by providing shirts, insurance, vitamins, etc., making the project a national enterprise with private equity.


Expected Outcomes

The NARS Project will:

1. Create a pool of 10,000 nurses who are adequately trained with enhanced clinical and public health competencies and readily available for local and overseas employment

2. Provide income of P8,000 per month to 5,000 unemployed nurses for the first six months and to another 5,000 for the second half of the year, to help pump prime the economy;

3. Promote the health of the people through the improvement of the delivery of nursing and health care services, particularly in the 1,000 poorest municipalities;

4. Bring the government closer to the people.


Recruitment and Selection

Recruitment and selection shall be the responsibility of DOLE, through its Regional Offices.

Registered nurses who are physically and mentally fit and willing to serve in their hometowns and with the following qualifications may apply online at www.nars.dole.gov.ph from February 20 to March 22, 2009:

a. With valid nurse license issued by the PRC;
b. Not over 35 years old;
c. Resident of the identified municipalities / nearby municipalities;
d. No nursing-related practice for the past 3 years.

Nurse applicants who are dependents of workers affected by the Global Crisis (e.g. laid off/rotated, etc.,) shall be given priority in the selection.

Triage in Nursing

Triage Defined

Triage is defined as a process of prioritizing patients based on the severity of their condition with the goal of treating as many patients as possible when resources are insufficient for all to be treated immediately. It comes from the French verb trier, meaning to separate, sort, sift or select. Triage can either be simple or advanced.


Simple Triage

In simple triage, patients are categorized based on the severity of their injuries and are usually labeled using triage tags or colored flagging. An example of simple triage is the S.T.A.R.T (Simple Triage and Rapid Treatment), a method used by first responders during a mass casualty incident. In S.T.A.R.T., the patients are evaluated in 60 seconds or less and are labeled with one of the four triage categories:

a.) Minor (Priority 3)
- treatment can be delayed up to three hours or when possible (e.g. abrasions, minor lacerations, sprains)

b.) Delayed (Priority 2)
- needs urgent care and constant observation; tansport when practical (e.g. minor amputations, flesh wounds, fractures, dislocations)

c.) Immediate (Priority 1)
- condition is life-threatening; needs immediate care and transport ASAP (e.g. arterial lesions, major bleeding, major amputations)

d.) Deceased
- the victim is dead so no medical care is required; collection, guarding of bodies, and identification when possible


Advanced Triage

Advanced triage is performed to divert scarce resources from patients who are not likely to survive. Doctors may withhold treatment from seriously injured patients because the available resources are not sufficient to treat all of those who need medical help.

During extreme situations, the medical team decides if a patient is hopeless to avoid saving a hopeless case at the expense of several other patients with a higher chance of survival. Triage, then, has to be continuous to ensure that prioritization remains correct and medical help is given to those who are more likely to survive.

Secondary triage is typically performed by skilled nurses in the ER during disasters. In advanced triage, patients are divided in the following categories:

a.) Black / Expectant
- injuries are so severe that patients are unlikely to survive even with treatment and so the goal is to reduce patients' suffering (e.g. severe trauma, massive burns, septic shock, cardiac arrest) by providing painkillers as necessary

b.) Red / Immediate
- immediate surgery or medical care is required as these patients are likely to survive with treatment

c.) Yellow / Observation
- patients under this category are considered stable but requires observation and re-evaluation

d.) Green / Wait (walking wounded)
- patients under this category will require medical care but not immediately; may be asked to wait or go home and come back the day after (e.g. broken bones without compound fractures, soft tissue injuries)

e.) White / Dismiss (walking wounded)
- these patients have minor injuries and only requires home care (e.g. cuts, scrapes, minor burns)


Emergency Room Triage vs. Disaster Triage

In a controlled environment such as in an emergency room setting, the sickest patient is prioritized and given medical care first. In uncontrolled environments such as in a disaster setting, the patient who is more likely to survive is given priority. Still, whatever the environment, nurses need to develop clinical decision-making skills before they can accurately triage patients.


Emergency Wound Care

The skin is the largest and most visible organ of the body. Intact skin is the body's primary defense mechanism. Once the protective skin barrier is disrupted, individuals are at greater risk for injury.

Impaired skin integrity is a common problem often requiring visits to a hospital's emergency department. Examples of skin integrity disruption are cuts from sharp objects, bites resulting in lacerations, scrapes, contusions, avulsions, abrasions, or puncture wounds.

To prevent complications such as infection and hemorrhage, emergency wound care is necessary no matter how minor a wound is. Emergency wound care, by definition, is the immediate and temporary treatment of wounds in order to prevent infection, hemorrhage, and further injury to the patient. For wounds requiring immediate medical attention, proper emergency wound care may be instrumental in saving the patient's life and ensuring a rapid recovery.

Before a health worker or any individual renders emergency wound care to a patient, it is important for him/her to remember the following:

1.) Only approach the patient if it is safe for you to do so.
2.) Observe universal precautions while rendering first aid measures.
3.) Call for medical help immediately if there are embedded objects in the wound, if the wound is at special risk of infection, or if old wounds are showing signs of infection.

Emergency wound care provided by healthcare professionals usually involves cleansing the wound, application of measures to control bleeding, closing the wound, application of a protective dresssing, and prohylactic treatment for tetanus or rabies as indicated. These simple first aid measures will improve the patient's rate of recovery and prevent further medical problems.

Kawasaki Disease

- also called mucocutaneous lymph node syndrome
- an inflammatory condition that affects small- and medium-sized arteries throughout the body, including coronary arteries
- also a febrile, multi-system disorder that also affects lymph nodes, skin, and mucous membranes of the mouth, nose, and throat
- occurs almost exclusively in children ages 2 to 5, and commonly affects boys than girls
- also common among children of Japanese or Korean descent
- no exact cause of Kawasaki disease has been identifiedand it doesn't appear to be hereditary


Assessment Findings

A.) Acute phase

- high fever--> does not respond to antipyretics
- enlarged cervical lymph nodes
- conjuctivitis--> inflamed mucous membranes of the eyes; without discharge
- 'strawberry' tongue
- red, cracked lips
- lethargy or irritability
- abdominal pain, anorexia, diarrhea
- red and swollen hands and feet
- rash--> often in diaper area and trunk
- swollen and reddened joints
- diagnostic tests: elevated WBC count, elevated ESR


B.) Subacute phase (about 10 days after onset)

- possible formation of coronary aneurysms--> very dangerous and can lead to death; requires sequential echocardiograms
- skin desquamation in palms and soles of the feet
- elevated platelet count--> increases clotting and necrosis of cells not receiving adequate blood supply, esp. in the fingertips


C.) Convalescent phase

- signs and symptoms go away unless complications develop



NOTE: to be diagnosed with kawasaki disease, a child must manifest fever and four of the following symptoms:

1.fever of more than 5 days
2.bilateral congestion of conjuctiva
3.red and dry pharynx, red and cracked lips, 'strawberry' tongue
4.peripheral edema, peripheral erythema, and desquamation of hands and soles
5.rash in trunk
6.swollen cervical lymph nodes



Medical Management

a.) aspirin--> reduces inflammation and prevents clot-formation; a dose of 100mg/kg/day may be required; not to be given if child develops flu or chickenpox during treatment (may cause Reye's syndrome)

b.) dipyridamole--> may be given with aspirin; increases coronary vasodilatation and decreases platelet accumulation

c.) IV gamma globulin--> decreases immune response; given instead of steroids ( may increase aneurysm formation)



Surgical Management

- If the patient develops coronary artery disease, the following procedures may be required:

a.) coronary artery angioplasty--> opening of the arteries that have narrowed

b.) stent replacement--> implanting a device to re-open a blocked artery

c.) coronary artery bypass graft--> involves rerouting the blood around a diseased coronary artery by grafting a section of blood vessel from the leg, chest or arm to use as the alternate route



Nursing Management

a.) always observe patient for signs of heart failure such as tachycardia, dyspnea, rales, and edema
b.) evaluate peripheral tissue perfusion
c.) monitor for chest pain and ECG changes
d.) administer medications as ordered
e.) observe for signs of aspirin toxicity (tinnitus, nausea, vomiting, headache, blurred vision)
f.) provide addition comfort measures such as rocking and holding
g.) protect lips from cracking and drying; apply lip balm
h.) ensure adequate fluid intake to maintain hydration
i.) protect edematous extremities from pressure
j.) offer soft, non-irritating foods such as gelatin
k.) provide oral care with the use of padded toungue blades or soft toothbrush
l.)provide health teachings (to parents ) regarding the importance of echocardiogram every 1-2 years to screen patient for heart problems



Prognosis

- Full recovery can be expected with early recognition and treatment. Unfortunately, 2% of patients with Kawasaki Disease die from complications of coronary blood vessel inflammation.


Prevention

Kawasaki disease is not preventable.

Electrocardiogram (ECG) Reading

The P Wave:

The P wave represents the spread of electrical activity over the atrium. The normal depolarization begins at the sinoatrial (SA) node near the top of the atrium. Because of the top-to-bottom, right-to-left path of the P wave, it’s normally largest in lead II. The normal P wave is upright in all leads except R.The P wave normally lasts less than 0.11 seconds (just less than three small boxes). An abnormally long P wave occurs whenever it takes extra time for the electrical wave to reach the entire atrium. This occurs in left atrial enlargement.

The height of the P wave is normally less than 2.5 small boxes (less than 0.25 millivolts). An abnormally tall P wave is seen when larger amounts of electricity are moving over the atrium. This usually indicates hypertrophy of the right atrium. The P wave may be decreased in height by hyperkalemia. 



The PR Interval:

Following the P wave is the PR segment. (NOTE: the PR segment and the PR interval are NOT the same thing.) The PR segment is not routinely measured, but may be commented on if it is depressed or elevated. During the PR segment, the electrical wave moves slowly through the atrioventricular (AV) node. This activity is not seen on the ECG.


The PR interval is the time from the beginning of the P wave until the beginning of the QRS complex. It is normally between 0.12 and 0.2 seconds (three to five small boxes) in length.The PR interval may be prolonged when conduction of the electrical wave through the AV node is slow. This may be seen with degenerative disease of the node, or with digoxin, hyperkalemia, hypercalcemia, or hypothermia.

The PR interval may be unusually short when conduction is rapid. A mildly short PR interval may be seen with hypokalemia or hypocalcemia. An artificially-short PR interval occurs when the QRS complex begins early, as happens with an extra conducting bundle — Wolff-Parkinson-White Syndrome (WPW). 







The QRS Complex:

The QRS complex represents activation of the ventricle. Special conducting bundles spread the wave of depolarization rapidly over the ventricle.

The QRS complex is normally less than 0.10 seconds in length — two and a half boxes. Lengthening of the QRS indicates some blockage of the electrical action in the conducting system. This may be due to ischemia, necrosis of the conducting tissue, electrolyte abnormality, or hypothermia.

If the first deflection of the QRS is downward, it’s called a Q wave. The Q wave represents activation of the ventricular septum. The electricity spreads from right to left through the septum.

Q waves may be normal. For example in lead I, a Q less than 1/4 of the R height, and less than one box wide, is considered normal. This is the early activation of the septum. This activation goes left — away from lead I — and is therefore negative on the ECG. “Septal Qs” are normal in I, F, V5 and V6. Qs are also generally innocent in lead III and lead V1 if no other abnormality is seen.

Q waves are “significant” if they are greater than 1 box in width (longer than 0.04 msec) OR are larger than 1/4 of the R wave. Significant Q waves indicate either myocardial infarction or obstructive septal hypertrophy (IHSS).

The first upward deflection of the QRS is called the R wave. Most of the ventricle is activated during the R wave. The R wave may be prolonged if the ventricle is enlarged, and may be abnormally high (indicating strong voltage) if the ventricular muscle tissue is hypertrophied.

The S wave is any downward deflection following the R wave. Like the R wave, an abnormally large S wave may indicate hypertrophy of the ventricle.

If a second upward deflection is seen, it’s called an R-prime wave. R-prime waves are never normal, but indicate a problem in the ventricular conduction system.
QRS complexes may be described by naming the waves that form them. For example, a complex with an R, an S, and an R’ is called an RSR’ complex. 








The ST Segment:

The ST segment is the portion of the tracing falling between the QRS complex and the T wave. During this time, the ventricle is contracting, but no electricity is flowing. The ST segment is therefore usually even with the baseline.

The length of the ST segment shortens with increasing heart rate. Abnormality of electrolytes may also affect the ST segment length, however measurement of the length of the ST segment alone is usually not of any clinical use.

Upward or downward shifts in the ST segment are extremely important. Deviation of the ST segment from baseline can indicate infarction or ischemia, pericarditis, electrolyte abnormality, or ventricular strain. ST segment elevation or depression is generally measured at a point two boxes beyond the QRS complex. 


The T wave:

The T wave represents the wave of repolarization, as the ventricle prepares to fire again. The T wave is normally upright in leads I, II, and V3-V6. It is normally inverted in lead R. Ts are variable in the other leads (III, L, F, and V1-V2).
T wave abnormalities may be seen with, or without ST segment abnormality. Tall T waves may be seen in hyperkalemia or very early myocardial infarction. Flat T waves occur in many conditions. Inverted T waves may be seen in both ischemia and infarction, late in pericarditis, ventricular hypertrophy, bundle branch block, and cerebral disease.

In young children, T waves may be inverted in the right precordial leads (V1 to V3). Occasionally, these T inversions persist in young adults. 



The U Wave:

A second wave following the T wave is called a U wave. Large U waves may be seen in electrolyte abnormality (such as hypokalemia), or with drug effects.







The QT Interval:

The QT interval is the time from the beginning of the QRS complex until the end of the T wave. The “normal” QT length varies with heart rate. Very fast rates shorten the QT length.

At normal heart rates, QT length is abnormal if it’s greater than 0.40 sec (10 boxes) for males and 0.44 sec (11 boxes) for females. Extreme QT prolongations (greater than 0.60 sec — 15 small boxes) predispose the patient to arrhythmias.The QT interval may be prolonged with electrolyte abnormality, such as hypokalemia, hypocalcemia, or hypomagnesemia. Myocardial ischemia may also prolong the QT interval

Communicable Disease Nursing Study Bullets

DRUG OF CHOICE

Tetanus: PEN G Na; DIAZEPAM (Valium)
Meningitis: MANNITOL (osmotic diuretic); DEXAMETHASONE (anti-inflammatory); DILANTIN/PHENYTOIN (anti-convulsive); PYRETINOL/ENCEPHABO L (CNS stimulant)
Rabies Vaccines: LYSSAVAC, VERORAB
Immunoglobulins: ERIG or HRIg

DIAGNOSTIC TESTS

Tetanus: WOUND CULTURE
Meningitis: LUMBAR PUNCTURE
Encephalitis: EEG
Polio: EMG; Muscle testing
Rabies: Brain biopsy (Negri bodies) Fluorescent rabies antibody test
Dengue: TOURNIQUET test (Rumpel lead)
Malaria: Malarial smear; QBC (Quantitative Buffy Coat)
Scarlet: DICK'S TEST; SCHULTZ-CHARLTON TEST
Diphtheria: SCHICK'S TEST; Moloney's Test
Pertussis: Nasal swab; agar plate
Tuberculosis: MANTOUX test
Leprosy: SLIT SKIN SMEAR
Pinworm: SCOTCH TAPE SWAB
Typhoid: WIDAL'S test
HIV/AIDS: ELISA; WESTERN BLOT; PCT: Polymerase Chain Reaction Test

CAUSATIVE AGENTS

Tetanus: CLOSTRIDIUM TETANI
Meningococcemia: NEISSERIA MENINGITIDIS
Rabies: RHABDOVIRUS
Poliomyelitis: LEGIO DEBILITANS (Type I Brunhilde); (Type II Lansing); (Type III Leon)
Dengue Fever: ARBOVIRUSES (Chikunggunya); (Onyong-nyong); (West Nile); (Flaviviruses) (Common in the Phil.)
Malaria: PLASMODIUM (protozoa) P. Falciparum (most fatal); P. Vivax P. Malariae; P. Ovale
Filariasis: WUCHERERIA BANCROFTI; BRUGIA MALAYI
Leprosy: MYCOBACTERIUM LEPRAE
Measles: PARAMYXO VIRUS
German measles: TOGA VIRUS
Chicken pox: VARICELLA ZOSTER VIRUS
Herpes zoster: HERPES ZOSTER VIRUS
Scarlet fever: Group A HEMOLYTIC STREPTOCOCCUS
Scabies: SARCOPTES SCABIEI (itch mite)
Bubonic plague: YERSINIA PESTIS
Diphtheria: KLEBS LOEFFLER
Pertussis: BORDETELLA PERTUSSIS
Tuberculosis: MYCOBACTERIUM TUBERCULOSIS
Typhoid: SALMONELLA TYPHI
Cholera: VIBRIO CHOLERA
Amoebiasis: ENTAMOEBA HYSTOLITICA
Leptospirosis: LEPTOSPIRA Spirochete
Schistosomiasis: Schistosoma japonicum
Gonorrhea: N. GONORRHEAE
Syphilis: TREPONEMA PALLIDUM
Chlamydia: C. trachomatis, T. vaginalis
Genital herpes: HERPES SIMPLEX 2

CD PHARMACOLOGY

Malaria: CHLOROQUINE
Schistosomiasis: PRAZIQUANTEL
Scabies: EURAX/ CROTAMITON
Chicken pox: ACYCLOVIR/ZOVIRAX
Tuberculosis: R.I.P.E.S.
Pneumonia: COTRIMOXAZOLE; Procaine Penicillin
Helminths: MEBENDAZOLE; PYRANTEL PAMOATE